OFC 017 : COMMUNICATION SKILLS 2. THE OPEN UNIVERSITY OF TANZANIA.

1. INTRODUCTION

Communication is the activity of conveying information. Communication has been derived from the Latin word “communis,” which means “to share.” Communication requires a sender, a message, and an intended recipient. However, the receiver need not to be present or be aware of the sender's intent to communicate at the time of communication; thus, communication can occur across vast distances in time and space. Communication requires that the communicating parties share an area of communicative commonality. The communication process is complete once the receiver has understood the message of the sender. Feedback is critical for effective communication between parties.

Words are the most powerful drug used by mankind

—Rudyard Kipling

Communication is part and parcel of our day-to-day professional as well as social life. It is interwoven in all nursing activities and is an inseparable part of the nursing process. The nurse has to communicate patient information and other facts to the members of health care team to achieve health-related goals of the patient. Similarly, she has to communicate with the patients while assessing, planning, implementing, and evaluating nursing care.

Example: Mrs. Radhika is a newly appointed staff nurse who got her first posting in Coronary Care Unit. She is assigned to Mr. Anjuman who is suffering with congestive heart failure and was admitted two days before. At the time of routine ward round, the doctor prescribed tablet digoxin 0.25 mg OD. Unfortunately, the doctor's handwriting was very poor and he did not mention 0 (zero) before .25. Mrs. Radhika misunderstood it as 25 mg and administered the same dose (25 mg) to the patient. Although, she was in doubt about the correctness of the dose, but she did not clarify it with the doctor or with a senior colleague because of some reason. The patient developed severe bradycardia and dysponea after 20 minutes of administration of the drug. Fortunately, he survived because of immediate treatment provided to him for digoxin toxicity and bradycardia. In this situation, the question arises that why all this happened to Mr. Anjuman? The answer: it happened due to lack of communication between the nurse and doctor. When in doubt due to poor handwriting of doctor, she must verify the dose from the concerned doctor or senior staff. The doctor also requires improvement in his handwriting so that this type of medication errors can be avoided.

In India, this is the particular skill that needs to be emphasized among all nurses as available evidences suggest that majority of the Indian nurses either are poor in communication skills or are not using it effectively as a professional nurse due to a variety of reasons.

Communication is a skill that can be learned in the same way as other nursing skills. Indeed, it will require some training similar to other nursing skills to learn it effectively. In the context of nursing education, communication is considered as a teaching skill. Without communicating the intended learning outcomes and contents effectively to the learners, learning cannot take place. So, to deliver effective teaching, a nurse-teacher must be a good communicator, which requires the understanding of the process and techniques of communication.

3. PROCESS, ELEMENTS, AND CHANNELS OF COMMUNICATION

3.1. Process of Communication

Communication is a cyclic process that starts when the sender feels that there is a need to communicate with the receiver for a particular reason (purpose).

The sender creates a message either in the written or in verbal or nonverbal form. The message is dispatched to the receiver with the help of channels of communication. The receiver takes the delivery of the message and provides feedback to the sender. The sender gets the feedback and determines whether the receiver has received the same message and meaning that the sender had intended to communicate with him; if the sender feels that the receiver has not received the same message and meaning, he/she again initiates the cycle of communication (refer Figure 1.2).

Figure 1.2 Communication Process

3.2. Elements of Communication

On the basis of Figure 1.2, the elements of communication are as follows:

