Course

Communication is an essential topic for nursing assistants due to the patients, coworkers, family members and visitors with whom they must interact on a regular basis. Since nursing assistants and professional caregivers interact with others routinely, their ability to communicate must be competent. Communication, defined as the process of exchanging information with other persons, includes the act of conveying messages as well as the receipt of them (Fuzy, 2003). People communicate by sending and receiving messages, either verbally or through nonverbal means.

Verbal communication entails the use of sounds, words and language to convey messages (Hanes, 2018). Shouting, whispering and speaking in a conversational tone are all forms of verbal communication. A human resources manager that asks a job-seeking candidate interview questions is considered to be verbally communicating. A phone conversation is also considered a type of verbal communication. Additionally, a face-to-face chat between a home health aide and a client would fall under the realm of verbal communication. 

On the other hand, nonverbal communication does not rely on the use of words or language to get the message across. Examples of nonverbal forms of communication include rolling one's eyes, frowning, smiling, pointing at an object, grimacing, making hand gestures, or nodding to convey messages to others. Problems might arise if a nursing assistant's nonverbal communication is not consistent with her verbal words because the intent of the spoken message can be changed dramatically. 

For example, a nursing assistant can utilize a joyful tone of voice to announce, "I am happy!" However, her sad facial expression (nonverbal communication) has changed the intent of her spoken words (verbal communication) due to the inconsistency between the two messages. Observant people will take note of the inconsistency between the nursing assistant's verbal and nonverbal communication and wonder if she truly is as happy as she claims to be. After all, her sad facial expression communicates an entirely different message than the one that she is verbally conveying.

Nursing assistants and caregivers must be able to communicate in a competent, effective manner to manage various situations that arise. They must be able to effectually present information such as vital signs, changes in clients' conditions, and other pertinent data to coworkers and supervisors as needed. They must be able to communicate with patients and clients regarding their needs and desires. In essence, effective communication skills are the cornerstone of a successful career in the healthcare field.

Numerous types of observations, findings and statements need to be communicated in the healthcare field. Nursing assistants, professional caregivers and other allied health workers must be very familiar with the differences between objective and subjective information in order to document patient care activities accurately. Also, the differences between objective and subjective information need to be known in order to communicate all findings appropriately to other members of the healthcare team. 

In the healthcare field, objective information is gathered through provable observations of numbers, measurements, and data that the nursing assistant collects through the five senses of sight, sound, smell, touch and taste. Objective information can be proven and verified because it is based on what the nursing assistant sees, hears, touches or smells (Fuzy, 2003). Examples of objective information include the following:

• Temperature of 98.5 degrees Fahrenheit 
• Heart rate of 68 beats per minute 
• Respiratory rate of 17 breaths per minute 
• Blood pressure of 118/78mmHg 
• Yellowing of the eyes noted
• 2 inch by 5 inch area of redness to the right hip
• Wheezing heard 
• Skin feels cool and clammy
• Fruity smell to the breath is noted
• Weight of 119.5 pounds
• 100 percent of meal was eaten

Subjective information is gathered through listening to and/or documenting statements that are subject to interpretation, such as the how the patient feels. Opinions also fall into the realm of subjective information because they are subject to interpretation. Subjective information is not witnessed and, therefore, cannot be proven. Nursing assistants do not directly observe subjective information. However, it is information that consists of what was reported to them by patients, families and others. Examples of subjective information include:

• Patient tells the nursing assistant that her stomach hurts. 
• Visitor reports to the nurse that the patient fell. 
• Client states, "I am hungry."
• Patient states, "I am in a lot of pain." 
• Family member reports that her mother is itching.
• Nursing assistant states, "The patient ate a lot of food."
• Nurse states, "The client's son is a big man."
• Nursing assistant tells the nurse that the patient drank a lot of water.
• Patient tells the nursing assistant that she urinated a little bit today.  

Communicating with patients from different cultures is an integral aspect of the delivery of well-rounded care. Nursing assistants must effectively relate to patients and clients from different cultural backgrounds in order to deliver the best care possible, but this feat is not possible without culturally competent communication. Cross-cultural communication is a term that refers to the manner in which persons from different cultures adjust to improve communication with each other (Stobierski, 2019).

