31350 • Communication and Soft Skills in Nursing Practice

Table of Contents

31350 • Communication and Soft Skills in Nursing Practice

How to Receive Credit

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Individual State Nursing Approvals

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planner

Division Planner Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. SOFT SKILLS

COMMUNICATION

ATTITUDE

NETWORKING

CRITICAL THINKING

PROFESSIONALISM

EMPATHY

CONFLICT RESOLUTION

ADAPTABILITY

INITIATIVE

3. COMMUNICATION SKILLS FOR NURSES

TYPES OF COMMUNICATION

COMMUNICATION ENHANCING NURSING EDUCATION

INTERPROFESSIONAL COMMUNICATION

BARRIERS TO GOOD COMMUNICATION

4. CONCLUSION

Works Cited

Evidence-Based Practice Recommendations Citations

31350 • Communication and Soft Skills in Nursing Practice

Mary Franks, MSN, APRN, FNP-C

www.netce.com

Copyright © 2023 NetCE, All rights reserved.

Soft skills are defined as the personal attributes that enable someone to interact effectively and harmoniously with other people. Strong soft skills help develop teamwork and problem-solving abilities and help nurses to communicate effectively, properly educate, engage in the workplace, and provide safe patient care. These skills can be essential in professional interactions, including in the practice of nursing. While clinical (or hard) skills are important, soft skills play a vital role in establishing strong patient-nurse relationships and ensuring the well-being of both patients and healthcare teams. This course will explore aspects of soft skills used in nursing practice, focusing primarily on communication. More specifically, different aspects of communication to enhance safe patient care, workplace engagement, and nursing education will be explored.

31350 • Communication and Soft Skills in Nursing Practice

Education Category. Management

Release Date. 10/01/2023

Expiration Date. 09/30/2026

How to Receive Credit

To complete this course for continuing education credit please go to http://www.netce.com/course/2680 in your browser.

For assistance with receiving continuing education credit, please contact us at help@netce.com.

Course Overview

Soft skills are defined as the personal attributes that enable someone to interact effectively and harmoniously with other people. Strong soft skills help develop teamwork and problem-solving abilities and help nurses to communicate effectively, properly educate, engage in the workplace, and provide safe patient care. These skills can be essential in professional interactions, including in the practice of nursing. While clinical (or hard) skills are important, soft skills play a vital role in establishing strong patient-nurse relationships and ensuring the well-being of both patients and healthcare teams. This course will explore aspects of soft skills used in nursing practice, focusing primarily on communication. More specifically, different aspects of communication to enhance safe patient care, workplace engagement, and nursing education will be explored.

Audience

This course is designed for nurses in all practice settings.

Accreditations & Approvals

In support of improving patient care, TRC Healthcare/NetCE is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. NetCE is accredited by the International Accreditors for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU.

Designations of Credit

NetCE designates this continuing education activity for 3 ANCC contact hour(s). NetCE designates this continuing education activity for 3.6 hours for Alabama nurses. AACN Synergy CERP Category C. NetCE is authorized by IACET to offer 0.3 CEU(s) for this program.

Individual State Nursing Approvals

In addition to states that accept ANCC, NetCE is approved as a provider of continuing education in nursing by: Alabama, Provider #ABNP0353 (valid through July 30, 2029); Arkansas, Provider #50-2405; California, BRN Provider #CEP9784; California, LVN Provider #V10662; California, PT Provider #V10842; District of Columbia, Provider #50-2405; Florida, Provider #50-2405; Georgia, Provider #50-2405; Kentucky, Provider #7-0054 through 12/31/2027; South Carolina, Provider #50-2405; West Virginia RN and APRN, Provider #50-2405.

Course Objective

The purpose of this course is to provide nurses with strategies to support the soft skills needed to provide optimal patient care and enhance professionalism in health care.

Learning Objectives

Upon completion of this course, you should be able to:

1. Define soft skills.

2. Provide examples of soft skills.

3. Describe how proper communication enhances safe patient care, interprofessional collaboration, and nursing education.

4. Analyze barriers to proper communication and how to overcome them.

Faculty

Mary Franks, MSN, APRN, FNP-C, is a board-certified Family Nurse Practitioner and NetCE Nurse Planner. She works as a Nurse Division Planner for NetCE and a per diem nurse practitioner in urgent care in Central Illinois. Mary graduated with her Associate’s degree in nursing from Carl Sandburg College, her BSN from OSF Saint Francis Medical Center College of Nursing in 2013, and her MSN with a focus on nursing education from Chamberlain University in 2017. She received a second master's degree in nursing as a Family Nurse Practitioner from Chamberlain University in 2019. She is an adjunct faculty member for a local university in Central Illinois in the MSN FNP program. Her previous nursing experience includes emergency/trauma nursing, critical care nursing, surgery, pediatrics, and urgent care. As a nurse practitioner, she has practiced as a primary care provider for long-term care facilities and school-based health services. She enjoys caring for minor illnesses and injuries, prevention of disease processes, health, and wellness. In her spare time, she stays busy with her two children and husband, coaching baseball, staying active with her own personal fitness journey, and cooking. She is a member of the American Association of Nurse Practitioners and the Illinois Society of Advanced Practice Nursing, for which she is a member of the bylaws committee.