1. Sender
2. Message
3. Channel of communication
4. Receiver
5. Feedback

1. Sender: The sender is the person who initiates the process of communication. Whenever the sender feels that there is a need to communicate some information to the other person (receiver), he/she starts the process of communication. The sender must be aware of the purpose of the communication and the receiver's abilities to understand the message in terms of language, interest, etc.
2. Message: The message is created by the sender to convey the information, facts or opinion to the receiver. The message should be clear and simple so that the receiver can understand it in the same way as the sender desires. While creating a message, the sender should take care of words, language, and meaning of the message if the message is to be communicated in verbal or written form or he/she should take care of body language and facial expression if the message is to be communicated in nonverbal form, along with the abilities and professional competencies of the receiver.
3. Channels of communication: Communication channels are the medium through which the message is communicated to the receiver. Channels of communication play an important role in the process of communication. If the sender selects an appropriate medium or channel of communication, there are more chances that the receiver will receive the same message; or else, there are chances that the message may get distorted. In this hi-tech era, there are a number of channels that can be used to communicate message, e.g., mobile, e-mail, voice mail, person, radio, TV, Internet, blogs, etc. “Through proper channel” is a common phrase used among the nurse administrators/managers that signifies the importance of communication channels. For example, a student of B.Sc nursing, II year, wants to communicate hostel problems to the director of the institute. In order to reach to the intended receiver first, he/she should communicate his/her message in the form of written application to the class teacher; the class teacher will forward the application (message) to the principal and finally the principal will forward the application to the director. That is how communication through proper channel takes place. In this case, the class teacher and principal were the channels of communication through which the message was communicated to the receiver (director).
4. Receiver: The receiver is the person who receives the message. The receiver may be a single person or a group of persons. The receiver understands the meaning of the message and provides feedback to the sender. The receiver should have the same language ability, comprehension, and cultural background as the sender. If not, it may lead to distorted understanding of the meaning of the message by the receiver.
5. Feedback: It is the most crucial element of communication. It is provided by the receiver to the sender. Receiving feedback is important for the sender to know that the receiver has received the message and interpreted the meaning of the message in the desired way. Without feedback, the process of communication cannot be complete. For example, when you send a mobile SMS to your friend, you get feedback in the form of delivery report that informs you whether your message has been delivered or not to the intended receiver; it also happens in the same way in the case of e-mail.

   4. TYPES OF COMMUNICATION

   Communication may be of different types depending upon the context in which the term communication is used. The important types of communication are shown in Figure 1.3.

   
   

   
   

   
   

   Figure 1.3 Types of Communication

   4.1. Verbal Communication

   When the sender conveys information, facts, and opinion either verbally or in writing to the receiver using different channels of communication, it is known as verbal communication. The sender should select appropriate words and language to communicate the message to the receiver. Figure 1.4 highlights the guidelines that should be followed to make the verbal communication effective.

   
   

   
   

   
   

   Figure 1.4 Guidelines for Effective Verbal Communication

   4.2. Nonverbal Communication

   Nonverbal communication takes place without the use of words. Nonverbal communication involves the unconscious mind acting out emotions related to the verbal content, the situation, and the environment. The sender uses the body language, facial expression, hand movements, eye movements, etc. to convey the feelings, emotions, and other information to the receiver. This type of the communication can be useful when both the sender and the receiver don’t have an understanding of a common language. This technique of communication is especially useful when you are dealing with a client who is deaf and dumb.

   Knapp and Hall (2002) provided a list of the ways how nonverbal messages accompany verbal messages (Figure 1.5).

   
   

   
   

   
   

   Figure 1.5 Nonverbal Ways to Accompany Verbal Communication (Kappa and Hall, 2002)

   
   

   The interesting fact about nonverbal communication is that it reflects a more accurate description of one's true feelings because nonverbal reactions cannot be controlled easily by the people. Nonverbal communication may include:

   • Vocal cues
   • Gestures
   • Posture
   • Physical appearance
   • Distance or spatial territory
   • Position or posture
   • Touch
   • Facial expression

   4.3. Meta Communication

   Meta communication is an important and useful tool for the effective interpersonal interaction. It is “communication about communication” so that the deeper “message within a message” can be uncovered and understood (Wood, 1999). This type of method is useful among a group of experts in a particular area.

   4.4. Formal Communication

   Formal communication is a type of communication which is used in the context of organization where a large group of employees work together to accomplish goals of organization. Formal communications usually take place in the form of written communication, which follows the lines of authority or scalar chain of command.

   4.5. Informal Communication

   Informal communication refers to the gossip or informal talks that take place among the various groups of people working in an organization that don’t follow organizational line of authority or hierarchy.

   4.6. Therapeutic Communication

   Therapeutic communication is a type of communication that takes place in the health care environment between nurse and patient. Therapeutic communications is a planned, deliberate, and professional act that uses communication techniques to achieve a positive relationship and shared understanding of information for the desired patient-care goals. The purpose of therapeutic communication is to explore the client's problems, planning the interventions along with the client and implementing these interventions. During therapeutic communication, the nurse encourages the client to communicate fear, anxieties, expectations, and self-care deficit needs. The nurse uses special techniques while engaging in the therapeutic communication with the client, e.g., active listening, asking open-ended questions, paraphrasing, etc.

   5. LEVELS OF COMMUNICATION

   Levels of communication are determined on the basis of the number of people involved in the process of communication as well as on the purpose of communication. These levels of communication are depicted in Figure 1.6.

