Community specialist practitioners (CSPs) have the skills to facilitate effective collaboration to the benefit of the patients they serve, as, without effective communication, patient care is compromised. This article aims to consider the different ways in which nurses communicate and collaborate with patients and other health professionals to improve and protect health.
Communication failures can occur at any time along the continuum of care. The negative impact of poor communication can include medical and surgical errors, an increased lack of trust between patient and clinician and financial loss to the NHS resulting from litigation payments (McDonald, 2016). Communication failure is the second largest complaint area cited by service users (NHS Digital, 2020). The importance of possessing communication and interpersonal skills to support person-centred care is highlighted in the code of professional practice and is expected of all nurses from qualification (Nursing and Midwifery Council (NMC), 2018). It is further highlighted that advanced skills in negotiation, coaching, teaching and collaborating are core to the role of the CSP (Queen's Nursing Institute (QNI), 2015). Within the Long Term Plan (NHS England, 2019), there is a call to action to prevent ill health through preventative action and health education. Realising the Making Every Contact Count initiative (Public Health England, 2016) requires excellent communication skills to recognise unhealthy behaviours and provide tailored education and health coaching to assist health promotion and collaborate with supporting services in delivering this message.
Communication
Communication involves the use of all our senses; not only the spoken word, but eye contact, body language and intonation play a major part in how messages are sent, received and interpreted (Grover, 2005). Since the pandemic, face masks have hindered communication, as most of our messages are conveyed by the mouth and eyes (Mitchell and Hill, 2020). This has posed a barrier, especially to those who are hard of hearing (Chodosh et al, 2020). With the pandemic, or at least some of the containment measures, here to stay for the foreseeable future, clinicians should acclimatise to optimising their communication as niqab wearers do, using intonation, eye contact and gestures to their advantage (Ong, 2020).
Internal and external factors influence the quality of an interaction. If the information recipient is in pain, emotional distress or simply embarrassed, messages received may be distorted or limited, as the recipient's focus may be elsewhere (Ali, 2018). The environment surrounding an interaction can help or hinder an effective exchange. Factors including noise or a harried location can be distracting and weaken the natural flow of dialogue (NHS Improvement, 2018).
NHS Improvement (2018) highlighted that having a good rapport with the patient involves trust. Trust that the clinician is abreast of their concerns and can provide answers and communicate the plan. Using medical jargon and ambiguous language in this discussion can further hinder the exchange (National Institute for Health and Care Excellence (NICE), 2012). Further, Wiechula et al (2016) suggested that, to reach the therapeutic potential of any relationship between clinician and patient, sophisticated, subtle and ordinary communication skills should be used. Sophisticated communication skills are shown when the nurse can identify opportunities to assess or deliver care in meaningful ways, without appearing to be undertaking a task (Wiechula et al, 2016). To some, this may seem devious, but, to others, it can tailor the care experience to be concise, personalised and efficient. To truly gain a holistic view of the patient-to include their physical, psychological, social and spiritual self-requires the act of talking, listening and observing up close and from a distance, which is collectively known as subtle communication skills. One can argue that time constraints would not allow this in practice, but these can be evolved over subsequent meetings. Using ordinary communication skills involves getting to know the patient outside the therapeutic relationship and being friendly, open and honest. Nursing someone in their own home affords a more personalised approach. The QNI (2019a) found that patients report a more holistic approach and the ability to be more candid with the practitioner within the home environment. CSPs are encouraged to ask ‘What matters to you?’ during initial assessment visits (Olsen et al, 2020). This can feel scripted and often does not flow naturally within the conversation. It can detract from the nurse's natural ability to use their sophisticated, subtle or ordinary communication skills already in place but can be viewed as a useful reminder.
Good spoken communication involves passing on clear, accurate information at the right time, in the right environment, to the right person, in the right way. During patient interaction, recognition of and response to spoken and unspoken needs and expectations is needed to enable the interaction to evolve and to allow the practitioner to gain deeper insight into the patient's situation (NHS Improvement, 2018). Additionally, listening is an important aspect of communication. To truly gain insight into a patient's problems, receiving their information correctly is vital. To be emotionally attuned to the needs of the patient, respect should be conveyed by actively listening and repeating key information to allow the conversation to evolve (Raphael-Grimm, 2014). Greater care is to be taken with those whose senses and understanding are impaired. Those with hearing or sight issues, learning disability or cognitive impairment require more time and a flexible, personalised approach for the communication to be effective (NHS Improvement, 2018).
