Communication is an integral part of life; without it, we would not survive. Verbal and non-verbal communication begins at birth and ends at death. We need communication not only to transmit information and knowledge to one another, but more importantly, to relate to one another as human beings around the world in the context of relationships, families, organizations, and nations.

The how, what, why, and wherefore of communication can either edify or harm us, as individuals, cultures, religions, and governments of countries, as we attempt to coexist. What we say, how we say it, and what we mean by it are extremely important, and can be life-changing. I recollect two teachers in elementary school. To me, one was a kind, caring person; the other was mean and sarcastic. Students, especially children, are particularly vulnerable during their formative years.  Adults, teachers, and other children have the power to either help us blossom as an individuals or to destroy our self-esteem, and thus impact our potential for life. How? A kind (or cruel) word, or facial expression, can mean the world to a child. These two teachers in my past were polar opposites, but both affected me deeply.

In our professional roles as nurses, we are responsible to care for persons who are ill. When ill, patients may be unable to speak or advocate for themselves. Vulnerable patients need our voices to speak for them. Due to our constant exposure to other human beings who are suffering, nurses are perfectly positioned to utilize effective interpersonal communication, and in doing so, support our own emotional, psychological, and spiritual development.

There is a well-established link between team communication, worker morale, and patient safety. Poor team communication has been directly linked to preventable medical errors, high nurse turnover rates, and low morale (Brinkert, 2010; Institute of Medicine, 1999; Vessey, DeMarco, & DeFazio, 2010). Low morale contributes to high levels of stress, burnout, poor job satisfaction, and an overall poor quality of life. Controlling stress and burnout is an essential component of a healthy lifestyle.

Use of effective interpersonal communication strategies by nurses... may reduce stress, promote wellness, and therefore, improve overall quality of life. Use of effective interpersonal communication strategies by nurses in both personal and professional settings, may reduce stress, promote wellness, and therefore, improve overall quality of life. This article briefly explores the concept of interpersonal communication as it relates to Maslow’s hierarchy of human needs; describes personal variables and the interaction of internal and external variables that can impact communication; and discusses possible causes and consequences of ineffective communication. Drawing on both the literature and my experiences as a longtime provider of care in the mental healthcare field, I offer multiple strategies, with specific examples of possible responses for effective communication. Recommendations in this article are intended for nurses to consider as they seek healthy communication strategies that may be useful in both their personal and professional lives.

Interpersonal Communication and Maslow’s Hierarchy of Human Needs

In 1943, Abraham Maslow developed a hierarchy of human needs wherein he described the basis of human behavior in terms of the priorities of survival (Figure 1). Oxygen, food, water, and shelter, our most basic needs, must be met first. Once these basic needs are met we can progress upward in the hierarchy toward fulfillment of needs for safety/security, love/belonging, and esteem. Finally, according to Maslow, the highest human needs revolve around finding one’s purpose and realizing one’s full potential, which culminate at the pinnacle of the hierarchy in self-actualization.

Figure 1: Source: Maslow’s hierarchy of needs, n.d.

Maslow’s hierachry of human needs can be applied to interpersonal communication. The concept of communication can be most appropriately considered in the context of three levels of the hierarchy: safety, love/belonging, and esteem. Of these, safety has the most intimate involvement with basic, “primitive” needs. For example, it feels very personal when one’s safety is threatened by loss of any kind, whether it is a perceived or actual loss.  A loss can invoke anger, grief, or fear in response to feeling helpless, powerless, unsafe, and vulnerable. Likewise, effective or ineffective communication may impact our ability to satisfy the needs of love and belonging, and also esteem.

