Lasswell’s model of communication

In 1948 Lasswell devised a very effective model of the communication process which can be used for any communication interaction (Fiske 1993). In daily life almost everything involves communication – from nursing hand-over to lectures, conversations with family to addressing a conference, from singing a nursery rhyme to a child to seeing a live band perform. Lasswell’s model looks at communication as a process that has an effect on (influences) the receiver’s behaviour to some degree (Fig. 9.1).

Fig. 9.1 Lasswell’s model of communication

Box 9.2 explores some of the questions associated with the components of Lasswell’s model.

Lasswell’s model provides information about the communication process. However, to ‘understand how to understand’ this process and how people make choices in this process, it is important to consider the influences on people’s perception of the world. For example, the design of buildings communicates a message. Hospitals may communicate clinical specialities, care, security and cleanliness, or quite the opposite (Box 9.3).

Blueprint of behaviour model

The neurolinguistic programming (NLP) model showing the blueprint of behaviour is a useful tool in appreciating how people understand the world around them, how this influences the way the person will communicate and therefore how others may respond to them (Fig. 9.2, see p. 224).

Fig. 9.2 Blueprint for behaviour

Everyone has unique life experiences that influence the way they understand the world. The senses are also unique: people see, hear, smell, touch and taste in ways that are particular to them. The language used and understood is also unique to and influenced by background, social class, education, family, spirituality and cultural heritage. Given so many individual distinctions, it is thepredisposition to communicate that enables people to create such effective connections with others.

However, language, senses, experiences, beliefs and values can act as filters that affect the way people interpret and internalize external stimuli and this determines the way people communicate and behave with others. The term ‘filter’ represents the physiological and neurological processes that act on information as it comes through the senses and into language, values and belief systems. Filtered external stimuli are internally represented and understood by each individual in a different way. These representations influence emotions, which in turn influence the language used and people’s subsequent behaviour.

Understanding how these filters create accessible or inaccessible pathways between individuals and groups enables nurses to be clear and creative in communicating often vital information to patients/clients, carers and colleagues.

A model derived from Shannon and Weaver’s model

A simple communication model, derived from Shannon and Weaver’s model (Fiske 1993), provides a description of the communication process between two people (Fig. 9.3): person 1 encodes, creates their message and transmits it to person 2 who decodes the message for meaning, and encodes or creates a response, which is transmitted to person 1 to decode and understand.

Fig. 9.3 Communication model derived from Shannon and Weaver’s model

It would be useful to consider this model while at the same time keeping the blueprint of behaviour model in mind. It helps to build a picture of the factors that affect:

Play as a communication tool

Most people can recollect the games they played with other children and adults as they grew up. Rememberingimaginary stories that were re-enacted, games with rules, games with songs and deep attachments to favourite toys can give a sense of happiness. Play is crucial to language development, understanding relationships and developing an understanding of ‘self’ and how the ‘self’ relates to the outside world.

In all societies children have a drive to play. Essentially play enables the child to make sense of the world around them, the relationships with others, the meaning of idea, and to develop language and strategies to enable them to function in their society.

Play is of vital importance for children who are either in receipt of healthcare or for children who are trying to understand and come to terms with illness, disability and death (see Ch. 12) in their family. Nurses can provide enhanced support for children by their ability to utilize play in the child–nurse relationship.

Babies use ‘practice’ play to understand their movements and sensations. Play is vital in developing control over gross and fine motor movements to start interacting with the world. This involves grasping, taking objects to the mouth, pulling, hitting, clapping, pushing, grabbing and moving objects, fitting one inside the other, delighting in the movement of the objects and the interaction and responses of parental figures. Babies continue with the trial and error approach to affecting change on objects in their environment, e.g. rolling balls away by pushing or discovering that hard objects make louder noises than soft objects.

During the second year children continue to develop by using play to explore more complex ideas, e.g. learning to feed themselves by pretend feeding of adults or toys. Adults actively encourage pretend play but their interactions are often triggered and controlled by the child who leads the play. This play encourages person-to-person interactions; it helps the child to modify behaviour according to the reactions of others. It also enables the child to practise social skills such as turn taking, waiting, requesting, constructing and destructing scenarios.

Preschool children delight in ‘rough and tumble’ using large pieces of furniture or nursery props to design sets for play. This play is vital for the development of coordina-tion, muscle development, playing with others, fighting battles against good and evil. This helps children understand a wider range of emotions and strategies for life.