   
   

   
   

   
   

   Figure 1.6 Levels of Communication

   5.1. Intrapersonal Communication

   Intrapersonal communication refers to communication with the self. It may be silent or verbal type of communication. Intrapersonal type of communication approximates with the thinking process, in which the person consciously sends information to himself/herself in order to analyze a situation. This communication strategy is particularly useful when someone has to make important life decisions or is facing a conflicting situation. “Positive self-talk” is a type of intrapersonal communication that can be used as a tool to improve the nurses or client's health and self-esteem.

   5.2. Interpersonal Communication

   It refers to one-to-one interaction between two persons that often occurs face to face. The purpose of interpersonal communication is to share information, opinion, ideas, and so on (Figure 1.7). Interpersonal communication can be further divided into three types:

   
   

   
   

   
   

   Figure 1.7 Types of Interpersonal Communication

   5.2.1. Assertive Communication

   It is a type of interpersonal communication that has the following characteristics:

   • Confidently expressing what you think, feel, and believe.
   • Raising voice for your rights while respecting the rights of others.
   • Conveying meaning and expectations without humiliating or degrading others.
   • Based upon respect for you and respect for other people's need and rights.

   It is noteworthy here that, unfortunately most of the nurses are not using assertive communication in their professional life because of so many reasons. There is a need to change the current situation, and the responsibility lies on young budding nurses so that the professional image of the nurses can be improved in India.

   5.2.2. Nonassertive Communication

   Nonassertive communication is characterized as follows:

   • Inability to express consistently what you think, feel, and believe.
   • Allowing others to violate your rights without challenge.
   • Reflecting lack of respect for your own preferences.
   • Others can easily disregard your thoughts, feelings, and beliefs.

   It cannot be considered a good communication strategy for a professional nurse.

   5.2.3. Aggressive Communication

   Aggressive communication takes place when someone expresses himself/herself in ways that intimidate, demean, or degrade another person, pursuing what you want in ways that violate the rights of another person. It is considered as an unsuitable communication technique for a professional nurse.

   5.3. Transpersonal Communication

   Communication that occurs within a person's spiritual domain is referred as transpersonal communication. The purpose of transpersonal communication is to realize self-hood, enhance spirituality, and answer the questions that are spiritual in nature.

   5.4. Small-group Communication

   This type or level of communication takes place within a small group. The purpose of small-group communication is to communicate information that is of common interest to group members or sometimes to know the opinions of group members to arrive at a decision.

   5.5. Public Communication

   Public is usually considered as a large group of people or laypersons with a vast difference in a number of factors, e.g., socioeconomic status, literacy level, occupation, and habitat. Communication to public serves some purposes that benefit the common man (e.g., health education) or sometimes to make requests or to get favors from the public in general elections. Public communication requires special communication skills as the size of the group is very large with so many differences among the group members as described earlier. There is a need to maintain different types of eye contact with the public, gestures, and voices, and media materials should be used to communicate messages effectively.

   5.6. Social Communication

   Social communication takes place in the social context. Being a social animal, human beings establish relationship with other people to accomplish several purposes throughout their life span. In order to keep these social relations alive and being social, one has to communicate with others. “Good morning. How are you?” “How are your children?” This type of communication is one's social obligation to communicate within his/her social group to which he/she belongs.

   6. FACTORS INFLUENCING COMMUNICATION

   There are certain factors that influence the process of communication, which are described briefly here.

   6.1. Attitude

   Attitude is referred to the internal predisposition of a person to act in a certain way toward a situation. The attitude of a person toward the given situation is influenced by the peers, parents, environment, life experiences, perception, and intellectual processes. A person may have the attitude of accepting, prejudiced, judgmental, negative, open and close, etc.

   A person with negative attitude may respond with “I’m sure it is of no use, it will not work ultimately.” On the other hand, a person with positive attitude will reply “come on guys, let us try it, we have nothing to lose.”

   6.2. Sociocultural Background

   Various cultures and ethnic groups display different communication patterns. For example, people of French or Italian heritage often are gregarious and talkative and willing to share thoughts and feelings. People from Southeast Asian countries such as Thailand or Laos are quiet and reserved. They appear stoic and reluctant to discuss personal feelings with persons outside their families.

   6.3. Past Experiences

   Previous positive or negative experiences influence one's ability to communicate. For example, teenagers who have been criticized by parents whenever attempting to express any feelings may develop a poor self-image and feel that their opinions are not worthwhile. As a result, they may avoid interacting with others, become indecisive when asked to give an opinion, or agree with others to avoid what they perceive to be criticism or confrontation (nonassertive).

