Learning Objectives
By the end of this section, you will be able to:
- Analyze different types of communication barriers
- Recognize how emotional intelligence can overcome communication barriers
- Describe the nurse’s role in overcoming communication barriers
Communication barriers are anything that prevent the message sent from being received or understood (Kunsman, 2022). Communication barriers can impact the health care that is delivered and produce negative outcomes. Miscommunication can cause breakdowns in the healthcare team and the nurse-patient relationship and can affect entire healthcare facilities, costing money and time. Nurses need to prevent miscommunication from occurring by recognizing common communication barriers and preventing them from occurring in the first place.
Types of Communication Barriers
There are many types of communication barriers. The nurse should analyze all of the possible communication barriers and develop or use strategies to overcome those challenges. Nurses who use effective strategies to overcome communication barriers can engage in effective communication with their patients and families promoting safe, effective healthcare.
Physical Barriers
A physical barrier is one of the biggest challenges to communication. Physical barriers include noise, architecture, environment, time, or distance (Table 2.7). Each of these physical barriers can cause difficulties with communication, and if more than one is present, communication breakdown can occur. Physical barriers with communication can also be language and hearing barriers. When these physical barriers are present, healthcare providers should use medical interpreters to overcome them (Figure 2.8).
| Physical Barriers | Definition | Example |
|---|---|---|
| Environment | The environment can prevent a message from being delivered clearly, and it is not always controllable. To prevent the environment from creating communication barriers, nurses should establish and practice emergency action plans for natural disasters. | A hurricane occurs and floods the first floor of the hospital. Patients are moved throughout the hospital in response. |
| Stimuli/noise | Noise is present in every setting. Nurses should strive to reduce extraneous noise for their patients, like attending to alarms on machines that are being used to care for the patient or closing a door to decrease noise in a patient’s room. Nurses can use written communication if they are unable to decrease the noise to overcome the communication barrier. Other stimuli, such as cell phones and televisions, also can prevent messages from being received. | The healthcare clinic is under construction, and there is the sound of drilling and sawing throughout the day as nurses take care of patients. |
| Space configuration | Healthcare providers need to have common areas for patient care along with private areas. Respect for a patient’s confidentiality demands certain designs for facilities. Nurses should be aware of the architecture when delivering sensitive information to patients, and change venue as warranted. | The clinic rooms have thin walls, and voices can be heard between the rooms. |
| Time | Health care is a time-relative profession, and nurses should always try to respect the timeliness of communication. Nurses may not be able to check all orders immediately; however, the nurse should recognize the timeliness of their response can overcome the communication barrier. | The nurse interrupts the patient to explain they have to return and will be right back, but the nurse does not return for two hours. |
| Distance | Distance is the physical area separating a patient from a healthcare provider, and it can include the patient being in a remote area without healthcare access. Sometimes technology can overcome a distance barrier, but that implies that the patient has access to technology. Telehealth, the delivery of health care remotely with telecommunication, can be used to bridge the distance. | The nurse on a remote island in Hawaii uses telehealth to connect to the university hospital on the mainland for a patient who has uncommon symptoms of a disease. |
| Technical difficulties | Technical difficulties are any unplanned or unexpected equipment problems. Nurses can help overcome technical difficulties by performing maintenance of communication and presentation tools, testing performance before use, troubleshooting difficulties with other peers, and utilizing information technology support staff. | The nurse works with information technology to fix a problem with the lectern during an education session for patients about heart disease and diet. |
| Volume of information | Information overload can occur easily, and each person’s threshold for information will be different. The healthcare provider or the patient can stop listening or tune out the information. Health care is an information-based industry, and when the volume of information has reached maximum capacity, healthcare outcomes are negatively impacted. | A patient at the clinic has researched their diagnosis, inguinal hernia, on the internet and is expressing concern about surgery based on the information they read. |
Patient Conversations
Getting a Patient Ready for Open-Heart Surgery
Scenario: A patient is scheduled for coronary artery bypass graft surgery in three days, and the presurgical nurse calls the patient on their mobile phone to discuss the upcoming surgery.
Nurse: Hello, Mr. Stanley, my name is Laura, and I am the presurgical nurse to check on you before your open-heart surgery.
Patient: Please call me Tom.
Nurse: Okay, Tom, how are you doing?
Patient: Well . . . not well considering I am having open-heart surgery, but I feel okay right now.
Nurse: Can I verify your name and date of birth before we continue this conversation, please?
Patient: Yes, Tom Stanley, DOB 4/30/1942.
Nurse: Thank you, so I am hearing you feel all right right now. Have you been feeling bad in the last couple of days?
Patient: No, I have been feeling all right physically for a couple of weeks, but I am overwhelmed about all of the preparation for this surgery.
Nurse: I am sorry you are feeling overwhelmed. What can I do to help?
Patient: So many people are contacting me—the healthcare provider’s office, the nurse practitioner for the surgeon, the laboratory, and radiology. I cannot answer them all back, I have stopped trying.
