Effective communication within the interprofessional team is one of the hallmarks to providing safe, quality care. Communication between individuals, groups, and organizations will either lead to successful interactions with high outcomes, or miscommunication, leading to poor quality, errors, unsafe care, and sentinel events (unexpected death or injury) (The Joint Commission [TJC], 2010; Weller, Boyd, & Cumin, 2014). To ensure effective interprofessional communication throughout acute care settings, TJC (n.d.) surveyors evaluate hospitals for compliance with patient-centered communication standards. TJC (n.d.) offers

Delivery of healthcare is complex, requiring clear and timely communication between multiple disciplines. It has been well documented that miscommunication is the root cause of medication errors, poor quality, and reduced health outcomes (O’Daniel & Rosenstein, 2008; TJC, 2015).

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO, 2005) explains how a patient may interact with 50 different employees during a 4-day hospital stay. The opportunity for miscommunication is vast, compelling healthcare institutions to develop tools and training programs to improve communication throughout the entire organization (Institute of Medicine, 2010). Holmes et al. (2015) found implementation of training programs and use of standardized tools and simulation has the potential to improve patient safety.

Positive communication is a critical ingredient found throughout the culture of an effective organization. Leadership practices that will positively influence the organization’s culture must be clearly defined. This plan will lead to the support that will encourage employees to identify problems early and be motivated to explore solutions and assist with implementation.

Standards of Practice

Professional nursing practice requires communication be maintained at a highly effective level. Developing a trusting relationship with patients, advocating for their needs, providing patient-centered care, and ensuring safe, quality care are vital reasons why this is indispensable.

As discussed in Week 1, the Scope and Standards of Practice, developed by the American Nurses Association (ANA, 2021), serves as a template for professional nursing practice for all registered nurses. Standard 10, Communication, states, “The registered nurse communicates effectively in all areas of practice.” (ANA, 2021, p. 94). The following is a summary of the competencies of the Communication standard:

• Assesses one’s own communication skills and effectiveness.
• Demonstrates cultural humility, professionalism, and respect when communicating.
• Maintains communication with interprofessional team members and others to facilitate safe transitions and continuity in care delivery.
• Assesses communication ability, health literacy, resources, and preferences of healthcare consumers to inform the interprofessional team and others.
• Demonstrates continuous improvement of communication skills.
• Uses communication styles and methods that demonstrate caring, respect, active listening, authenticity, and trust (ANA, 2021, pp. 94-95).

In Week 4, Leadership in Nursing, the Healthy Work Environment Model (HWEM) (American Association of Critical Care Nurses [AACN], 2016) is introduced. The HWEM was created to improve practice environments and nursing practice by implementing six evidence-based standards. These standards have been found to improve and maintain a healthy work environment. The first standard is Skilled Communication, defined as nurses should be as proficient in communication skills as they are in clinical skills.

Becoming proficient in communicating with others and understanding the barriers to having successful interactions with others is a necessity for all nurses. Unless nurses view communication skills as equally important as honing clinical skills, work environment and patient outcomes will decline.

See Week 4 for more information about the Healthy Work Environment standards.

Types of Communication

Communication is an interactive process whereby one person (the sender) influences another (the receiver) with information (a message). Messages are sent verbally, non-verbally, and by the tone of voice. Effective communication occurs when both the sender and receiver have a shared understanding of the message, and both perceive the message in the same way (JCAHO, 2005).

Verbal

• Verbal communication occurs through spoken language.

Paraverbal

• During verbal communication, the qualities of an individual’s voice influence transmission of the message, including:
  • Tone: indicates a feeling, such as sadness, humor, anger
  • Inflection: rise and fall of the voice
  • Rhythm
  • Flow (O’Daniel & Rosenstein, 2008)

Non-Verbal

Non-verbal communication is an interactive process that occurs continuously, with and without verbal communication. Non-verbal behavior includes posture, body movements, mimics, facial expressions, gestures (O’Daniel & Rosenstein, 2008).

Nurses can interpret their patient’s body language and other non-verbal and paraverbal behaviors as part of the assessment process. Some patients may not have the ability to express themselves and body language may offer multiple inconclusive meanings. Proper follow up with additional questioning to confirm assumptions and understand new developments is prudent.