From the age of about 4 years children start to understand games with rules; these games have a number of ways to support the development of the person. All games for two or more players require communication and language skills. They develop the child’s understanding of competition, fair play, choosing a team, working together and developing a defensive or offensive strategy to win. The child develops a sense of what it means to belong to a group, and how to form and work in a group. Games with rules can be a major part in developing a child’s self-esteem and self-awareness, and understanding their own skills and limitations.

Pretend play allows the child to develop and practise life skills. Children use the scenarios around them to develop their meaning of the world. Children will role-play scenes from family interactions, taking on the role of carer or healer, and developing skills in looking after others. They will also use information from wider cultural roles, from the media and current characters such as Postman Pat or an action hero/heroine. Objects are used to trigger play, e.g. dressing-up boxes can provide an infinite range of possibilities. Children can use pretend play to work through conflict situations, negotiate results and stage the scenarios so that they can understand or impose their views and wishes on the events.

Nurses and play specialists utilize play with children in a number of ways, such as in relation to painful or invasive interventions. Play becomes the communication vehicle for identified aims for the child’s care (Table 9.1).

Table 9.1 Therapeutic play – uses in healthcare

Adults also play, and many care environments, e.g. mental health units, provide facilities for play, e.g. board games, pool or table tennis. Play with adults has a number of benefits; it:

Developmental problems – receptive and expressive language

Developmental problems of language may affect reception and/or expression of language.

Children who have hearing loss have problems developing language because they cannot receive sound information in a meaningful way. It is crucial to provide access to language for the child in a mode that is accessible. Children with a useful residual level of hearing may be helped by hearing aids or a cochlear implant depending on the cause of the hearing loss. These children develop speech, comprehension and expression by relying on aids and lipreading. For children from signing families, or for children whose residual hearing is not at a level that would facilitate understanding, sign language is preferable. Children who learn to sign from an early age follow the same developmental process as children learning speech.

Children who are deaf–blind face immense challenges in learning language. SLTs, parents/carers, educators and support groups such as Sense (www.sense.org.uk) support their language development very closely.

Children with cerebral palsy may have difficulties in speech production (expression) due to lack of muscle control. Nurses need to be aware that people with cerebral palsy may take longer to express themselves; people who are familiar with their speech may be helpful in understanding the person. However, it is important to be aware that family members acting as interpreter may be neither wanted nor appropriate (see pp. 247, 248–249).

Children with a cleft palate and/or cleft lip may also experience difficulty in speech production. Cleft palate is an abnormal opening in the palate that connects the nasal and oral cavities; this may also involve the upper lip. Most cleft palate problems are swiftly and effectively rectified by early surgery but input from specialist dental/orthodontic services and an SLT may be needed.

Formality

Consider the following statements:

The same person spoke each sentence but in different situations, at home with his partner, during shift handover and in a court of law. It is obvious which statement was used in each situation, but what is it about the sentence that fits the context in which it is spoken? The level of formality in each situation determines the level of formality in the language used.

The first sentence suggests an informal setting, a friendship or relationship with a person not involved in the speaker’s work life. Not a great deal of factual information is given because of confidentiality (see Ch. 6). Social information is provided to inform the listener of the speaker’s feelings.

The second sentence is more formal, the context supports increased information about the patient rather than the member of staff. The sentence does suggest some informality initially, which can have a positive effect on team and individual connections, though it moves quickly on to deal with the pertinent issue of care.

The final sentence is very formal, there is a high degree of clarity, and more words are used to provide detailed information. There are no feelings expressed at all. People would certainly find it odd if people spoke in this way on a daily basis; it is highly structured and by the absence of emotional information it lacks any social use and could estrange the listener. In a court situation, however, the facts of the matter are of ultimate importance and feelings are not relevant in this context. In each example the situation determines the language style used.

The people within the situation also determine the language used. For example:

One person is speaking to a small child of about 2 years old, another is speaking to a colleague and the third is speaking to an adult who has annoyed them considerably. How do people know?

Clearly, reading the statements above requires some degree of guesswork because it is not possible to hear or see the speaker. Different tones, facial expressions and gestures could change the meanings completely.