... little has addressed how effective interpersonal communication can contribute to a healthy lifestyle in both the personal and professional life of the individual nurse. Many would agree that interpersonal communication is an intimate, human activity that can weigh heavily on our overall psychological health and wellness, and therefore, warrants much discussion and attention. Despite this realization, the literature, especially in nursing, has not addressed this topic adequately. Although much has been written on workplace safety, lateral violence, and bullying to address issues that we face as professionals in the workplace, little has addressed how effective interpersonal communication can contribute to a healthy lifestyle in both the personal and professional life of the individual nurse. As each person seeks to meet his or her human needs, a number of variables, both internal (or personal factors) and external (or behavior of others) can combine to support effective or ineffective interpersonal communication. The next section will offer professional insight that I have gained in my nursing practice related to how multiple variables may impact communication. I offer this not as an exhaustive list of variables, but in the hope that it will provide some context for readers to reflect on their own unique mix of variables as they go on to read and consider the recommendations for effective communication.

Personal Variables: Internal Predisposing Factors

Human beings are complex creatures. We are composed of a plethora of variables that are continuously interacting with one another. Some of these personal variables are internal in nature; they are part of our makeup. Figure 2, developed by the author, is a simple representation of how variables might interact to produce a unique individual. In addition to our genetic makeup and gender, the variables (termed internal predisposing factors) consist of thoughts, feelings, and perceptions that are often learned early in life and shaped by childhood upbringing and experiences. In my clinical experience with patients, I have observed that early experiences can affect persons deeply, and perceptions of these experiences are not easily changed. Indeed, the impact of these experiences can cause a person to be rigid and inflexible. For example, a person who has been abused physically, verbally, or sexually by the opposite sex, and unhealed from this, can become unyielding in any future interactions with persons of that gender regardless of the situation or circumstances. However, all is not lost. In addition to factors that CAN be controlled and factors that CANNOT be controlled, there are factors that may change over time. Consider the variables listed in Figure 2. Which can be changed or controlled? Which cannot? Which are subject to change? These are important distinctions that will become clearer in the discussion of the following sections, as applied to interpersonal communication.

Figure 2: Personal variables: Internal predisposing factors (Source: Author)

Interaction of Internal and External Variables

Figure 3, developed by the author, represents how internal personal variables demonstrated in Figure 2 and external variables (behavior of others and situations) might interact.  Further, consider how the interactions depicted in Figure 3 could influence the outcome and effectiveness of (our) interpersonal communication. Understanding and acceptance that one cannot control others and/or situations can create the psychological freedom necessary to develop insight into one’s own behavior. That insight can be the first step toward positive change and improve communication. The next section will consider some causes and consequences of ineffective interpersonal communication, along with strategies and selected examples to support alternatives.

Figure 3: Interaction of Internal and External Variables (Source: Author)

Causes and Consequences of Ineffective Interpersonal Communication

Some consequences of ineffective interpersonal communication can be chaos, confusion, disorder, fear, conflict, inefficient systems, and wasted resources. Some consequences of ineffective interpersonal communication can be chaos, confusion, disorder, fear, conflict, inefficient systems, and wasted resources. Poor team communication has been cited as the number one cause of unnecessary patient deaths related to medical error since the 1990s (Institute of Medicine, 1999). Further, criticism has been directed at healthcare providers, including physicians, for their lack of study of interpersonal communication (Hull, 2007; Shapiro, 2011). Although numerous interpersonal communication theories exist, few have been applied to healthcare communication or utilized in any relevant manner by providers (Bylund, Peterson, & Cameron, 2012). Thus, a knowledge gap exists necessitating a frank discussion and pragmatic strategies for change. This section will offer selected strategies for effective communication for consideration, drawn from both literature and practice experience.

Personal life versus professional role calls us to develop and apply competent skills based on the specific situation, and adopt an appropriate demeanor and response. However, behavior based solely on role expectations may not always be appropriate. Here are some suggestions to begin to think differently. When applying what is discussed in this article to your personal and professional lives, think of yourself holistically.  In other words, you cannot compartmentalize basic personality structure, or your personal way of relating to the world; you are who you are. Divorce yourself from antiquated acculturated role expectations of how women or men and nurses are supposed to behave. Strive to develop new ways of relating to support more rewarding interpersonal communication experiences.

