Learning Objectives
By the end of this section, you will be able to:
- Compare and contrast different forms of communication
- Define and describe the four levels of communication
Communication in health care is essential. The act of communication involves the sharing of ideas and thoughts among people, and it should be clear, honest, and confidential. For healthcare providers to offer care, they require information from the patient, and effective communication is the best way to obtain that information. Patients should feel comfortable sharing medical information with their healthcare providers, and they must never feel intimidated, fearful, or disrespected. This includes sharing trauma from life experiences, such as rape or previous medical incidents involving themselves or their family members. Healthcare communication also includes helping patients navigate the healthcare system, fill out forms, and make appointments.
Healthcare providers must consider the patient’s health and general literacy levels when engaging in communication. The ability of a patient to understand and use information to make health-related decisions is known as health literacy. For example, does the patient fully comprehend the benefits and drawbacks of a prescription, or does the patient understand the benefit of a follow-up appointment? When a patient has health literacy, they understand the health information being provided.
Healthcare providers should offer culturally competent care to the patient. Providing culturally competent care includes meeting and respecting a patient’s social, cultural, and linguistic needs while providing care. For example, to provide culturally competent care for a patient who is deaf, the nurse should include an interpreter who is fluent in American Sign Language, which meets the linguistic needs of the patient. When the healthcare provider does not prioritize culturally competent care, gaps in communication occur, and the health care provided may be deficient. Providing for the patient’s needs during communication challenges is paramount to patient-centered, high-quality care.
Healthcare providers need to communicate effectively with other members of the healthcare team while maintaining patient confidentiality. The healthcare team is considered interdisciplinary, or relating to more than one branch of knowledge, and interdisciplinary care includes team members from other healthcare professions, such as physical therapists or pharmacists. When multiple healthcare professionals from various disciplines collaborate on patient care, communication breakdowns may result. Inadequate or inappropriate communication can lead to errors, compromising patient care and outcomes.
Cultural Context
Healthcare Interpreters
Healthcare interpreters used in a healthcare setting should not be family members or healthcare staff members. Family members should not be used because they may not be familiar with medical terms, which may lead to incorrect translation. Healthcare staff members should not be used as interpreters because it can be a violation of patient privacy. Nurses should seek out healthcare interpreters who are certified by the National Board of Certification for Medical Interpreters. The legal requirements for medical interpreters (Title VI of the Civil Rights Act) require organizations that receive federal funds, including Medicare, Medicaid, and the Affordable Care Act, to provide a professional medical interpreter (Patient Engagement Hit, 2022). Healthcare facilities should have lists of preapproved medical interpreters for better communication with patients. Some facilities may use electronic means, such as video chat or a telephone, for interpretation (NCBMI, 2016).
Forms of Communication
Communication is the sharing of ideas and thoughts among people and the means of sending or receiving information. Communication requires a sender and a receiver. There are five forms of communication: verbal, nonverbal, written, visual, and electronic (Table 2.1). These forms may be used alone or in combination with another. Communication is better received and understood if more than one form is utilized (Mosaic Projects, n.d.). For example, when a nurse attends a verbal lecture on the latest medical equipment and has the opportunity to ask questions during the lecture, they are more likely to receive all the intended communication because more than one communication method was utilized: verbal and visual. Combining different forms of communication can make the message clearer for the receiver. To be most effective, nurses should ask the patient their preferred form of communication.
| Type of Communication | Example |
|---|---|
| Verbal | Spoken word |
| Nonverbal | Facial expressions and gestures |
| Written | Text messages |
| Visual | Emojis |
| Electronic | Electronic health record |
Verbal Communication
The term verbal communication can be defined as the production of spoken language to send to a listener. Verbal communication can include aspects of pitch, tone, volume, pace, clarity, pronunciation, and content. The pitch of verbal communication can be affected by the situation. For instance, a person who is communicating with an infant may use a higher pitch when talking so the infant can learn sound patterns to develop speech. The tone of the verbal communication can convey information to the listener. For example, an angry person may have a curt or rude tone, which may change the way the communication is received.
Content is important in verbal communication, especially among healthcare providers. When healthcare providers speak medical jargon to patients, much of the intended communication can be lost. Healthcare providers should carefully consider their words when communicating with patients.