Age

Age has an interesting influence on language; people may speak to older people in the same ‘singsong’ style using short encouraging sentences that they would use with children. This can sound patronizing and does not respect the life experience the older person brings to the situation. However, when people are caring for individuals who may not be able to respond on the same level as the carer, the carer may inappropriately resort to language that reinforces a care relationship that the carer can understand. This tendency is neither appropriate nor useful to the client. Caring in a way that is respectful and dignified for older people is a high level skill that requires nurses who are particularly skilled in communication (Box 9.8).

People with learning and physical disabilities, and mental distress

People with learning and physical disabilities also face similar situations. Again, carers must cope with a complex communication situation and sometimes, rather than adjust their language to suit a person with cognitive difficulties in an age-appropriate way, they resort to speaking to the individual as if the person was a child. These limitations in carers’ communication skills must be addressed, as they disempower the person they are working with.

Such influences on the interaction are based on fundamental differences that include the:

Nurses who work with people with learning disabilities or with children, or nurses who work in more than one language, show skills in ‘convergence’ (see below).They develop skills in talking to each individual in a way that meets their communication and cognitive level.

Another example of this can be found in services for deaf people with mental health problems. Some specialist mental health nurses work with deaf people in services where clients may use British Sign Language (BSL), Sign-Supported English (SSE; a variation of BSL) and speech. Figure 9.4 represents a cline for these languages and language variations and other considerations such as distress.

Fig. 9.4 Considerations in communications to meet clients’ needs

Nurses move up and down each cline depending on the communication needs of the person with whom they are engaging. By doing this, they match the communication needs of the clients to provide as full access to communication as possible, given the skills and limitations of the nurse and the client. The nurse and the client accommodate to the needs of each other in this fluid situation – remember that clients also have the innate skill to match the needs of the nurse. Typically in settings where more than one language is used, clients do assist nurses and other professionals in understanding their [the client’s] language. This puts the client in an empowered position, thus giving respect to and acknowledgement of their language skills.

In addition to the considerations on the cline, nurses consider issues of gender, social background, education experience, family connections, spirituality and culture. This creates a very complex communication situation where highly skilled communicators are essential.

Strategies – questioning with good intentions

People use positive intentions when questioning others. This helps them to show courtesy (see above) and respect and this develops trust; therefore they get the correct information in a short space of time with ‘ecology’, i.e. without damaging the relationship environment.

Assertive communication

The skill of assertiveness is important to nurses. Assert-iveness enables people to be honest with themselves and in their relationships with others. Assertiveness helps to enhance relationships, avoid power games and is a vehicle for clear outcomes. Hargie (1996) details four elements of assertive communication:

Negotiation and delegation

These are areas that depend on assertive communication. Negotiation is the process where people come together with their own ideas, discuss their ideas and agree on an outcome that is acceptable to both parties. It could be as simple as negotiating a change in the off duty, e.g.

Delegation is another way of getting things done. Delegation often occurs between people of different authority, for example:

Staff Nurse A has delegated the task of collecting the prescription from pharmacy to Andrew, a first year student nurse. When delegating to another person it is imperative to be polite, assertive and clear. Offering information to support the request allows the other person to understand why they are being asked to perform a task. Delegation is reliant on a number of issues:

Gesture

Gesture is a crucial aspect of non-verbal communication. Some psychologists and linguists suggest that early humans used gesture before they used spoken or signed language (Armstrong et al 1996). Gestures can be classified into categories of increasing complexity.

Universal gestures that are understand by most people include opening arms and eyes wide to suggest bigness; furrowed brows, pursed lips, drawing body inwards and moving index fingers together would suggest smallness. Subtler gestures include a cupped hand to the mouth to indicate a drink, or a single upwards gesture of the hand with palm facing upwards suggests that someone stand up.

Certain gestures are recognized as specific to a language community, such as the ‘OK’ gesture with thumb and index finger touching to make a circle with the other fingers raised. However, it is important to be aware that some gestures that are acceptable in one community are possibly offensive in another. For example, the ‘OK’ gesture is offensive in Brazil. Each language community shares an understanding of its own group of gestures.

Touch

This is a complex and intricate communication subject and often difficult to tackle. Children tend to be touched more than adults. Interestingly, babies and young children who are not touched do not thrive as well as those who are (Hargie 1996).

Touch for many people is an essential aspect of their working lives. Nurses in particular must learn how to touch people in a professional context without causing embarrassment or concern to the patient/client. In addition, nurses must ensure their own safety. Nurses use two clear types of touch: first and often the most intimate type is the necessary touch nurses use when attending to people’s physical needs and during other nursing interventions; the second type is the touch that communicates a feeling or a meaning, such as, ‘I am here to care for you’ or ‘It will feel better soon’. Everyone has a very personal view about touch, when it is appropriate and when not. People from different cultures will touch each other according to their accepted norms.

