Communication in Nursing: The Foundation for Caring

Module 1

Continuing Education Course 2 Contact hours

Instructor: Marlene V. Obermeyer, RN, MA

Culture Advantage (Marlene Obermeyer) is approved as a provider of continuing

nursing education by the Kansas State Board of Nursing.

Kansas State Board of Nursing: Provider # LT0243-1250.

©mobermeyer2006

Nurses’ major communication tasks are not only to inform the patient

about his/her disease and treatment, but also to create a therapeutically effective relationship by assessing patients’ concerns,

showing understanding, empathy, and providing comfort and support.1

Course Objectives:

By the end of this course, the participant should be able to:

1. Define communication.

2. Discuss the development of theories of communication and examples of each.

3. Describe the 6 elements of communication. 4. List barriers to effective communication.

5. Evaluate two nursing communication encounters using

communication theory.

This module introduces the basic concepts of communication. What does it mean people say they understand? What are the elements of

effective communication? What are the barriers to effective communication? How can we use communication theory to improve

our nursing practice?

COMMUNICATION: Introduction What is communication?

From the Latin communicare, meaning to share, to impart, to partake,

to make things common, communion, community.2

Dictionary definitions:

com����mu����ni����ca����tion 3

1. the act or process of communicating; fact of being communicated.

2. the imparting or interchange of thoughts, opinions, or information

by speech, writing, or signs.

3. something imparted, interchanged, or transmitted.

4. a document or message imparting news, views, information, etc.

5. passage, or an opportunity or means of passage, between places.

6. communications, used in technology:

a. means of sending messages, orders, etc., including telephone, telegraph, radio, and television.

b. routes and transportation for moving troops and supplies from a base to an area of operations.

What is your definition of communication?

________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

Test yourself COMMUNICATION: Fact or fiction?

Fact or Fiction?

1. Listening is a passive activity. 2. The audience does not play a role in communication. 3. People who speak the same language do not have problems

with communication.

4. Speaking directly is universally acceptable. 5. The more words used in communicating, the better. 6. It’s the speaker’s job to make me understand. 7. Communication is an inborn talent. Either you have it or you

don’t.

8. Nonverbal signals are universally understood.

9. Silence is not feedback. 10. Communication means giving information.

Communicating4 with others is an essential part of our everyday life. The need to communicate shows itself in many ways. Communication

fulfils several functions that are important for our well-being and survival. It helps us establish relationships, share information and

ideas, and give meanings to everything we do. In the health care professions, communication assumes major significance in

demonstrating a caring and a therapeutic approach. Failure to give accurate and easily understood information, for example, can lead to

anxiety and may have serious consequences where sensitive treatment are concerned. Communication is a dynamic and complex process.

Miscommunication can lead to conflict and misunderstandings, and most importantly, can jeopardize patient safety.

When we consider a social encounter, we may become aware of the many visible and invisible aspects of communication. The spoken

word, the written message and the non-verbal gesture or facial expressions play an important part in getting the message across.

Similarly, these aspects are part of showing acknowledgement and understanding of the message.

In effective communication, the shared meaning of the message is crucial to the outcome of the social encounter. Understanding of the

meanings of what is being conveyed can be achieved through the

congruent interpretation of language and associated non-verbal

gestures and symbols. (6, RCN publication.)

From Drumbeats to Bandwidth: A Short History of Communication

We know that ancient men communicated and transmitted

messages through their cave paintings, smoke signals and drum beats.

We have come a long way. Today we communicate across distances

faster and with more accuracy. In today’s electronic

communication, we use “bandwidth” to transmit messages.

Bandwidth is the term for electronic data transfer rate- the amount of data that a channel can carry from one point to another within a

given time period, usually in one second.5 This term is usually used to describe the speed of Internet connection.

In this module, we will trace the different models of communication

throughout history and their relationship with technology. We will discuss how the study of communication theory or models helps us

in understanding the role of communication in the nurse-patient relationhip.