   6.4. Knowledge of Subject Matter

   A person who is well-educated or knowledgeable about certain topics may communicate with others at a high level of understanding. The receiver who is relatively less knowledgeable of the topic under discussion may be unable to comprehend the message or consider the sender to be an expert. As a result of this misperception, the receiver may neglect to ask questions and may not receive the correct information. For example, nurses are required to communicate with the patient in a language that is understandable to the patient (patient's native language). She is also required not to use jargons while delivering health education or some other useful information to the patient. The educational status of the patient must be taken into consideration while communicating with the patient.

   6.5. Ability to Relate with Others

   Some people are “natural-born talkers” who claim to have “never met a stranger.” Others may possess an intuitive trait that enables them to say the right thing at the right time and relate well to people. “I feel so comfortable talking with her,” “She is so easy to relate to,” and “I could talk to him for hours” are just a few comments made about people who have the ability to relate well with others. These persons are considered as good communicators.

   6.6. Interpersonal Perception

   Interpersonal perceptions are mental processes by which intellectual, sensory, and emotional data are re-organized logically and meaningfully, which determine how we perceive others. Inattentiveness, disinterest, or lack of use of one's senses during communication can result in distorted perceptions of others. Satir (1995) warns of looking without seeing, listening without hearing, touching without feeling, moving without awareness, and speaking without meaning. The following passage reinforces the importance of perceptions: “I know that you believe you understand what you think I said, but I’m not sure you realize that what you heard is not what I said.”

   6.7. Environmental Factors

   Environmental factors such as time, place, number of people present, and noise level can influence communication between people in that particular surrounding. Timing is important during a conversation; a very well-timed response catches the attention of others. The place in which communication occurs, as well as the number of people present and noise level, has a definite influence on interactions among people )Figure 1.8).

   
   

   
   

   
   

   Figure 1.8 Factors Influencing Communication

   7. BARRIERS OF COMMUNICATION

   Communication plays a major role in developing a relationship. It can also affect the relationship among family members or management in any institute. More specifically, communication influences the effectiveness of instruction, performance evaluation, and the handling of discipline problems. Communication should be straightforward. What can make it complex, difficult, and frustrating are the barriers. Some barriers of communication are the following.

   7.1. Physiological Barrier

   Physiological barriers to communication are related with the limitations of the human body and the human mind (memory, attention, and perception). Physiological barriers may result from individuals’ personal discomfort, caused by ill-health, poor eye sight, or hearing difficulties.

   7.1.1. Poor Listening Skills

   Listening to others is considered a difficult task. A typical speaker says about 125 words per minute. The typical listener can receive 400–600 words per minute. Thus, about three-fourth of listening time is free time. The free time often sidetracks the listener. The solution is to be an active rather than passive listener. A listener's premature frown, shaking of the head, or bored look can easily convince the other person/speaker that there is no reason to elaborate or try again to communicate his/her excellent idea.

   7.1.2. Information Overload

   Nurses are surrounded with a pool of information. It is essential to control the flow of the information, else the information is likely to be misinterpreted or forgotten or overlooked. As a result, communication may get distorted.

   7.1.3. Inattention

   At times, we just do not listen but only hear. For example, your boss is immersed in his/her very important paper work surrounded by so many files on the table and you are explaining him/her about an urgent office problem. In this situation, due to the inattention, the boss will not listen to you (he/she will only hear you); hence, he/she may not get what you are saying and it may lead to disappointment.

   7.1.4. Emotions

   The emotional state of a person at a particular point of time affects his/her communication with others as it has an impact on the body language (nonverbal communication). If the receiver feels that the sender is angry (emotional state), he/she can easily infer that the information being obtained will be very terrible. Emotional state causes some physiological changes in our body that may affect the pronunciation, pressure of the speech, and tone of the voice of the sender as well as the perception, thinking process, and information interpretation of the receiver during verbal communication.

   7.1.5. Poor Retention

   Human memory cannot function beyond a limit. One cannot always retain all the facts/information about what is being told to him/her especially if he/she is not interested or not attentive. This leads to communication breakdown.

   7.2. Physical and Environmental Distractions

   Physical distractions are the physical things that get in the way of communication. Examples of such things include the telephone, an uncomfortable meeting place, and noise. These physical distractions are common in the hospital setting. If the telephone rings, the usual human tendency will be to answer it even if the caller is interrupting a very important or even delicate conversation. Distractions such as background noise, poor lighting, uncomfortable sitting, unhygienic room, or an environment that is too hot or cold can affect people's morale and concentration, which in turn interfere with effective communication.

