How does the situation make you feel as a nurse manager?



Managers’ duty to maintain good workplace communications skills The delivery of safe care requires good nurse-patient relationships, in an

environment in which staff feel free to speak out and put forward ideas.

Fiona Timmins describes how managers can achieve such practice

Summary I Communication is a fundamental element of care at every level of nursing

practice. It is important, therefore, for nurse managers to create environments that

promote and encourage good communication, and help nurses to develop their

communication skills formally and informally. This article discusses the effects

of communication on the quality of care. It examines nurses’ professional duty to

maintain good communication skills and how managers can help them do this. It

also discusses nurse managers’ communication skills in the context of leadership

style, conflict resolution and self-awareness. Finally, it considers the notion of

shared governance as good practice.


Nurse, manager, communication, management

PATIENT SAEETY and the provision of good care are important components of contemporary healthcare delivery, and effective communication is a crucial element of these (Health Information and Quality Authority (HIQA) 2010). It is important, therefore, that nursing managers ensure that staff in clinical areas have good communication skills (Thyer 2002).

Communication includes many elements (Box 1). Poor relationships between stciff, and poor communication in general, can eiffect patient care and safety, and should therefore be of concern to nurse managers (Thyer 2002). Meanwhile, evidence suggests that impaired communication can affect patient outcomes, and many studies indicate that the information that patients receive often fails to meet their, or their families’, needs (Gambling 2003, Scott and Thompson 2003, Alm-Roijer et al 2004, Hanssen et al 2005, Oterhals et al 2005).

Eaüure to communicate effectively can also have legal repercussions. Eor example, medication errors that result in patient injury, can be caused or compounded by communication problems.

Professional duty Historically, UK nurses have been expected to be proficient in communication from the point of registration, but the most recent Nursing and Midwifery Council (NMC) (2010) guideline on pre-registraüon communication makes the requirement more explicit, stating: ‘AU nurses must… communicate effectively using a wide range of strategies and interventions including the effective use of communication technologies. Where people have a disability nurses must be able to work with service users and others to obtain the information needed to make reasonable adjustments that promete optimum hecdth and enable equal access to services. ‘

The NMC (2010) also sets out competencies that nurse must attain within the domain of communication and interpersonal skills, including: ‘Adult nurses must demonstrate the ability to listen with empathy. They must be able to respond warmly and positively to people of all ages who may be anxious, distressed, or facing problems with their health and weUbeing.’

Within this broad competence is a range of ‘field competencies’ that nurses are expected to demonstrate within the communication and interpersonal skUls domain, including those outlined in Box 2.

Nurses are deemed competent in communication skills when they register, but there is Httle systematic, standardised assurance of competence beyond this stage. Ongoing demonstration of competence in communication is not mandatory, although they are expected to fvdfU criteria in relation to minimum levels of cUnical experience and to attend at least five days of learning over three years (NMC 2006).

Authors such as Vandewater (2004) suggest, however, that from the nursing perspective, this

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is insufficient, saying that ‘within the context of a rapidly changing healthcare environment and associate(d changes in knowledge and practice, a periodic re-examinaüon of individual’s competence is might be necessary to ensure safe practice’.

In the UK, the NHS knowledge and skills framework (Department of Health (DH) 2004) stipulates communication as a core required skiU.

Promoting good communication Ensuring nurses’ competence in a rcinge of skills can be challenging when ongoing assessment is not compulsory. However, from a professionell perspective, cdl nurses must ensure that they have the skiUs and knowledge required to practise at a competent level, and nurse managers have a degree of responsibility to ensure standards are maintained.

Nurse managers can ensure that staff are skilled and effective communicators by making sure that: • Competent staff are recruited (HIQA 2010). • Nursing staff are competent at all times. • Adequate standards-of-care guidelines are

available to steiff. • Policies and procedures are available to staff. • Effective communication systems are in place. • Staff are encouraged to develop their

communication skills through performance review.

Learning cind development Encouraging nurses to use portfolios, for example, can promote

Communicating witli multidisciplinary team members.

Chairing and contributing to meetings.

Providing orai and wrtten patient reports at siiift cliangeover.

Assessing, pianning, evaluating and impiementing services.

Communicating with famiiies and relatives, and providing tiiem witli information.

Recording interventions sucii as medication deiivery.

Recording patient observations and vitai signs.

Breaking bad news.

Providing updates to multidisciplinary teams on patient status.

Communicating timely information about changes in patient condition.

