Jay when she was living and working in Ethiopia before her nursing career. Image credit: Colin Cosier
By Jay Court MACN, mental health nurse and Australian College of Nursing Stage Two Emerging Nurse Leader
“The greatest problem in communication is the illusion that it has been accomplished.” George Bernard Shaw
As I undertake a Graduate Transition Program as a registered nurse, I reflect on my previous career as a producer of broadcast television documentaries in Australia and East Africa. This background has influenced my belief that communication deserves greater recognition as a crucial foundational technical skill in nursing.
- How communication has been framed as a ‘soft’ nursing skill
Communication, as defined in the Merriam-Webster dictionary, is a ‘process by which information is exchanged between individuals through a common system of symbols, signs, or behaviour‘ (Merriam-Webster dictionary, 2020). However, communication is more than the transmission of information, rather, it is about building rapport and using empathy to create connections between people (Howick et al., 2018). According to Nestel et al (2011, p.2) ’communication is an example of a specialised body of knowledge and skills relevant in almost every facet of clinical practice.’
In nursing education and health care literature more broadly, there is an unhelpful delineation between technical (clinical) skills and so-called “non-technical skills” (NTS), such as teamwork, interpersonal skills and communication skills. The implication is that “non-technical skills” are perceived as less important than technical skills and therefore less worthy of investment and training. I am not alone in noting that this artificial division between technical and non-technical skills in the literature and in clinical practice is problematic and counterproductive (Murphy, Nestel, & Gormley, 2019; Nestel, Walker, Simon, Aggarwal & Andreatta, 2011). Nestel et al (2011,p.2) “posit that the term NTS is misleading, inaccurate, and oversimplifies critical aspects of professional clinical practice”.
Murphy et al (2019) argue that a change in language reflects a change in understanding and a shift in attitudes which thereby increases the value we place on important skills, such as communication. ‘Human factors’ or ’behavioural skills’ have been proposed as two alternative descriptors that better value these crucial skills (Gaba, 2011; Murphy et al., 2019; Nestel et al., 2011). However, these broad terms can extend beyond the interpersonal context and into other areas. It is difficult to see how communication will be given greater priority in nursing education and professional development when it is undermined by imprecise terminology such as ‘non-technical skills’ or ’soft skills’. A terminology shift is therefore fundamental to ensure the ongoing professional development of communication skills in nursing.
The case for prioritising communication skills in the nursing profession
There is a strong case for prioritising communication skills in nursing and health care contexts. Problems with communication are identified as one of the top five contributing factors to sentinel events in Australia and worldwide We know that up to 80% of health care errors are attributable to human factors, including communication breakdowns (Moss & Maxfield, 2007; Peddle, Bearman, Radomski, McKenna, & Nestel, 2018). This shows a need for clinical interpersonal skills to be reframed and prioritised in nursing education to ensure nurses continue to develop communication skills throughout their careers. Sir Michael Marmot questions why health care systems “treat people and send them back to the conditions that made them sick” (Marmot,2017). Through richer communication, nurses can acknowledge these social determinants of health and better appreciate the biopsychosocial needs of each patient to deliver more humane and empathic care at every presentation.
My clinical experience as a nurse and my clinical placements as a nursing student have highlighted how communication could be prioritised further in nursing training, clinical practice and continuing professional development. In my own work, I have witnessed instances where the safety and quality of nursing care was compromised by communication breakdowns between nursing staff and patients. For example, I observed an occasion where nurses working in an Emergency Department were not prepared to engage with a patient presenting in acute distress. Instead, they attended solely to the patient’s biomedical needs, leaving the patient feeling invalidated after making a significant disclosure. While this attitude likely stems from systemic issues such as inadequate training, time pressure and poor resourcing, nurses can act on an individual basis to improve empathic communication and thereby prevent adverse outcomes. Anecdotally, I find nurses who prioritise strong clinical communication and a therapeutic use of self are able to achieve their nursing goals while addressing the holistic, biopsychosocial needs of the patient.
The way forward
I have experienced some of the promising work that is being done to educate student nurses in advanced clinical communication, including micro skills workshops (Ausmed, 2020). Further, initiatives such as the ’Angry Stan’ conflict resolution tool are training student nurses how to de-escalate aggressive patients using Virtual Reality and biofeedback technology (The Australian Broadcasting Corporation, 2019). The Agency for Clinical Innovation (ACI) is invested in developing frameworks and resources to elevate communication skills as a foundational skill for all nurses (Australian Commission for Safety and Quality in Health Care, 2019). The Virtual Empathy Museum is an Australian resource developed to foster empathic interactions between health care professionals and patients and thereby improve physiological and psychosocial outcomes (The Virtual Empathy Museum, 2020).
Whilst these initiatives are promising, there is still a long way to go in ensuring communication skills are properly prioritised and valued by nurses. However, through greater investment and prioritisation of communication skills, nurses can transform missed opportunities and potentially harmful interactions into respectful connections that deliver safe, effective and holistic care.
Ausmed. (2020). Communication Skills: A guide to practice for nurses and midwives. Retrieved from https://www.ausmed.com.au/guides/communication-skills
Australian Commission for Safety and Quality in Health Care. (2019). A Framework to support Clinical Communication. Retrieved from https://www.safetyandquality.gov.au/sites/default/files/2019-06/shared_resource_guide.pdf
Gaba, D. M. (2011). Training and nontechnical skills: the politics of terminology. In: LWW.
Howick, J., Moscrop, A., Mebius, A., Fanshawe, T. R., Lewith, G., Bishop, F. L., . . . Onakpoya, I. J. (2018). Effects of empathic and positive communication in healthcare consultations: a systematic review and meta-analysis. Journal of the Royal Society of Medicine, 111(7), 240-252. doi:10.1177/0141076818769477
Marmot, M. (2017). The health gap: Doctors and the social determinants of health. Scandinavian Journal of Public Health, 45(7), 686-693. doi:10.1177/1403494817717448
Miriam-Webster dictionary. (Ed.) (2020) Miriam-Webster
Moss, E., & Maxfield, D. (2007). Silence Kills: A Case Manger’s Guide to Communication Breakdowns in Healthcare Part I of III. Professional Case Management, 12(1), 52-54. Retrieved from https://journals.lww.com/professionalcasemanagementjournal/Fulltext/2007/01000/Silence_Kills__A_Case_Manger_s_Guide_to.10.aspx
Murphy, P., Nestel, D., & Gormley, G. J. (2019). Words matter: towards a new lexicon for ‘nontechnical skills’ training. Advances in Simulation, 4(1), 8. doi:10.1186/s41077-019-0098-5
Nestel, D., Walker, K., Simon, R., Aggarwal, R., & Andreatta, P. (2011). Nontechnical skills: an inaccurate and unhelpful descriptor? Simulation in Healthcare, 6(1), 2-3.
Peddle, M., Bearman, M., Radomski, N., McKenna, L., & Nestel, D. (2018). What non-technical skills competencies are addressed by Australian standards documents for health professionals who work in secondary and tertiary clinical settings? A qualitative comparative analysis. BMJ Open, 8(8), e020799. doi:10.1136/bmjopen-2017-020799
The Virtual Empathy Musuem (2020 ). Retrieved from https://www.virtualempathymuseum.com.au