   7.3. Psychological Barrier

   Psychological factors such as misperception, filtering, distrust, unhappy emotions, and people's state of mind can jeopardize the process of communication. We all tend to feel happier and more receptive to information when the sun shines. Similarly, if someone has personal problems such as worries and stress about a chronic illness, it may impinge his/her communication with others.

   7.4. Social Barriers

   Social barriers to communication include the social psychological phenomenon of conformity, a process in which the norms, values, and behaviors of an individual begin to follow those of the wider group. Social factors such as age, gender, socioeconomic status, and marital status may act as a barrier to communication in certain situations.

   7.5. Cultural Barriers

   Culture shapes the way we think and behave. It can be seen as both shaping and being shaped by our established patterns of communication. Cultural barrier to communication often arises when individuals in one social group have developed different norms, values, or behaviors to individuals associated with another group. Cultural difference leads to difference in interest, knowledge, value, and tradition. Therefore, people of different cultures will experience these culture factors as a barrier to communicate with each other.

   7.6. Semantic Barrier

   Language, jargon, slang, etc., are some of the semantic barriers. Different languages across different regions represent a national barrier to communication, which is particularly important for migrating nurses. Use of jargon and slang also act as barrier to communication. For example, while delivering health education to a cardiac patient, if a cardiac nurse uses jargons such as “coronary artery disease,” “anticoagulants,” and “homocysteine and C-reactive proteins,” the patient will listen attentively as he/she cannot understand these medical jargons. Therefore, she is required to use simple words “heart ki nadi ki bimari,” “khoon patla karne ki dawai,” and “certain chemicals in our body” so that the patient can understand what the nurse is supposed to communicate with him/her.

   7.7. Linguistic Barriers

   Individual linguistic ability may sometimes become a barrier to communication. The use of difficult or inappropriate words in communication can prevent the people from understanding the message. Poorly explained or misunderstood messages can also result in confusion. The linguistic differences between the people can also lead to communication breakdown. The same word may mean differently to different individuals. For example, consider a word “face.”

   • He is facing a problem
   • What is the face value of this share bond?
   • Your face is oval shape

   “Face” means differently in different sentences. Communication breakdown occurs if there is wrong perception of the meaning of the message by the receiver.

   7.8. Past Experience

   If someone has awful experiences in the past related to some particular situation, then he/she will try to avoid communication in that situation. For example, a staff nurse who, while providing detailed information regarding the patient care at the time of routine clinical round to her boss, is always facing negative body language and discouraging words from her boss will ultimately limit her communication to the boss at that time.

   7.9. Organizational Barriers

   Unclear planning, structure, information overload, timing, technology, and status difference are the organizational factors that may act as barriers to communication.

   7.9.1. Technological Failure

   Message not delivered due to technical failure (e.g., receiver was not in mobile network area and the sender has not activated delivery report in message setting).

   7.9.2. Time Pressures

   Often, in organization the targets have to be achieved within a specified time period, the failure of which may have adverse consequences for the employee. In a haste to meet deadlines, usually an employee tries to shorten the formal channels of communication that can lead to confusion and misunderstanding among the various levels of supervisors, hence leading distorted communication. Therefore, sufficient time should be given for effective communication.

   7.9.3. Complexity in Organizational Structure

   Greater the hierarchy in an organization (i.e., the more the number of managerial levels), more are the chances of communication getting destroyed. Only the people at the top level can see the overall picture while the people at low level just have a knowledge about their own area and a little knowledge about other areas of the organization.

   7.10. Barriers Related with the Message

   7.10.1. Unclear Messages

   Effective communication starts with a clear message. Unclear messages in terms of meaning, grammar, and words may act as a barrier to communication because the receiver may not be able to intercept the actual meaning of the message.

   7.10.2. Stereotypes

   Stereotypes are beliefs or generalizations about characteristics or qualities that are felt to be typical of a particular group (Funk & Wagnalls, 1966). Stereotyping is a barrier to communication because people with stereotype thoughts either will not read the message completely or will not read it at all because of their thinking that they already know everything (Figure 1.9).