Benbenishty and Hannink (2015) states non-verbal communication has the capability to build trust by displaying an open body posture. In nursing, posture is a very important part of active listening during assessment or patient education. Consider body positions when listening to patient concerns, such as crossing arms or looking down at a patient during an interview. Positioning oneself and asking questions while looking at a laptop instead of looking directly at the patient with an open body posture will not foster open, effective, and honest communication.

Verbal communication has a smaller impact on the transmission of a message from one person to another and must be kept in perspective. Benbenishty and Hannink (2015) discuss the use of the 55/38/7 formula, used by communication psychologists, to understand the influence of each form of communication:

Verbal communication has a smaller impact on the transmission of a message from one person to another and must be kept in perspective. Communication psychologists refer to the 55/38/7 formula to understand the influence of each form of communication:

• 55% non-verbal
• 38% paraverbal
• 7% verbal (Benbenishty & Hannink, 2015)

Non-Verbal Communication and Culture

The preferences and accepted norms for non-verbal behaviors listed below will vary depending on culture. Respecting patient preferences is essential for effective communication and developing trusting relationships with patients and team members. Nurses can empower patients by encouraging them to speak up if their preferences and values are overlooked or misunderstood.

• Physical space: Americans prefer more personal space, generally, than other cultures (more information about physical space later in the chapter)
• Touching: physical contact is associated with one’s personality or communication style and can create discomfort. While touching an arm or shoulder shows support and empathy in American culture, it is best to ask patients if touching is okay.
• Gestures: some cultures become animated during communication, such as waving hands. Some cultures may find such gestures insulting and rude.
• Eye contact: in America, eye contact is understood as a sign of respect and a confident speaker. In contrast, eye contact can have negative connotations and can be insulting.
• Silence: some cultures are uncomfortable with silence, while others consider it as an opportunity to contemplate the message and meaning.
• Body language: verbal communication may be contradicted or confirmed by the use of body language. Consider the patient’s impression when the nurse welcomes the patient to the unit with folded arms (Hosley & Molle, 2006; Leininger & McFarland, 2006).

View the following video on eye contact and non-verbal communication:

video on eye contact and non-verbal communication

(ElaN Holding, 2012)

View the video below for an animation of miscommunication:

animation of miscommunication

(TED-Ed, 2016)

The sender and receiver take certain roles in the transmission of the message. The sender wants to be heard and receiver needs to share acknowledgement of the message. Transmission and acknowledgement may not occur for a number of reasons, including ineffective communication skills, conflicting non-verbal behaviors, or communication barriers. Evaluating one’s communication behaviors and assessing for barriers is a constant challenge. Developing a broad base of communication skills is a necessity in a complex healthcare environment where communication is at the heart of interprofessional collaboration.

How does the nurse in charge of unlicensed staff at a group home, charge nurse at a hospital, or school nurse at an elementary school adapt the type of communication needed for their setting? They must evaluate the age/education level of receiver, common communication gaps and barriers, and through experience and seeking new solutions, gaps in communication can be reduced.

Communication Styles

It is undisputed that clear and accurate communication among the interprofessional team is vital for teamwork, collaboration, and ultimately, improved outcomes. Miscommunication is often the root cause reduced patient outcomes, often due to team members having diverse, and often conflicting communication styles. In order for teams to collaborate and share knowledge in a timely way, nurses need to understand their team members’ communication styles. Recognizing and understanding team members’ communication styles allows nurse to adjust their communication behaviors in order to reduce or prevent conflict and misunderstanding (Plonien, 2015).

In addition to learning about the three basic communication concepts (listed below), there are additional communication styles (Controller, Supporter, Promoter, and Analyzer) discussed at the Maximum Advantage website.

