#31350: Communication and Soft Skills in Nursing Practice

The first thought that comes to mind when discussing communication is talking—verbal communication. However, effective communication involves much more than just talking. It takes place on many different levels and has many different variables.

Communication between healthcare professionals and within interdisciplinary teams helps to facilitate treatment planning, patient care, and patient/family education. Consistently communicating with patients, other nurses, physicians, physical and occupational therapists, pharmacists, social workers, and case managers is an everyday part of nursing. This communication may take place via in-person conversations, e-mail, telephone, text, or instant messaging. How a nurse communicates is important because it can avoid (or cause) miscommunications, misinterpretations, or misunderstandings. Different types of communication will be discussed in detail later in this course, along with guidelines for communication-enhanced nursing education, workplace engagement, patient care, and interprofessional collaboration.

Attitude is defined as reactions to events, objects, or situations, and a professional attitude is the manner in which one conducts themselves in a workplace [3]. A positive professional attitude is necessary for efficacy and productivity and also plays a key role in professional identity. Research indicates that professional attitudes and compassion are correlated [3]. One study surveyed 349 nurses in Turkey using the Inventory of Professional Attitude at Occupation (IPA) questionnaire and the Compassion Scale [3]. Nurses' scores in measures of kindness, common humanity, and mindfulness increased as their professional attitude scores also increased; conversely, measures of indifference, separation, and disengagement subscales increased when professional attitudes scores were low. Certain factors were associated with variability in professionalism scores, including weekly working time, satisfaction with colleague relationships, suitability of the nursing profession, and working in specific settings (e.g., emergency department, outpatient clinics) [3].

Attitudes can be positive, neutral, or negative and have explicit (conscious) and implicit (unconscious) characteristics. There are three components of attitude: affective, cognitive, and behavioral. Attitudes are expressed through thoughts, feelings, and actions and are formed from a variety of influences, including previous experience, social factors, learning, conditioning, and observations [4]. Often influenced by previous experiences or upbringings, attitude can have powerful impact on the development of biases, behaviors, and actions. While attitudes can change, they are often persistent [4].

Some of the best careers are built around networking. Having large networks can provide nurses and other healthcare professionals with unique learning and professional opportunities. Building professional networks and relationships facilitates new jobs and career paths, allowing for the exploration of opportunities that may not be available otherwise [5].

Networking involves connecting with others on professional and, in some cases, personal levels. It can result in nurses building long-term and fulfilling relationships. It can be easier to build these types of relationships when one lives in the moment and is mindful of the skills and opportunities others may provide—as well as the opportunities one can offer to others. Networking requires active listening, which can be practiced in five steps [5]:

Networking should be a consistent piece of the professional role. It is ideal to build a professional network before it becomes a necessary part of seeking a new professional opportunity. Attending networking events and reaching out on social media professional networks are great ways to build personal and professional networks [5].

Critical thinking is defined as actively and skillfully analyzing and evaluating information through observation, and making a decision for action [6]. Critical thinking is essential in nursing practice but is applied in all healthcare professions. In order to learn critical thinking, professionals should develop independence in thought, fairness, perspicacity, humility, and integrity [6]. There should also be an interest in research. Critical thinking is important to provide safe, effective, skilled patient care.

Healthcare professionals should adopt a critical-thinking perspective and refine critical reasoning skills in order to meaningfully assess old and new evidence. In cases of limited resources, critical-thinking skills support an ability to think and act quickly and efficiently.

Critical-thinking skills are broad and include critical analysis, introductory and concluding justification, valid conclusion, distinguishing facts and opinions, clarification of concepts, and recognition of conditions [6]. The Socratic method, defined as a method of exploring dilemmas through argumentative dialogue, can be effective. The Socratic method is an ancient technique that was developed by Socrates to explore the underlying beliefs that shape opinions [7]. It is taught to help identify thought-provoking questions and to address these questions through shared dialogue or debate to demonstrate complexity and to tease out areas of similarity or agreement [7].

Critical thinking can aid in the development of several nursing skillsets [7]:

In the case of each of these types of skills, nurses should be able to make decisions based on the stages of decision making: recognition of purpose, definition of criteria, calculation, exploration and consideration of alternative solutions, design, implementation, and evaluation [7].