One way to do this is to think in terms of the use of “self” versus “skills.” Effective interpersonal communication is much more than techniques, skills, or procedures to be mimicked or parroted. Parroting or mimicking is generally viewed as insincere; if one behaves as a robot, most people will sense this. To say one must perform a certain skill or competency, in my opinion, diminishes our ability to have spontaneous human interactions that are meaningful. Techniques and skills can become too automatic and thus may limit your options.

Genuine human rapport requires creativity and flexibility. Genuine human rapport requires creativity and flexibility. Best practice would dictate relating genuinely, human to human, and disregard of communication “scripts.” Since new behavior can be risky and frightening, pragmatic strategies aimed at prevention of ineffective interpersonal communication are needed.  With this goal in mind, Table 1, developed by the author, provides a brief overview of possible causes, consequences and cures for ineffective interpersonal communication, as well as possible strategies and/or examples for application.  The section that follows elaborates on the information in Table 1 and offers additional discussion and/or practical guidance.

Table 1: Ineffective Interpersonal Communication: 12 Possible Causes, Consequences, Cures, and Examples for Effective Communication (Source: Author

Additional Insight about Barriers to Effective Communication: Thoughts from the Trenches

The above table offers many “possibilities” to explain and address some common areas that may contribute to ineffective interpersonal communication. Below is some additional discussion and implications for practice to provide further insight into these concerns.

Cultural and Organizational Taboos/NO TALK Rules

It may be helpful to question “NO TALK” rules and communication taboos, such as the expression, “Children should be seen and not heard.” In much of today’s society, this may seem an absurd statement, but likely it was an accepted societal norm at some time in the past. But times have changed. In 2014, do not accept statements or situations at face value that do not make sense. You are entitled to an explanation and rationale when it is spoken or inferred that you should “not talk about” something. Find out why. If you are afraid to speak up, ask yourself why.  If you are afraid or uncomfortable with conflict, then you must understand that fear of conflict can lead to poor conflict management and poor negotiation/problem solving skills (numbers 2 and 3 in the above table). NO TALK rules are often unspoken; in fact they are generally inferred, creating a more confusing situation.  This can add to frustration, helplessness, lack of trust, and avoiding discussion about and problem solving of important issues. The only way around this frustrating barrier is to bring NO TALK issues forward and discuss them openly and honestly.

In the workplace, most nurses know that not reporting (i.e., not talking about) something that they know is wrong or against policy (or could bring harm to a patient) because “you don’t want to get someone in trouble” is unethical behavior. A striking example of this is failure to report an impaired colleague. How might you talk about this NO TALK issue? Here are some suggestions that I have found helpful. Stick with the facts. Do not make judgments, or offer moralizing and/or solutions for fixing the problem. Go to the person’s supervisor and ask if you can speak privately. If you are uncomfortable, say so. You might try saying, “I am not comfortable discussing this, but I feel it is my duty to report that I smelled alcohol on Fred when he gave me report this morning.” Keep a record of the date, time, and name of the person with whom you had this conversation. If the behavior is not addressed and occurs again, your next step is to go up the chain of command.

Poor Conflict Management

... it is ok to disagree, and not all problems will be or can be solved. If you are not comfortable with conflict, chances are somewhere along the line you may have learned that conflict is “bad.” Maybe you witnessed conflict that escalated into inappropriate aggression or violence, or you were not allowed to express negative feelings in order to solve conflict.  The term “conflict management” that was coined years ago by the business world suggests that conflict must be managed or kept under control. This is not always true. Conflict often can provide the friction we need to discuss issues, consider alternative strategies and solve problems. Conflict in and of itself is not bad, but necessary. Opinions that differ from our own help us to learn and grow (Peck, 1978).  Keep an open mind and discuss solutions respectfully when conflict arises. Remember, too, it is ok to disagree, and not all problems will be or can be solved. You do not have to fix everything.

