Barriers to effective communication

The following tasks are aimed at raising awareness of the barriers to effective communication and developing a common language and understanding of communication skills (Box 1). This knowledge has the potential to improve effectiveness and focus the consultation on the needs of the patient. By having a conscious awareness of the potential barriers to effective communication, it is possible to manage and minimise the effect of these barriers in the clinical environment.

Box 1. Barriers to effective communication

Patient and carer barriers:

• Environment – noise, lack of privacy, no control over who is present or not present (staff or relatives).
• Fear and anxiety – related to being judged, being weak, or breaking down and crying.
• Other barriers – difficulty explaining feelings (no emotional language to explain feelings), being strong for someone else, or communication cues being blocked by healthcare professionals.

Healthcare professional barriers:

• Environment – high workload, lack of time, lack of support, staff conflict, lack of privacy or lack of referral pathway.
• Fear and anxiety – related to making the patient more distressed by talking and/or asking difficult questions.
• Other barriers – not having the skills or strategies to cope with difficult reactions, questions and/or emotions. Thinking ‘it is not my role’, and ‘the patient is bound to be upset’.

(Wilkinson 1991, Booth et al 1996, Heaven and Maguire 1998, Maguire 1999)

Complete time out activity 3

Make a list of all the effective communication skills you can think of and categorise these into skills that:

• Assist in keeping the focus on the patient and/or carer.
• Demonstrate listening.
• Assist with information giving.

It may help you to think about an interaction you had recently or the challenges you reflected on in time out activity 1.

Once completed your time out activity is saved and stored in "My Modules”.

Effective communication skills

It is essential that nurses have skills that keep the focus of communication on the patient, that demonstrate active listening and assist with information giving (Box 2). Examples of communication skills that are integral to nursing are provided in Box 3. It is important that these skills are developed in pre-registration training and further developed during preceptorship, clinical supervision and mentorship throughout a nursing career to promote confidence and competence in this area.

Box 2. Effective communication skills

Skills that assist in keeping the focus on the patient and/or carer:

• Looking and listening for cues.
• Asking open questions. For example: ‘How are you?’
• Asking open directive questions. For example: ‘How have you been since I last saw you?’
• Asking open questions about feelings.
• Exploring cues. For example: ‘You said you are not with it, can you tell me more about that?’
• Using pauses and silence.
• Using minimal prompts.
• Screening, for example asking ‘Is there something else?’ before continuing with the discussion.
• Clarifying, for example asking ‘You said you are not with it, from what you say, it sounds like it is hard to concentrate?’

Skills that demonstrate listening:

• Reflecting.
• Acknowledging.
• Summarising.
• Empathising.
• Making educated guesses.
• Paraphrasing.
• Checking.

Skills that assist with information giving:

• Checking what information the person knows already.
• Giving small amounts of information at a time, using clear terms and avoiding jargon.
• Avoiding detail unless it is requested – do not assume people want to know.
• Checking understanding using an open question. For example: ‘I’ve gone through some difficult information, what sense have you made of it?’
• Pausing and waiting for a response to what you have said before moving on.
• Checking, with sensitivity, the effect of the information you have given on the patient or carer. For example: ‘There has been a lot of information to take in today, how are you feeling?’

Box 3. Definitions and examples of core communication skills

Skills to keep the consultation patient-focused:

Empathising Saying something to show you appreciate (not understand or sympathise) how the other person seems to be feeling. For example: ‘Everything has happened so fast, no wonder you are finding it difficult to take in.’

Making educated guesses Seeing or hearing something (cues) that gives you a hint about how the person is feeling. For example: ‘You are telling me you know what is going to happen, but you look a little confused.’

Looking and listening for cues Cues are hints and can be words, gestures or body language. Noticing verbal and non-verbal cues is important to understanding the patient’s needs.

Psychological focus Recognising and responding to emotions, feelings and concerns. Patients appreciate healthcare professionals asking about their feelings.

Using pauses and silence Pauses and silence provide a slower pace and will help the person to engage in the conversation and give them time to think what they want to say.

Using minimal prompts Small, encouraging words and gestures, for example, nodding or saying ‘go on’.

Negotiating Negotiating and asking permission. For example: ‘Would it be okay to talk about what is worrying you?’

Active listening: acknowledging Showing a response to what you are noticing or hearing. For example: ‘I can see you are very upset about this.’

Active listening: summarising A clear way to prove you have heard all the cues, concerns or questions. For example: ‘So what you told me you are concerned about is the treatment, your husband and how long you may need to be off work.’

Reflecting Reflecting is a helpful way to pick up a cue. Reflection can also function like a question, but is easier for the person to respond to. Reflect back to the patient or relative their own words, or use your own words to check that you understand. For example: ‘You have been thinking, what will happen… [pause].’

Learning points

1. Some professional barriers to effective communication are: high workload, lack of time, lack of support, staff conflict, and lack of privacy, making the patient more distressed by talking and/or asking difficult questions, not having the skills or strategies to cope with difficult reactions, questions and/or emotions.
2. Skills that demonstrate listening are: reflecting, acknowledging, summarising, empathising, making educated guesses, paraphrasing and checking.
3. Skills to keep the consultation patient-focused are: empathising, making educated guesses, looking and listening for cues, psychological focus, using pauses and silence, using minimal prompts, negotiating, active listening and reflecting.
4. Using minimal prompts is the core communication skill which involves using encouraging words and gestures.
5. Looking and listening for cues is a communication skill that assists in keeping the focus on the patient. Cues are hints and can be words, gestures or body language.