Faculty Disclosure

Contributing faculty, Mary Franks, MSN, APRN, FNP-C, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planner

Margo A. Halm, RN, PhD, NEA-BC, FAAN

Division Planner Disclosure

The division planner has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

Soft skills are defined as the personal attributes that enable someone to interact effectively and harmoniously with other people. Strong soft skills help develop teamwork and problem-solving abilities and help healthcare professionals to communicate effectively, properly educate, engage in the workplace, and provide safe patient care. These skills can be essential in professional interactions, including in the practice of nursing. While clinical (or hard) skills are important, soft skills play a vital role in establishing strong patient-nurse relationships and ensuring the well-being of both patients and healthcare teams.

This course will explore aspects of soft skills used in nursing practice, focusing primarily on communication. More specifically, different aspects of communication to enhance safe patient care, workplace engagement, and nursing education will be explored.

2. SOFT SKILLS

Soft skills encompass a wide range of competencies, including [1]:

- Communication

- Attitude and confidence

- Teamwork

- Networking

- Critical thinking

- Creative problem-solving

- Professionalism

- Empathy

- Conflict resolution

- Adaptability

- Initiative and work ethic

Nurses who develop strong soft skillsets are more able to effectively use technical abilities and knowledge. Also known as non-technical or non-clinical skills, soft skills have been recognized as more desirable and important in the ever-changing healthcare market over the past several years. It has been estimated that soft skills account for up to 85% of job retention success [2].

Due to changes in payment structuring, healthcare delivery standards, and nurse staffing, the quality of nursing care and time spent with patients in active listening have significantly declined in recent years. Nurse educators specifically have a responsibility to teach and model soft skills [2]. Developing strong personal rapport with patients and providing essential emotional support have been identified as gaps in healthcare education and delivery [2]. Healthcare leaders should encourage and mentor work environments that help develop soft skills, as part of the larger goal of improving patient outcomes. The better one is at using soft skills, the more likely one will succeed at leadership and managing others [15].

COMMUNICATION

The first thought that comes to mind when discussing communication is talking—verbal communication. However, effective communication involves much more than just talking. It takes place on many different levels and has many different variables.

Communication between healthcare professionals and within interdisciplinary teams helps to facilitate treatment planning, patient care, and patient/family education. Consistently communicating with patients, other nurses, physicians, physical and occupational therapists, pharmacists, social workers, and case managers is an everyday part of nursing. This communication may take place via in-person conversations, e-mail, telephone, text, or instant messaging. How a nurse communicates is important because it can avoid (or cause) miscommunications, misinterpretations, or misunderstandings. Different types of communication will be discussed in detail later in this course, along with guidelines for communication-enhanced nursing education, workplace engagement, patient care, and interprofessional collaboration.

ATTITUDE

Attitude is defined as reactions to events, objects, or situations, and a professional attitude is the manner in which one conducts themselves in a workplace [3]. A positive professional attitude is necessary for efficacy and productivity and also plays a key role in professional identity. Research indicates that professional attitudes and compassion are correlated [3]. One study surveyed 349 nurses in Turkey using the Inventory of Professional Attitude at Occupation (IPA) questionnaire and the Compassion Scale [3]. Nurses' scores in measures of kindness, common humanity, and mindfulness increased as their professional attitude scores also increased; conversely, measures of indifference, separation, and disengagement subscales increased when professional attitudes scores were low. Certain factors were associated with variability in professionalism scores, including weekly working time, satisfaction with colleague relationships, suitability of the nursing profession, and working in specific settings (e.g., emergency department, outpatient clinics) [3].

Attitudes can be positive, neutral, or negative and have explicit (conscious) and implicit (unconscious) characteristics. There are three components of attitude: affective, cognitive, and behavioral. Attitudes are expressed through thoughts, feelings, and actions and are formed from a variety of influences, including previous experience, social factors, learning, conditioning, and observations [4]. Often influenced by previous experiences or upbringings, attitude can have powerful impact on the development of biases, behaviors, and actions. While attitudes can change, they are often persistent [4].

NETWORKING

Some of the best careers are built around networking. Having large networks can provide nurses and other healthcare professionals with unique learning and professional opportunities. Building professional networks and relationships facilitates new jobs and career paths, allowing for the exploration of opportunities that may not be available otherwise [5].