Healthcare providers need to recognize that some patients have specific considerations for communication. For example, the patient may be a non-native speaker of the language the healthcare provider is speaking, making communication difficult. Or a patient could have a clinical condition that affects their ability to communicate verbally, such as a stroke or a cleft palate. In these instances, the healthcare provider should carefully consider their communication techniques and make appropriate accommodations when necessary. It is important for nurses to assess the patient’s level of health literacy, any medical condition impacting communication, or other barriers when first providing care.
There are specific standards that healthcare providers must respect when providing communication. The Health Insurance Portability and Accountability Act (HIPAA), a federal law creating the national standards to protect sensitive patient health information from being disclosed, describes the dangers of violating patient privacy with careless or unmonitored communication. The HIPAA laws govern not only verbal communication but also all other forms of communication. Healthcare providers need to be familiar with HIPAA laws so that they can assure the patient’s privacy and avoid violating the law. For instance, a patient has the right to specify who has access to their chart, and if it is discovered that this right has been violated by the healthcare provider, the healthcare provider can incur criminal penalty with possible fines or jail time (U.S. Department of Health and Human Services, n.d.).
Nonverbal Communication
The term nonverbal communication can be defined as all communication that is not spoken, including facial expressions, posture, eye contact, gestures, and physical touch. When a healthcare provider communicates with a patient, they should make their verbal and nonverbal communication congruent. When noncongruent messages are sent, the receiver is more likely to pay attention to the nonverbal communication than the verbal communication. Head nodding conveys acceptance, and the healthcare provider should use this nonverbal communication when agreeing verbally with the patient.
Eye contact is important for healthcare providers, especially when delivering verbal communication that is unpleasant. If the healthcare provider maintains eye contact throughout the communication, the healthcare provider is more likely to be viewed as respectful and honest (Baugh et al., 2020). Some patient conditions may rely heavily on nonverbal communication. For example, if a patient is blind, using nonverbal communication like touch is appropriate. The healthcare provider should use caution when communicating nonverbally, assessing the patient’s situation carefully (Bambaeeroo & Shokrpourm, 2017).
Healthcare providers should be attuned to diverse cultural norms in nonverbal communication. For example, in some cultures, eye contact is considered disrespectful. When providing culturally competent care, the nurse should ask the patient about their cultural beliefs and respect those beliefs. Healthcare providers can use touch to convey encouragement; however, the healthcare provider should respect the patient’s boundaries and cultural norms when using touch.
Unfolding Case Study
Unfolding Case Study #1: Part 1
The nurse is conducting the initial assessment on a 28-year-old patient who presents to the family walk-in clinic. The patient is accompanied by her 10-year-old son.
| Past Medical History | Patient is a mother of one, who cares for her child and older mother in a small apartment. The older mother is homebound and is not present at the appointment. The patient engages in housecleaning to financially support her family; however, the income is inconsistent. Patient has an eighth-grade education, is a native Spanish speaker, and does not speak English. Medical history includes seasonal allergies, sinusitis, and two episodes of COVID-19 in the past two years. Family history: Patient’s father is deceased, and patient’s mother has stage II Alzheimer disease. Patient’s son is in good health, talkative, and attentive to his mother. Social history: Patient is primary caregiver for older mother and son. No other support systems available. Patient has difficulty shopping and making doctor appointments due to lack of care for the mother. Patient has difficulty communicating in English, so the son translates for his mother. No current medications and no known allergies. |
| Nursing Notes | 1630: Triage Assessment Patient responds to gestures but speaks little English. Son provides translation for his Spanish-speaking mother. Patient reports frequent coughing episodes with production of large amounts of yellow sputum, which are exacerbated with activity. Patient is alert and cooperative, but son reports frequent periods of lethargy, sleepiness, and states “Momma feels hot and sweaty.” Patient holds the side of her head in her hands. Son reports patient has been complaining of an earache for three days. Patient intermittently grabs at ear and grimaces. |
| Flow Chart | 1630: Triage Assessment Blood pressure: 142/88 mmHg Heart rate: 100 beats/minute Respiratory rate: 24 breaths/minute Temperature: 101.1°F (38.4°C) Oxygen saturation: 95 percent on room air Pain: 8/10 (ear) |
| Lab Results | CBC: (Abnormal) WBC 17,000 WBCs per microliter (4.5 to 11.0 × 109/L). Rapid strep test: negative Rapid COVID test: negative |
Written Communication
Any written message, from formal letters to text messages, is considered written communication. Written communication may be thought of as the most prevalent form of communication; however, miscommunication can occur with written communication, dependent on the person’s learning style and ability to read (Vermeir et al., 2015). To create clear written communication, the healthcare provider should concentrate on providing good structure, clarity, and content. Using paragraphs, punctuation, and line breaks may help the reader better receive the written communication, as reading long paragraphs of text can increase miscommunication. Clarity and content are equally important, as is understanding the patient receiving the message. Written communication can be referred back to by patients for clarification after the encounter with the healthcare provider is over.