Communication Concepts

Passive Communication

• Not expressive
• Disregards their own rights, in turn encourages others to disregard their rights
• Speaks in an apologetic way
• Hesitant to share feelings with others
• Does not respond clearly
• Unconsciously accumulates complaints, which often causes an outburst, leading to unacceptable behavior and damaged relationships, in turn, causing blame and guilt, leading again to passive behavior (Tripathy, 2018)

Aggressive Communication

• Domineering
• Ambitious
• Demands others maintain order, especially when the situation gets out of control
• Bullies and intimidates peers (Tripathy, 2018)

Assertive Communication

• Considered the best form of communication, a balance between passive and aggressive
• Positive attitude
• Good listener, respects others’ opinions
• Shares views in a calm and peaceful way
• Peers establish strong relationships with these communicators
• Expresses their thoughts, feelings, and emotions openly (Tripathy, 2018)

Omura, Maguire, Levett-Jones, and Stone (2016) discuss assertiveness as a powerful tool that eliminates the power differences between individuals. When individuals assert themselves, they are acting in their own best interest (such as advocating on the patient’s behalf). Being assertive helps people stand up for themselves without feeling nervous or anxious.

Professional Communication

Professional communication is defined as the interaction between healthcare professionals with the principal goal of meeting health-related outcomes (Street & Mazor, 2017). When successful communication practices become a central component of an organization it can transform healthcare delivery. Successful nurse-patient interactions require a patient-centered approach, where patient preferences and values are the center of their communication. Nurses’ communication skills and strategies need to be focused on educating, supporting, and empowering patients to manage their healthcare needs (Arnold and Boggs, 2019). Effective nurse-patient communication leads to patients having a better understanding of their health conditions leading them to be more active participants in their care.

Impact of Effective Communication:

• Development of nurse-physician relationships
• Increased patient satisfaction
• Early identification of changes in health status
• Improved understanding of patient’s needs, health status
• Improved patient outcomes last longer (Arnold and Boggs, 2019)

Therapeutic Communication

Effective communication occurs when nurses establish trusting, therapeutic relationships with their patients (Arnold & Boggs, 2019). When nurses communicate in a therapeutic way, they are interacting for the purpose of learning about the patient’s values, preferences, culture, interests, health needs, and developmental level (Rosenberg & Gallo-Silver, 2011). Developing therapeutic relationships is akin to Standard 1 (Assessment) of the Standards of Practice, where the nurse collects relevant information about the patient’s health and condition. Knowledge of valuable patient information allows the nurse to create a patient-centered plan of care.

Peplau (1960), a well-known nursing theorist, states healthcare providers must be skilled in therapeutic communication. Effective therapeutic communication is a learned skill, requiring a concerted effort to acquire knowledge on essential communication skills. Peplau (1960) states nurses need to uphold the concept called skilled mindfulness, which is an approach that allows the healthcare provider to consider the unique needs of the patient and at the same time having a personal awareness of one’s own responses and reactions. Peplau (1960) defines the nurse’s role as the “participant observer.”

Communication as an Art

Similar to nursing practice, effective communication is an art and a science. The art of communication is in the expression of how a message is conveyed. The speaker’s personality, sense of humor, non-judgmental approach, level of respect, calmness, and their attitude towards the dialogue will vary between individuals (Arnold & Boggs, 2019). Reading the situation in which nurses communicate with patients, coworkers, and other healthcare professionals is also an important skill to master. The speaker needs to be intuitive to the receiver’s preferences and needs, such as the amount of physical space, use of humor, or use of touch. Ensuring a positive first impression will influence the outcome of the interaction.

Communication Behaviors and Skills

The fundamental components of successful patient-centered communication include empathy, clarity, and honesty (Arnold & Boggs, 2019).

Empathy

Empathy is an essential component to building relationships with both patients and team members. Understanding each other’s needs leads to better outcomes and improved work environments.

Empathy with Patients

Clinical empathy involves understanding patients’ emotions and experiences regarding care. When nurses have empathy for a patient, it means they are able to communicate an understanding of the patient’s experience and needs, with the intention of alleviating suffering or pain (Hojat et al., 2013).

Clinical empathy is necessary for effective patient care (Hojat, Louis, Maio, & Gonnella, 2013) and creating therapeutic caring relationships (Mercer & Reynolds, 2002). Furthermore, Egan (2013) describes empathy as a skill or way of being that are central to forming therapeutic relationships with others.