Nursing assistants and other types of professional caregivers must be cautious when communicating with patients from other cultures to avoid mistakenly offending them or their visitors. Hence, it is imperative that healthcare workers communicate in a way patients and their families understand and will not become offended due to differing "standards for loudness, speed of delivery, spatial distance, silence, eye contact, gestures, attentiveness and response rate during communication" (Inscol Healthcare, 2015).

The first step is identifying one's own biases before proceeding with care. Once the nursing assistant has identified his or her biases, he or she can ensure that they do not interfere with communication with patients and their families. The next step is to identify communication patterns that are common to patients from other cultural backgrounds. Patient care situations might arise when (Inscol Healthcare, 2015):

• Patients from Arabic cultures might avert their eyes when listening or talking to superiors
• Speaking with the hands inside the pockets may offend patients from South America
• Patients from Russia would peck a kiss on one's cheeks to express their gratitude.
• Patients from some cultures hesitate to address people using first names until they know them better.

• Facial expressions of happiness might be taken as anger or masking sadness in Japanese or Chinese culture.

In many cultures, nonverbal communication has a more profound impact than verbal communication. For instance, direct eye contact is regarded as hostile or aggressive in many American Indian, Indo-Chinese and Arabic cultures, and some "Hispanic patients may keep their eyes downcast as a sign of respect to others" (Pullen, 2014). Patients from some cultural backgrounds place a high value on modesty, whereas others do not see it as a significant issue. Also, some patients want their caregivers to remain one arm's distance away, while others do not mind closer body positioning.

To foster a positive relationship with patients from different cultural backgrounds, the nursing assistant should avoid stereotyping. Stereotyping is utilizing set beliefs about what certain types of people are like. The nursing assistant should also avoid acting rushy or harried when providing care to patients. A hurried attitude might be offensive to Hispanic or Asian patients because they tend to place a high value on politeness, "or American Indian patients, who value an unhurried approach to communication" (Pullen, 2014).

In sum, all nursing assistants should take heed and be mindful that cultural background has a definite impact on communication. Effective communication with patients from different cultures results in notably enhanced clinical outcomes, higher degrees of satisfaction, and numerous other benefits. Deliberate engagement in cross-cultural communication is a fundamental aspect for the provision of safe, competent, quality patient care.

The communication process can be hindered or even shut down altogether by multiple barriers, of which nursing assistants must be careful to avoid at all times. A barrier to communication is an approach, action or situation that obstructs communicative attempts. Common barriers to communication include slang words, clichés, elaborate vocabulary words, medical jargon, language barriers, unsolicited advice, and defense mechanisms. 

Slang is an exceedingly common barrier to communication that can lead to countless misunderstandings. Slang is defined as very informal phrases and expressions that are used between persons who know each other extremely well. Some slang words can lead to miscommunication between older and younger generations due to changes in meaning over the years (Your Dictionary, 2020). It is best for the nursing assistant to avoid using slang words and expressions altogether, at least during work hours.

A cliché is a phrase or expression that is excessively overused, unoriginal, and has lost much of the meaning that had made it unique at one point in time. A classic example of a common cliché is, "Time heals all wounds." However, a patient or family member is not really going to be helped or reassured by hearing their professional caregiver or nursing assistant make this statement. Hence, avoid clichés (Fuzy, 2003).   

Elaborate vocabulary words can serve as barriers to effective communication because the patient and/or family member might not understand much of what is being said. As an example, a patient might not know what the word 'sorrowful' means, but the vast majority of persons understand exactly what 'sad' means. Do not use words the patient does not understand; instead, speak to them using simple words (Fuzy, 2003). 

Medical jargon has been described as a second language used by and between "healthcare professionals to shorten and ease communication" (Pacific University Oregon, 2020). Medical jargon can be a major barrier to communication since the patient and/or family member might struggle to comprehend what healthcare workers are telling them. For instance, some patients may not know what 'perineal care' means. Instead, clarify by saying, "I am going to clean your private area."   