To incorporate best practice in communication is essential but time consuming. Demands on the district nursing service are presenting difficulties in the delivery of high-quality care, but good communication skills are paramount to the success of any care given.
Emotional intelligence in communication
Emotional intelligence is cited as being self-aware and enabling self-regulation of behaviour as appropriate to the situation and is fundamentally recognised as a quality all nurses should possess (Goleman, 2007; NMC, 2018). Using emotional intelligence in communication involves being aware of how the emotions of the patient and clinician can subsequently influence behaviours (Mansel, 2017). It requires having the insight to regulate what and how information is communicated before instigation, having the self-motivation to continue striving for good care even when there are barriers and having the art of reading people and interacting at a level and intensity the other needs to deliver the message (Ellis, 2017). It is the art of truly knowing oneself through self-reflection and to be aligned with how others perceive you, so that self-regulation can be applied (Beeton, 2016). Using emotional intelligence in interprofessional communication encourages positive interactions across the team and has favourable biological implications that improve health (Goleman, 2007). Equally, negative interactions, where the emotional needs of both parties are not recognised, have the ability to affect health adversely (Goleman, 2007). Consequently, the recognition and fostering of emotional intelligence across interprofessional and patient communication will naturally affect health and wellbeing in a positive manner and create resonance within the team that generates a reservoir of positivity, bringing out the best in people (Goleman, 2007).
Nurses with higher levels of communication skills are associated with having high emotional intelligence (Raeissi et al, 2019). A barrier to using emotional intelligence is viewing patient interaction in a task-oriented way. While patients value compassionate care, they also highly value technical expertise, but one without the other will not ensure a good therapeutic relationship (Raeissi et al, 2019). The CSP possesses the skill of emotional intelligence in providing care that is often given in emotionally charged situations, such as with the terminally ill patient and their families, while simultaneously leading the team impeded by staff shortages and limited resources (Davies et al, 2010).
Collaborative communication
Working collaboratively in healthcare aims to deliver complex care that cannot be delivered by one person alone (QNI, 2019b). It brings together different areas of thought to reach the best outcomes for the patient, as no one single profession can meet all the patient's needs. Effective interprofessional co-operation can improve patient and caregiver satisfaction, improve clinical management and enhance organisation of finite resources (Dahl and Crawford, 2018). Within the community, not all organisations involved in the care of patients are healthcare based. Social workers, charitable organisations and families can be involved and, therefore, communication must be tailored to ensure effective outcomes. How community practitioners communicate with patients differs from how other health and social care professionals do. For example, nurses and doctors approach communication differently. Doctors are taught to be objective and concise, whereas nurses are trained to view the patient using emotional intelligence to form a more holistic view and, therefore, may deliver a lengthy commentary (Tan et al, 2017). This could either compliment the narrative or confuse it, depending on the relationship between the professionals. Pype et al (2018) agreed with this view, suggesting that, within the community, the relationship between nurses and GPs dictates how effective their collaboration will be. Ultimately, the GP has the final responsibility over the medical management of the patient. Therefore, they require communication of the nursing management to effectively optimise treatment. Doctors are seen to be more engaged with negotiating overlaps between work roles and responsibilities within the collaborative setting, which paints the doctor in the leading role (Schot et al, 2019). This can uphold a hierarchical view, disempowering the nurse or encouraging doctors to act independently without discussion, leading to distrust (Pype et al, 2018). On the other hand, the CSP is empowered through specialist training and is best placed, alongside the patient to identify, highlight and share any crucial health-related information (Maybin et al, 2016).