The study of communication started in ancient Greece and was resumed after the invention of the telegraph in the 1800s.

I. Aristotle’s Triad of Communication (350 BC) 6

According to Aristotle, three elements that ensure effective communication are: Speaker, Subject, and Audience.

The credibility, knowledge, skills of speaker; the topic of conversation;

and the interest or benefits to the audience/listener ALL affect the communication process. However, the listener or audience ultimately

determines whether communication takes place or not.

Elements of communication: Speaker, Subject, Audience

Goal: Persuasion

Based on:

Clear, Linear thinking

Facts

Speaker credibility Audience readiness/emotion

According to Aristotle,

The _______ holds the key to whether or not

effective communication takes place.

Subject

Speaker

Audience

II. The Telegraph Model (1948)

Linear Model

In this model, communication is the transfer of information from one

point to the next.

Goal: maximum line capacity with minimum distortion.

Noise is anything that interferes with the transfer of the message. Noise is any barrier encountered when sending, receiving, or

interpreting messages. To improve communication, decrease interference or noise.

The technology model of communication is based on the telegraph

model. Human beings themselves have a fixed rate at which

information can be transferred (maximum line capacity). 7

SENDER

NOISE

Transmitter RECEIVER Destination

Channel

Message sent Message received

Message

received:

E=mc²

Message

sent:

E=mc²

In this model, when the information sent is the same as the

information received, communication has taken place. Example: A nurse receives an order for Lasix 100 mg IV, and

administers Lasix 100 mg IV.

III. Interactional model: 1950s

This is a circular model of communication, in which the message is sent and received, encoded and decoded, and interpreted, by both the sender and the

receiver.

“In fact, it is misleading to think of the communication process as starting somewhere and ending somewhere. It is really endless. We

are little switchboard centers handling and rerouting the great endless current of information.... “ Schramm 1954

The model emphasizes the ____________ nature of communication. The participants swap between the roles of

_______________________ and ___________________.

The encoding and interpreting of messages by both sender and receiver started to get recognized.

Encoder

Sender

Interpreter

Decoder

Receiver

Interpreter

Message

Message

For example, a nurse asks the patient, “What’s your pain level? On a

scale of 1 to 10?” The patient answers, “I guess around 5 or 6.”

In this communication model, the cycle is not completed until the nurse responds to the patient’s feedback. The nurse then becomes the

receiver, and the patient, the sender.

IV. SMCR Model (Berlo, 1960s)

In this Source-Message-Channel-Receiver (SMCR) Model by Berlo, the

Linear telegraph model of communication becomes more complex.

According to Berlo8:

The Sender encodes the message through his speaking and writing

skills. The Receiver decodes the message through his listening and reading skills.

Both sending and receiving are influenced by knowledge, attitudes, experiences, and skills, and affected by the channel through which the

RECEIVER

CHANNEL

MESSAGE

Attitude

Tasting

Touching

Seeing

Hearing

Culture

Social

Knowledge

Attitude

Symbols

“Code”

Structure

Content

Social

system

Knowledge

Culture

Smelling Skills Skills

Encoding Decoding

SOURCE

message is sent. For example, some cultures value direct

communication in order to reduce uncertainty, while some cultures value indirect communication, in order to preserve harmony.

The sender “encodes” the message through the use of symbols,

through a “channel” such as speaking, writing, etc.

The Receiver receives the message (which is encoded in symbols) through the channels of listening, reading, etc.

Interpretation is the Receiver’s understanding of the message. The

Receiver is actively listening and “decoding” or interpreting the symbols transmitted by the Sender.

Nurse (Sender): “What’s your pain level on a scale of 1 to 10?”

Patient (Receiver): “4” (Patient grimacing and splinting surgical site

with every movement.)

The nurse “encodes” the question using the numeric scale without assessing the patient’s understanding of what the numbers mean to

the health care team.

The patient “decodes” the pain scale numbers using his own interpretation.