Professionalism reflects the values, respect, advocacy, and responsibility a healthcare professional must use in their field. The three main categories of professionalism are cognitive, attitudinal, and psychomotor [8].

Cognitive professionalism entails focusing on continuously learning about professional conduct and applying this knowledge to the work setting. Attitudinal professionalism involves exercising discretionary judgment, assessment, evaluation, and decision making, often in a highly complex situation and in collaboration with patients, colleagues, and managers. Psychomotor professionalism involves growing professionals—meaning, as experience grows, the nurse's professional skills and ability also grow [8].

The Registered Nurses' Association of Ontario (RNAO) established a nursing best practice guideline program that focuses partially on professionalism in nursing. This best practice guideline was developed to help individual practitioners reflect on their own situations, assist educators in relaying the concept of professionalism, and reinforce professionalism in nursing practice [9]. The guideline identifies eight attributes that comprise professionalism [9]:

Each of these attributes has a role in successfully building professionalism in the workplace [9].

Empathy is the ability to understand the personal experiences of others. Emotional, cognitive, and behavioral communication dimensions are all involved in empathy [10]. Research indicates that healthcare professionals with high levels of empathy can better fulfill their role in therapeutic change. However, while empathy is undeniably important, many healthcare providers find empathy difficult to adopt in everyday practice. In order to better support nursing development, empathy skills should be an aspect of the education and training of healthcare professionals and should be supported by continuing education [10]. Factors that influence empathy include age, self-reflection, appraisal, and emotions. It is important to note that empathy can be developed even without directly bonding.

A person-centered approach to communication and patient care requires empathy [10]. Empathy is multi-dimensional, involving cognitive, affective, and behavioral components. The affective aspect of empathy involves sincerity and congruency with others. Persons with this type of empathy offer assistance and support without stereotyping [10]. The cognitive dimension involves an availability and openness to understanding others' perspectives, including verbal and nonverbal cues. This has also been described as "taking a walk in someone else's shoes" [10].

The empathetic relationship of professionals with their patients builds rapport, ensures that patients are centered in decisions, and underpins therapeutic plans and interventions tailored specifically to the patient. Providing this type of care increases patient satisfaction. Following this path, quality of care is improved, errors are lessened, and an increased proportion of patients are compliant with treatment plans and have a positive experience with their treatment [10].

In addition to its role in building patient rapport and improving care, empathy is also essential in effective interprofessional collaboration. Empathy improves communication skills, including active listening, nonverbal communication, and emotional intelligence. These skills are vital for effective interprofessional communication, as they facilitate clear and respectful interactions. In addition, empathy helps in conflict resolution by enabling individuals to see the situation from the other person's perspective and find common ground. Healthcare professionals who express understanding and compassion are more likely to listen actively, ask clarifying questions, and share patient information accurately. Empathy contributes to a more supportive work environment. Lack of empathy is associated with increased stress, which is a risk factor for burnout and compassion fatigue [10].

As in most professions, nurses engage in conflict resolution frequently throughout their careers. However, conflict resolution is often a learned task and can be difficult to navigate. These types of skills are important for management and higher leadership, but they are also important for clinicians and those working at the bedside.

Conflict is defined simply as a disagreement or a clash of interest, opinion, or principles, and workplace conflicts in health care can be complicated by ongoing complex relationships within interdisciplinary teams and the high-stress situations that frequently occur. Conflicts include substantive, procedural, and psychological dimensions; perceptions of each of these aspects of the conflict influence decision making and resolution [11]. The Center for American Nurses conducted a survey to identify conflict-related challenges nurses encountered in their profession. Interpersonal conflicts were identified as the most common type of conflict encountered, followed by peer conflict between a direct patient care nurse provider and nurse manager. The third most common type of conflict was between a nurse and other members of the interprofessional team (e.g., physician). Interprofessional conflicts often involved the acute care environment, specifically concerns about lab results, imaging, and consulting other team members [11].

Conflict management styles are complex, and many different styles may be used to resolve a conflict. The five styles of conflict resolution have been identified as dominating, obliging, avoiding, compromising, and integrating. Avoidance is often used in health care, especially when the conflict is between members of the care team. However, this approach is not ideal, as avoidance leads to poor communication and poor patient outcomes [11].