Nurse: I am hearing that you are finding it hard to navigate through the appointments required for the open-heart surgery, is that right? I have some suggestions to help you.
Patient: I would love to hear them.
Nurse: I can contact the laboratory and radiology for you and make you an appointment at a time you find acceptable, would that help?
Patient: Yes, that would be a great start, thank you.
Nurse: Then we can make a list together of priorities for the rest of the calls you need to make. Do you think that would be helpful?
Patient: Yes, thank you so much, Laura. I already feel better.
Emotional Barriers
Emotional barriers can also hinder communication. An emotional barrier is a mental limitation or block that influences how others’ actions are perceived. All people process things differently, attaching emotions to the processes. In health care, the additional emotions of fear, pride, anger, and anxiety cause disruption in the communication process (Table 2.8). Nurses should attempt to mitigate emotional barriers to communication when possible, as often these kinds of barriers can cause the most miscommunication.
| Emotional Barriers | Definition | Examples |
|---|---|---|
| Fear | Fear occurs when a patient feels frightened or intimidated by the facility, procedure, personnel, or consequences. When patients are afraid, they are less likely to seek out help or information. | The patient states they did not hear what the nurse said because they are worried about the upcoming antibiotic injection they will receive, as they are afraid of injections. |
| Pride | Pride is a feeling of great satisfaction in oneself or one’s own achievements. Patients who are proud may delay seeking out health care because they might be perceived as weak. Healthcare providers can also disrupt communication with feelings of pride. Healthcare providers may not ask for help because they want to appear competent. In many situations, help is necessary, and not seeking help can cause detrimental healthcare outcomes. | A patient falls when getting out of bed after insisting they did not need help. |
| Anger | Anger is a strong feeling of annoyance, antagonism, or displeasure. Patients who are angry at either healthcare providers or healthcare processes are less likely to accept and interpret communication appropriately. Nurses should try to deescalate anger when it is present in communication. | A family member yells at a healthcare provider, upset about continuity of care for their significant other. |
| Anxiety | Patients in any healthcare setting often experience some form of anxiety. Anxiety is a feeling of unease, trepidation, or uncertainty. Patients who are anxious are less likely to hear and correctly interpret an entire message, hearing only parts of the message. Healthcare providers can also experience anxiety and may change the way they send the message to the patient. | The nurse prepares the patient for surgery, the patient is visibly upset and shaking their head, stating they cannot understand anything. |
Emotional Intelligence
Sometimes referred to as emotional quotient, emotional intelligence (EI) is the capacity to control and express emotions. Emotional intelligence can be used to improve communication as healthcare providers who are emotionally intelligent are more likely to handle interpersonal relationships empathetically (Meng & Qi, 2018). Emotional intelligence includes self-management, self-awareness, social awareness, and social management ( Figure 2.9).
Link to Learning
Take this quiz to test your emotional intelligence so you can improve your communication with patients.
Self-Management
The ability to control impulsive feelings and behaviors is called self-management. Self-management includes being able to manage emotions in healthy ways, like exercise and mediation. Healthcare providers who practice self-management take initiative on projects and follow through on commitments to themselves and those around them. When practicing self-management, healthcare providers can adapt to changing circumstances, which are ever present in healthcare environments.
Perceptual Barriers
A perceptual barrier to communication is an internal bias that influences the way an individual perceives others. Perceptual barriers can include personal experiences, beliefs, preferences, and individual triggers, and they can cause a breakdown in communication. For instance, if a patient has experienced sexual assault, they may be triggered by any experience in which they may perceive they are being dominated, causing miscommunication to occur. Nurses can ask patients about their personal experiences, belief preference, and triggers before and during care to overcome this barrier. Be aware of your own perceptual barriers and how they might impact your communication.
Expectations
Managing expectations can eliminate emotional reactions. An expectation is the belief that something will happen. Once emotional reactions are managed, expectations are managed in return. Healthcare providers who manage expectations are better able to care for patients. For example, a patient may have the expectation that they will feel better immediately postoperatively from knee replacement surgery, only to find that they are in pain from the surgery. The nurse should help the patient manage their expectations for the postoperative period, thereby helping to manage the emotional reactions the patient might have.
Self-Awareness
Having self-awareness is being able to recognize and understand one’s own emotions that are occurring in communication encounters. Healthcare providers should attempt to have self-awareness when caring for patients. Healthcare providers can encounter circumstances in which their nonverbal communication may show their thoughts that may not always be positive. For instance, a patient who has a large, necrotic wound with a foul odor will probably be embarrassed about the wound and will appreciate healthcare providers who can care for them without betraying their emotions in their facial expressions like holding their breath or making a facial expression of disgust.
Biases
A bias includes prejudice for or against a person or group compared to another group. Biases in healthcare providers obstruct the nurse-patient relationship, nurses’ assessments, and patient care. An implicit bias is unconscious bias that can affect both patients and nurses, defining how care is given and received (Bedford, 2018; FitzGerald & Hurst, 2017). Bias is most often directed toward people who have a higher weight, older people, and people who identify as lesbian, gay, bisexual, transgender, queer/questioning, intersex, and asexual (LGBTQIA+) (Gopal et al., 2021). However, bias can occur toward a different race, religion, ethnicity, sexual orientation, age, or even someone’s size. Nurses should address biases by working to eliminate them from their practice.