It is suggested that a well-timed touch on the shoulder or hand can help a person in distress to feel comforted, or feel the care of another person, which creates a sense of trust. Touch in this scenario is thought to encouragekthe person’s cathartic release by communicating that you are right with them in the moment, close to them and sharing their feelings. This affirms their sense of self; it respects their distress and shows the nurse’s commitment to their needs.

There is also a view that touch can block an emotional release. The use of touch when someone is crying, for example, is a means to stop them crying rather than conveying the message that crying is fine and to be encouraged. If this were the case the nurse would be communicating a need to control the patient’s/client’s emotions for the nurse’s benefit, rather than it being a positive patient/client-centred intervention.

Touch is more appropriate in some clinical settings than in others. Understanding what is acceptable in each area is important and nurses can learn much from each other (Box 9.10). As a student new to a client group it is useful to know how people deal with the patients’/clients’ emotions. Also crucial is an understanding of common courtesy (see pp. 230–231) and the social norms of the patients/clients and carers who are most likely to attend the clinical setting. Nurses need to be able to consider this information while at the same time working with the emotional needs of the people in their care (Varcarolis 1998).

It is vital that nurses also recognize their own feelings around touch (Box 9.11).

Proxemics

Proxemics is a fascinating area of communication because people have very different views about their own personal space; how close people like to be to others and how close they like others to be to them can be very complex and bound by personal rules.

Boundaries enable people to feel comfortable in their environment. Some boundaries are fixed, such as walls and rooms within buildings; others are semi-fixed, such as the seating in the health centre or seating arrangements in a dining room and the location of the television. These arrangements are an indication of where to sit, where to eat and which way to face. Fixed and semi-fixed boundaries can help or hinder communication between people.

The other type of boundary is the informal space between people. This space is fluid and is utilized in different ways for different messages and in different settings.

The person listening will be aware of the distance between themselves and the speaker and vice versa. There are clear cultural differences in the distance people accept between each other.

Knowingly intruding into someone’s personal space can be very intimidating for the listener. This approach is used to interrogate or bully people, resulting in their disempowerment. It may be necessary to gently remind colleagues or children or clients that their comfort zone may be smaller than that of other people. Some people are so at ease with another person that they may use them as a ‘human prop’ when recounting a story. To re-enact a story they may talk to the listener and relate to them physically as if they were there at the time to show the listener the gravity of the situation, the humour or the distress. Some people are happy to be human props but others find it disconcerting and embarrassing because it focuses attention directly on them.

Posture

How a person holds their body in relation to other people and in relation to the fixed and semi-fixed boundaries communicates a great deal about what they are feeling and thinking. Posture sends a very clear message; for example, leaning forward indicates interest and respect for the other person. On the other hand, despite looking at the other person, a lack of interest is portrayed if the listener’s body is orientated towards the door, and sitting back in the chair with feet turned towards the door suggests they would rather be somewhere else.

How a person filters the information provided by the external event will affect their thoughts, feelings and behaviours; therefore their posture is a mirror of their inner beliefs (see p. 235).

When a nurse wants to create a sense of confidence they walk into the situation with their head held high, at a moderate pace, and do not slouch because they recognize that this would convey a message that is unsuitable.

People will look at the nurse’s posture and decide very quickly whether they like them or not and whether they can be trusted or not. Where clients have poor short-term memory and have difficulty remembering people’s faces, names or roles it is imperative to use posture that is confident and respectful because the client has to make continual assessments of people to see if they ought to trust them or not.

Once people have made a judgement it is difficult to convince them otherwise. This may seem a little harsh but it is a survival technique that has helped people to function in social settings for thousands of years.

Characteristics of good listening

Good listening skills are vital to rapport and empathy, which are discussed later (see pp. 237–238). The following characteristics of good listening are based on English speaking Western cultural norms. People from different linguistic and cultural groups have different norms of communicative behaviour (see pp. 247–248).

