As healthcare expert Sarah Connor noted in Nursing Times: “Nurses provide the ‘glue’ – escorting a patient into the consulting room; identifying with challenges in adhering to lifestyle changes by reporting their own experience; allowing patients to disclose concerns not shared with doctors; being chatty; sharing a joke; and providing explanations where doctors’ communication has failed.”
Here, we’ll discuss the various schools of thought pertaining to the ways humans interact with one another, and how these different modes apply to the field of professional nursing. We’ll also delve into some common workplace problems associated with communication and explore effective strategies for overcoming these obstacles.
The Four Styles & Behaviors of Communication
The Four Communication Styles
|Clear and Direct||Plainly and succinctly stating your message to the appropriate person. Dr. Nielsen calls this “the most healthy form of communication.”||An employee is unhappy with their coworker and says to them, “Your contributions to our group project were lackluster, and we’d like you to provide more support in the future.”|
|Clear and Indirect||Multiple people are addressed and allusions are made to certain topics without specifically targeting the individual for whom the message is intended.||An employee is unhappy with their coworker and expresses displeasure to a group of coworkers by saying, “I get really annoyed when people don’t pull their weight around here.”|
|Masked and Direct||This style occurs when someone delivers a muddled, unclear message to another individual. The target is aware he/she is the intended recipient, but may not understand what the message means, or even why he/she is being addressed.||An employee is annoyed with their coworker says to them, “People in this office used to work a lot harder.”|
|Masked and Indirect||This is when the message and the intended recipient are unclear. Dr. Nielsen is critical of ‘masked and indirect,’ citing it as a common characteristic of ‘unhealthy relationships.’||An employee addresses a group of coworkers and says, “This office just isn’t doing what it needs to be doing lately.”|
The Four Communication Behaviors
These styles manifest as the following four communication behaviors. We provide real-world examples centered around the nurse-patient relationship:
|Assertive||Assertive behavior is straightforward and honest without being inappropriate or belligerent; this is the preferred communication style. “I” statements and objective terms are used.||A nurse tells a patient, “Your condition requires a surgical procedure, but with some follow-up therapy, I’m confident you’ll start to feel better in a matter of days.”|
|Aggressive||The aggressive approach should only be used to maintain control over a belligerent individual; otherwise, it is considered inappropriate within a professional setting. Aggressive behavior is characterized by “you” statements, accusations, and subjective terms.||A nurse tells a patient, “You’re going to die of lung cancer if you don’t quit smoking.”|
|Passive||Passive behavior involves the concession of needs and rights in order to placate another individual. Whereas aggressive people tend to view themselves as superior to others, passive individuals often suffer from feelings of insecurity and timidness.||A nurse gives into a patient’s demands for stronger prescription medication, rather than following the proper diagnostic schedule.|
|Passive-Aggressive||In addition to the previous three (which are often considered the three, core communication behaviors), this fusion of two, seemingly contradictory behaviors occur when someone expresses their “needs and feelings in an unclear and confusing manner,” says Dr. Nielsen. It often includes components of sarcasm, ridicule, and insinuations about others.||A nurse tells her patient, “I’ve told you my diagnosis, but clearly you’re the medical expert here so just do what you want.”|
Quiz: What Style Are You?
- You are in a restaurant and order a steak medium-rare, but it is served to you well done. You would:
- Accept it since you sort of like it well done anyway
- Angrily refuse the steak and insist on seeing the manager to complain about the poor service
- Call the waiter and indicate you ordered your steak medium-rare, then turn it back
- You are a customer waiting in line to be served. Suddenly, someone steps in line ahead of you. You would:
- Let the person be ahead of you since he/she is already in line
- Pull the person out of line and make him/her go to the back
- Indicate to the person that you are in line and point out where it begins
- After walking out of a store where you purchased some items you discover you were short-changed. You would:
- Let it go since you are already out of the store and have no proof you were short-changed
- Go to the manager and indicate how you were cheated by the clerk, then demand the proper change
- Return to the clerk and inform him/her of the error
- You are in the middle of watching a very interesting television program when your spouse comes in and asks you for a favor. You would:
- Do the favor as quickly as possible, then return to the program to finish watching it
- Say “no,” then finish watching your program
- Ask if it can wait until the program is over and, if so, do it then
- A friend drops in to say hello, but stays too long, preventing you from finishing an important work project. You would:
- Let the person stay, then finish your work another time
- Tell the person to stop bothering you and to get out
- Explain your need to finish your work and request he/she visit another time
- You ask a gas station attendant for five dollars worth of gas. However, he fills up your tank by mistake and asks for twelve dollars. You would:
- Pay the twelve dollars since the gas is already in your tank and you will eventually need it anyways
- Demand to see the manager and protest being ripped off
- Indicate you only requested five dollars worth of gas and give him only five dollars
- You suspect someone of harboring a grudge against you, but you don’t know why. You would:
- Pretend you are unaware of his/her anger and ignore it, hoping it will correct itself
- Get even with the person somehow so he/she will learn not to hold grudges against you
- Ask the person if they are angry, then try to be understanding
- You bring your car to a garage for repairs and receive a written estimate. But when you pick up your car, you are billed for additional work and for an amount higher than the estimate. You would:
- Pay the bill since the car must have needed the extra repairs anyway
- Refuse to pay, and then complain to the Motor Vehicle Department or the Better Business Bureau
- Indicate to the manager that you agreed only to the estimated amount, then pay only that amount
- You invite a good friend to your house for a dinner party, but your friend never arrives and neither calls to cancel nor to apologize. You would:
- Ignore it, but manage not to show up the next time your friend invites you to a party
- Never speak to this person again and end the friendship
- Call your friend to find out what happened
- You are in a group discussion at work that includes your boss. A co-worker asks you a question about your work, but you don’t know the answer. You would:
- Give your co-worker a false, but plausible answer so your boss will think you are on top of things
- Do not answer, but attack your co-worker by asking a question you know he/she could not answer
- Indicate to your co-worker you are unsure just now, but offer to give him/her the information later
To score your assessment, add up your total number of “a”, “b”, and “c” answers, then defer to the key below.
- Mostly A’s: You’re more likely to engage in passive communication.
- Mostly B’s: You’re inclined toward aggressive communication.
- Mostly C’s: You generally practice assertive communication.
Find more self-assessment questionnaires at:
The Components of Effective Communication
- “Tone” refers to the emotions and attitudes conveyed through the level, volume, and pace of one’s voice. Tone does not necessarily correlate to the message, and if the speaker isn’t careful, their delivery can result in a confused audience. For example, if a manager is attempting to give employees a pep talk, but comes off as unenthusiastic or sarcastic, the employees are likely to leave the meeting unsure of how to approach their tasks. Your tone should always be clear, confident, and friendly; never sarcastic, condescending, or disinterested.
Joyce E.A. Russell, who serves as the director of the Executive Coaching and Leadership Development Program at The University of Maryland’s Robert H. Smith School of Business, recently discussed ways to improve tone in a Washington Post article. She notes the following three-step approach can be used to modify one’s tone and deliver a clearer, more pointed message:
- Step 1: Ask your coworkers and managers for feedback about tone, emphasizing confidence vs. insecurity. Additionally, tape yourself with a voice recorder and listen to yourself.
- Step 2: Once you have an accurate understanding of how your tone sounds to others, consult with one of your most trusted colleagues. Ask this person for constructive criticism that will enable you to further improve your workplace habits.
- Step 3: Practice using an improved tone in front of coworkers or associates who are not necessarily familiar with your speaking habits. If it feels appropriate, seek positive feedback from them as well.
- Improving your nonverbal communication habits can actually improve the way you verbally interact with others. Like tone, body language will essentially contradict the speaker’s message if it does not correspond with what is being said. Henrik Edberg, a contributor to The Positivity Blog, notes the following telltale signs of good (or poor) body language, and encourages others to optimize their nonverbal communication skills using a mirror at home:
- Eyes: You should make eye contact with whoever is speaking to you, but also do your best not to stare blankly at that person. Too much eye contact can make others uncomfortable, while no eye contact will make you appear insecure.
- Head: Be sure to nod; this will indicate you’ve understood what your coworker has told you, and that you are receptive to his or her ideas. Also, be sure to keep your head upright; staring at the ground will make you seem disinterested or distracted.
- Face: According to Edberg, touching your face “might make you seem nervous and can be distracting for the listeners or the people in the conversation.”
- Mouth: Smile and laugh when appropriate. This will demonstrate your engagement in the current conversation ― but grinning ear-to-ear for too long may come off as disingenuous.
- Shoulders: Be sure to relax both shoulders; otherwise you’ll appear tense. If you are naturally stiff-shouldered, try loosening them up before you get to work by shaking them or stretching your neck.
- Arms and legs: “Don’t cross your arms and legs,” Edberg warns. This will tell others you feel “defensive or guarded.”
- Hands: Fidgeting is one of the surest signals of poor body language. Constantly moving your hands will distract others ― but infrequent, controlled pointing or gesturing will help you deliver a clearer message. Also, avoid using drinks or other objects to block your face. This is a sign of timidness.
