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Nursing and Midwifery Council (2018b) The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates

Practice effectively:

1 7.0 Communicate clearly. To achieve this, you must:

2 7.1 use terms that people in your care, colleagues and the public can understand

3 7.2 take reasonable steps to meet people’s language and communication needs, providing, wherever possible, assistance to those who need help to communicate their own or other people’s needs

4 7.3 use a range of verbal and non‐verbal communication methods and consider cultural sensitivities to better understand and respond to people’s personal and health needs

5 7.4 check people’s understanding from time to time to keep misunderstanding or mistakes to a minimum

6 7.5 be able to communicate clearly and effectively in English

Every communication is important, however insignificant it may seem, especially when working in healthcare. The Royal College of Nursing (2016) identified three reasons why communication is important:

 Good communication helps patients/clients feel at ease

 Good communication helps patients/clients to feel in control

 Good communication makes patients/clients feel valued

Richardson (2017) developed a tool to aid healthcare professionals in effective communication, the PER tool (Propose, Engage and Reflect). This advocates that prior to any conversation, the healthcare professional proposes what they are planning to discuss to ensure that they have all the information needed and are aware of who will be involved in the conversation. This also includes ensuring there is a suitable place for the conversation to happen, as it is difficult for anyone to focus in a busy, noisy environment. The engagement aspect is the professional’s opportunity to introduce themselves, gain the other person’s attention, clarify who else is there and ensure the person(s) receiving the information is/are responding appropriately. The final element is for the healthcare professionals to reflect on whether they achieved what they set out to, if it went well and what they could have done differently (Richardson 2017).

In preparing for communication, the nursing associate can consider the 5Ws and 1H, derived from Lasswell’s (1948) 5W model of communication.

 What

 Why

 When

 Where

 Who

 How

Careful planning of communication encounters can result in more meaningful and effective communication. See Table 2.1 for an overview of planning communication encounters.

It is important to have an awareness of the different formats of communication when proposing planned communication with patients and colleagues. There are generally four different types of communication to consider, namely verbal, non‐verbal, written and visual (Table 2.2). Each of these will be described in detail in subsequent chapters of this book.

The engagement aspect of communication is when the nursing associate will work collaboratively with patients, families and carers to develop therapeutic relationships. As nursing associates work across all four fields of nursing practice (adult, mental health, children and young people and learning disabilities), as well as with people across the lifespan, they will need to consider the target audience when engaging in communication.

The NMC’s (2018a) standards of proficiency require the nursing associate to demonstrate the skills and abilities required to develop, manage and maintain appropriate relationships with people, their families, carers and colleagues. The trainee nursing associate needs to be deemed proficient in this aspect of care provision.

When working with children and young people, family‐centred care is a key concept, and the nursing associate needs to be aware that while the child is a pivotal member within the family unit, care must extend to involve the parents and wider family (Roberts et al. 2015). Children, more than any other age group, are keen observers and easily detect when a person is being disingenuous or impatient (Edwards & Coyne 2019). The nursing associate can strive to achieve a trusting and collaborative therapeutic relationship by demonstrating a genuine interest in the child and paying attention to all aspects of verbal and non‐verbal communication.

Table 2.1 Planning communication encounters.

What – The ‘What’ question answers:

What am I required to communicate? What should the message be? What action is the audience required to take as a result of the communication?

Why – The ‘Why’ question deals with:

Why communicate now? Why this audience? Why is this important?

When – The ‘When’ explores:

When is the communication required? When is the action or result required?

Where – The ‘Where’ question answers:

Where is the venue or location of communication? Where can I get more information? Where is this communication going to lead?

Who – The ‘Who’ question defines the audience:

Who is the audience? Who does it impact? Who needs to take the required action? Who is in charge?

How – The ‘How’ question is about:

How am I going to communicate? (consider channel and reasonable adjustments) How am I going to handle any challenges? How should action be taken?

Table 2.2 The four different types of communication.

Verbal	Spoken wordVocal gestures e.g. sighs and gaspsFace‐to‐face and telephone
Non‐verbal	Body languageGestures e.g. pointing
Written	Patient notesEmailText
Visual	Graphs and chartsSymbols e.g. sign on toilet doorPosters

Table 2.3 Tips for effective communication with children and young people.

