Articles
Introduction
Nurses are entrenched in a complex system of clinical relationships some of which include nurse-nurse, nurse-patient and nurse-physician. Communication forms the basis for these relationships and depends on the nurse’s ability in listening, assimilating, interpreting, discriminating, gathering and sharing of information within dynamic systems comprising of various disciplines and hierarchies. Communication is complex encompassing skill, emotion, cognition and value. Formulation and implementation of daily care plans are among the most vital patient related communications. These activities call for shared responsibility in order to enhance clear, concise, relevant and timely exchange of patient information across disciplines usually in chaotic environments. Lack of effective communication between patients, families and the healthcare team is one of the leading causes of medical errors. It also accounts for over 60% of sentinel event causes reported to the joint commission on accreditation of healthcare organizations since 1995 (Manning, 2006).
Relationships provide a foundation for building communication. Relationships change over time and vary between and among nurses as well as other members of the healthcare team. It is quite difficult to develop and nurture clinical relationships in dynamic healthcare environments because there is less opportunity. For instance, an initial encounter with a nurse may occur when there is a need to contact an unfamiliar physician to offer assistance in an emerging critical event. It is not easy to trust unknown colleagues on judgment, decision-making and clinical knowledge. The patterns of communication are highly variable. The factors that influence these communication factors consist of individual style differences, education, gender, previous experiences, perspectives, culture, fatigue, stress, social structures and established hierarchies. Environments for clinical care are often noisy, hectic and full of interruptions especially in common places (Miller, 2006). Conversation avoidance devices like personal digital assistants, audiotape players, text pagers and cell phones interfere with the ability of nurses to listen to other people. It is therefore worth noting that the complexity of clinical communication increases the chances of communication failure and hence resulting to inadvertent patient harm. However, adoption of certain standardized approaches and tools can provide solutions to the improvement of clinical communication, which in turn prevents medical errors (Manning, 2006). This paper will focus on what other people have written regarding the task focused and patient centered communication behaviours in the nursing field, particularly within the context of the United States.
Patient Centered Communication Behavior
Patient-centered communication (PCC) refers to a group of communication behaviors and strategies, which enhance mutuality, shared understandings and consequently shared decision making in day-to-day encounters of healthcare (Brown, 1999). It enables the patients to influence and participate in their healthcare. PCC is the root of patient-centered healthcare (Stein-Parbury, 2009). Patient-centered healthcare involves the provision of care that respects and responses to patient’s needs, preferences, and values while ensuring the guidance of patient values in all clinical decisions (Brown, 1999). A patient-centered approach to healthcare shifts the focus of nurses from a task orientation to patient-centeredness where the values and needs of patients are considered. Patient-centered care makes communication and relationship with patients the basis for nursing practice. A recent research study into experiences of patients with nurses’ communication points out that nurses focus more task as opposed to communicating with patients. This shows that not much has changed towards embracing the patient-centered approach and perhaps many healthcare institutions still lack practices and systems that present the core values of patient-centered care (Stein-Parbury, 2009).
The Institute of Medicine identified patient-centeredness as one of the specific aims in the carrying out the project of restructuring the American healthcare (Institute of Medicine, 2001). There is evidence indicating the use of certain patient-centered strategies by advanced nurses and patients in clinical practice to co-produce clinical discourse that are highly individualized (Brown, 1999). A study was conducted at a big children’s hospital in order to determine the extent to which PCC affects satisfaction with both communication and care. The study required parents of child patients to report on the communication practices of nurses, physicians and other hospital team members during their latest stay in the hospital. The results of the study linked the use of PCC behaviors, particularly immediacy and perceived listening to the satisfaction with communication and care. Additionally, the study indicated a frequent use of PCC behaviors with children in better health than those on poorer health status. Generally, a few people enjoy receiving healthcare because they often get distressed whenever they visit physicians. Patient anxiety may result from lack of supportive and patient-oriented communication behaviors among the healthcare providers (Wanzer, Booth-Butterfield, & Gruber, 2004).
Many government policies and initiatives have promoted service-user involvement and patient-centered communication as basic concepts in the delivery of high-quality healthcare. The World Health Organization (WHO) also encourages these initiatives by incorporating indicators of health services responsiveness, which is a combination of health system effectiveness and patient satisfaction, in its World Health Reports (Jones, 2006). For instance, some major policy programs have recently resolved to focus on patient-centered communication importance between patients and health professionals in delivering initiatives like shared decision-making (Institute of Medicine, 2001). In addition, various nursing literature have reflected and supported these initiatives. The assimilation of these concepts in both literature and health policy to enhance nursing practices raises questions as to what constitutes suitable and effective clinical communication. This scenario calls for more research concerning nurse communication practices as they transpire in clinical practice (Jones, 2006).