- Whole body: Avoid standing too close to other people, and try not to “lean in” too excessively. These actions are often perceived as aggressive, and most people will not respond positively.
- Absorbing and appropriately reacting to another person’s message is just as crucial as communicating your own message confidently and clearly. Mind Tools, a website dedicated to improving professional skills, offers the following tips for active listening:
- Pay attention: Give the speaker your full attention, and demonstrate your engagement with eye contact; don’t let yourself be distracted by other conversations or the need to “mentally prepare a rebuttal.”
- Show that you’re listening: Use body language to indicate the speaker has your undivided attention. Nodding, smiling, and using good posture will all accomplish this end.
- Provide feedback: “Our personal filters, assumptions, judgments, and beliefs can distort what we hear,” notes the Mind Tools tutorial. Clarifying questions and statements (“So, what you’re saying is…”) will tell the speaker you’ve been paying attention, and that you have your own thoughts about what has been said.
- Defer judgment: Rather than interrupting or arguing with the speaker before he/she is finished, allow that person to conclude the message and then offer constructive, non-argumentative points of view if your opinion is different.
- Respond appropriately: This is a great point to practice clear/direct style and assertive behavior. Be honest and straightforward with the speaker about the message without over-criticizing or broaching subjects that are irrelevant to the topic at hand.
- EQ stands for emotional quotient (or ‘emotional intelligence’), the ability to effectively express and manage feelings when interacting with our family members, friends, and colleagues. As noted by Jeanne Segal, Ph.D., and Melinda Smith, M.A., in an article for HelpGuide.org, EQ consists of four basic components:
- Self-awareness: People with high EQ are cognizant of the emotions they are conveying, and recognize that thoughts and behavior trigger self-confidence.
- Self-management: High EQ is linked to the ability to suppress unhealthy urges and rein in compulsive feelings; effective self-management allows us to “take initiative, follow through on commitments, and adapt to changing circumstances.”
- Social awareness: In addition to recognizing their own emotions, high-EQ individuals can also perceive the feelings and attitudes of other people, and modify their own style and behavior to accommodate them.
- Relationship management: Healthy interaction with spouses, children, parents, friends, and close coworkers is a hallmark of high EQ.
“It takes a lot of concentration and determination to be an active listener,” the Mind Tools article concludes. “Be deliberate with your listening and remind yourself frequently that your goal is to truly hear what the other person is saying. Set aside all other thoughts and behaviors and concentrate on the message. Ask questions, reflect, and paraphrase to ensure you understand the message.”
Emotional Intelligence: EQ
How to Improve Your EQ
- “Rapidly reduce stress in the moment.”
- “Beat relationship stress with emotional awareness.”
Everyone reacts to stress differently. Some endure a proverbial rollercoaster of emotions during stressful moments, others experience physical discomfort, and there are even those who naturally shut down and refuse to address the situation at hand. None of these responses are particularly healthy, but “having a relationship with your emotions” will at least prepare you for stressful moments and allow you to let the moment pass and reconnect with your surroundings in a positive manner.
- “Use nonverbal communication.”
This corresponds to the body language strategies listed above. If you find yourself in a confrontation or argument with a coworker, you can mitigate the stressfulness of the situation through eye contact, sincere smiling and nodding, non-aggressive stance, and calm facial expressions.
- “Use humor and play to deal with challenges.”
This will not always be the most appropriate response, but a joke or innocuous comment will often alleviate the stress and tension that accompany confrontational encounters, and enable you to work through seemingly impassable differences with other people. This method also works when it comes to relieving your own stress independently of other individuals. Don’t sweat the details, learn from your mistakes (instead of dwelling on them), and find ways to relax once the stressful moment has passed.
- “Resolve conflict positively.”
“It takes two people to keep an argument going,” the authors note. “You can choose to disengage from a conflict, even if you still disagree.” By resolving little conflicts and finding ways to overcome the major ones, you’ll be able to foster positive interaction with those around you ― even if you don’t always agree with them.
Now that we’ve discussed ways to improve style, behavior, and other components of communication, we can explore specific ways for professional nurses to put these skills into practice.
Stress is one of the factors that most detrimentally affects one’s EQ. Immediately recognizing stressful feelings, identifying how/how well you respond when stress sets in, and mitigating stress in healthy, productive ways will boost your EQ and improve your general outlook across the board ― but especially at work. “If you tend to become angry or agitated under stress, you will respond best to stress-relieving activities that quiet you down,” the authors note. “If you tend to become depressed or withdrawn, you will respond best to stress-relieving activities that are stimulating. If you tend to freeze—speeding up in some ways while slowing down in others—you need stress-relieving activities that provide both comfort and stimulation.”