V. The addition of feedback: Transactional Model

(1960s)

ASKCE ASKCE

Speaking, writing Speaking, writing Listening, reading Listening, reading

Feedback is the Receiver’s reaction to the message, which he sends

back to the Sender.

Feedback is any message that the receiver sends to the sender. It

could be verbal, nonverbal, or silence. Nonverbal feedback can create misunderstandings as different cultures interpret nonverbal gestures

differently. A nod in one culture may mean “yes,” while in other cultures, a nod of the head means “no.” Feedback is returned to the

Sender, who in turn becomes the Receiver.

“In the final analysis the communication process is not linear, circular

or even interactive. It is transactional—meaning that encoding, decoding, receiving and sending feedback, and other components of

MESSAGE

Feedback loop

the process are all interrelated and all happen simultaneously in at

least two places at once.”9

Nurse as Sender: “What’s your pain level on a scale of 1 to 10?” Patient as Receiver: (Nurse wants me to give her a number but I’m

not sure what she means by pain scale.) Patient as Sender: “About a 4.” (Patient grimacing, moaning, and

splinting surgical site with every movement.) Nurse as Receiver/Sender: “4? You look like you are hurting a lot with

any kind of movement.” (Feedback) Patient as Receiver/Sender: “You’re right. I am in a lot of pain right

now!”(Feedback)

INTENDED MEANING = RECEIVED MEANING

Transactional: give and take of sending and receiving of messages.

Physical, semantic and internal noises distort the messages transmitted from sender to receiver and vice versa.

FEEDBACK

Intended

meaning Received

meaning

Sender

MESSAGE MESSAGE

Receiver Physical Noise

Semantic Noise

Internal Noise

ASKCE ASKCE

FEEDBACK

MESSAGE

Is feedback always beneficial?

The feedback loop may be positive or negative. Negative feedback can

perpetuate an undesirable response as the following illustration shows.

POSITIVE or NEGATIVE Feedback LOOP?

Charmed loop:

Nancy RN’s Perspective

Self-concept: I’m a nurse.

Perceived message: He thinks I’m incompetent. (He doesn’t need to tell me how to change a dressing. He’s rude.)

Feedback given: “I’m a nurse. I KNOW how to change a dressing! (I won’t ask him anything again!)”

Dave MD’s Perspective

Self-concept: I’m a doctor.

Perceived message: She seems disorganized, and she’s rude!

I better make sure she understands exactly what to do. I’ll make a note to keep an eye on her.

Feedback given: Gives very specific orders on how to change a dressing. (She’s rude! I don’t think she knows what she’s doing.)

Nancy, RN Dave, MD

Self-concept: I’m a nurse. I’m a doctor.

Message received: He’s rude. She’s rude and

incompetent.

ENVIRONMENT OR CONTEXT

ENVIRONMENT OR CONTEXT

SENDER

Feedback: I won’t ask him anything again.

I need to give her specific directions.

VI. CONVERGENCE MODEL of Communication

(Kinkaid 1980s)

Communication is the convergence of meaning. Not merely the exchange of information.

Sender Receiver

My REALITY My REALITY

Pool of shared meaning

And experience.

CONVERGENCE: Where my reality and your reality meet. A pool of

shared meaning between Sender and Receiver.

Goal: Mutual understanding and collective action.10

Each person in an interaction aims to:

• Maximize coherence (make sense of the event)

• Reduce uncertainty, enhance predictability • Coordinate events (data, symbols) towards a common goal

For example, a patient was given instructions to take his medications

for “hypertension.” He returns to the office after a month and reports

that he has stopped taking his medications. The patient says he does not feel “hyper” anymore, nor is he experiencing any more “tension” in

his life.

According to the Telegraph model, the information was transmitted correctly. The patient understood the message that he had

hypertension. However, there was no assessment of his understanding of the term. There was no shared meaning of the word hypertension.

In order for convergence of meaning to occur, there has to be a coordination of the symbols used in the communication process, in this

case, the term, “hypertension.” Both nurse and patient need to maximize their mutual understanding of is hypertension and the goal

of controlling the patient’s high blood pressure and preventing its complications.