Active listening

Nurses and others often highlight active listening as an essential skill, as the term implies a requirement forenergy and concentration on the part of the nurse. The aim is to enhance the quality of the therapeutic relationship and to facilitate problem-solving by being with the speaker on a social, psychological and emotional level (Egan 1998). In active listening, the listener:

Active listening requires the practitioner to understand:

Attributes of a nurse–patient/client relationship

Not all nurse–patient/client relationships are the in-depth type utilized by nurses who work in learning disability or mental health settings. The focus of nursing relationships is to bring about change in a person’s health or facilitate an optimum quality of life. Sometimes this is about empowering the person to do this independently; on other occasions the nurse will be undertaking a nursing intervention for a client. There are some attributes common to all nurse–patient/client relationships that are also witnessed in nurse–family/carer relationships.

Empathy

Empathy is when a person puts themselves in the other person’s position, attempting to understand the world as they see it. Empathy is an emotional response to another person’s situation; people often describe feeling a physical sensation in their abdomen or chest when they see someone in a bad emotional or physical state.

It is not uncommon for people to want to laugh if they see or hear others laughing, yawn when they see others yawning and cry when others are upset. They are ‘wired’ to echo the movements and the expressed emotions of others. By doing this people feel the same physical feeling, have thoughts that relate to the feeling and behave in ways that relate to the thoughts and feelings. People can influence others with their happy mood or bad temper. Emotions are ‘catching’ because people have a tendency to automatically empathize. Other people’s movements also influence people, e.g. by making chewing movements while feeding a child or nodding at a conversation on television.

For some people empathizing does not come easily. These people are naturally self-orientated. This does not mean they are self-centred, it means they are more internally focused. People with autism and Asperger’s syndrome have challenges in empathizing because they have a limited ‘theory of mind’. This constrains their ability to understand that they and other people have thoughts, feelings and behaviours, which results in serious limitations in their social and communicative competence.

Another result is the chaos that people with autism feel with regard to other people’s behaviour that can look random and bewildering to them. Some people with autism will go through life without social connections or needing to be with others, preferring the calm of their own world, routines and structures. Other individuals can be aware that there is a difference in the way they relate to others. This realization of poor psychological connectedness can be challenging and confusing and can result in an increased sense of difference for the individual.

Children with autism show this lack of psychological connectedness with those around them and also in their play; they do not role-play because they cannot attribute behaviours, thought and feelings to the toys. The inability to imitate others such as playing ‘mum’ or ‘teacher’ stifles the child’s development in attributing roles to people, standing in other people’s shoes and seeing the world through their eyes, i.e. empathizing (Box 9.15, see p. 238).

Facilitating change

In the therapeutic relationship nurses are trusted to assist change in patients/clients and carers by facilitating the understanding of information. They are also entrusted with the task of helping a person involved in this health process to move from the current state A to the desired state B (Fig. 9.5).

Fig. 9.5 Facilitating change from the current state to the desired state

Essential communication and interpersonal skills underpin facilitation. Box 9.16 considers the nurse–patient/client relationship in different settings. A patient/client is unable to move from A to B if they cannot relate to the nurse, i.e. if rapport, trust, the nurse’s concern and the nurse’s skills in ‘being there’ for the client are not evident. Nor will they move from A to B if the nurse does not have the communication strategies to be a resourceful facilitator.

It is clear that all the scenarios provide different levels of contact between nurse and patient/client/carer, all of which require different levels of relationship building. No one way fits all and nurses have to accept that while they continue to value good interpersonal communication skills and strategies, not all nurse–patient/client/carer relationships need to be in-depth to be resourceful but it is vital that some are.

Positive regard

Positive regard is the ability to hold and convey feelings for other people that are not based on negative beliefs about the person. Having positive regard for patients/clients, carers, parents and colleagues enables the nurse to approach others with positive intentions towards them. Maintaining positive regard for people can help nurses manage their thoughts, feelings and behaviours even insituations where the other person may be behaving in a way that is not appropriate.

Attachment

People learn how to relate to others from the attachments they develop as children (see Ch. 8). These attachments focus on principal caregivers and result in the ability to relate to themselves and to others. Where they have strong, nurturing, encouraging and fulfilling relationships with others they are confident in their skills and developing abilities, which is expressed through their mental well-being. Environments without emotional sustenance, encouragement, love or stability can result in people having emotional problems and an impoverished sense of mental well-being, thus creating people who experience vulnerability and dysfunctional relationships.