Mercer and Reynolds (2002) describe three purposes for instilling empathy in therapeutic relationships:

1. Initiating supportive, interpersonal communication in order to understand the perceptions and needs of the patient
2. Empowering the patient to learn, or cope more effectively with his or her environment
3. Reduction or resolution of the patient’s problems (p. S9)

Empathy within the Interprofessional Team

Supporting teamwork and collaboration within the interprofessional team fosters safe, quality care. Caprari et al. (2018) conducted a study on ways to improve teamwork and collaboration through building empathy among the interprofessional team. The researchers found improved their experience and collaboration among each other when team members understood each other’s needs, goals, and roles. When team members built personal relationships with each other, and understood their actual duties and needs, they felt more confident and trustworthy about their peers.

Active Listening

Active listening is an interactive process between two or more people. In nurse-patient interactions, nurses listen to a message, interpret the meaning, ask questions to clarify the meaning, then share feedback about the message to the patient. Nurses need demonstrate active listening through verbal and non-verbal communication, by asking open-ended questions and actively observing the patient. When the nurse is in a relaxed position, leans slightly forward, maintains eye contact, nods, and restates patient concerns, it shows interest and commitment (Arnold & Boggs, 2019).

Nurses need to offer their full attention during nurse-patient communication, without making any judgments. Ineffective body language during these interactions can impede message transmission, such as looking at the clock or watch, responding to a text message, or begin walking away from the patient.

Listening makes up 40% of the communication process (Burley-Allen, 2005) and requires the listener to be actively immersed in the dialogue. The listener must be both physically attentive and mentally focused on the spoken message while visibly displaying a relaxed, open-minded body language (Chichirez & Purcărea, 2018).

Van Servellen (2009) explains the following listener responsibilities:

• Perform active listening skills and behaviors
• Understand the message
• Interpret and ask questions about the speaker’s body language
• Motivate the speaker to substantiate their message with supports, such as sharing a rationale

Henrico and Visser (2012) expressed the importance of being supportive and genuine during the communication process. An effective listener needs to be concerned about the speaker’s feelings and listen in an empathetic way.

Longweni and Kroon (2018) studied the communication process between managers and their employees. The researchers found employees were more engaged and committed when their manager paid attention to their emotions during the communication process. Researchers found employees with lower levels of education perceived less effective communication and required adjustments in communication behaviors. Considering a variety of factors and abilities about the listener will increase the odds of successful communication.

Nurses communicate with interprofessional team members and a variety of other staff and employees on a daily basis. Nurses need to listen effectively and be flexible in their communication approach. The goal of effective communication is to empower all involved in the delivery of care.

Consider the following communication skills and behaviors and their impact on effective message transmission:

• Silence: opportunity for the patient to interpret the meaning of the message and develop a meaningful response
• Open-ended questions: allow for a broader exploration of the patient’s situation or concerns
• Distance reduction: the amount of physical space varies depending on culture and the nature of the interaction. More information on physical space in the Communication Barriers section below.
• Restating and Clarification: confirms accurate understanding of the patient’s message throughout the dialogue; demonstrates to the patient the nurse is listening and is interested in the dialogue
• Focusing: create an environment where the dialogue can be understood clearly, eliminate distractions.
• Summarizing: at the end of a dialogue, share a summary of the patient’s messages, their needs, concerns, and requests.
• Collaboration: encourage patients to be an active participant in their care by communicating needs and concerns, asking questions.
• Honesty: honesty and trust coexist. In order to achieve a trusting relationship, honesty and truth telling are required (Bok, 1999). Without honesty, there can be no trust. Additionally, veracity (the ethical principle known as truthfulness) is the foundation for earning another’s trust. Pergert and Lutzen (2012) state truth-telling in healthcare is considered a universal communicative virtue. It is important to identify the instances where truth telling is warranted, collaboration with the patient and family at the start of care is necessary.
• Genuineness: be yourself, authentic in your daily practice.
• Respect: one of the fundamental principles of nursing practice is respect for human dignity, as stated in the ANA (2015a) Code of Ethics, Provision 1: “The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person” (p. 1).