Definition: Communication is the transfer, exchange, and coordination

of information, to create shared meaning and mutual understanding, in order to achieve a common goal.

How is the “convergence of meaning” accomplished?

Convergence of meaning occurs when11:

1. Participants with differing points of view listen to one another by paraphrasing each other’s point of view to the other’s

satisfaction.

2. Each one acknowledges the conditions under which the other’s point of view can be accepted as valid.

3. Each one acknowledges the overlap or similarity of both points of

view. 4. Each one assumes accountability for their part in achieving the

desired goal.

Communication convergence can lead to divergence or conflict when:

The participant’s interests and values are in conflict and they are

not willing or able to engage in dialogue to come to a minimal level of understanding to achieve a common goal.

Further communication is required to identify the elements that are in

conflict, or elements that do not support achievement of their goals.

Principles of effective communication according to the convergence model:

• Communication is a dynamic process. • It is a system of elements that make up the whole.

• The parts interact and influence each other. • The parts are subject to the environment in which they exist.

• Communication is a skill that can be learned.

Six Elements of Communication:

Sender Message

Channel

Receiver Noise

Feedback

Using a communication checklist to evaluate nurse-patient communication patterns:

You are teaching two newly diagnosed diabetics how to self-administer

Insulin and how to check blood sugars at home. One patient is a 17-year-old female athlete and the other patient is a 74-year-old retired

farmer who lives alone. Using the checklist below, analyze how you as the Sender, should adjust and adapt your communication patterns

when speaking with these two different patients.

Communication Checklist

Sender:

Knowledge: How much do I know about this topic/subject matter?

Do I need to research or review the topic before this encounter? Skills: Do I have skills to accomplish the goal?

Attitude: What is my motivation? What attitude do I have toward this information?

Culture: What are the influences from my cultural background and

experiences that affect how I encode and send the message? Purpose: Do I want to inform, persuade, inspire, inquire, motivate,

or analyze? Do I have a clear purpose in mind?

Message:

What is the message I want to convey?

Facts or raw data? Motivate? Interpretation of information?

Answer questions? Explain a disease process?

Teach a skill? What is the tone of the message: impersonal, personal, professional,

friendly? What symbols to use to convey the message?

Channel:

How do I send this information in a way that the receiver would understand the meaning of the message?

What is the best method to motivate the receiver to listen? Written instructions versus verbal instructions.

Video or face-to-face demonstration? Telephone, fax, or email?

Verbal or nonverbal messages?

Environment/noise: communication barriers

Noise is any barrier that interferes with the transmission of the

message.

Consider the following: Environmental noise: Background noise, poor lighting, poor print

quality, illegible handwriting, static on the phone lines, print that is too small to read without magnifiers, poor contrast in printed

materials, other distractions, etc. Physical noise: hunger, pain, exhaustion, etc

Psychological noise: preconceived ideas, previous experience and knowledge, attitude, current emotional status

Cultural noise: values, knowledge and belief systems, culturally-based health care practices, direct or indirect communication styles.

Semantic: word usage, idioms, metaphors, learning styles Language: words may have different meaning even when using the

same language. For example, “stress” may mean different things to different people.

Speaking the same language is not a guarantee for successful

communication to occur.

The Receiver:

Always have the receiver or listener in mind. Is the receiver ready to listen?

What is the attitude of the receiver toward this information? Is the receiver knowledgeable about the subject, or is this the first

time they have ever heard of this subject? What have they heard about this topic from their friends, family,

significant others?

Are you using a common language? A nurse and a pharmacist may share a common “language” or specialized vocabulary that a

layperson might not understand. Is the receiver a superior, a subordinate, or a peer? Does this affect

how the message is received and interpreted? Literacy level, language use, generational differences?

Interpretation:

How could I convey the message so that my intended meaning is clear to the receiver?