DO

DO NOT

Get to know a child’s developmental levelLearn the child’s interests based on your observations of their activitiesTalk at the child’s level and with vocabulary they will understandInvolve the child in decision‐making appropriatelyMaintain a calm, unhurried, caring and gentle approachUse concrete examples and/or link information to activities of daily livingAllow opinions to be expressedBe an active, attentive listener

Make a child self‐conscious by drawing attention to themUse abstractions with a child who is a concrete thinker (e.g., for a child who does not understand time, tell them ‘after lunch’, not ‘later’ or ‘at 2 o’clock’)Jump to conclusionsGet ‘in the middle’ between a child and a parent, especially in front of the child

When communicating with children and young people, the nursing associate must recognise the variable needs of children in relation to their age, development and ability. They must draw on their knowledge of the stages of child development and utilise communication skills, such as active listening, paraphrasing, summarising, reflecting and questioning, that are fundamental to the development of rapport and empathic therapeutic relationships (Nelson 2012). They should find out what children, young people and their parents want and need to know, what issues are important to them and what opinions or fears they have about their health or treatment.

Babies, when in infancy, communicate via sounds such as gurgles and cries. They also use facial expressions such as smiles, grimaces and eye contact to communicate their needs (Grainger 2018). As children develop, they begin to use single words to express their needs. When communicating at this stage, it is important to make use of pictures and objects to convey meaning as well as simple language (Edwards & Coye 2019). When communicating with adolescence, it can be difficult to develop rapport due to the challenges physiologically, psychologically and socially for this age group. Templeman (2019) explains how to foster a rapport with adolescents by introducing yourself, offering a hand to shake and making small talk. This can also be done by showing an interest in the individual, what do they enjoy doing, how is school and so forth. This will encourage the therapeutic relationship, as the individual is given time to talk about themselves to someone who is interested in them. The nursing associate needs to listen carefully and respond appropriately without being directive to show the adolescents that they are being taken seriously, which will develop their confidence (Templeman 2019).

It is imperative that children and young people are involved in discussions about their care and that the nursing associate explains things using language or other forms of communication they can understand. Some tips for communicating with children adapted from Boggs (2016) are listed in Table 2.3.

When communicating with adults, nursing associates need to be aware of the vocabulary they use, but also the words that are not spoken by the patient. The words left unspoken can be an indicator of feelings of low self‐worth or fear of judgement. For example, a patient who is withdrawn and does not talk about their future may be contemplating suicide, or patients when talking about spirituality may not give any details about their beliefs due to fear of being judged (Richardson 2017).

The vocabulary used when talking to patients should change dependent on the person being spoken to, as those words needs to be understood. Parnell (2015) refers to this as ‘plain language’ – it should be to the point, clear and accurate. Nursing associates have a professional responsibility to communicate with colleagues, patients, patients’ family and other professionals. When delivering information or explaining a procedure, it is difficult to gauge how much the person who is receiving the information has understood. Quite often, the information that is being communicated is complex and the population receiving this information is more diverse than ever. An effective technique is to keep it simple and ask the person to repeat back what they have understood. By doing this, the nursing associate can adapt the language used to clarify any points of misunderstanding (Parnell 2015).

Currently in the United Kingdom, approximately 1.5 million people have a learning disability (Mental Health Foundation 2019), and for this group of people, it is more likely that communication may be difficult. People with learning disabilities access mainstream healthcare, and as they are significantly more likely than the general population to be diagnosed with a wide range of conditions, the nursing associate will undoubtedly care for people with a learning disability throughout their nursing career. It is important that the nursing associate take the time to get to know their patients and see them, not the disability, and listen to them and their family/carers. Where people have communication needs or a disability, it is essential that nursing associates make reasonable adjustments, providing and sharing information in a way that promotes good health and health outcomes and does not prevent people from having equal access to the highest quality of care.

To be a good communicator with people with a learning disability, the nursing associate will need to:

 Always use accessible language and speak clearly

 Keep their head up and be on the same level as the person

 Avoid jargon or long words that might be hard to understand

 Be creative and prepared to use different communication tools such as visual cues to support understanding

 Take time and follow the lead of the person

 Go at their pace

 Check out understanding

 Ask for help if they need to

For people with profound and multiple learning disabilities (PMLD), it can be difficult to communicate intentionally, making this group of people particularly vulnerable. Nursing associates need to adapt the way they communicate with people with PMLD to find a way of listening and communicating in a way that is individualised and appropriate (Mansell 2010). This will involve being creative; it may be through the use of hand gestures and movements, or through picture and music. The purpose of communication, although via a more creative mode, is the same; it should remain a two‐sided process where both parties are able to express themselves and communicate their needs. Mansell (2010) talks about other specialities in assisting people with PMLD such as speech and language therapists, family and carers, as each of these can provide insight into effective ways of communicating, be this a particular gesture, sign, object, sound or behaviour. A communication passport can be a useful tool, not only for people with PMLD but for a variety of people who have difficulty communicating. Communication passports should contain everything about the way that individual communicates. These should be updated regularly and readily available for anyone in contact with or involved in that person’s care (Mansell 2010).