Networking involves connecting with others on professional and, in some cases, personal levels. It can result in nurses building long-term and fulfilling relationships. It can be easier to build these types of relationships when one lives in the moment and is mindful of the skills and opportunities others may provide—as well as the opportunities one can offer to others. Networking requires active listening, which can be practiced in five steps [5]:

- Pay attention and maintain eye contact with the individual speaking.

- Provide positive feedback to the speaker by nodding, positive facial expressions, and the occasional verbal affirmation.

- Provide feedback, with reflection on the subject being discussed, and summarize what you heard and believe the speaker meant.

- Defer judgment by not assuming anything, and do not interrupt the speaker.

- Respond appropriately in an honest and respectful manner.

Networking should be a consistent piece of the professional role. It is ideal to build a professional network before it becomes a necessary part of seeking a new professional opportunity. Attending networking events and reaching out on social media professional networks are great ways to build personal and professional networks [5].

CRITICAL THINKING

Critical thinking is defined as actively and skillfully analyzing and evaluating information through observation, and making a decision for action [6]. Critical thinking is essential in nursing practice but is applied in all healthcare professions. In order to learn critical thinking, professionals should develop independence in thought, fairness, perspicacity, humility, and integrity [6]. There should also be an interest in research. Critical thinking is important to provide safe, effective, skilled patient care.

Healthcare professionals should adopt a critical-thinking perspective and refine critical reasoning skills in order to meaningfully assess old and new evidence. In cases of limited resources, critical-thinking skills support an ability to think and act quickly and efficiently.

Critical-thinking skills are broad and include critical analysis, introductory and concluding justification, valid conclusion, distinguishing facts and opinions, clarification of concepts, and recognition of conditions [6]. The Socratic method, defined as a method of exploring dilemmas through argumentative dialogue, can be effective. The Socratic method is an ancient technique that was developed by Socrates to explore the underlying beliefs that shape opinions [7]. It is taught to help identify thought-provoking questions and to address these questions through shared dialogue or debate to demonstrate complexity and to tease out areas of similarity or agreement [7].

Critical thinking can aid in the development of several nursing skillsets [7]:

- Problem-solving abilities: Assists the healthcare professional to secure knowledge and information by rationalizing the problem at hand and developing possible solutions using intuition, research, and scientific methods.

- Experimental methods: Mainly used in home care situations in which the staff cannot function efficiently due to a lack of supportive tools. This approach forces the healthcare professional to experiment with what they have on hand to develop the best course.

- Intuition: Intuition is the perception and understanding of concepts without reasoning. Healthcare professionals may formulate hypotheses (which may or may not be appropriate) based on their professional and/or personal knowledge and experiences.

- Research/scientific methods: Based on rational and systemic approaches, this approach allows for all possible solutions to be considered prior to making a decision.

- Decision making: This concept is based on the healthcare professional selecting the appropriate action through critical thinking. The professional should examine the advantages and disadvantages of each option, implement priority needs based on Maslow's theory, assess delegation opportunities, and implement solutions.

In the case of each of these types of skills, nurses should be able to make decisions based on the stages of decision making: recognition of purpose, definition of criteria, calculation, exploration and consideration of alternative solutions, design, implementation, and evaluation [7].

PROFESSIONALISM

Professionalism reflects the values, respect, advocacy, and responsibility a healthcare professional must use in their field. The three main categories of professionalism are cognitive, attitudinal, and psychomotor [8].

Cognitive professionalism entails focusing on continuously learning about professional conduct and applying this knowledge to the work setting. Attitudinal professionalism involves exercising discretionary judgment, assessment, evaluation, and decision making, often in a highly complex situation and in collaboration with patients, colleagues, and managers. Psychomotor professionalism involves growing professionals—meaning, as experience grows, the nurse's professional skills and ability also grow [8].

The Registered Nurses' Association of Ontario (RNAO) established a nursing best practice guideline program that focuses partially on professionalism in nursing. This best practice guideline was developed to help individual practitioners reflect on their own situations, assist educators in relaying the concept of professionalism, and reinforce professionalism in nursing practice [9]. The guideline identifies eight attributes that comprise professionalism [9]:

- Knowledge

- Spirit of inquiry

- Accountability

- Autonomy

- Advocacy

- Innovation and visionary

- Collegiality and collaboration

- Ethics and values

Each of these attributes has a role in successfully building professionalism in the workplace [9].

EMPATHY

Empathy is the ability to understand the personal experiences of others. Emotional, cognitive, and behavioral communication dimensions are all involved in empathy [10]. Research indicates that healthcare professionals with high levels of empathy can better fulfill their role in therapeutic change. However, while empathy is undeniably important, many healthcare providers find empathy difficult to adopt in everyday practice. In order to better support nursing development, empathy skills should be an aspect of the education and training of healthcare professionals and should be supported by continuing education [10]. Factors that influence empathy include age, self-reflection, appraisal, and emotions. It is important to note that empathy can be developed even without directly bonding.