Best practices for effective conflict resolution include engaging in dialogue and addressing the conflict directly. Having a nonpunitive debriefing with staff to manage conflict provides nurses an opportunity to reflect and express frustrations related to the conflict. These debriefings promote an openness within the organization or unit and promote effective conflict resolution in the future.

Coaching also plays a role in conflict management, as nurse leaders can help their colleagues develop the skills necessary to resolve conflict themselves. Education and training on conflict management empowers clinicians to solve the problem early and maintain a positive work environment.

Identifying potential conflicts early helps to recognize opportunities for growth in managing conflict. The Joint Commission suggests organizations establish policies and guidelines to facilitate collaboration and interprofessional communication across all disciplines in a proactive manner [11]. These policies can provide a framework for addressing conflict issues, working through conflicts, and moving toward resolutions. The policies should clearly communicate goals and objectives.

The Center for Creative Leadership defines adaptability as being ready to shift and experiment when change is necessary; this requires access to a range of behaviors [12]. Behaviors and beliefs that support adaptability include optimism, seeing opportunity in change, mastering new skills, leading by example, empathically considering others' concerns, sorting strengths and weaknesses, admitting mistakes, and moving forward. Sherman has identified five skills required to be adaptable as a healthcare provider [12]:

The COVID-19 pandemic brought the issue of adaptability in health care to the forefront and highlighted several barriers and challenges to this approach. During the height of the pandemic, nurses and other healthcare professionals were having to adapt to practice outside typical guidelines with patients, providing care via newer telemedicine platforms, and working with less staff to care for an influx of patients into the health system. Further, many providers were assigned to units or care environments outside of their specialty. In these types of situations, adaptability is only one aspect of maintaining good nursing practice and self-care; resilience, which is a long-term strategic process, is also necessary and is demonstrated by successful recovery [13]. Nevertheless, having adaptability helps healthcare professionals to manage well-being, stress, exhaustion, and emotional balance.

The trait of initiative is a valuable asset in nursing practice. It leads to improved patient care, better teamwork, professional growth, and a positive impact on the healthcare organization. Skills such as critical thinking, adaptability, and effective communication are essential to support and manifest this trait effectively in nursing practice.

Initiative is defined as the ability to assess and take action independently. It is linked to leadership and an ability to take charge of situations. Initiative in nursing involves the proactive identification of problems or opportunities for improvement and taking appropriate actions to address them. Nurses who demonstrate initiative are more likely to identify potential issues with patient care or safety before they escalate. For example, recognizing subtle changes in a patient's condition and promptly informing the healthcare team can prevent adverse outcomes. Initiative-driven nurses advocate for their patients by ensuring that their needs, preferences, and concerns are communicated to the healthcare team. They actively participate in care planning and decision making to achieve the best possible outcomes. Nurses with initiative take the time to educate patients about their conditions, treatment options, and self-care. This empowers patients to actively participate in their own care.

Initiative also fosters teamwork, as proactive nurses are more willing to collaborate with colleagues, share information, and seek input from others. This leads to more effective interprofessional communication and coordinated patient care. Nurses with initiative often play a crucial role in resolving conflicts within the healthcare team by addressing disagreements or misunderstandings promptly and professionally, promoting a harmonious work environment.

Initiative-driven nurses also seek opportunities for professional development and lifelong learning. They actively pursue new knowledge, skills, and certifications to stay current in their field.

This approach is also expanded to health care in general, and initiative is essential for identifying inefficiencies in healthcare processes and proposing solutions to enhance the quality of care. Nurses can lead or participate in quality improvement projects that benefit both patients and the healthcare organization. Developing best practice initiatives drives a leader to empower others to lead positive change in the nursing environment. Initiatives help ENGAGE healthcare providers, meaning they result in [14]:

One example of initiative is posting an idea board in the unit, break room, or shared conference room. The board is available to nurses and other staff members to post their ideas on how to improve patient care and outcomes. For example, one staff member, a respiratory therapist, might suggest moving the respiratory equipment closer to patient rooms [14]. Another staff member might post a suggestion to purchase a blanket warmer for the unit, which once implemented, improves patient and staff satisfaction. In one study of a unit that implemented the idea board, approximately 40 ideas were posted after six months, 70% of which were completed and several others of which were pending upper management budget approval. A significant increase in staff engagement was noted, and staff felt management was listening to their concerns [14]. Taking initiative requires resilience and determination to get tasks done. One may have to do things proactively, researching ideas and taking advantage of opportunities.