Communication Tools

Nurses and physicians have different communication styles due to a variety of factors, one being their training. Nurses are educated to share more descriptive accounts of clinical situations compared to physicians who are trained to be more concise in their communication (O’Daniel & Rosenstein, 2008). In order to reduce this communication gap, standardized communication tools have been developed.

Situation-Background-Assessment-Recommendation Tool

In 2002, a group of physicians at Kaiser Permanente developed a communication tool called Situation-Background-Assessment-Recommendation (SBAR) (Sutcliffe, Lewton, & Rosenthal, 2004). The SBAR tool is widely used in healthcare organizations to provide a framework for nurse-physicians communication. The SBAR tool is especially useful in urgent situations when immediate attention and action is critical. The Institute for Healthcare Improvement (IHI, 2020) explains SBAR as follows:

S = Situation: a concise statement of the problem

B = Background: clinical background or context of the problem

A = Assessment: patient data shared, analysis and consideration of options

R = Recommendation: action requested, recommendations shared (para. 1)

O’Daniel and Rosenstein (2008) explains the use of the SBAR tool improves critical thinking for the person (nurse) initiating the communication. When using the SBAR tool, the individual (in this case nurses) needs to assess the problem holistically, then analyze the assessment data, suggest potential underlying causes of the problem, and finally, offer solutions. Using the SBAR tool, or other communication tools, nurses learn how to problem solve in a systematic, holistic way.

View the following video on SBAR:

video on SBAR

(IHI, 2020)

TeamSTEPPS®

Healthcare facilities have instituted formal approaches using models of care to improve communication, teamwork, and facilitate a more streamlined, and safer delivery of healthcare. The Agency for Healthcare Research and Quality (AHRQ, 2019), in collaboration with the Department of Defense, has created a teamwork system called Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS^®).

TeamSTEPPS^® is an evidence-based approach used to improve communication, safety, and teamwork skills. The TeamSTEPPS^® model involves a series of training modules and integration of healthcare principles throughout all areas of the healthcare system (AHRQ, 2019). TeamSTEPPS^® improves safety and the quality of care by:

• Producing highly effective medical teams that optimize the use of information, people, and resources.
• Increasing team awareness and clarifying team roles and responsibilities.
• Resolving conflicts and improving information sharing.
• Eliminating barriers to quality and safety (AHRQ, 2019, para. 2)

Clapper et al. (2018) found improved teamwork and communication knowledge as a result of the TeamSTEPPS^® training. Parker et al. (2019) completed a review of 19 studies assessing the success and influence of TeamSTEPPS^® in improving communication, reducing errors, and the impact on patient satisfaction. These studies were focused on outpatient clinic settings and the results of the review found a marked improvement in communication, decrease errors, and improvement in patient satisfaction.

Implementing new communication processes requires significant research, planning, administrative support and especially, buy-in from all employees. Shaw et al. (2012) writes about the importance of having a “change champion” on each unit, a critical player who supports innovation and change. Nurses are uniquely positioned to take this role because they are positioned at the center of the interprofessional team. Nurses must take the initiative to find gaps in the healthcare delivery process and actively seek out “change” solutions.

Targeted Solutions Tool® for Hand-Off Communication

Hand-off communication has been found to be a contributing factor to adverse events (Scott et al., 2017), wrong-site surgery, delay in treatment, falls, and medication errors (CRICO Strategies, 2015). The Joint Commission for Transforming Healthcare (JCTH, 2020b) has identified inadequate hand-off communication as a sentinel event in healthcare facilities.

The JCTH (2020b) defines hand-off as “a transfer and acceptance of patient care responsibility achieved through effective communication. It is a real- time process of passing patient- specific information from one caregiver to another or from one team of caregivers to another for the purpose of ensuring the continuity and safety of the patient’s care” (para. 2). The JCTH (2020) has identified an average of 4000 hand-offs each day in a typical teaching hospital. The opportunity for inadequate communication is vast.