A person-centered approach to communication and patient care requires empathy [10]. Empathy is multi-dimensional, involving cognitive, affective, and behavioral components. The affective aspect of empathy involves sincerity and congruency with others. Persons with this type of empathy offer assistance and support without stereotyping [10]. The cognitive dimension involves an availability and openness to understanding others' perspectives, including verbal and nonverbal cues. This has also been described as "taking a walk in someone else's shoes" [10].

The empathetic relationship of professionals with their patients builds rapport, ensures that patients are centered in decisions, and underpins therapeutic plans and interventions tailored specifically to the patient. Providing this type of care increases patient satisfaction. Following this path, quality of care is improved, errors are lessened, and an increased proportion of patients are compliant with treatment plans and have a positive experience with their treatment [10].

In addition to its role in building patient rapport and improving care, empathy is also essential in effective interprofessional collaboration. Empathy improves communication skills, including active listening, nonverbal communication, and emotional intelligence. These skills are vital for effective interprofessional communication, as they facilitate clear and respectful interactions. In addition, empathy helps in conflict resolution by enabling individuals to see the situation from the other person's perspective and find common ground. Healthcare professionals who express understanding and compassion are more likely to listen actively, ask clarifying questions, and share patient information accurately. Empathy contributes to a more supportive work environment. Lack of empathy is associated with increased stress, which is a risk factor for burnout and compassion fatigue [10].

CONFLICT RESOLUTION

As in most professions, nurses engage in conflict resolution frequently throughout their careers. However, conflict resolution is often a learned task and can be difficult to navigate. These types of skills are important for management and higher leadership, but they are also important for clinicians and those working at the bedside.

Conflict is defined simply as a disagreement or a clash of interest, opinion, or principles, and workplace conflicts in health care can be complicated by ongoing complex relationships within interdisciplinary teams and the high-stress situations that frequently occur. Conflicts include substantive, procedural, and psychological dimensions; perceptions of each of these aspects of the conflict influence decision making and resolution [11]. The Center for American Nurses conducted a survey to identify conflict-related challenges nurses encountered in their profession. Interpersonal conflicts were identified as the most common type of conflict encountered, followed by peer conflict between a direct patient care nurse provider and nurse manager. The third most common type of conflict was between a nurse and other members of the interprofessional team (e.g., physician). Interprofessional conflicts often involved the acute care environment, specifically concerns about lab results, imaging, and consulting other team members [11].

Conflict management styles are complex, and many different styles may be used to resolve a conflict. The five styles of conflict resolution have been identified as dominating, obliging, avoiding, compromising, and integrating. Avoidance is often used in health care, especially when the conflict is between members of the care team. However, this approach is not ideal, as avoidance leads to poor communication and poor patient outcomes [11].

Best practices for effective conflict resolution include engaging in dialogue and addressing the conflict directly. Having a nonpunitive debriefing with staff to manage conflict provides nurses an opportunity to reflect and express frustrations related to the conflict. These debriefings promote an openness within the organization or unit and promote effective conflict resolution in the future.

Coaching also plays a role in conflict management, as nurse leaders can help their colleagues develop the skills necessary to resolve conflict themselves. Education and training on conflict management empowers clinicians to solve the problem early and maintain a positive work environment.

Identifying potential conflicts early helps to recognize opportunities for growth in managing conflict. The Joint Commission suggests organizations establish policies and guidelines to facilitate collaboration and interprofessional communication across all disciplines in a proactive manner [11]. These policies can provide a framework for addressing conflict issues, working through conflicts, and moving toward resolutions. The policies should clearly communicate goals and objectives.

ADAPTABILITY

The Center for Creative Leadership defines adaptability as being ready to shift and experiment when change is necessary; this requires access to a range of behaviors [12]. Behaviors and beliefs that support adaptability include optimism, seeing opportunity in change, mastering new skills, leading by example, empathically considering others' concerns, sorting strengths and weaknesses, admitting mistakes, and moving forward. Sherman has identified five skills required to be adaptable as a healthcare provider [12]:

- Stay curious to change.

- Be less insistent.

- Build support systems for the change.

- Be honest to change.

- Embrace change.

The COVID-19 pandemic brought the issue of adaptability in health care to the forefront and highlighted several barriers and challenges to this approach. During the height of the pandemic, nurses and other healthcare professionals were having to adapt to practice outside typical guidelines with patients, providing care via newer telemedicine platforms, and working with less staff to care for an influx of patients into the health system. Further, many providers were assigned to units or care environments outside of their specialty. In these types of situations, adaptability is only one aspect of maintaining good nursing practice and self-care; resilience, which is a long-term strategic process, is also necessary and is demonstrated by successful recovery [13]. Nevertheless, having adaptability helps healthcare professionals to manage well-being, stress, exhaustion, and emotional balance.