Because text messages are not secure, they should not be used for discussing protected health information with other providers. Text messaging is appropriate for providers to communicate with patients if the patient has provided written consent. Utilizing text messaging for patient communication should only be done by following the policies of the healthcare organization. Text messaging can also be used among providers, with secure electronic messaging, using either healthcare facility internal messaging or certain platforms recommended by the healthcare facility as secure, as unsecure communication between providers is more likely to violate HIPAA guidelines.
Visual Communication
In visual communication, visual elements are used to create the message for communication. Visual communication includes forms of communication that can be seen, such as charts, photographs, sketches, videos, models, graphs, and emojis. Healthcare providers rely on visual communication as it can help to explain complex concepts of health (Osbourne, 2006; Figure 2.2). When creating visual communication, choose images, fonts, and colors carefully, keeping in mind the audience. If the nurse is creating a visual presentation for patients who have visual challenges, such as a patient who has red-green color deficiency, attention to color, font, and background of the communication should be addressed. For example, a patient with visual challenges may have difficulty reading smaller font or distinguishing between colors for font and background.
Electronic Communication
All communication transmitted electronically is electronic communication. Electronic communication can include faxes and text messages that are broadcast, transmitted, stored, or viewed using electronic media like computers or cell phones. Electronic communication is growing in popularity in health care (Yang et al., 2022). Patient portals provide patient access to their own health information. Healthcare providers can readily access most patient records through electronic communication. Electronic communication may help healthcare providers treat patients more effectively, reduce medical errors, and improve patient safety (Rodiewicz et al., 2023). For instance, a healthcare provider could view imaging reports, lab values, or consult with a specialist all in one place to possibly avoid medical error. The electronic health record (EHR) and the electronic medical record (EMR) are the most common forms of electronic communication between patients and healthcare providers. An EHR is a digital format of a complete medical record of a patient that is able to be shared across multiple healthcare organizations. In contrast, EMRs capture the medical chart within a single healthcare organization and are not transferable to other settings. HIPAA laws govern this electronic information with the HIPAA Security Rule, a national standard to protect a patient’s electronic personal health information.
Listening
The ability to thoughtfully receive and interpret messages is called listening. The listener should be able to restate someone’s words after the speaker has finished. Listening can be active or passive. When someone listens by giving their full attention, listening to understand, and providing thoughtful input, they are active listening; when someone listens to simply hear the messages being sent but may not be mentally or emotionally present and does not engage in the communication process, they are passive listening. Healthcare providers should use active listening including both verbal and nonverbal communication. Passive listening includes nonverbal communication only, and if the listener speaks, then it is considered active listening.
Healthcare providers must be actively listening as patients are giving them information that helps them treat the patient safely and effectively. Nurses also need to recognize when the patient may not understand the messages received, even though the patient provided nonverbal communication like a head nod that they understood. For example, when the patient is asked to repeat the instructions received, the nurse may find that there are discrepancies. The nurse needs to ensure the listener understands, preventing discrepancies regarding the patient’s medical care.
Levels of Communication
There are four levels of communication: intrapersonal, interpersonal, small-group, and public communication. The nurse should consider the levels of communication when providing health care. For example, a healthcare provider does not want to use public communication when providing a patient with their test results, as doing so would violate the patient’s right to privacy and HIPAA laws. A healthcare provider must use interpersonal communication when speaking with other healthcare providers on the interdisciplinary healthcare team.
Intrapersonal Communication
Communication with oneself is called intrapersonal communication. The practice of reviewing past communication experiences is known as reflective thinking, and it plays a crucial role in health care, enabling healthcare providers to adapt and improve their care delivery methods. The practice of reflective thinking in nursing allows the nurse to not only think about communication errors but also reexamine the corresponding actions and lack of communication that occurred. For example, if a nurse makes a medical error when providing the patient with their morning medications, the nurse uses intrapersonal communication to reflect on the incident after it happens, and the chance that the episode would happen again can be decreased.