The Joint Commission Resources

Since TJC (2010) required hospitals to implement standardized communication procedures for patient-centered care, they developed a variety of resources, tools, and protocols to assist with improving effective interprofessional communication skills. The following resources assist hospitals with breaking down communication barriers, including cultural, language, and diversity:

• Advancing Effective Communication, Cultural Compentence, and Patient- and Family- Centered Care: A Roadmap for Hospitals
• Hospitals, Language and Culture: A Snapshot of the Nation
• Exploring Cultural and Linguistic Services in the Nation’s Hospitals: A Report of Findings
• One Size Does Not Fit All: Meeting the Health Care Needs of Diverse Populations

TJC (2017) also established a hand-off communication procedure as one of the National Patient Safety Goals in 2006, then in 2010 hand-off communication became a Provision of Care standard, as follows:

The organization’s process for hand-off communication provides for the opportunity for discussion between the giver and receiver of patient information. Note: Such information may include the patient’s condition, care, treatment, medications, services, and any recent or anticipated changes to any of these (The Joint Commission, 2017, para. 4).

The risk for inadequate discourse and miscommunication is vast, which led the JCTH (2020a) to create the Targeted Solutions Tool^® (TST) to improve hand-off communication. The TST provides a framework for improving the effectiveness of communication when a patient moves from one setting to another within the organization or to the community. The TST has the following benefits:

• Increased patient, family, and staff satisfaction
• Successful patient transfers without “bounce back” (patients returning to previous unit)
• Improved safety (JCTH, 2020a)

Benjamin, Hargrave, and Nether (2016) implemented the TST in the Emergency Department to determine the rate of defective handoffs (a TST concept) and the factors that contributed to the handoff. Prior to implementing the TST, the defective handoff rate was 29.9% (32 defective handoffs/107 handoffs). Sixty-nine percent of the contributing factors were uncovered:

• Inaccurate/incomplete information
• Ineffective methods for handoff
• No standardized procedures for handoff
• Lack of patient knowledge of the person initiating the handoff

After implementation of the TST, the defective handoff rate dropped 58% to 12.5% (13 defective handoffs/104 handoffs). As the defective handoff rate declined, the number of adverse events declined.

In a 2015 report, it is estimated that 30 percent of all malpractice claims in U.S. hospitals and medical practices were due to communication failures, resulting in 1,744 deaths and $1.7 billion in malpractice costs over five years (CRICO Strategies, 2015).

View the following video illustrating the breakdown of communication between physicians and patients:

video on breakdown of communication

(CRICO Strategies, 2015)

Nurses can bridge this communication gap by identifying and reducing communication barriers within the healthcare team.

Family-Centered Rounds

Khan et al. (2018) implemented a family-centered communication program to reduce errors and improve communication. The outcome of the study reduced harmful medical errors and improved communication processes and family experiences. To view the report and a short video on the study and its outcomes visit the publisher’s website.

Communication Barriers

Personal Barriers

Holmes, Wieman, and Bonn (2015) conducted a comprehensive review of the research on interprofessional communication and found a number of barriers led to miscommunication, including misunderstood motives, lack of confidence, poor organization, and structural hierarchies. In addition to reduced health outcomes, Storlie (2015) found poor communication impacted not only the patient, but also the healthcare provider and the employer:

Older adults

• chronic elevated levels of stress
• hurt feelings
• delay of care
• dissatisfaction of care

Healthcare provider

• interpersonal conflicts
• health risks
• poor morale
• absenteeism
• burnout
• staff turnover

Employer

• reduced quality of care (leading to reduced reimbursement and a poor reputation)
• reduced patient satisfaction (leading to reduced reimbursement and a poor reputation)
• lower staff retention rates leading to increased cost for new hires (Storlie, 2015)

Barriers to communication may originate from the patient or nurse perspective, the physical environment, or the structure of the team dynamics. Nurses can often identify communication barriers among the patient and entire healthcare team and assist individuals on how to reduce miscommunication.