INITIATIVE

The trait of initiative is a valuable asset in nursing practice. It leads to improved patient care, better teamwork, professional growth, and a positive impact on the healthcare organization. Skills such as critical thinking, adaptability, and effective communication are essential to support and manifest this trait effectively in nursing practice.

Initiative is defined as the ability to assess and take action independently. It is linked to leadership and an ability to take charge of situations. Initiative in nursing involves the proactive identification of problems or opportunities for improvement and taking appropriate actions to address them. Nurses who demonstrate initiative are more likely to identify potential issues with patient care or safety before they escalate. For example, recognizing subtle changes in a patient's condition and promptly informing the healthcare team can prevent adverse outcomes. Initiative-driven nurses advocate for their patients by ensuring that their needs, preferences, and concerns are communicated to the healthcare team. They actively participate in care planning and decision making to achieve the best possible outcomes. Nurses with initiative take the time to educate patients about their conditions, treatment options, and self-care. This empowers patients to actively participate in their own care.

Initiative also fosters teamwork, as proactive nurses are more willing to collaborate with colleagues, share information, and seek input from others. This leads to more effective interprofessional communication and coordinated patient care. Nurses with initiative often play a crucial role in resolving conflicts within the healthcare team by addressing disagreements or misunderstandings promptly and professionally, promoting a harmonious work environment.

Initiative-driven nurses also seek opportunities for professional development and lifelong learning. They actively pursue new knowledge, skills, and certifications to stay current in their field.

This approach is also expanded to health care in general, and initiative is essential for identifying inefficiencies in healthcare processes and proposing solutions to enhance the quality of care. Nurses can lead or participate in quality improvement projects that benefit both patients and the healthcare organization. Developing best practice initiatives drives a leader to empower others to lead positive change in the nursing environment. Initiatives help ENGAGE healthcare providers, meaning they result in [14]:

- Empowerment

- Nursing support

- Gap identification

- Accountability for change

- Goals

- Excellence in performance

One example of initiative is posting an idea board in the unit, break room, or shared conference room. The board is available to nurses and other staff members to post their ideas on how to improve patient care and outcomes. For example, one staff member, a respiratory therapist, might suggest moving the respiratory equipment closer to patient rooms [14]. Another staff member might post a suggestion to purchase a blanket warmer for the unit, which once implemented, improves patient and staff satisfaction. In one study of a unit that implemented the idea board, approximately 40 ideas were posted after six months, 70% of which were completed and several others of which were pending upper management budget approval. A significant increase in staff engagement was noted, and staff felt management was listening to their concerns [14]. Taking initiative requires resilience and determination to get tasks done. One may have to do things proactively, researching ideas and taking advantage of opportunities.

3. COMMUNICATION SKILLS FOR NURSES

As noted, communication is more than just talking. In fact, there are five main forms of communication: verbal, nonverbal, written, listening, and visual [16]. Communication is essential in many professions and is a vital element in health care. It applies to all areas of nursing practice, including prevention, treatment, therapy, rehabilitation, education, and health promotion. Communication is a fundamental characteristic of human nature, meaning all people communicate to some degree. It has two main components: content (what is said) and value (how it was said). Communication is never unidirectional; in order to communicate, there must be a receiver of the message. Failure to recognize the two-way nature of communication leads to negative conclusions and attitudes.

TYPES OF COMMUNICATION

Verbal Communication

Verbal communication encompasses any exchanges and engagements when speaking with others [16]. This does not require face-to-face engagement; it can be done by telephone, voice memo, or video conference. These verbal interactions can be assessed by caliber and complexity, tone, and how words are sequenced together in a sentence [16]. The nursing process is achieved through dialogue and verbal communication [17].

Evidence Based Practice Recommendation

The Institute for Clinical Systems Improvement recommends that clinicians should follow the established best practices of utilizing professional medical interpreters when English is not a patient's first language or when there are gaps in understanding English.

https://www.icsi.org/wp-content/uploads/2020/01/PalliativeCare_6th-Ed_2020_v2.pdf

Last Accessed: September 13, 2023

Strength of Recommendation/Level of Evidence: Low-Quality Evidence, Strong Recommendation

In many cases, the purpose of verbal communication is the exchange of information. So, it is important to consider the receiver and his/her ability to decode the verbal messages. If complex medical jargon is used, this can create a barrier to patients' understanding of the treatment plan, the disease process, and/or prevention of an illness. Differences in language fluency are also a concern, and an individual's comfort with a given language and the necessity for interpretation or translation should be considered.

There are five different conversational traits: formality, intimacy, directness, acknowledgment, and tolerance of conflict [27]. Formality involves the degree of hierarchy acknowledged in the relationship during the communication. Intimacy refers to the amount of personal information that is disclosed [27]. Directness refers to the extent the message or content is explicit without any assumption that the party receiving the communication will understand any hidden meanings. Acknowledgment and tolerance of conflict refers to the extent to which conflict is openly dealt with and the extent to which one is comfortable with conflict.