Interpersonal Communication
Communication that occurs between two or more people is called interpersonal communication. A healthcare provider uses interpersonal communication to establish a relationship with the patient and to communicate with other healthcare providers on the team to provide safe and effective care for the patient. Interpersonal communication can be used during shift report for continuity of care for the patient (Dahm et al., 2022).
Patient Conversations
Establishing a Relationship with a Patient and Family
Scenario: A nurse is working in a pediatric healthcare provider’s office in a small rural town in Montana, when a parent presents for a wellness check with a 9-month-old infant.
Nurse: Hello, my name is Evan, and I am going to help the healthcare provider care for your child during this visit. What can I help you with today?
Parent: Hello, we are here today for Leo’s 9-month checkup. He has been fine since our last checkup.
Nurse: Has he had any illnesses or problems since his last checkup at 6 months of age?
Parent: No, he has been fine.
Nurse: Which milestones have you observed since his last checkup? Is he babbling words? Is he crawling? How is he eating?
Parent: He is babbling, and it sounds like he is saying “mama,” but he does not just say it to me. He is not yet crawling but getting up on his hands and knees and rocking sometimes. I have some questions about his eating.
Nurse: What are your questions about his eating? I would be happy to help answer them, you can ask the healthcare provider as well.
Parent: I would like to ask you, I feel like you listen when I ask questions, thank you.
Nurse: Thank you, now what did you want to ask?
Parent: We are feeding him two times a day. When should we move up to three times a day?
Nurse: You can move to three times a day. Does Leo seem to want to eat with you?
Parent: Yes, he sits at the table with us for breakfast, lunch, and dinner. I feed him at breakfast and lunch, but for dinner we just give him a snack on his tray and a bottle of formula. Should we give him dinner too?
Nurse: It is appropriate at his age to be fed three times a day. After nine months you can also start giving Leo two healthy snacks a day.
Parent: Thank you so much for this information. I really appreciate you.
Nurse: You are welcome. I am willing to answer any questions you have, and if there is anything I have not currently addressed, please feel free to reach out to me again.
Small-Group Communication
When communication occurs among three or more people, it is called small-group communication. Small-group communication is a formal process of interacting verbally and nonverbally within a group where individuals perform certain roles. Some examples of small-group communication among healthcare providers could be bedside rounds or a more formal care conference about the patient. Each healthcare provider brings their expertise to add to the care of the patient.
The nurse functions in small-group communication as both a care provider and an advocate for the patient. The nurse as advocate for the patient is one of the many roles a nurse can have on the healthcare team. The nurse uses small-group communication to plan and participate in interdisciplinary conferences, serving as educator, supervisor, and manager. For instance, the nurse, along with other healthcare team members, can provide diabetes education to patients. The nurse can be responsible for patient referrals, ensuring continuity of care, such as referring a newborn and family to home care for additional care. Nurses may perform evaluation of patient outcomes, reporting the findings to the healthcare team. The nurse may collect the data from a research study on the unit they work on, and then present the research to peers and colleagues. All these nursing roles are integral parts of the interdisciplinary healthcare team, and often the nurse is the leader of these examples of small-group communication.
Link to Learning
The Agency for Healthcare Research and Quality TeamSTEPPS program offers additional information about providing safe and effective care for patients by having good small-group communication among healthcare providers.
Public Communication
Communication to any size audience is called public communication. Public speaking is a form of public communication in which one or more people speak to a larger group. Public communication does not include communication to an audience when there is an expectation of privacy, like when a healthcare provider speaks with a patient, their four family members, a care manager, and an allied health worker.
Public communication includes verbal and nonverbal feedback. Anyone who has attended a lecture or classroom period has provided verbal and nonverbal feedback to the speaker. Verbal and nonverbal feedback can take many forms, from asking questions and taking notes to not paying attention to the speaker. Nurses provide public communication by hosting community vaccination education sessions, safe sitter or newborn care sessions, or healthy nutrition seminars for the community. Public communication can induce anxiety, yet healthcare providers should recognize that it is inherent in their role, whether during team meetings about a patient or at research conferences.