   
   

   
   

   
   

   Figure 1.9 Barriers to Communication

   7.10.3. Inappropriate Channel

   Variation of channels helps the receiver understand the nature and importance of a message. While making a choice for a channel of communication, the sender needs to be sensitive to such things as the complexity of the message; consequences of a misunderstanding; knowledge, skills, and abilities of the receiver; and immediacy of action to be taken from the message.

   7.10.4. Lack of Feedback

   Feedback is the mirror of communication. Feedback mirrors what the sender has sent. Without feedback, communication cannot be considered complete. Both the sender and the receiver can play an active role in using feedback to make communication truly two-way.

   7.11. Some Other Blocks to Communication

   • Failure to listen: Communicator may or may not feel able to speak freely to the listener, if the listener is not listening carefully or not responding.
   • Conflicting verbal and nonverbal messages.
   • Failure to interpret with knowledge.
   • Changing the subject: A quick way to stop conversation is to change the subject.
   • Inappropriate comments and questions: Certain types of comments and questions should be avoided in most situations because they tend to impede effective communication, e.g., close-ended questions and using comments that give advice.

   8. METHODS OF OVERCOMING BARRIERS OF COMMUNICATION OR FACILITATING COMMUNICATION

   Overcoming the communication barriers requires a vigilant observation and thoughts of potential barriers in a particular instance of communication. State all the anticipated barriers that may have impact on your day-to-day communication. Strategies to overcome barriers will be different in different situations depending upon the type of barriers present. Following are some of the important general strategies that will be commonly useful in all the situations to overcome the barriers of communication.

   • Taking the receiver more seriously
   • Crystal clear message
   • Delivering messages skillfully
   • Focusing on the receiver
   • Using multiple channels to communicate instead of relying on one channel
   • Ensuring appropriate feedback
   • Be aware of your own state of mind/emotions/attitude

   8.1. Facilitators of Communication

   In addition to removal of specific barriers to communication, the following general guidelines may be helpful to facilitate communication:

   • Have a positive attitude about communication. Defensiveness interferes with communication.
   • Work at improving communication skills. The communication model and discussion of barriers to communication provide the necessary knowledge to improve communication. This increased awareness of the potential for improving communication is the first step to better communication.
   • Include communication as a skill to be evaluated along with all the other nursing skills for undergraduates.
   • Make communication goal oriented. Relational goals come first and pave the way for other goals. When the sender and receiver have a good relationship, they are much more likely to accomplish their communication goals.
   • Experiment with communication alternatives. What works with one person may not work well with another. Use diverse communication channels, listening and feedback techniques.
   • Accept the reality of miscommunication. The best communicators fail to have perfect communication. They accept miscommunication and work to minimize its negative impacts.
   • Use of simple and clear words should be emphasized. Use of ambiguous words and jargons should be avoided.
   • Noise is the main communication barrier in most of the health care settings, which must be handled on priority basis. It is essential to identify and eliminate the source of noise.
   • Listen attentively and carefully. There is a difference between “listening” and “hearing.” Active listening means hearing with a proper understanding of the message. By asking questions, the speaker can ensure whether his/her message is understood or not by the receiver in the same manner as intended by him.
   • The organizational structure should be simple to facilitate communication between various hierarchy levels. The number of hierarchical levels should be optimum, and there should be an ideal span of control within the organization. Simpler the organizational structure, more effective will be the communication.
   • The managers should know how to prioritize their work. They should not overload themselves with the work, should spend quality time with their subordinates, and should listen to their problems and feedbacks actively.

   There are 6 C's of effective communication, which are applicable to both written and oral communication. They are as follows:

   1. Complete—The message must be complete in all respect and should convey all facts required by the receiver. Incompleteness of the message may lead to misunderstanding or incomplete understanding and confusion between the sender and the receiver. It is the responsibility of the sender to make sure (before mailing the message) that the information provided in the message is complete as per the purpose of the communication.
   2. Clear—Clarity in communication makes understanding easier and enhances the meaning of a message. A clear message uses exact, appropriate, and concrete words and avoids ambiguous words.
   3. Correctness—Correctness in communication implies that there are no grammatical and spelling errors in communication.
   4. Concise—Conciseness means eliminating wordiness and communicating what you want to convey in least possible words without forgoing the other C's of communication. Conciseness is a necessity for effective communication.
   5. Consideration—Consideration implies “stepping into the shoes of others.” Effective communication must take the receiver/s into consideration (i.e., the audience's viewpoints, background, mindset, education level, etc.). The sender should make an attempt to understand the audience, their requirements, emotions, as well as problems. Ensure that the self-respect of the audience is maintained and their emotions are not hurt.
   6. Courtesy—Courtesy in message implies that the message should show the sender's expression as well as respect to the receiver. The sender of the message should be sincerely polite, judicious, reflective, and enthusiastic (Figure 1.10).