Nonverbal Communication

Nonverbal communication is defined as the transfer of a message without use of linguistic content—messages sent without using words. Nonverbal communication is often considered an adjunct to verbal communication, and it is estimated that nonverbal cues are included in approximately 58% of all face-to-face interactions [26]. Aspects of nonverbal communication include artifacts (i.e., the presence of physical and environmental objects), chronemics (i.e., the use and perception of time), haptics (i.e., the use of touch), kinesics (a form of movement of the body), physical appearance (e.g., clothing), proxemics (i.e., the use of space and distance), vocalics (i.e., aspects of the voice), and silences [18]. In a 2010 study, researchers found that nurses who presented positive facial expressions with patients appeared to bond better and produce positive affection, especially toward older adults [19]. However, those who demonstrated gestures of negativity and frustration were more likely to experience patient irritability and make older patients feel embarrassed.

In some cases, nonverbal communication can contradict the message of verbal communication, making the patient feel uncomfortable or unsettled about the information discussed and causing confusion about how treatment/care will proceed. When nonverbal and verbal communication are in congruence, patients feel more secure and reassured and an honest, open-ended discussion is possible [19]. However, nonverbal communication can be difficult to interpret and is highly culturally coded. Body language with arms crossed, frowns, and lack of eye contact are all components of body language that are considered negative in Western culture. However, in some cultures, these behaviors are considered a sign of respect [19]. Persons from Western cultures will feel encroached upon and uncomfortable if an individual maintains a closer conversational distance. However, in other cultures, such as Latino and Middle Eastern groups, a closer distance would be the norm [28]. Asian persons tend to prefer more space between the two conversational parties until they have developed a relationship. In clinical settings, it can be best practice to sit first and permit the patient to select where he/she wants to sit.

Eye contact is an important aspect of nonverbal communication, as it conveys attentiveness and interest. In the clinical setting, eye contact shows confidence and confirms reception and understanding of the message being sent. However, as noted, degree of acceptable/preferred eye contact is culturally coded. Ethnic or cultural discordance between the patient and provider can result in misunderstood nonverbal messages related to eye contact. Nurses should take time to consider and explore cultural differences in nonverbal expression and how this might impact their communication with patients and colleagues.

Challenges Related to Nonverbal Communication

Three major challenges associated with nonverbal communication have been identified: decreased participation, the use of computers and technology, and cultural differences [19]. Some healthcare providers have noted that patients display nonverbal blocking cues when they are encouraged to increase participation in their health. This can be a clue that additional support, explanation, and encouragement are necessary to encourage patients to participate in their health care.

The second challenge is the growing role of technology in patients and professional communication. This is most evident when providers use computers or other devices during the assessment process, resulting in a lack of eye contact and other rapport-building communication cues. The over-attention to electronic devices during patient communication and interprofessional debriefings can result in a perception that providers are task-oriented and less concerned about the connection with patients [19].

As discussed, cultural differences are another potential challenge when considering nonverbal components of communication. When both parties do not share a native language, nonverbal communication can end up replacing what was verbally communicated. Cross-cultural communication is by no means simple, and there is no set of rules to merely abide by. Instead, promoting culturally sensitive communication is an art that requires practitioners to self-reflect, be self-aware, and be willing to learn. Therefore, as practitioners become skilled in noticing nonverbal behaviors and how they relate to their own behaviors and emotions, they will be more able to understand their own level of comfort and comprehend behavior from a cultural perspective [27].

Written Communication

Written communication is the purposeful development, expression, and revision of ideas in written format [20]. In health care, these communications are typically created for specific audiences for the purposes of education or to convey information. In nursing, written communication is a component of research, nursing care plans, communication with other providers in patient care, and patient education. As such, nurses should work to build skills related to written communication with patients, families, and colleagues. All healthcare providers should be able to provide purposeful writing that creates a better understanding of the subject. Without proper written communication, the hard work that goes into developing a care plan could be miscommunicated and result in the failure of understanding, compliance, and care [20].

Visual Communication

Visual communication is beneficial to almost all audiences and is often an adjunct to written communication. This type of communication allows for interpretation in different ways and can be especially useful for those with lower literacy and numeracy skills [22]. Graphics, charts, pictures, and diagrams are a few examples of tools that are useful in visual communication. While one individual may understand information presented in written format or heard during a presentation, others may require visuals to help pull the information together [22].

As healthcare professionals, especially those working directly with patients, it is important to assess each patient's literacy in order to ensure the most effective education and teaching is provided. For example, an individual with a wound may not remember how to properly dress the wound on their leg, despite having been told verbally how to do this. Providing handouts with the instructions in stepwise format or pictures while also providing a demonstration is the most effective for teaching and reinforcing concepts.