Language barriers occur when the patient speaks a different language than the caregiver. Language barriers can completely block communication. Since the patient and caregiver do not speak a common language, they do not understand what is being said to each other. Solutions to improve communication between patients and healthcare workers when a language barrier exists include interpreters, translators and language translation hotlines. If possible, children under the age of 18 should not be utilized to translate.

Unsolicited advice consists of guidance and recommendations that the receiver did not request beforehand. Although nursing assistants that deliver unsolicited advice usually have good intentions and mean to be resourceful, the patient might react in a hostile manner or not want to be bothered. Therefore, unsolicited advice can act as a powerful block to communication. Giving advice is not appropriate, so avoid advising patients or offering up personal opinions (Fuzy, 2003).   

Some defense mechanisms can be regarded as barriers to communication. A defense mechanism is a subconscious behavior used to relieve tension and/or cope with stressful situations (Fuzy, 2003). For instance, an angry patient might accuse the nursing assistant of being mad. In reality, the patient is angry at the nursing assistant. However, the patient is projecting her feelings onto the nursing assistant by subconsciously believing that the nursing assistant is the angry one. Projection is a defense mechanism that involves assigning unwanted thoughts and feelings onto another individual.

Many people have visual impairments, and healthcare workers must use special techniques in order to effectively communicate with this specific patient population. A visual impairment, also called low vision or a vision impairment, is a loss of sight that is not correctable by glasses or contact lenses. Depending on the severity, visual impairments can interfere with the completion of instrumental living tasks such as meal preparation, financial management, operating a motor vehicle, and working certain jobs.

Recall that communication is blocked when the recipient is unable to receive the message as the sender had intended. Thus, a visual impairment is a unique barrier to communication because the patient's loss of sight may prevent him or her from receiving the correct message. Since visual impairments can interfere with communication, it is imperative that caregivers take deliberate actions to ensure that their visually-impaired patients successfully accept and interpret messages that have been conveyed.

A number of simple methods exist for communicating with patients that have visual impairments to ensure they understand what is being said to them. When speaking with a patient who is blind or visually impaired (Australian Government, n.d.; Fuzy, 2003):

• Identify oneself when entering the patient's room: "Hi, Mrs. Andrews! I am Natalie, your nursing assistant."
• Do not ever touch the patient until identifying oneself by name.
• Introduce others who are present: "Dr. Walker is standing near the doorway and Jane is setting up the equipment to draw your blood."
• When entering a new room with the patient, provide sufficient lighting and orient him or her to the surroundings.
• To describe the location of objects in front of low-vision patients, utilize the face of an imaginary clock with a second hand (pictured below).
• Speak simply and use everyday language. Do not avoid words like ‘look’ and ‘see.’ 
• Indicate when you are ending the conversation or leaving the space: "I am leaving your room now. I will return in approximately one hour."
• Use specific wording when giving instructions: "The bedside stand is to the right of your bed."

Most importantly, the nursing assistant or professional caregiver should ensure that the patient has all adaptive devices available if he or she uses them. Adaptive devices include tools such as eyeglasses, wheelchairs, canes and walkers, that help the patient lead a more independent life. The caregiver should make sure that the patient's adaptive devices are clean and in good working order. Adaptive devices are important, especially for visually impaired patients, because their use can potentially enhance communication.

Hearing impairment is the loss of some or all hearing. A hearing impairment can occur in one or both ears; moreover, it can be temporary or permanent. Additionally, a hearing impairment could have developed over the span of many years, or the patient might have been born with hearing loss (Fuzy, 2003). A hearing impairment can certainly hinder communication because the hearing-impaired patient might be unable to hear what the caregiver is attempting to tell him or her.