   
   

   
   

   
   

   Figure 1.10 6 C's of Communication

   8. METHODS OF OVERCOMING BARRIERS OF COMMUNICATION OR FACILITATING COMMUNICATION

   Overcoming the communication barriers requires a vigilant observation and thoughts of potential barriers in a particular instance of communication. State all the anticipated barriers that may have impact on your day-to-day communication. Strategies to overcome barriers will be different in different situations depending upon the type of barriers present. Following are some of the important general strategies that will be commonly useful in all the situations to overcome the barriers of communication.

   • Taking the receiver more seriously
   • Crystal clear message
   • Delivering messages skillfully
   • Focusing on the receiver
   • Using multiple channels to communicate instead of relying on one channel
   • Ensuring appropriate feedback
   • Be aware of your own state of mind/emotions/attitude

   8.1. Facilitators of Communication

   In addition to removal of specific barriers to communication, the following general guidelines may be helpful to facilitate communication:

   • Have a positive attitude about communication. Defensiveness interferes with communication.
   • Work at improving communication skills. The communication model and discussion of barriers to communication provide the necessary knowledge to improve communication. This increased awareness of the potential for improving communication is the first step to better communication.
   • Include communication as a skill to be evaluated along with all the other nursing skills for undergraduates.
   • Make communication goal oriented. Relational goals come first and pave the way for other goals. When the sender and receiver have a good relationship, they are much more likely to accomplish their communication goals.
   • Experiment with communication alternatives. What works with one person may not work well with another. Use diverse communication channels, listening and feedback techniques.
   • Accept the reality of miscommunication. The best communicators fail to have perfect communication. They accept miscommunication and work to minimize its negative impacts.
   • Use of simple and clear words should be emphasized. Use of ambiguous words and jargons should be avoided.
   • Noise is the main communication barrier in most of the health care settings, which must be handled on priority basis. It is essential to identify and eliminate the source of noise.
   • Listen attentively and carefully. There is a difference between “listening” and “hearing.” Active listening means hearing with a proper understanding of the message. By asking questions, the speaker can ensure whether his/her message is understood or not by the receiver in the same manner as intended by him.
   • The organizational structure should be simple to facilitate communication between various hierarchy levels. The number of hierarchical levels should be optimum, and there should be an ideal span of control within the organization. Simpler the organizational structure, more effective will be the communication.
   • The managers should know how to prioritize their work. They should not overload themselves with the work, should spend quality time with their subordinates, and should listen to their problems and feedbacks actively.

   There are 6 C's of effective communication, which are applicable to both written and oral communication. They are as follows:

   1. Complete—The message must be complete in all respect and should convey all facts required by the receiver. Incompleteness of the message may lead to misunderstanding or incomplete understanding and confusion between the sender and the receiver. It is the responsibility of the sender to make sure (before mailing the message) that the information provided in the message is complete as per the purpose of the communication.
   2. Clear—Clarity in communication makes understanding easier and enhances the meaning of a message. A clear message uses exact, appropriate, and concrete words and avoids ambiguous words.
   3. Correctness—Correctness in communication implies that there are no grammatical and spelling errors in communication.
   4. Concise—Conciseness means eliminating wordiness and communicating what you want to convey in least possible words without forgoing the other C's of communication. Conciseness is a necessity for effective communication.
   5. Consideration—Consideration implies “stepping into the shoes of others.” Effective communication must take the receiver/s into consideration (i.e., the audience's viewpoints, background, mindset, education level, etc.). The sender should make an attempt to understand the audience, their requirements, emotions, as well as problems. Ensure that the self-respect of the audience is maintained and their emotions are not hurt.
   6. Courtesy—Courtesy in message implies that the message should show the sender's expression as well as respect to the receiver. The sender of the message should be sincerely polite, judicious, reflective, and enthusiastic (Figure 1.10).