Patients may also use visual aids to help convey information to their healthcare providers. These tools are most often utilized for preverbal children, patients with limited English literacy, or those with limited cognitive abilities, but they have value with almost all patients. One example of this is the assessment of acute pain with the Wong-Baker FACES scale, which presents a series of six faces ranging from a happy face at 0 (no hurt) to a crying face at 10 (hurts worst). Even persons who have good verbal communication skills may be better able to convey their meaning (in this case, level of pain) through images.

The Teach-Back Method

The teach-back method is an excellent form of visual communication [23]. Studies have demonstrated that approximately 40% to 80% of the information presented to patients during office visits is forgotten, and nearly half of the information retained is wrong [23]. The teach-back method, which very simply consists of the patient teaching back the provided information, allows for better understanding of the instructions provided while also allowing the nurse to assess the patient's comprehension and retention. Any issues or misunderstandings are addressed immediately, if necessary. The teach-back method can also decrease callbacks to the office and improve patient satisfaction [23].

It is imperative that visual communications and methods such as the teach-back are promoted and supported in patient care. This requires nurses to have a solid understanding of the information or task as well.

Listening

Though often overlooked, listening is part of being a great communicator. Effective listening requires the individual to recognize messages that are directed toward them, process and interpret the message, and accurately remember the content of the message; this allows for an appropriate response. Essentially, effective listening involves four stages: receiving, understanding, evaluating, and responding [21]. Those who engage in all the stages are effectively listening.

Effective listening and active listening are often used interchangeably; however, active listening includes an additional step of translating back the message one has received, by means of restating or paraphrasing [21]. The goal of active listening is to confirm the message and relate understanding, which can improve rapport and reduce misunderstandings. In active listening, it is important to not think ahead during the conversation, which can lead to poor receiving, remembering, or understanding of the message, resulting in poor interpretation of the information.

COMMUNICATION ENHANCING NURSING EDUCATION

Because therapeutic communication is used by nurses to connect with patients and colleagues on many levels, effective communication skills should be included in nursing school curricula and continuing education. However, the feasibility of in-depth, one-on-one exchanges and conversations with patients during clinical training has decreased in recent years, primarily due to the increased number of nursing students and difficulties finding clinical placements for these students [24]. In response, simulation-based training has been established to provide this component in nursing education. While this has provided benefits, programs with lower monetary resources still find this difficult to obtain. Computer-based, interactive simulations have been developed to provide opportunities to communities with limited access to resources.

In a Korean study of nursing students engaged in a simulation-based scenario involving patients with depression or psychosis, false reassurance was the most common nontherapeutic communication error among the participants, followed by difficulty communicating with physicians regarding the patient's condition [24]. Several students in the study, upon communicating with a patient with suicidal ideation, were reportedly silent and avoidant of the situation. This was attributed to lack of confidence in their own ability to make decisions regarding the best care step, likely related to a lack of suicide assessment training. Some students in the study were noted to abruptly change the conversation in situations in which the patient would directly report hallucinations or delusions, again likely related to the lack of exposure to appropriate assessment and intervention strategies for patients experiencing psychosis [24]. Participating nursing students displayed numerous problems communicating changes in a patient's condition to a physician, such as missing key information, using ambiguous words, repeating the same words with hesitation, and failing to make suggestions regarding the treatment plan. These situations were consistent with previous studies that found inexperienced nursing students had considerable difficulty communicating adequately and clearly in similar situations.

The findings of this study support the need for simulations that offer nurses and nursing students opportunities to practice their communication skills in clinical situations [24]. Moving forward, numerous programs using simulated or augmented reality techniques would allow students the experience of a more lifelike clinical practicum or the opportunity to augment an in-person course [24].

INTERPROFESSIONAL COMMUNICATION

In nursing practice, communication in the workplace is just as important as communicating with patients. When nurses lack strong communication skills, missing critical information, misinterpretation of information, providing unclear orders, and overlooked patient status changes can occur. Poor interprofessional communication is also a risk factor for potentially fatal medical errors [25].

The Joint Commission reports that if medical errors appeared on the National Center for Health Statistic's list of leading causes of death in the United States, they would rank number five—ahead of accidents, diabetes, Alzheimer disease, breast cancer, and firearm-related injuries [25]. In many cases, the root cause of these medical errors is a failure of the interprofessional team to effectively communicate, which can lead to medication errors, delays in treatment, wrong-site surgeries, operative or postoperative adverse events, and patient falls [25].