Could a word have a double meaning or unintended meaning? How about your nonverbal message and how the receiver might

interpret this message? Does the receiver have enough information or background

experience to interpret the message? Does the receiver have the capacity to receive the message, i.e.,

seeing, hearing, reading, etc?

What cultural background and life experiences does the receiver have that might affect how he/she interprets the message?

Feedback:

What is the intended result of your communication?

What kind of feedback do you want to see from the communication? What kind of verbal and nonverbal feedback are you receiving?

What do you want the receiver to be able to do as the result of this communication?

Verbal? Demonstration?

Is the received message the intended message? What is the intended short-term result, end-term result?

How do you know that the receiver has understood the message?

Complete the worksheet below using the Communication

Checkist.

Communication Worksheet for teaching patient self-administration of

insulin.

Patient: 17-year-old female athlete

Sender (nurse)

Message (self-

injection of insulin)

Channel

Noise

Interpretation

Feedback

What may be the communication barriers with a 17-year old diabetic learning about

self-injection of insulin?

a. Attitudes of friends about diabetes?

b. Believing that insulin shots can cure diabetes?

c. Talking on the cell phone while watching a demonstration on drawing up insulin?

d. Any other communication barriers?

What may be the communication barriers for a 74-year-old learning about diabetes?

a. Hearing loss?

b. Vision impairment?

c. Crowded and noisy room?

d. Fine print?

Communication Worksheet for teaching self-administration of insulin

Patient: 74-year-old retired farmer

Sender

Message

Channel

Noise

Interpretation

Feedback

In this module, we discussed several communication theories in order to give us a better understanding of the dynamics in the nurse-patient

interaction. We explained that communication is not only the transfer of information, but also the exchange of meaning. We described

“noise” and listed barriers to effective communication. And we used a communication checklist to evaluate our communication patterns with

two different listeners or Receivers.

Communication: The Foundations Review Questions

To take the exam, log in at:

http://www.culture-advantage.com/etraining/

1. According to Aristotle, the three elements of communication are:

a. audience

b. speaker

c. message

d. desires

e. all of the above

f. a,b, and c only.

2. In the Communication Triad, the _____ determines the success of

communication.

a. audience

b. speaker

c. message

d. desires

e. all of the above

3. The Telegraph Model of communication is:

a. Linear

b. Circular

c. Negotiable

d. Verbal

e. Noisy

4. According to the Telegraph Model, the __________

transmits the message through a __________

and is received by the __________.

5. Noise includes:

a. Poor lighting

b. Loud rock music

c. Illegible handwriting

d. Cold room

e. All of the above

6. A nurse receives an order for 50 units of Regular Insulin subq,

and administers 50 units of Regular Insulin subq. This is an example of

a successful communication according to:

a. Aristotle

b.Telegraph Model

c. Analysis Model

d. Meaning Model

7. Encoding a message means:

a. receiving the message

b. sending the message through the use of symbols

c. using technical language

d. using a "secret code"

8. What factors influence how the message is sent and interpreted?

a. attitudes, knowledge and skills of the sender and receiver

b. environmental noise

c. cultural backgrounds of both sender and receiver

d. all of the above.

9. What is the best description for "transactional communication?"

a. It is a linear process.

b. Negative loop

c. All the elements are interrelated and happen simultaneously.

d. The sender and receiver take turns speaking.

10. What describes the "Convergence" theory of communication:

a. Sender sends message. Receiver receives message.

b. A pool of shared meaning is created between the sender and the receiver.

c. Persuading others to your point of view.

d. When verbal and nonverbal signals are understood.

11. When does convergence of meaning occur?

a. When both sender and receiver speak the same language.

b. Participants with differing points of view listen to one another.

c. Each one acknowledges the other person's point of view can as valid.

d. Each one acknowledges the overlap or similarity of both points of view.

e. Each one assumes accountability for their part in achieving the desired goal.

f. All except a.

12. When does conflict occur?

a. When interests and values are in conflict.

b. Participants are not willing to engage in dialogue.

c. Participants not willing to come to a minimal understanding to achieve a common

goal.

d. all of the above.