   
   

   
   

   
   

   Figure 1.10 6 C's of Communication

   9. TECHNIQUES OF EFFECTIVE COMMUNICATION

   Effective communication techniques are useful to make the communication efficient and meaningful. There are several techniques of effective communication, which can be used as per the context and type of communication. For example, maintaining eye-to-eye contact with the listener is essential for effective communication while communicating with a single person or a small group of people. However, the technique of eye-to-eye contact has to be used in a different way while communicating with a large group of audience. Similarly, some people are considered experts to communicate bitter information quite comfortably, whereas, others may feel difficulty because they don’t know how to communicate in such a situation. Likewise, some people communicate the message straightforward without providing unnecessary detailed background information, whereas, others may provide detailed background information before communicating the main fact. Techniques of communication used by an individual are determined by the family environment, culture, life philosophy of the person, and various other factors. Being a nurse, you must learn how to communicate with the patient and the members of health care team effectively. Communication techniques are often the key to climb up the professional ladder, and the budding nurses should master the skills earlier in their career to be a successful nurse. Given below are some of the communication techniques that should be used by nurses in a health care setting.

   9.1. Listening Actively

   To listen closely and reply well is the highest perfection we are able to attain in the art of conversation

   —La Rochefoucauld

   Listening actively means to be attentive to what the other person is saying verbally and nonverbally. Active listening is an effective communication skill for therapeutic communication, which must be practiced and mastered by every professional nurse. Several nonverbal behaviors can facilitate the skill of active listening which are as follows:

   1. Sit squarely facing the other person, establish eye-to-eye contact.
   2. Keep the posture open.
   3. Lean forward toward the client.
   4. Be relaxed.
   5. Concentrate on what the other person is saying.
   6. Restating what the other person said and showing him that you’re listening.

   9.2. Use Silence

   Silence during communication process can carry a variety of meanings. It provides an opportunity to the communicator to explore his/her inner thoughts or feelings comfortably that will be required to facilitate the communication.

   9.3. Observe Nonverbal Behavior of the Client

   Nonverbal cues are more important than the verbal message because 60 percent of the impact from every conversation you have comes from your nonverbal cues. These include eye contact, your posture, and the gestures you make.

   The nonverbal cues indicate what you think, even if your words say something else entirely. Some people don’t like to be touched, and invasion to their personal space is one nonverbal cue you can easily avoid to facilitate communication. Nonverbal cues are just as important as any other communication technique you’re trying to master.

   9.4. Tone and Words

   It is observed by communication experts that 30 percent of what you actually mean while communicating something is determined by the tone of your voice. For example, if you say that “You’ll be happy to sacrifice this opportunity for someone,” but you’re yelling when you say it, the other person will clearly notice that you’re actually not happy to do it. Only 10 percent of the real meaning of your conversation is usually determined by the actual words you use. Therefore, having a big vocabulary is less important to the communicative process than having the right hand signals and facial expressions.

   9.5. Be Consistent Verbally and Nonverbally

   Inconsistency in verbal and nonverbal communication by the sender may lead to confusion and misunderstanding of the message on the part of the receiver (Figure 1.11).

   
   

   
   

   
   

   Figure 1.11 Determinants of Verbal Communication

   9.6. Ask Open-ended Questions

   Open-ended questions encourage the client to communicate more and more, whereas, close-ended questions discourage the communication. For example, “What are your food preferences?” is an open-ended question, whereas, “Do you like Dalia Khichdi?” is a close-ended question.

   9.7. Use Language Understood by the Patient

   The patient will not respond until and unless you are not using the same language as understood by the patient. For example, you are not supposed to use Tamil while communicating with a patient who belongs to Karnataka.

   9.8. Restating

   Let the client know whether an expressed statement has or has not been understood. For example, “You told me that, you are constipated since the last two days.”

   9.9. Reflecting

   This directs questions or feelings back to client so that they may be recognized and accepted.

   9.10. Focusing

   This takes notice of a single idea or even a single word. For example, “You told me that, your father was suffering from a chronic illness, which type of chronic illness it was?” Here, the nurse is focusing on chronic illness as mentioned by the client about his father.

   9.11. Exploring

   This delves further into a subject, idea, experience, or relationship. For example, “You told me that your father was not a good person, why do you think so?”

   9.12. Giving Broad Openings

   This allows the client to select the topic.

   9.13. Offering General Leads

   This encourages client to continue.

   9.14. Making Observations

   Verbalize what is observed or perceived.

   9.15. Encouraging Description of Perceptions

   Ask the client to verbalize what is being perceived.

   9.16. Encouraging Comparison

   Ask the client to compare similarities and differences in ideas, experiences, or interpersonal relationships.

   9.17. Seeking Clarification and Validation

   Strive to explain what is vague and search for mutual understanding.

   Warmth and friendliness, openness and respect, and providing personal space are some other important communication skills.