Among the limitations of research on nurse-patient interaction is the lack of work that sufficiently explores communication styles in natural clinically based conversations between patients and nurses rather than collecting research data from focus group discussion and staged interviews with nurses or interactions between nurses and the patients’ family members. Aled Jones from School of Health Science, Swansea University, United Kingdom, collected and analyzed research data from student-patient interactions in order to gain some insights into the present interaction practices between student nurses and patients. At the end of the study, he concluded that students experience difficulty in applying the principles of effective communication learnt from the classroom into their individual interactions with patients (Jones, 2006).
According to Amy Wilson-Stronks, the health disparities project director-Division of Quality Measurement and Research, New York, the patient centered communication standards produced by The Joint Commission ( TJC) will go a long way in supporting the work being undertaken by Patient Education Managers (PEMs). PEMs have been advocating for writing of patient materials using clear language and communication techniques that enable patients to understand their respective medical conditions, treatment options and how they would comply with a treatment plan. Dialogue between the healthcare provider and the patient is a prerequisite for positive health outcomes (Wilson-Stronks, 2010). One of the new standards established by TJC, the United States organization that certifies healthcare organizations (Krautscheid, 2008), describes dialogue as a two-way conversation where the healthcare providers provide information to patients in an understandable manner while allowing them to provide their own information as well. Effective communication in healthcare requires providers to learn appropriate education techniques like avoiding medical jargons and using plain language. It is also necessary to use examples in communicating including the use of diagrams, models and pictures to demonstrate procedures and conditions (Wilson-Stronks, 2010).
Use of Simulation in Nursing Education
Improvements in healthcare require integration of academia and practice to bridge nursing education gaps and help in the accomplishment of quality outcomes. Technological explosion has brought about tremendous changes in various sectors of life including nursing (Connor, 2009). Human patient simulation is a technology that allows nurses and other healthcare team members to refine and apply their skills in real clinical situations and take part in their learning experiences as a way of meeting their educational needs. Simulated clinical situations similar to actual clinical environments help clinicians to gain experiences, learn skills and develop competencies in a planned and prescribed manner (Kobokovich & Beyea, 2004). A human patient simulator is a very sophisticated and technologically advanced mannequin in infant, child or adult size. They completely integrate with computer software that enhances the development of pre-planned situations resembling a wide range of clinical situations. Majority of human patient simulators possess anatomically correct pulses; produce heart, lung and bowel sounds; and respond to pharmacological and medical interventions with anticipated physiological responses. It is possible to program these simulators to speak hence enabling interactions with clinicians, as is the case with actual patients. Human patient simulators are equipped with different features that support various learning experiences. For instance, some simulators allow for the application of wound or trauma care kit or insertion of a chest tube. Such features support the ability of educators to develop learning scenarios that address different clinical needs or problems (Kobokovich & Beyea, 2004).
Simulation proves to be a suitable strategy for teaching safe clinical practices in nursing education. However, there are barriers to the strategy such as space, cost and faculty resources. Computer-based social simulations demands less resource and are effective in developing skills in critical thinking. A pilot study was carried out to compare resource demand and learning outcomes of students for computer-based versus traditional simulations. The results of the study suggested that the computer-based simulations are an efficient and effective learning strategy for developing patient-centered care competencies (McKeon et al., 2009). Hence, simulation is the mainstay for clinical learning in nursing education, particularly in areas regarding to safety, team building, problem solving and communication (Tanner, 2006).
Another study was conducted to assess the usefulness of clinical simulations in improving self-efficacy of nursing students in clinical skills as a preparation for real clinical experiences. The analysis of the study data suggested that experiences with clinical simulations could be effective in boosting the self-efficacy of students in patient care. The study also supports the use of clinical simulations in preparing students for real clinical experiences. Due to the current limited availability of clinical placements for undergraduate students in nursing, the clinical simulations offer a suitable option for equipping students with practical skills within a safe environment, without harm to living patients (Bambini, Washburn, & Perkins, 2009). A certain study sought to explore the effects of high-fidelity simulations on the development of clinical judgments in students. The study’s conclusion was that high-fidelity simulation offer students a forum for advancing their skills in clinical judgment although there is a need for more research on the same (Lasater, 2007).