Link to Learning
Nurses can take free courses at the Institute for Healthcare Improvement (IHI) in the IHI Open School. Search for the Triple Aim for Population Courses, focusing on TA 101 (Introduction to the Triple Aim for Populations), TA 102 (Improving Health Equity), and TA 104 (Building Skills for Anti-Racism Work). These courses help healthcare providers examine their responsibilities in order to care for patients and families optimally.
Stereotypes
A stereotype is defined as an oversimplified image of a certain people or group. For example, a stereotype might be assuming all older people are hard of hearing. Stereotypes can be described as a prejudgment of a patient based on their appearance, for example. Nurses should attempt to avoid stereotyping patients, which can lead to negative outcomes. Stereotypes can be present for a patient’s sexual identity, socioeconomic status, education level, age, disability, and geographic location. Healthcare providers should be aware of their stereotypes and replace them with new perspectives whenever possible. Healthcare providers should also educate themselves about stereotypes and prevent those stereotypes from negatively affecting the care they provide.
Social Awareness
Another dimension of EI is social awareness. Social awareness is an understanding of the strong emotions one might encounter as part of their experiences and how they can empathize with others. For instance, a nurse who witnessed a fetal demise during delivery may develop intense emotions of sadness with subsequent deliveries. Being socially aware of the perspective of a parent who is experiencing fetal demise gives the healthcare provider a new perspective to understand the behavior of others who experienced fetal demise. Healthcare providers who have emotionally charged experiences should engage in self-care to relieve the intense emotions so that they can continue to serve patients (Fessell & Goleman, 2020). Healthcare providers who are depleted and not self-aware of or unable to manage emotions will not be able to provide care to patients. During the COVID-19 pandemic, nurses experienced deeply emotional experiences caring for many patients who died; patients who included coworkers, friends, and families. Nurses needed to participate in self-care to prevent burnout.
Cultural Barriers
A cultural barrier can affect the delivery of health care. Healthcare providers should strive for cultural competence as well as cultural humility when caring for patients. Cultural competence is the ability to understand a patient's cultural context to effectively provide quality care (AACN, 2021). Cultural humility involves continuous self-reflection to identify personal cultural characteristics and how those may impact actions toward those with similar or different cultural contexts. While cultural competence is a solid foundation to understanding a patient's cultural context, cultural humility allows for deeper execution of these conceptualized ideals.
Link to Learning
Resources for healthcare providers to take steps toward cultural competence are provided by the Agency for Healthcare Research and Quality.
Social/Relationship Management
The final aspect of EI is social/relationship management. Relationship management includes building and maintaining good relationships, with empathy and patience as the tenets of those relationships. Relationship management can close the feedback loop for communication in which healthcare providers make sure their communications are frequent, clear, and open to feedback, creating a stable base for a good working relationship.
Interpersonal Barriers
An interpersonal barrier can cause conflict within relationship management. Nurses know good communication with patients increases quality healthcare delivery and influences patient satisfaction and better health outcomes. When interpersonal barriers are present within the nurse-patient relationship and communication fails, catastrophe can occur leading to patient injury or death. Nurses should strive to avoid interpersonal barriers.
Nurse’s Role in Overcoming Communication Barriers with Patient Teaching
Patient teaching helps nurses overcome communication barriers and in turn helps patients overcome poor health outcomes. Good communication in the nurse-patient relationship helps the patient understand and apply the concepts being taught, which leads to more positive health outcomes for the patient. Nurses who teach without overcoming communication barriers give ineffective instruction that can lead to poor health outcomes for the patient because they could not understand what the nurse was teaching.
Effective Teaching Strategies
Effective teaching strategies allow the nurse to address the communication barriers first. Once the nurse has determined what the communication barrier is—for example, a patient has a vision impairment—the nurse can use effective teaching strategies to help the patient better understand the concepts being taught. In this case, the nurse would ask the patient for their preferred accommodations. The nurse could then obtain the form of educational information the patient prefers, whether it is Braille, audiotape, extra-large print, or electronically formatted handouts.
Evaluating Patient Learning
Once the nurse has determined the patient’s preferred form of communication, the nurse is tasked with evaluating the patient’s learning. With deference to the patient’s communication preference, the nurse should assess the patient’s learning by return demonstration, asking the patient to restate the instructions or asking questions to check learning. All these approaches should include questioning and clarification from the nurse.
Document Teaching-Learning Process
The nurse must document the teaching-learning process. The nurse should document all teaching to the patient and the patient’s response to the teaching that occurred and describe or list the educational materials that were given to the patient. The nurse should use the correct forms as dictated by the facility. The nurse should include in the documentation the teaching strategies that were used, the communication barriers that may be present, and further learning needs and recommendations for further education.