Nurses meet people who are in extreme situations – people who are frightened, ill, angry and anxious, whose ability to deal with their current crisis is based on their mental and physical well-being, which by the very fact that they are seeing a nurse could be compromised. Therefore it is reasonable to suggest that nurses work with people who have difficulty with relationships, whether this is situational and transient or long-term and embedded in the thoughts, feelings and behaviours of the individual.

Not all nurses have high levels of mental well-being nor have they experienced positive nurturing upbringings in secure and loving environments as this is clearly not plausible, nor should it be a prerequisite for the profession. What is important is that nurses understand themselves and the positive and negative experiences that contribute to their current ability to relate to others, to develop insight and to be resourceful for the people they work for and with (Box 9.17).

Some children have families that are highly nurturing and safe, with the potential to be resilient to emotional challenges. Most people have families that experience the ups and downs of emotions, love, loss and nurturing with some resilience to these challenges. A few people with little innate resilience to emotional challenges experience the most challenging of environments and these people may develop attachment disorders. It is clear that whether it is an issue of physical illness, developmental need or mental well-being, nurses can be involved with people at all stages on this attachment continuum (Fig. 9.6). Mental health nurses will be more involved with people with attachment problems and emotional distress, depression and behavioural disturbances because of the clear link between these issues and challenges to mental health.

Fig. 9.6 Attachment continuum

Nurses provide care for others, i.e. they are caregivers. This is a very powerful position to be in because of the responsibility given to the nurse while the patient is in need. For people who have experienced good attachment there is little to do other than reinforce their sense of emotional well-being through being there for them, being concerned for their care and health outcomes, and being skilled in the delivery of that care. For people who have experienced more negative attachments and who do not express a sense of well-being, nurses must realize that their actions can have considerable impact on the patient/client and carer as they take on the role of caregiver. Nurses need to develop skills in areas that include:

The points above are a guide to skills that are useful in providing services for all and particularly for people with more complex relationship needs. With this in mind, consider the nurse who feels special because they are the only person who can work with or care for a patient/client, or who a patient/client wants near them. This nurse should reflect on their own need to feel needed, to feel special and how the patient/client may be fulfilling these needs and why this may lead to an unhelpful service for the patient/client. Student nurses are often able to spend more time with patients/clients and carers and so can find that they develop strong attachments. Hopefully, with the issues raised above, nurses will be able to develop their resourcefulness further, thus protecting themselves and the people they work with from emotional stress or harm.

Boundaries are healthy

Boundaries are useful and positive rules that enhance resourceful relationships to improve health outcomes. Some nurses find the correct level of boundary between themselves and patients/clients easy to judge, whereas others find it more challenging and many nurses can remember experiences where they ‘got it wrong’.

Boundaries begin to develop as soon as the nurse meets the patient/client or carer and explains their role and responsibilities. A clear and concise explanation gives information about what the nurse does, thus enabling the patient/client or carer to begin to develop a picture of why each healthcare professional is involved and, crucially, how they, the patient/client or carer will be involved in the process.

On one level the public needs to know the roles, responsibilities and level of involvement they can expect from healthcare practitioners, as outlined above. At a deeper level nurses are enhancing the ability to be in a resourceful position for the people they work with. Boundaries enable nurses to maintain a professional commitment to the public; nurses are resources who offer healthcare, expertise and skills to facilitate change in ways that would be difficult if they became ‘friends’ with the people they work with. Professional and therapeutic boundaries are safety nets for the protection of everyone involved.

Boundaries also provide clarity for professionals. People working in healthcare often find themselves working across professional boundaries; nurses may overlap with occupational therapists (OTs) or social workers in the same way as they may overlap with traditional nursing roles. For example, supporting people in their own homes with developing independence skills could be facilitated by a nurse, an OT or a social worker, particularly when they work in multidisciplinary teams (MDTs) such as assertive outreach teams or home treatment teams in community mental health services (see Ch. 3).

These teams function with clear communication systems and full understanding of each member’s roles and responsibilities, skills, specific training and the therapeutic relationships they have with the patients/clients. Of primary importance to such teams is the consistent engagement of difficult-to-engage clients rather than individual professionals being territorial about their traditional roles. The client is paramount; the clinician’s skills support the patient/client and each other through enhanced teamwork and communication.

Boundaries sometimes go wrong by being unclear, breached, ignored, too stringent or, more seriously, abused. Unclear boundaries do not provide the supportive structure needed for clinicians to deliver the service required. Moreover, lack of clarity disempowers the patient/client and carer because they do not have the information required to be fully involved in their care. Unclear boundaries can lead to breaches of professional conduct (see Ch. 7), including over-involvement or abuse by either the care provider or the person receiving care.