Professional Communication Obstacles: Nursing
Discussing Difficult Medical Issues
RNs care for patients who are dealing with a wide range of medical conditions, many of which are chronic ― and terminal, in some cases. Nurses are obligated to discuss these issues with patients in a manner that is honest, straightforward, and easy for non-medically trained individuals to understand. Megan M. Krischke, a contributor for NurseZone.com, notes that one of the most common mistakes in nursing is “failing to assess a patient’s health care literacy and then speaking to them in terms they understand.” Nurses, she says, should not only evaluate each patient’s ability to understand medical terminology and treatment procedures, but also “intervene” by assisting them as they navigate the confusing network of doctors, specialists, and care providers.
One area of medicine where this skill is crucial is palliative care, which is reserved for patients with terminal conditions who are nearing the end of their lives. In a journal entry for Oxford Medicine Online, Lesley Fallowfield writes that honest, open communication is key “if patients are to be permitted the dignity of deciding how to spend their remaining time.” This level of honesty can be difficult for nurses to present ― and difficult for patients and their families to digest ― but studies have shown that most people would much rather hear the truth in situations like these. By using the clear/direct, assertive approach, maintaining an empathetic tone, practicing confident body language, and minimizing the level of visible emotion, nurses, can provide terminal patients and their loved ones with the information they need without exacerbating an already traumatic experience.
Adapting to Cultural Challenges
The United States is a highly diverse nation, and nurses who practice here must treat patients from a wide range of ethnic, religious, and cultural backgrounds. Members of certain groups tend to be more resistant to modern medicine, while others are morally opposed to routine procedures like blood transfusions or certain childbirth methods. In fact, a 2014 survey from the Centers for Disease Control (CDC) found that only 4% of U.S. citizens are trained medical professionals ― meaning that 96% of the country’s population “probably define good health or wellness” in terms that are different from those used within the medical community.
NurseTogether.com contributor Lanette Anderson recently penned an article in which she described the importance of ‘cultural competence.’ “Barriers to cultural sensitivity,” she notes, include racism, sexism, religious intolerance, and general stereotyping of certain groups. Nurses should never make assumptions about patients or their families, but simply use their medical training to provide the highest level of treatment and care at all times without lending credence to uninformed beliefs about medicine and healthcare. Cultural competence, Anderson says, requires effective verbal and nonverbal communication ― and in cases when patients have difficulty understanding English, the latter takes on a greater level of importance.
Handling Poor Communications with Doctors or Other Nurses
Hospitals, clinics, and physician’s offices can be very hectic workplace environments ― and poorly communicated instructions will only add to the chaos. Healthcare Traveler contributor James M. Fraleigh urges nurses to present themselves with confidence and professionalism beginning with their first day at their workplace. Newly hired nurses should go above and beyond to show their supervisors and peers that they have the technical ― and interpersonal ― skills needed to do their jobs properly.
But inevitably, communication between nurses and doctors will break down from time to time. “In the real world, physicians may be rude, dismissive or intimidating,” noted Beth Greenwood in a recent article on Chron.com. “Nurses may also contribute to problems by failing to communicate or engaging in open conflict.” These situations call for stress management, high EQ, and effective verbal communication between colleagues. If possible, nurses and doctors with conflicting opinions should collaborate during high-stress situations to ensure the patient in question receives all of the necessary care ― and then openly discuss their experience after the fact using some of the active listening strategies discussed above.
We can’t simply master good communication skills, and then just move on. Direct style, assertive behavior, clear tone, effective body language, active listening, and high emotional intelligence all require retraining and retooling throughout the course of our adult lives ― and we enter different life stages, we may find that new and different strategies work better than methods that have been useful in the past.
- Collaborative Learning and Integrated Mentoring in the Biosciences (CLIMB): This four-part oral communication lecture series tackles different strategies for delivering effective scientific presentations and collaborating with colleagues in medical/scientific settings.
- Emotional Intelligence Consortium (EIC): This website is dedicated to the latest research, surveys, and other findings related to EQ.
- ‘It’s Not Your Mouth That Speaks Volumes’: This article from Bloomberg Businessweek explores some effective strategies for improving body language and communicating with professional colleagues.
- Listening First Aid: an Empathic Approach: This 15-part podcast series from the University of California explores ways for adults to be more active listeners within a professional setting.
- Physician cultural competence: Cross-cultural communication improves care: This 2014 report from the Cleveland Clinic Journal of Medicine explores trends and findings related to treatment and healthcare of minority groups in the United States.
- Leadership Academy: This blog from Nursing Times features posts that discuss ways to foster an environment of collaboration and creative problem-solving within medical workplace environments.