Nursing assistants and other types of healthcare workers must utilize a specific array of communicative strategies when speaking with hearing-impaired patients. A number of these strategies might take a little more time than usual, but they will help patients with hearing impairments better understand what is being said to them. Some optimal communication strategies for interacting with hearing-impaired patients include the following (Queensland Government, n.d.):

• Minimize the physical distance: Volume of voice decreases over distance, so standing within three feet of the patient when talking is ideal.
• Use sufficient lighting: Adequate lighting helps with lip-reading ability. 
• Speak clearly: Talk at a normal or slightly slower pace, and keep the vocal volume up but natural. Do not yell.
• Avoid background noise: Communication is more difficult with environmental factors such as background noise.
  

Finally, the nursing assistant must directly face the hearing-impaired patient whenever speaking with him or her. Patients with hearing impairments need to see peoples' faces "clearly to gain help from facial expressions and to lip-read" (Queensland Government, n.d.). If the patient uses an adaptive device such as a hearing aid, ensure that it is in good working order with fully operational batteries. Also, make sure the patient regularly wears the hearing aid to facilitate good communication and better hearing abilities.

Nursing assistants must be exceedingly careful with their word usage, phraseology and tone to avoid allegations of verbal abuse whenever communicating with patients. Verbal abuse, which falls into the significantly broader category of psychological abuse, "is the use of spoken or written words, pictures, or gestures that threaten, embarrass or insult a person" (Hartman Publishing, 2014). 

Verbal abuse is a profoundly negative form of communication that can damage the victim's psyche in a relentless manner for many years after the occurrence of the abusive event. In addition, some agencies and healthcare facilities such as nursing homes have deemed verbal abuse a form of workplace violence due to the lasting psychological damage it inflicts on countless individuals.  

Many differing types of verbal abuse exist. Examples of verbal abuse include yelling "in an angry tone, using abrasive or inappropriate language, threats, or cursing" (Town of Blacksburg, n.d.). Even if the nursing assistant or caregiver had spoken no inappropriate words to the patient, statements made using a condescending or overtly hostile tone of voice are considered to be verbally abusive.  

Name-calling is a classic example of a verbally abusive behavior. In fact, name-calling is one of the most blatant types of verbal abuse, and all name-calling is considered verbally abusive (Corner Canyon Counseling, 2015). Therefore, nursing assistants and professional caregivers should remain calm under high-pressure situations and be mindful of their communication patterns. They must avoid calling their patients names because this hurtful behavior constitutes verbal abuse.

In a nutshell, caregivers are to never inflict any kind of abuse upon their patients. This includes less visible acts such as verbal abuse. Due to their status as mandated reporters, nursing assistants possess the legal obligation to report all actual and suspected instances of abuse to their supervisors as promptly as possible. Reporting abuse is the law; conversely, it is not a choice that the nursing assistant can opt out of (Hartman Publishing, 2014).   

Healthcare facilities often utilize the 24-hour clock, also known as "military time, to document information" (Alvare, Dugan & Fuzy, 2005). The use of military time in healthcare settings serves to enhance communication between members of nursing staff and other care providers due to its extremely high level of accuracy and precision. Unlike regular a.m. and p.m. times, military time is harder to confuse and tends to result in less disastrous mishaps for healthcare workers.

Regular times can create confusion in healthcare facilities such as hospitals and nursing homes. Regrettably, some people cannot tell the difference between a.m. and p.m., leading to a higher potential for timing errors. Caregivers might misread regular times, resulting in measuring vital signs and performing treatments at the incorrect times. For example, vital signs might be taken at 8:00 p.m. when they had been due at 8:00 a.m.

Meanwhile, the military must have a time system that eliminates misunderstandings. If the military used regular times, the outcomes could include masses of potential deaths and wrongly timed messages due to operations in multiple time zones around the world. So, healthcare facilities use military time to limit confusion and communicative misunderstandings. In military time, the healthcare worker recognizes day or night by the hour, so 9:00 a.m. can never be confused with 9:00 p.m. This is because 9:00 a.m. is 0900, and 9:00 p.m. is 2100.

Military time operates on a 24-hour clock that starts at 0001 to represent 12:01 a.m. and ends at 2359 to represent 11:59 p.m. In military time, 'a.m.' and 'p.m.' are totally eliminated, and so are the colons. In other words, military times do not utilize the colon to separate hours & minutes.  