Good interprofessional communication requires the recognition of clear roles and responsibilities and the focus to be on the patient (Dahl and Crawford, 2018). Being familiar through previous interaction facilitates communication, enhancing trust in one another's competencies and allowing a tailored and more efficient communication. History of poor communication dictates how future collaboration is undertaken, and, if past conflicts are not resolved, it can result in missed learning opportunities (Pype et al, 2018). Nieuwboer et al (2018) cited that the most common cause of conflict between GPs and community nurses was challenging a GP's authority or either side being uncooperative. Lessons must be learnt from past conflicts, as, if the causes are not attended to, the problem may reoccur, causing further distrust between the professionals and risking disjointed care. Matziou et al (2014) also found that conflicts between doctors and nurses were often the outcome of confused role expectations. Within the clinical arena, there is an expectation of respect from the GP regarding the ongoing management of those with multiple pathologies, as is part of the CSP role (QNI, 2015). The acknowledgement and respect for one's competencies has been cited by Dahl and Crawford (2018) as resulting in increased discussion and shared decision making. Schot et al (2019) observed that nurses are more strongly engaged with bridging gaps and controlling the flow of information from the patient to the doctor and back again. The CSP is at the centre of the care with the patient and is, therefore, best placed to ascertain and bridge care needs between patient and GP. For example, CSPs with a qualification in leg ulcer management routinely undertake assessment and diagnosis and initiate treatment of leg ulcers without direction from the GP. This enables faster decision making and timely access to treatment, but, unless the GP is informed of the process, it could be detrimental to future relationships.
The world's population is living longer in ill health, and community services are, therefore, being faced with increasing numbers of patients with complex co-existing morbidities (Raleigh, 2020). Medical management of these patients is often shared between hospital consultants, GPs and specialist nurses, with the CSP acting as the glue holding everything together. It is possible to optimise care of the patient with multiple speciality management alongside the GP with the CSP coordinating the care and leading the collaboration (QNI, 2015). However, communication difficulties cause frustration when contact cannot be made to ascertain important information or when the CSP is left out of the loop (Nieuwboer et al, 2018).
Leadership in collaboration
It is imperative that leaders promote effective collaboration and foster good relationships to ensure that effective care planning is not delayed. The King's Fund (2015) cite aligned direction and commitment as the drivers of high-quality care across organisations. To be fully committed requires leadership that champions interprofessional communication and fosters continuity of care (The King's Fund, 2015). Bezrukova et al (2012) identified that professional groups with the same focus are protected against ‘fault lines’, defined as group and status disparities that impede effective collaboration, and is cited as a widespread problem in healthcare organisations. A shared sense of purpose has the ability to influence cooperation across boundaries and not just within organisations and requires a focused communication of the goal of effective collaboration across boundaries through leadership (Bezrukova et al, 2012). Further, Rosen et al (2018) suggested that collective leadership positively influences the perception of the organisation's values and priorities across the wider health and social care team by prioritising patient care rather than celebrating the success of their component of it. Actively bringing people together frequently and promoting collaboration in patient care will aid the narrative. The COVID-19 pandemic has presented many obstacles to collaboration and interprofessional communication. Meetings have moved online, inhibiting those with digital inexperience. Virtual meetings risk becoming one-sided conversations and increase the possibility of missing verbal and non-verbal cues (Sullivan and Phillips, 2020). The CSP leads in daily safety huddles to discuss patients of high priority, such as those with diabetes requiring insulin or those with a terminal illness, clients who are new to the caseload and any problematic nursing issues. The meeting offers an opportunity to relay high-priority key messages from the trust, such as lessons learnt from safety senate. It requires skill to host a virtual meeting between numerous locations to keep information succinct while offering all a chance to contribute and support those who are inexperienced with communication software (QNI, 2017).
Conclusion
Communication is the cornerstone of nursing. It is an essential, intricate skill involving all the senses and is affected by intrinsic and extrinsic factors. In particular, care in the community, where complex illness is coupled with social issues, requires an emotionally intelligent and highly skilled communicator, such as the CSP, to collaborate with other services to ensure the best care outcomes. The CSP also has the superior communication skills to promote public health initiatives through coaching and behavioural training. Effective leadership in collaboration requires respect for everybody's contribution to patient care and will enhance the quality of the interprofessional relationship. It is a leader's responsibility to promote interprofessional teamwork, update those regarding professional roles and responsibilities and overcome barriers, which should, in turn, enhance reciprocal respect and quality of collaboration.
KEY POINTS
- Communication is a complex skill and is regarded as essential in nursing practice
- Superior communication skills are required to undertake effective public health work
- Community specialist practitioners are trained in communicating within highly complex situations and are strategically placed to deliver public health messages
- Effective collaboration with other professionals in care management, requires the ability to use emotional intelligence within leadership to align the priorities of both the patient and the professionals involved
CPD REFLECTIVE QUESTIONS
- What are the particular communication challenges that health professionals working in community settings face?
- How do community specialist practitioners act as a bridge between various health organisations providing care in the community?
- Why is effective communication with patients so important?