Poor Negotiation/Problem-Solving Skills

...poor negotiation and/or problem-solving skills often happen when people are in a hurry to fix a problem... In my experience, poor negotiation and/or problem-solving skills often happen when people are in a hurry to fix a problem, whether at home or in the workplace. A person may not take time to thoroughly think about the problem and possible solutions because we live in what I have heard described as a hurry-up, fix it now, instant mashed potatoes, just put out the fire culture. This “hurry up and fix it/get it away from me” ideology is sometimes due to discomfort with problems. Why? Because problems can evoke negative feelings within us, and we do not want to feel negative feelings. In my opinion, this is a real shame because “problems call forth our courage and wisdom; indeed they create our courage and wisdom” (Peck, 1978, p.16).

It is common knowledge in present day healthcare that the population requiring care is growing and resources are shrinking. A hurry up, problem-avoidance mentality (one that I have often heard described in my years as a provider, especially recently) may deprive people of the opportunity to learn: 1) toleration for unfinished business; 2) creative problem solving; 3) flexible thinking; 4) coping; 5) spontaneity; 6) testing of boundaries; and most importantly 7) to sit with uncomfortable feelings. Emotional maturity is born of the foregoing experiences, and maturity is necessary to become skilled at negotiation and problem solving. Work to both develop negotiation and problem solving skills and also to ensure adequate time to allow for appropriate consideration of the problem at hand.

Lack of Empathy

...emotional detachment, a technique adopted by some providers, does not protect one from future or worsening burnout. If you live in a family or work on a team, empathy is a must; however, empathy requires a complex balance of well-developed boundaries, emotional stability, experience, and indeed, effective interpersonal communication. Helping professionals may find themselves on one end or the other of the emotional caring spectrum and err by being overinvested in or, conversely, detached from patients. Unfortunately, emotional detachment, a technique adopted by some providers, does not protect one from future or worsening burnout. For example, physicians have been criticized for their lack of empathy, whereas nurses have been hailed as owning the concept of caring (Spiro, Curren, Peschel, & St. James, 1996). If you lack empathy, you may have become hardened to the world for some reason. Perhaps you have been hurt or are burned out.  Compassion fatigue, a term coined in the mid 1990s, describes a phenomenon wherein professionals working with traumatized clients were actually at risk for secondary traumatization due to over-identification with their clients’ experiences (Sabo, 2006). This phenomenon occurs in all types of healthcare providers. Therefore, to maintain both physical and emotional health, it is important to strive to maintain the delicate balance between over and under caring.

Unresolved Emotional Issues

To support your own health, make the time and effort to get this [professional help] if you need it. While an extensive discussion of this complex topic is beyond the scope of this article, some basic outcomes of unresolved emotional issues are commonly known by all. A disruptive or abusive childhood, adult victimization or trauma of any kind can leave emotional and psychological scars that can be difficult to heal. Survivors of abuse have trouble trusting, and as a result, can misperceive and misinterpret the motives of others. Mistrust of others can create distorted perceptions of the world, distorted communication patterns and general difficulty in personal and professional relationships. If you need professional help to resolve your own emotional issues, you owe it to yourself to do this. To support your own health, make the time and effort to get this help if you need it.

Poor Self–Image/Negative Self-Talk

If you want respect, you must demonstrate this by respecting yourself. A poor self-image, possibly combined with negative self-talk, can set the stage for ineffective interpersonal communication. Never degrade yourself or allow others to denigrate or be disrespectful to you. Never refer to yourself or your personal characteristics in pejorative terms. Make a decision to view these behaviors as unacceptable. If you want respect, you must demonstrate this by respecting yourself.

Sometimes we have to teach people how to treat us. For example, if you are spoken to in a disrespectful or condescending manner, by anyone, especially a co-worker, first know that this is unacceptable. You do not have to take verbal abuse from anyone, especially in the workplace. The expectation is for nurses, physicians, and all members of the healthcare team to behave professionally at all times. Should inappropriate behavior occur, you must make the decision to stand up for yourself. Even if it is hard, try calmly stating words such as, “Excuse me, but I would like to be addressed with courtesy and respect at all times” or “Please refrain from making pejorative remarks and focus on a solution to this problem.”

