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Publications & Resources > The Standard > September 2005

   Last modified: Aug. 25, 2005

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Mastering communication

Angela McNabb, RN, maintains that communication skills are paramount in developing the therapeutic nurse-client relationship. A unique communication challenge that McNabb faces at the Law and Mental Health Program in Toronto is her need to strike a balance between custody and care.

Photo: M. Gordon

To be effective, a nurse must excel in both the art and the science of communication.

At the core of nursing is the therapeutic nurse-client relationship. Communicating receptivity, empathy, trust and respect is how nurses establish and maintain therapeutic relationships.

Communication is defined as the act of transmitting information by speaking, writing or using non-verbal means. But communication in the nursing profession is more than that. Nurses first learn the science, the technique, of communicating as students. The art of communicating, the ability and confidence to finesse both verbal and non-verbal messages so interactions can be purposeful and effective, is acquired gradually and improves with reflective practice and experience.

Nurses regularly apply the art and science of communication in establishing and maintaining relationships with clients and other members of the health care team, in resolving ethical dilemmas or situations of conflict, in their advocacy efforts on behalf of clients and in promoting quality practice environments that help them meet the standards of practice. “Good communication skills are essential to a regulated profession such as nursing,” says Elizabeth Bildfell, RN, a Practice Consultant at the College. “In nursing, staff focus on every aspect of verbal and non-verbal communication so interactions are therapeutic.” Nurses are accountable to the public and, through self-regulation, are responsible for ensuring that nursing practice and conduct – including communication in all of its forms – meet the standards of the profession. A major component of this accountability involves conducting oneself in ways that promote respect for the profession.

“Individual nurses form the group which the public recognizes as the nursing profession,” says Phyllis Lewis, RN, an adjunct assistant professor at Queen’s University School of Nursing in Kingston. “To maintain the public’s trust and respect, and our fine reputation, nurses have the responsibility to achieve and maintain proficient communication skills.”

The RN and RPN entry-to-practice competencies contain an expected standard of communication competency. After entering practice, nurses are expected to develop their communication skills throughout their careers. The College offers a number of documents and learning resources to help members facilitate this ongoing process.

“Since communication is integral in nursing, it’s a theme found in most CNO practice standards and practice guidelines,” says Bildfell. “Another relevant document is the Self-Assessment Tool, which includes six statements on the assessment of nurses’ communication competencies. The College also provides Regional Education Network sessions that focus on issues of communication.”

When communication breaks down

Expert communicators are inquisitive, systematic, analytical, open-minded, self-confident, empathetic and receptive. Communication starts to erode in situations in which there is a lack of empathy, respect and trust. It can also be undermined by not actively listening to clients, family members and colleagues.

A vital component of skilled communication is critical thinking; the ability to analyse gestures and words and determine what is and is not working.

“A nurse must sift through an enormous amount of information gathered from a multitude of sources to accurately assess clients’ status and monitor risk,” says Craig. “Without critical-thinking skills, the nurse becomes merely a conduit passing on information. Nurses skilled in critical thinking are able to analyse client information, synthesize it with their expert knowledge and experience, prioritize the care required and communicate effectively with physicians and other team members.” At the root of many complaints to the College is communication breakdown. According to Karen Puckrin, RN, an Investigations Case Coordinator at the College, there are two common types of complaints made to the College. “The first is nurses communicating inappropriately with clients and family members,” she says, “and the second is nurses communicating inappropriately with colleagues.”

Building relationships

To build a therapeutic nurse-client relationship, a nurse must first seek to understand the client’s needs and situation, and this takes strong skills in active listening.

“Nurses develop nurse-client relationships by building trust between themselves and their clients,” adds Puckrin.

“Most clients understand that there are heavy demands on nurses as they work in challenging practice environments in the health care system. Clients are part of the system because they have certain needs,” says Puckrin. “As long as clients believe that the nurse is making every effort to understand and meet their needs, and they trust that the nurse really cares about their situation, the clients, and by extension the clients’ families, will accept that nursing resources might be limited.” Inherent in the nurse-client relationship are power and goal differentials that the nurse must be able to recognize and address. The nurse has more power than the client because of her/his nursing knowledge and influence in the health care system. Furthermore, the goal of the nurse-client relationship is to promote the health and well-being of the client and not to meet the needs of the nurse.

Nurses must acknowledge their role when first establishing the nurse-client relationship and remain empathetic and receptive to what the client is going through. For Angela McNabb, RN, an advanced practice nurse in the Law and Mental Health Program at the Centre for Addiction and Mental Health in Toronto, that means remembering that her clients’ freedom is limited, in varying degrees, by their legal status.

“The very nature of my practice setting of forensic psychiatry, having to strike a balance between custody and care, often makes it more difficult to engage a client in a therapeutic relationship,” says McNabb. “Therefore, good communication skills are paramount to developing this relationship, encouraging trust and relaying respect.”

Dynamics of group communication

Nurses seldom work in isolation. They are part of a larger health care community, and communication among colleagues is essential for facilitating client care.

“Nurses may be under the mistaken belief that their interaction with health care colleagues falls within the purview of labour relations and is not subject to professional regulatory review,” says Puckrin. “This is not the case.” Nurses have a regulatory obligation to work collaboratively and promote an environment of collegiality. They have a commitment to each other, their health care colleagues and the nursing profession.

Establishing collegial relationships requires a wide range of communication strategies similar to the interpersonal and communication skills used in developing nurse-client relationships — the difference being the sharing of power and having common goals.

Maintaining positive team relationships through good communication may seem easy, but collegial communication can be the first victim of a busy practice setting. “There are many stresses in today’s health care environment that can negatively affect communication patterns,” says McNabb. “When the unit is extremely busy and stress levels are high, team functioning may begin to deteriorate and this may lead to the deterioration of group communication.”

For positive team dynamics, Lewis teaches her students to recognize their own strengths and limitations related to the task that the group is to accomplish. As well, nurses need to learn as much as possible about other individuals’ strengths, and be willing to listen and learn.

McNabb finds the appropriate use of power contributes to successful team relations. In my practice setting, we work with clients who have chronic conditions, says McNabb. “The team informally reassesses the clients’ care plans each day, but we come together more formally, as an interdisciplinary team, at least once every two weeks. In this formal review, each member of the team has the opportunity to share their work with the client over the past two weeks and to come to a consensus on the continuing plan of care.”

Kathy Chesnick, RN, a professional practice leader at Kingston General Hospital and Hotel Dieu Hospital, finds that a lack of appreciation for the contribution of each team member can challenge effective group communication, and can lead to poor listening, resistance to new ideas and the absence of a common goal.

To facilitate good communication in stressful situations, Chesnick advises nurses to be organized and systematic in their approach. State your purpose and main points, add supporting points, she says. Then summarize and recommend an action. “These steps can be used effectively when speaking one-on-one or with several people.”

When reviewing all of the elements of skilled communication, certain themes recur: empathy, receptivity, trust, respect and listening. By learning and integrating these skills into daily practice, nurses can become, with experience and judgment, expert communicators. “When you can communicate clearly, you feel more confident,” says McNabb. “Communication skills are one of the best assets that any nurse could have.”

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