Professionals who are unclear about each other’s roles create confusion, which can lead to breakdown in communication and service delivery. This means that patients/clients and carers suffer. Unclear professional boundaries can lead to missing information, which can have extremely serious consequences such as role confusion, misdiagnosis, incomplete risk assessments or poor care and health outcomes.

Stages of the therapeutic relationship

The stages of the therapeutic relationship identified in Varcarolis (1998) are:

Working in partnership with families – confidentiality

Confidentiality is an important concept for nurses (see Chs 6 and 7). The Nursing and Midwifery Council (NMC) (2004, Clause 5, p. 8) provides a clear statement: ‘As a registered nurse, midwife or specialist community public health nurse, you must protect confidential information.’

The principle of confidentiality is to protect individuals from indiscriminate disclosure and divulgence of their personal information. All people have the right to privacy and to personal information to be protected by the professionals who work with them.

Nurses build relationships on trust, ensuring patients/clients develop trust and so enhance the ability to work therapeutically. Nurses ask people to give very intimate and detailed information as part of the nursing process (see Ch. 14). People need to know that the information they give to health professionals is safe from improper disclosure:

Nurses who breach confidentiality are liable to disciplinary action from their employer, action by the regulatory body that could result in their removal from the professional register and ultimately legal action from the patient/client or carer (see Ch. 6).

Nurses have a duty to inform patients/clients and carers of their responsibilities regarding maintaining and possibly breaching confidence. Nurses may initially find this a difficult topic to discuss with someone who has come to them for ‘help’. However, having the confidence to clearly outline your role as a nurse and the boundaries of that role shows the client respect and honesty, which should help in developing the nurse–patient/client relationship.

Nurses do need to judge whether they should explain the full details of when they would be required to breach confidentiality. For example, a community nurse working to support an adult newly diagnosed with diabetes may find it unnecessary to discuss ‘abuse’ or ‘serious offences’. However, it is acceptable to outline roles, responsibilities and boundaries in a clear and informative manner.

Breaking bad news

It is a particularly daunting prospect to tell someone something that they would class as ‘bad news’. Breaking bad news often focuses on informing people about serious illness or death. However, just as with the experience of pain, ‘bad news’ is very individual to the person receiving it, e.g. a patient/client being told that their partner has phoned to say they missed the bus and cannot visit today may consider this to be ‘bad news’. Therefore, it is useful to assume that, because people have different blueprints of behaviour and different internal maps of the world, it is impossible to know how the person will react to news.

Most patients/clients, carers and parents want to know the truth, even the bad news. Breaking bad news to a child is very dependent on their age, stage of development and the wishes and involvement of the parents. People with cognitive and communication difficulties, people who speak another language and people in distress need nurses to be sensitive to their communication needs.

In breaking bad news to a client with a cognitive disability, the nurse needs to be aware of the person’s cognitive level and their concept of illness or death, and it is important that the person is told straight away in terms they can understand, i.e. provided with information that is as meaningful as possible. This is not considered to be patronizing, as it provides the information needed to build their understanding of issues.

Registered nurses who give bad news will use their interpersonal skills, rapport and empathy. They will be aware of their verbal and non-verbal communication. They will use skills to match the other person’s communication by converging, matching vocabulary, pace and loudness, and being congruent to the message (Kurtz et al 2004). Feedback skills are used by the speaker to ensure that the message has been decoded and understood, to ensure their communication has the desired outcome. Again, having a communication model in mind will help the nurse focus on the communication act and outcome.

Different strategies for breaking bad news have been developed and most follow a set pattern (Box 9.18) which provides assistance to the nurse and the right level of information to the listener. These strategies can be tailored to all clients, carers and children by adapting your language and interpersonal skills in accordance with their communication needs.

Communication and care coordination within the MDT

It is important to recognize that, despite each person’s professional independence, they also relate to each other as members of a team. This enhances the unity, effectiveness and efficiency of the team and meets the individual need for belonging. Most, though not all, people find this relationship positive (Mullins 1995). Members of the team relate along a number of dimensions including power, status, liking, communication, roles and leadership (see pp. 243–244) (Buchanan & Huczynski 2004). All the dimensions are communicated through non-verbal, verbal and other communication strategies.