All of us are a mix of positive and not-so-positive characteristics. Learn to appreciate the good qualities in yourself and others. It can be difficult to avoid judging yourself or others. You may find it helpful to pick one quality or character trait you would like to improve. Then, seek the wisdom of a trusted friend, counselor, or sage and ask for support and advice in order to accomplish your goal.

Lack of Boundaries/Inability to Set Limits

Assertiveness, or saying NO and setting limits appropriately is an ART that must be learned. The inability to set limits is generally related to fear of rejection, people pleasing, or emotional insecurity. You may think, “They won’t like me.” Accept that you will not like everyone, and everyone will not like you, and that is okay. Assertiveness, or saying NO and setting limits appropriately is an ART that must be learned. Setting limits requires one to make simple, short statements in a calm, respectful manner. Focus on the positive and describe the desired behavior, as opposed to one that is undesired. Following this, describe the consequences for continuation of the undesired behavior. Do not argue, threaten, and attempt to intimidate, or show fear. State only the consequences that you have power to enforce, and that you will follow through upon. Do not promise what you cannot deliver. In your role as a nurse, you will deal with upset patients at times; however, you have the right and responsibility to set limits on inappropriate behavior. This is true both in your professional and your personal life. Table 1 provides selected examples of suggested verbal interventions that you might utilize to set limits.

Importance of Self Analysis and Insight

Simply taking the time to engage in self-analysis... can support the effective interpersonal communication necessary to maintain your health. Since we do not live in a vacuum or in isolation, understanding yourself and developing insight into YOU is paramount to effective communication. Refer back to the personal variables in Figure 2. Consider how your upbringing may have influenced you. What was your home like? How were you treated and addressed by your parents and teachers? Was your family patriarchal (led by father) or matriarchal (led by mother)? Who delivered the discipline to children in your home? Who were the other significant adults in your life? How has your race, culture, and/or religion possibly influenced you? As an adult, how has your education and real world experience impacted you? Have you travelled to other countries? How have adult relationships such as spouse, children, and significant other influenced you? Have you been ill or lost someone close to you? It is important to understand how these factors have shaped and influenced you, and to what extent. These variables influence how you present, behave, and communicate in the world. Simply taking the time to engage in self-analysis to develop this type of personal insight can support the effective interpersonal communication necessary to maintain your health.

Physical or Mental Illness

Depression, anxiety, and alcoholism appear more likely to be high in professions with high stress, but there remain gaps in the research literature. Ross and Goldner (2009) conducted a review of the literature to examine stigma, negative attitudes and discrimination toward mental illness from a nursing perspective. They determined that although substance abuse among nurses has been studied, no such parallel examining nurses with mental illness could be found. The paucity of literature on the subject of nurses with mental illness is of concern. However, Ross and Goldner (2009) did find that nurses with mental illness are both stigmatized and stigmatizers; they judge themselves and others. In regard to ineffective interpersonal communication, Farrell (2001) reported that nurses who have mental illness often felt as though they were targets of bullying and lateral violence in the workplace.

Research supports that mental illnesses are biochemical brain disorders that are strongly genetically linked (Perese, 2012). Mental illness is not caused by weakness or lack of moral character. Ghaemi (2011) noted that some of the greatest leaders in history suffered from mental illness. Moreover, he purported that it was because of their suffering that these men (e.g., Lincoln, Churchill, Sherman) developed the personal characteristics necessary to become exceptional leaders during times of crisis.

Mental illness can be treated and should not be ignored. There is no shame in seeking the help of a mental health provider. Nurses seeking treatment for mental health disorders not only have the ability to improve their own health, but also by their actions may help to address perceived stigma associated with mental illness.