Nursing programs need to graduate nurses who are ready for practice and who show quality and safety in patient care as well as interdisciplinary communication. A faculty used structured clinical assessment simulations to conduct a quality improvement project in the attempt to evaluate the ability of every nursing student to perform in various aspects of patient care including effective communication with physicians through telephone in emergent situations. The project involved results reporting of a three-year evaluation of undergraduate student nurse performance. Alterations in teaching-learning strategies, which comprised of integration of a standardized communication tool, resulted in improvement of student competency. Communication is essential in providing quality and safe healthcare and this emphasizes the need to ensure preparation and assessment of communication competency for all nursing students before exiting their study programs (Krautscheid, 2008). It is noteworthy, therefore, that simulations play an important role in equipping and assessing nursing students for necessary skills and experiences and thereby promoting patient-centered care.
Quality and Safety Education for Nurses (QSEN)
The issues of safety and quality identified in the healthcare system of the United States have led to a call to modify healthcare education to prepare graduates to work in teams and within healthcare systems that encourage patient safety. The funding by the Robert Wood Johnson Foundation enabled the American Association of Colleges of Nurses and a National Nursing Advisory Board to create six nursing competencies for Quality and Safety Education for Nurses (QSEN). This include patient-centered care, evidence based practice, teamwork and collaboration, quality improvement, safety, and informatics. The competences presented a systematic pedagogical structure for redesigning of course content in order to prepare nursing students to uphold safety and quality while caring for patients. The course redesigning integrated various active learning modalities including simulation, which is ideal for implementing QSEN due to its multiple levels of skills, knowledge and attitudes that are possible to practice and evaluate in each competency (Brady, 2011).
The National Organization of Nurse Practitioner Faculties (NONPF) issues documents that outline the anticipated competencies for nurse practitioner practice to make sure that every nurse practitioner is ready for delivery of safe and high quality healthcare. There are frequent assumptions that quality and safety, in resemblance to patient-centered healthcare, are central to nursing teaching and practice. Conversely, new insights on safety and quality of patients are now on the forefront via the national commission secretaries highlighting the magnitude of this problem in the present healthcare system. The Institute of Medicine challenged nursing and medicine faculties to embark upon educational experiences to ensure adequate preparation of all graduates at all levels for the delivery of patient-centered care with a greater emphasis on evidence-based practice, informatics and quality improvement (Pohl et al., 2009).
Many national commissions have documented substantial problems associated with quality and safety in the healthcare system of the United States. The conclusion from reports of multiple national committees is that providers ought to possess a set of competencies that are different from those developed in the existing educational programs. Health professionals that use scientific evidence have to describe the constituents of good care, identify and if possible close loopholes in good care, and be acquainted with the activities they can initiate. Ideas, execution and will are necessary to incorporate the mentioned competencies in nursing education. Nursing has no agreed competencies to apply to all nurses, unlike medicine, which has IOM competencies in place. Nevertheless, at the centre of nursing lies an incredible historical will to guarantee safety and quality for patients. This is evident in nursing publications, accreditation guidelines and standards of practice. The American Association of Colleges of Nursing Task Force on the Essential Patient Safety Competencies for Professional Nursing Care lately completed an improvement to the Essentials of Baccalaureate education for Professional Nursing Practice to incorporate exemplars of safety and quality competencies. The only challenge to this initiative is the lack of teaching materials, teaching strategies as well as the learning assessment techniques with the exception of schools claiming to execute comprehensive safety and quality curriculum (Cronenwett, 2007).
Task-Focused Communication Behaviors
Task-focused communication refers to behaviors that are necessary for assessment and problem solving. It involves conversations between patients and healthcare providers whose primary interest is to gather information to help in providing care for the patient. Task-focused communications can be being either formal or informal. Formal conversations encompass admission interviews, discussions of advance directives, health assessments or patient-family education. In this kind of conversation, the healthcare provider initiates the interaction with a specific intention of gathering information that will help in diagnosing or treating the patient’s problems. On the other hand, informal conversations can involve asking of simple questions by the nurse such as, “What do we offer you for your meal today?” Like in formal conversations, the focus of informal conversations is to obtain information needed for caring for the patient. In both cases, the healthcare provider initiates the conversation in order to know how best they care for the patient (Mauk, 2010).