Patient-related barriers

• Preoccupation with pain, discomfort, worry
• Feelings of being judged, insecure, or defensiveness
• Confusion, too much information, complex messages
• Lack of privacy
• Physical barrier: sensory or cognitive deficits

Nurse-related barriers

• Concerned about agenda, heavy workload
• Making assumptions about patient motivations or needs
• Cultural stereotypes
• Insecurity about ability to help patient
• Poor listening/thinking about what to say next (Arnold & Boggs, 2019)

Nurses have an ethical responsibility to prevent personal issues from impacting professional communication (Arnold & Boggs, 2019). Incorporating self-awareness and reflection into practice can assist nurses with reducing communication barriers. Nurses may consider taking a brief “planning pause” before an interaction to remind oneself on the goal of the upcoming communication, to approach the interaction without bias, and consider how non-verbal behaviors may contradict the spoken word.

Interprofessional Communication

O’Daniel and Rosenstein (2008) list the following common barriers to interprofessional communication and collaboration:

• Personal values and expectations
• Personality differences
• Hierarchy
• Disruptive behavior
• Culture and ethnicity
• Generational differences
• Gender
• Historical interprofessional and intra-professional rivalries
• Differences in language and jargon
• Differences in schedules and professional routines
• Varying levels of preparation, qualifications, and status
• Differences in requirements, regulations, and norms of professional education
• Fears of diluted professional identity
• Differences in accountability, payment, and rewards
• Concerns regarding clinical responsibility
• Complexity of care
• Emphasis on rapid decision-making (para. 12)

Hierarchy

Hierarchy is defined as “the classification of a group of people according to ability or to economic, social, or professional standing” (Merriam-Webster, 2019). This definition applies to different units and professions throughout most healthcare organizations. Hierarchical relationships, such as nurse-physician, novice-to-senior nurse, or other relationships throughout the organization where levels of education, knowledge, or status vary.

Historically, nurses have held subservient roles in their everyday work with physicians. In these situations, physicians are in charge of all decision-making without nursing input leading to poorer quality of care. These hierarchical team structures, where physicians hold a senior position within the team, disempower nurses, resulting in a lack of confidence, fear of humiliation, and the feeling their knowledge and opinions are not valued. Nurses and physicians communicate differently, and while this diversity may offer valuable perspectives and a patient-centered care approach, the fast-paced, complex healthcare environment increases the occurrence of miscommunication (Foronda, MacWilliams, & McArthur, 2016).

Quality patient care is jeopardized when nurses are reluctant to communicate with physicians in order to avoid conflict and fear of repercussions (Gillespie, Chaboyer, Longbottom, and Wallis, 2010). Addressing this dangerous and unsafe communication barrier is crucial to improving communication and reaching optimum patient care outcomes.

Leadership must approach the negative consequences of a hierarchical team structure with a zero-tolerance policy. To reduce the negative aspects of hierarchy among the team, nurses need to discuss their fears and concerns with management, and together, come up with a plan for remediation. It is the nurse’s ethical responsibility to take action, to reduce the impact of hierarchical structures. By collaborating with management, nurses are taking an important step towards improving the delivery of safe, quality patient care.

The following interventions led to improved nurse-physician communication in the ICU setting:

• Daily goal sheet or form
• Bedside whiteboard
• Door communication card
• Team training
• Electronic SBAR documentation templates (Wang, Wan, Lin, Zhou, and Shang, 2017)

Effective listening and receiving unwavering support from management has also been found to reduce the negative impact of hierarchy between nurses and physicians (Lyndon, Zlatnik, & Wachter, 2011)

Interventions can be modified to apply to a variety of healthcare settings. Nurses need to assess gaps in communication at their workplace, take the initiative to find solutions and integrate them into practice. Creating unit or agency policies on the use of communication tools or interventions is a necessary step towards reducing the hierarchical structure of the team, leading to improved nurse-physician collaboration.

Implementation of the TeamSTEPPS^® training program has been found to be a powerful tool in reducing hierarchy within an organization. The program provides employees with tools that empower them to voice their concerns, especially in clinical practice situations when patient safety is at risk. When employees are given opportunities to communicate in a safe way, without fear of repercussion or conflict, it minimizes the negative aspects of the hierarchical relationship (Clapper, 2018).