Hidden Agendas, Politics, Games, and Tests

Over a decade ago Horsfall (1998) addressed several important “personal” variables with respect to effective communication.  Two of her foci addressed how power inequalities and personal prejudices affect communication. Even chosen seating in a meeting (i.e., who sits where) can be the subject of interpretation. Unfortunately much of what Horsfall discussed in 1998 has not changed in the present day. Unequal power structures, abuse of power, and feelings of powerlessness (including certain unspoken practices both within nursing, medicine and the world) prohibit equalization of power structures. For example, persistent use of patriarchal (or exclusively male led) systems still exist and contribute to the “inadequacy of mainstream nursing [and other] concepts of communication” (Horsfall, 1998, p. 78). Women, in particular, who communicate in a firm, assertive manner, may be subject to pejorative remarks in a male dominated environment. If there appears to be a gender barrier to effective communication, be firm anyway. Again, table 1 above offers information about how to address communication barriers due to these concerns, using neutral, nonthreatening, wording and actions.

Lack of Clear Plain Speech/Writing

Lack of clarity in speech and/or writing often contributes to ineffective communication. Avoid jargon, any kind of “isms,” clichés, slogans and boring overused stories. If you have heard something before, it is likely that others have, too.  Use others’ work discriminately and give credit as appropriate. Be original. Shorthand, texting, hashtags, and social networking lingo should never be used in professional communication. Say what you mean and mean what you say. Use plain, straight-forward talk that addresses the issue at hand.

...if a matter has escalated, make the time to talk in person to clarify concerns. Do not always resort to email to communicate important messages; you can sometimes improve communication by asking for a face to face meeting. Email communication is indeed inappropriate in certain situations.  According to a Forbes magazine article, Do You Hide Behind Email?, there are four times you should never use email: when you are mad, criticizing or rebuking; when there is a chance you could be misunderstood; when you are cancelling; or when apologizing (Warrell, 2012). Furthermore, when issues are delicate, sensitive, awkward, or negotiation is needed, they should always be discussed in person.  Personal discussions facilitate trust and add to the richness of the experience by facial expression and body language (Warrell, 2012). Confident, mature individuals will speak with you face to face and will not hide behind email to communicate important information. Especially if a matter has escalated, make the time to talk in person to clarify concerns.

Conclusion

Effective interpersonal communication is necessary to negotiate the challenges of everyday living, whether in your personal or professional life. Because human beings are complex and each individual brings his or her own set of internal variables to every situation, the possibilities of interactional outcomes of any given communication can be exponential.

Although much has been written regarding workplace violence (e.g., bullying), practical strategies for addressing the mechanics of effective interpersonal communication are lacking. In order to address this, we need frank, open conversations regarding how our personal internal variables affect our interpretation of the world as we see it. This article has hopefully provided an opening dialogue in that direction with pragmatic discussion of common areas of concern. These recommendations are often ones that we, as nurses, offer to patients every day. Taking the time to consider them as they may apply in our professional and personal lives may go a long way to encourage healthy communication, and thus healthy nurses!

Author

Kathleen A. Vertino, DNP, PMHNP-BC, CARN-AP
Email: Kathleen.vertino@va.gov

Dr. Vertino received her DNP and MS degrees from the University at Buffalo. She holds dual national board certification as a PMHNP and CARN-AP. In addition to her role as a Nurse Practitioner in the Behavioral Health Clinic at the VA Western New York Healthcare System, she is involved in a number of scholarly, academic, and community service activities which include publishing and presenting. Due to her clinical expertise, leadership qualities, compassion for and understanding of patient care, and business acumen she has is sought by peers, colleagues and superiors for participation in numerous diverse task forces, academic and professional development programs, strategic planning initiatives and operations issues both within and outside the Veterans Healthcare Administration (VHA). She is a VHA Certified Mentor at the Fellowship level and has mentored staff with special projects. She is an active voice at the National level for Advanced Practice Nursing.

© 2014 OJIN: The Online Journal of Issues in Nursing
Article published September 30, 2014