Communication within MDTs requires clear man-agement and facilitation on a number of levels, including the:

Communication within MDTs also requires systems and assertive control and the flexibility to respond to changes. The information should go through as few people as possible to avoid the possibility of distortion (Guirdham 2002).

Nurses empower the MDT and their profession by clearly explaining their roles, responsibilities and professional boundaries to facilitate joint working that provides efficient, effective, evidence-based care (see Ch. 5).

Leadership

There is much literature that discusses the need for good quality leaders in all areas of healthcare and particularly in nursing. Leaders are identified as those who influence the behaviour of others (Mullins 1995). Nurses as team leaders enable the people they lead to care for patients/clients and carers by:

Team leaders also have to focus on the broader information sources and strategies that inform their practice and that of the nursing team they lead. It is little surprise that nurses in this position can spend over 80% of their time in communicating.

Leadership behaviours

For nurses, their approach to leading will depend on the situation they find themselves in, the individuals and teams around them and the tasks that are required. This author proposes that nurses have a responsibility to evaluate and develop their emotional intelligence skills (see p. 244), as it is these skills that enhance relationships and the care environment and are also strongly suggestive of good leadership. Before looking more closely at emotional intelligence, it is appropriate to consider some styles of leadership. All the styles described below are appropriate in healthcare but when they are utilized depends significantly on the situation.

The plethora of leadership approaches can be daunting when nurses begin to explore the subject. Research by Binney et al (2005) shows leadership has three main elements:

• Leadership occurs between people, i.e. it is a social interactive process that facilitates links between people in organizations

• A leader’s behaviour is shaped by the context in which they find themselves leading; as the situation/environment changes, so does the leader’s behaviour

• Leaders are most effective when they take their skills to a situation, for the benefit of the individuals, groups and task, when they can relate to others as real people with emotional and cognitive intelligence and life experience that they can draw upon for the benefit of those around them.

It is useful to recognize what types of leadership behaviour are suitable in what situation. In accepting that there is a continuum of leadership behaviour that moves from high levels of control by the leader to high levels of freedom for those who are led, it can provide a framework for nurses to identify effective leaders and also assess their own leadership skills. This continuum in often described in terms of three leadership styles identified by Lewin et al (1939) (Fig. 9.7):

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• Autocratic

• Democratic

• Laissez faire.

Fig. 9.7 Leadership styles

Adair (1998) focuses leadership action in three interlinked areas: the task, the team and the individual. Communication and interpersonal competence of the leader are key to their ability to lead individuals as a team to achieve the task.

Relationships with families and main carers

Relationships with main carers and families are as important as the ones with patients/clients. As discussed above, nurses facilitate good relationships with carers by clearly describing their roles, responsibilities and boundaries.

Good relationships with families/carers are vital for the health outcomes of the patient/client. They are also important in ensuring that families/carers are supported in their caring role. Caring for carers has been a low priority for some nurses. However, carers’ needs are increasingly being addressed through support and lobbying from carer organizations, government initiatives, e.g. National Service Frameworks, Essence of Care (NHS Modernisation Agency 2003), and patient involvement bodies (see Ch. 3).

Working with carers enhances the experience of patients/clients. Good support is far reaching and makes a positive difference to people’s lives. Any working involvement requires effective interpersonal skills and good communication strategies and systems. For example, the scenario in Box 9.20 requires tact, commitment, courtesy, empathy, rapport, matching language, and understanding how the nurse’s and carer’s beliefs and values may influence their actions.

Differences in language and communication rules

Despite sharing a great deal, there are differences in the way language is used to communicate. For example, there are differences in prosody, i.e. tempo, speed, rhythm and pitch of speech.

Working with interpreters

When the communication barrier is due to the nurse not speaking the patient’s/client’s language, a third party who speaks both languages will be needed (Henley & Schott 1999).

A person who can speak two or more languages is not the same as an interpreter. Interpreting is a learned skill, and working with an interpreter is also a skill that has to be learned. Furthermore, interpreters are a professional body of people, most of whom work to exacting codes of ethics and professional standards. Interpreters are skilled in enabling each party to understand the culture of the other, particularly where cultural differences would cause misunderstandings.

Without quality interpreting services, people can be misdiagnosed, mistreated, undiagnosed, uninformed, etc. If the interpreter is untrained these issues are unresolved. Ultimately this means that people’s health suffers, carers are unable to support the process effectively and many service users avoid the health service, believing that they will not receive any sort of service.