• Morning hours: 0000 (12:00 a.m.) to 1159 (11:59 a.m.) 
• Evening hours: 1200 (12:00 p.m.) to 2359 (11:59 p.m.) 
• There will always be four digits.
• First two digits represent the hour: 1301 = 1:01 p.m. 
• Last two digits represent minutes: 2215 = 10:15 p.m. 
• Military time is a 24-hour clock; count from 0 to 24 
• Morning hours - 0000, 0100, 0200, 0300, 0400, 0500, 0600, 0700, 0800, 0900, 1000, 1100 
• Evening hours - 1200, 1300, 1400, 1500, 1600, 1700, 1800, 1900, 2000, 2100, 2200, 2300 
• Midnight - can be written as 0000 or 2400
  

Morning hours prior to 1:00 p.m. in military time are almost just as they appear in standard time. So, 12:20 p.m. becomes 1220 and is pronounced “twelve-hundred-twenty,” whereas 6:53 a.m. becomes 0653 and is pronounced “zero six-hundred-fifty-three.” To convert regular morning times to military time, just drop the colon and add a zero to the front as needed to make four digits. As an example, 6:53 a.m. became 0653 since it had received a fourth digit during its conversion to military time.

Evening standard times can be converted into military times by adding 12 to the standard time and removing the colon that separates the hours and minutes: 

• 1:05 p.m. + 12 = 1305 
• 8:32 p.m. + 12 = 2032 

Keep in mind that 0000 or 2400 are both acceptable ways of writing 12:00 a.m. or midnight in the military time system. However, 2401 does not exist, so the nursing assistant would essentially start the day all over again at 0001 to represent 12:01 a.m. So, at 2400 or 0000 (midnight), the day ends. The day starts anew at 0001, not 2401. Always remember this!

Australian Government. (n.d.). Communicating with people who are blind or have vision impairment. Retrieved April 25, 2020 from http://resources.fahcsia.gov.au/ConsumerTrainingSupportProducts/docs/employers/physical_vision.pdf

Corner Canyon Counseling. (2015). Categories of Verbal Abuse. Retrieved April 25, 2020 from https://cornercanyoncounseling.com/wp-content/uploads/2015/05/Categories-of-Verbal-Abuse.pdf

Fuzy, J.L. (2003). The Nursing Assistant's Handbook. Hartman Publishing.

Inscol Healthcare. (2015). Importance of Cross-Cultural Communication in Nursing. Retrieved April 24, 2020 from https://www.inscol.com/canada/blog/importance-of-cross-cultural-communication-in-nursing

Hanes, T. (2018). What is Verbal Communication? Retrieved April 23, 2020 from https://oureverydaylife.com/what-is-verbal-communication-4934342.html

Hartman Publishing. (2014). Hartman's Nursing Assistant Care - The Basics (4th ed.). Albuquerque, NM: Hartman.

Pacific University Oregon. (2020). Health Literacy for Interprofessional Education (IPE) Toolkit. Retrieved April 25, 2020 from https://pacificu.libguides.com/HLeT/JargonFreeTerms

Pullen, R.L. (2014). Communicating with patients from different cultures. Nursing Made Incredibly Easy! 12(6), 6-8.

Queensland Government. (n.d.). How to work with a person who is deaf or hearing-impaired. Retrieved April 25, 2020 from https://www.health.qld.gov.au/__data/assets/pdf_file/0024/157362/howtoworkwithdeaf.pdf

Stobierski, T. (2019). How to Improve Cross-Cultural Communication in the Workplace. Northeastern University Blog. Retrieved April 24, 2020 from https://www.northeastern.edu/graduate/blog/cross-cultural-communication/

Town of Blacksburg. (n.d.). Section 13 - Workplace Violence. Retrieved April 25, 2020 from https://www.blacksburg.gov/home/showdocument?id=5856

Your Dictionary. (2020). 30 Examples of Slang Words. Retrieved April 25, 2020 from https://examples.yourdictionary.com/20-examples-of-slang-language.html