13. What are the six elements of communication?

a. sender/speaker, message, motivation, information, language, feedback

b. sender/speaker, receiver/listener, message, verbal, nonverbal.

c. sender/speaker, message, channel, noise, receiver/listener, feedback

d. sender/speaker, message, goal, implementation, environment, interpretation.

14. The Sender of a message should consider the following except:

a. Own knowledge, skills and experience with the subject.

b. Own cultural background and life experiences

c. Personal motivation and attitude

d. Clear purpose

e. The listener's job is to follow directions.

15. Creating the message to be sent to the Receiver requires consideration of the:

a. Tone of the message.

b. Content of the message: facts, data, interpretation,etc.

c. Use of symbols to convey the message.

d. Possible interpretation of the message.

e. All of the above.

16. What may be the communication barriers with a 17-year old diabetic learning

about self-injection of insulin?

a. Attitudes of friends about diabetes.

b. Believing that insulin shots can cure diabetes.

c. Listening to cellphone while watching a demonstration on drawing up insulin.

d. All of the above.

17. What may be the communication barriers for a 74-year-old learning about

diabetes?

a. Hearing loss

b. Vision impairment

c. Crowded and noisy room

d. Fine print

e. All of the above.

18. When teaching a patient about signs and symptoms of hypoglycemia, which

of the following words may have different meanings?

a. "shocky"

b. hypoglycemia

c. sugar

d. meals

e. All of the above.

19. When planning a teaching session with a patient, which of the following

do you need to assess:

a. Patient's socio-economic status

b. Patient's knowledge and experience of the subject

c. Patient's physical and emotional needs at the moment

d. Environmental noise

e. All of the above.

f. All except a.

20. Which is a form of feedback?

a. Receiver asks questions about the topic.

b. Receiver does not answer.

c. Receiver repeats the major points of the conversation.

d. All of the above.

e. None of the above.

REFERENCES

1 Kruijver I, Kerkstra A, Francke A, Bensing J. (2000) Evaluation of communication

training programs in nursing care: a review of the literature. Patient Education and

Counseling Volume 39, Issue 1 , Pages 129-145.

2 ARTFL Project, Webster Dictionary, 1913. Accessed October 7, 2006 at :

http://machaut.uchicago.edu/cgi-bin/WEBSTER.sh?WORD=communicate

3 communication. (n.d.). Dictionary.com Unabridged (v 1.0.1). Retrieved October 30,

2006, from Dictionary.com website:

http://dictionary.reference.com/browse/communication

4 Husband C, and Torry B. (2004). Transcultural Health Care Practice:

An educational resource for nurses and health care practitioners. Published by the

Royal College of Nursing. Online:

http://www.rcn.org.uk/resources/transcultural/foundation/sectiontwo.php Accessed December 28, 2006.

5 Bandwidth. (2006) Encarta® World English Dictionary [North American Edition] ©

& (P)2006. Retrieved October 30, 2006 at:

http://encarta.msn.com/dictionary_1861588703/bandwidth.html

6 Griffin, E. (1997). A First Look at Communication theory (3rd ed.), McGraw-Hill.

7 Information theory. (n.d.). The Columbia Electronic Encyclopedia. Retrieved

October 30, 2006, from Reference.com website:

http://www.reference.com/browse/columbia/inform-th

8 Underwood, Mike, (2003). Introductory Models and Concepts. Retrieved online

October 26, 2006 at:

http://www.cultsock.ndirect.co.uk/MUHome/cshtml/introductory/smcr.html

9 C. Windley M. Skinner, (2006).

http://www.class.uidaho.edu/comm101/chapters/selecting_topic/selecting_topic4.ht

m 10 Figueroa, M., Kincaid, L., Rani, M., Lewis, G. (2002). Communication for Social

Change Working Paper Series. Retrieved online October 21, 2006 from:

http://www.comminit.com/strategicthinking/stcfscindicators/sld-1500.html

11 Ibid.