Because therapeutic communication is used by nurses to connect with patients and colleagues on many levels, effective communication skills should be included in nursing school curricula and continuing education. However, the feasibility of in-depth, one-on-one exchanges and conversations with patients during clinical training has decreased in recent years, primarily due to the increased number of nursing students and difficulties finding clinical placements for these students [24]. In response, simulation-based training has been established to provide this component in nursing education. While this has provided benefits, programs with lower monetary resources still find this difficult to obtain. Computer-based, interactive simulations have been developed to provide opportunities to communities with limited access to resources.

In a Korean study of nursing students engaged in a simulation-based scenario involving patients with depression or psychosis, false reassurance was the most common nontherapeutic communication error among the participants, followed by difficulty communicating with physicians regarding the patient's condition [24]. Several students in the study, upon communicating with a patient with suicidal ideation, were reportedly silent and avoidant of the situation. This was attributed to lack of confidence in their own ability to make decisions regarding the best care step, likely related to a lack of suicide assessment training. Some students in the study were noted to abruptly change the conversation in situations in which the patient would directly report hallucinations or delusions, again likely related to the lack of exposure to appropriate assessment and intervention strategies for patients experiencing psychosis [24]. Participating nursing students displayed numerous problems communicating changes in a patient's condition to a physician, such as missing key information, using ambiguous words, repeating the same words with hesitation, and failing to make suggestions regarding the treatment plan. These situations were consistent with previous studies that found inexperienced nursing students had considerable difficulty communicating adequately and clearly in similar situations.

The findings of this study support the need for simulations that offer nurses and nursing students opportunities to practice their communication skills in clinical situations [24]. Moving forward, numerous programs using simulated or augmented reality techniques would allow students the experience of a more lifelike clinical practicum or the opportunity to augment an in-person course [24].

In nursing practice, communication in the workplace is just as important as communicating with patients. When nurses lack strong communication skills, missing critical information, misinterpretation of information, providing unclear orders, and overlooked patient status changes can occur. Poor interprofessional communication is also a risk factor for potentially fatal medical errors [25].

The Joint Commission reports that if medical errors appeared on the National Center for Health Statistic's list of leading causes of death in the United States, they would rank number five—ahead of accidents, diabetes, Alzheimer disease, breast cancer, and firearm-related injuries [25]. In many cases, the root cause of these medical errors is a failure of the interprofessional team to effectively communicate, which can lead to medication errors, delays in treatment, wrong-site surgeries, operative or postoperative adverse events, and patient falls [25].

Interprofessional collaboration involves team members assuming and understanding roles and working cooperatively. The team shares responsibility for decision making and facilitating plans of care for patients. Collaboration enhances team members' perception of the knowledge and skills of each profession, steering continued improvement and diversity in decision making. It is important to note that fostering interprofessional collaboration may have obstacles to overcome, including [25]:

A review of the literature shows that effective communication in the workplace leads to positive outcomes in all areas: knowledge flow, effective interventions, employee morale, and patient satisfaction. It encourages teamwork and promotes opportunity, while also promoting transparency in the workplace [25].

The complexity of medical care paired with the limitations of human performance makes standardized communication tools invaluable in the healthcare workplace [25]. Nurses often use the SBAR acronym to write notes, and this same approach can be used when communicating about a patient to other members of the team. SBAR stands for situation, background, assessment, and recommendation. The mnemonic device allows for ease of communication, decreases the likelihood of missed or omitted information, and supports critical thinking skills [25].

There are a variety of potential barriers to communication, including [25]:

Addressing these communication barriers in health care requires a combination of cultural, structural, and interpersonal strategies to create a collaborative and patient-centered care environment (Table 1). Regular communication training and ongoing evaluation of communication practices are also crucial for success.