View the following video on nurse-physician communication:

video on nurse-physician communication

(VitalSmarts Video, 2011)

Physical Barriers

Consider the ten major concepts of Nightingale’s Environmental theory and how nurses automatically make adjustments to the patient’s environment in order to aid in healing, health, improve mood, but also with communicating clearly and accurately with patients:

• Ventilation and warming
• Light and noise
• Cleanliness of the area
• Health of houses
• Bed and bedding
• Personal cleanliness
• Variety
• Offering hope and advice
• Food
• Observation (Pepetrin, 2016)

Assessing the patient’s immediate environment is standard nursing practice, though it is important for the nurse to view the environment as a potential barrier to communication. Consider a patient with Chronic Obstructive Pulmonary Disease, with symptoms including shortness of breath, anxiety, restlessness, discouragement, pain, weakness, and activity intolerance. Patients with these symptoms may struggle with a number of environmental factors that could impact sending and receiving messages from others. Patients may struggle with bright or low lights; warm, still air; or a noisy environment.

Lowering the lights, turning on a fan or air conditioning, and reducing the number of visitors can improve comfort, reduce pain or discomfort, ultimately improving the patient’s ability to concentrate on nurse-patient interactions and communication more easily.

Papastavrou, Andreou, Efstathiou (2014) found the following environmental barriers negatively impacted communication for stroke patients in an acute care setting:

Provider

• physical characteristics, such as their hearing or speech attitude about caring and respect

Physical environment

• assistive devices (call bell out of reach, lack of hearing aid)
• external sounds
• poor lighting, lack of large print

Hospital procedures

• lack of staff

While this list of barriers was found to be present in a stroke unit, many of them can apply to other units or settings.

Physical Space

DeVito (2016) identifies four ranges of interpersonal space for communication in the United States:

• Intimate relationships: touch to 18 inches
• Personal: 18 inches to 4 feet
• Social: 4-12 feet
• Public: 12-25 feet (p. 152-153)

Arnold and Boggs (2019) state therapeutic communication occurs at 3-4 feet, though more physical space is needed if a patient is anxious. In contrast, less than 3 feet is often used during a painful procedure or injury. Though a patient-centered approach is needed in all situations, assessing for patient preference can prevent miscommunication.

Gender

Men and women differ in many ways in respect to both verbal and non-verbal communication behaviors. Yang et al. (2016) found men tended to stand closer to those of the same gender compared to women. This means women tend to give more space to other women compared to men. Patients and coworkers will find it awkward to tell someone to move back though having the awareness that adequate space is essential for transmission of a message from one person to the other.

Another gender barrier to communication is verbal communication. How men and women speak can be judged incorrectly. Smith (n.d.) explains the differences in how men and women communicate in Table 1:

Table 1: Gender Differences in Communication

Women	Men
Talk about other people	Talk about tangible things like business, sports, food and drinks
Ask questions to gain an understanding	Talk to give information rather than asking questions
More likely to talk to other women when a problem or conflict arises	Known for dealing with problems or issues internally
Focus on feelings, senses and meaning. They rely on their intuition to find answers	Focus on facts, reason and logic. They find answers by analyzing and figuring things out
Disagreement affects many aspects of their relationship and may take a long time to resolve	Can argue or disagree and then move on quickly from the conflict

Jargon

Subramaniam et al. (2017) defines jargon as the language that is focused on a specific profession or group. Jargon is commonly used during communication by medical professionals, and those who are not familiar with these terms are excluded from the conversation. Examples include “frequent flyer”, “trainwreck” and “boyfriend”. How would a patient appreciate overhearing a nurse referring to someone as a trainwreck?

The use of slang is a more casual type of jargon that is not usually used in professional settings, though can occur among nurses and other staff. One popular term is “LOL”. As with jargon, those who do not use or know these terms are again excluded from the conversation.

One negative side of slang and jargon is they can have multiple meanings. Consider “LOL”, it can mean laugh out loud, lots of love, smiling, amusement, lots of luck, lots of love. While some of these meanings can apply to the same situation, one can see how the intended message can be lost when using a word or phrase with multiple meanings.

 

The best approach to effective communication is to follow best practices, as follows:

• know your audience
• reduce communication barriers
• monitor non-verbal behaviors and tone of voice
• speak clearly and assertively
• use professional terminology
• listen effectively