Interprofessional collaboration involves team members assuming and understanding roles and working cooperatively. The team shares responsibility for decision making and facilitating plans of care for patients. Collaboration enhances team members' perception of the knowledge and skills of each profession, steering continued improvement and diversity in decision making. It is important to note that fostering interprofessional collaboration may have obstacles to overcome, including [25]:

- Time stressors

- Perceived loss of autonomy

- Lack of confidence or trust in the decisions of others

- Clashing perceptions

- Territorialism

- Lack of awareness or appreciation of the education, knowledge, and skills of other disciplines and professions

A review of the literature shows that effective communication in the workplace leads to positive outcomes in all areas: knowledge flow, effective interventions, employee morale, and patient satisfaction. It encourages teamwork and promotes opportunity, while also promoting transparency in the workplace [25].

The complexity of medical care paired with the limitations of human performance makes standardized communication tools invaluable in the healthcare workplace [25]. Nurses often use the SBAR acronym to write notes, and this same approach can be used when communicating about a patient to other members of the team. SBAR stands for situation, background, assessment, and recommendation. The mnemonic device allows for ease of communication, decreases the likelihood of missed or omitted information, and supports critical thinking skills [25].

BARRIERS TO GOOD COMMUNICATION

There are a variety of potential barriers to communication, including [25]:

- Personal values and expectations

- Personality differences

- Hierarchy

- Disruptive behaviors

- Culture and ethnicity

- Generational differences

- Gender differences

- Historical intraprofessional and interprofessional 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 reward

- Concerns regarding clinical responsibility

- Complexity of care

- Emphasis on rapid decision making

Addressing these communication barriers in health care requires a combination of cultural, structural, and interpersonal strategies to create a collaborative and patient-centered care environment (Table 1). Regular communication training and ongoing evaluation of communication practices are also crucial for success.

Table 1: STRATEGIES TO ADDRESS COMMUNICATION BARRIERS

Barrier

Strategies

Personal values and expectations

Encourage open dialogue to explore and understand individual values and expectations.

Find common ground and align communication with shared goals and values.

Personality differences

Use personality assessment tools to better understand team members' personalities.

Tailor communication styles to accommodate different personalities, such as adapting assertiveness levels.

Hierarchy

Promote a culture of open communication and teamwork in which all team members are encouraged to share their perspectives.

Use structured communication tools like SBAR to ensure important information flows up and down the hierarchy.

Disruptive behaviors

Establish and enforce a code of conduct that addresses disruptive behaviors.

Provide training and resources for conflict resolution and addressing disruptive behaviors effectively.

Culture and ethnicity

Offer cultural competency training to healthcare providers to increase awareness and sensitivity.

Use professional interpreters when language barriers exist to ensure accurate communication.

Generational differences

Foster intergenerational understanding and collaboration through mentorship programs.

Recognize the strengths of each generation and encourage knowledge sharing.

Gender differences

Promote gender equity and inclusion in healthcare settings.

Ensure that everyone's voice is heard and respected regardless of gender.

Historical intraprofessional and interprofessional rivalries

Acknowledge historical conflicts and work to build trust and collaboration.

Encourage joint educational programs and interprofessional teamwork to break down silos.

Differences in language and jargon

Use plain language and avoid medical jargon when communicating with patients.

Establish a glossary of common terms and ensure shared understanding among team members.

Differences in schedules and professional routines

Implement standardized handoff procedures to ensure continuity of care during shift changes.

Coordinate schedules to facilitate team meetings and communication.

Varying levels of preparation, qualifications, and status

Recognize and respect each team member's qualifications and expertise.

Encourage a culture of continuous learning and mentorship.

Differences in requirements, regulations, and norms of professional education

Promote cross-disciplinary education and training to create a shared understanding of each profession's requirements.

Collaborate on the development of standardized protocols and guidelines.

Fears of diluted professional identity

Emphasize the unique contributions of each profession within the healthcare team.

Clarify roles and responsibilities to prevent overlap and maintain professional identity.

Differences in accountability, payment, and rewards

Align incentives and rewards with collaborative efforts.

Establish clear accountability structures that promote shared responsibility for patient outcomes.

Concerns regarding clinical responsibility

Define clear lines of clinical responsibility and communication channels within the team.

Use tools like checklists and protocols to ensure comprehensive care.

Complexity of care

Develop interdisciplinary care plans that outline roles and responsibilities for managing complex cases.

Regularly review and update care plans as needed.

Emphasis on rapid decision making

Implement structured decision-making processes like team huddles or debriefings.

Encourage critical thinking and rapid information sharing in time-sensitive situations.

Source: Compiled by Author

4. CONCLUSION

Commitment to the effective use of soft skills promotes a healthy, cohesive healthcare environment. Focused team training programs along with personal one-on-one training in soft skills can significantly improve patient care and professional morale. A huge aspect of this is communication, which impacts all areas of health care. Good communication encourages interprofessional cooperation and collaboration, which helps ensure patient-centered care and prevents errors. It is important for healthcare organizations to assess for possible root causes of poor communication and to identify poor soft skills in its nurses. Organizations should be diligent about offering programs and outlets to help foster improvement of these skills.

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