Supporting patients and families.

learning and development in communication skills. Managers can also offer formal education sessions on communication requirements and provide structured educational support for newly qualified staff through performance review, mentorship or clinical supervision.

Competency frameworks There is a range of national competency frameworks aimed at measuring competence in specific clinical areas or roles, such as those of clinical nurse specialists and advanced nurse practitioners (National Councu for the Professional Development of Nursing and Midwifery íNCNM) 2008a, 2008b), but competency frameworks can also be developed locally. Kalb et al (2006), for example, developed

Aduit branch nurses must promote the

concept, knowiedge and practice of seif-care

with people with acute and iong-term

conditions, using a range of communication

skilis and strategies.

Aii nurses must:

• Buiid partnerships and therapeutic

relationships through safe, effective and

non-discriminatory communication. They

must take account of individual differences,

capabilities and needs.

• Use a range of communication skiiis and

technologies to support person-centred

care and enhance quality and safety.

They must ensure people receive

ail the information they need in a

language and manner that allows them

to make informed choices and share

decision making. They must recognise

when language interpretation or other

communication support is needed and

know how to obtain it.

Use the fuli range of communication

methods, including verbai, non-ßrbai and

written, to acquire, interpret and record

their knowledge and understanding of

people’s needs. They must be aware of

their own values and beliefs and the impact

this may have on their communication

with others. They must take account of

the many different ways in which peopie

communicate and how these may be

influenced by iil health, disability and

other factors, and be able to recognise and

respond effectively when a person finds it

hard to communicate.

Recognise when peopie are anxious or

in distress and respond effectively, using

therapeutic principles, to promote their

wellbeing, manage personal safety and

resolve conflict. They must use effective

communication strategies and negotiation

techniques to achieve best outcomes,

respecting the dignity and human rights

of aii concerned. They must know when

to consult a third party and how to

make referrals for advocacy, mediation

or arbitration.

Use therapeutic principles to engage,

maintain and, where appropriate, disengage

from professional caring relationships,

and must always respect professional


Take every opportunity to encourage

health-promoting behaviour through

education, role modelling and

effective communication.

Maintain accurate, clear and complete

records, including use of electronic formats,

using appropriate and plain language.

Respect individual rights to confidentiality

and keep information secure and

confidential in accordance with the law and

relevant ethical and regulatory frameworks,

taking account of local protocols. They must

aiso actively share personal information.

NURSING MANAGEMENT June 2011 | Volume 18 | Number 3


a competency assessment tool that focused on communication for public health nurses (PHNs) in the US. The tool was used as part of performance appraisal and replaced an outdated version that no longer reflected PHN roles.

The tool was tested in a three-month pilot. The nurses’ job descriptions and national guidelines relating to PHN competence were used to develop the tool, which incorporated eight domains of competence, including communication.

The communication domain (Kalb et al 2006) described the necessary skills as ‘respectful communication, reliability and appearance’.

Kalb et al (2006) considered the latter important because they thought that it portrayed professionalism to patients and fostered trust.

Role modelling Ntirse managers are in a strong position to effect change in relation to commtmication skills by influencing policy and standards, drawing nurses’ attention to areas that need improvement, role modeUing good commimication behaviours and supporting staff. According to Rosenblatt and Davis (2009), how ‘managers approach… potentially sensitive or difficult areas can make all the difference in how the situation turns out’.

Role modeUing good communication provides staff with informal support and leadership. Managers who have good communication skills create good working atmospheres that ultimately improve nurses’ confidence, motivation and morale.

To foster good relationships, ensure good clinical environments and staff job satisfaction, managers need to adopt open, approachable leadership styles that involve actively listening to and respecting staff, and involving them in decision making and governance (Thyer 2002). Regular staff meetings that are effective managed are also crucial (Thyer 2002).

Other authors agree that nurse managers should adopt open, friendly and flexible approaches to their interactions with nurses (Drach-Zahavy 2004), while Rosenblatt and Davis (2009) emphasise the importance of face-to-face communication and suggest using metaphors in place of direct communication. Eor example, rather than saying ‘Your approach to this is a bit too severe’, nurse managers could use phrases such as ‘This is Uke using a sledge hammer to crack a nut’.

Ultimately, nurse managers should treat colleagues with respect and be positive at all times, even when the situation makes it difficult to be so (Almost et al 2010).

Actively listening to staff is good communication behaviour that helps nurses feel supported and requires managers to be receptive to nurses’ ideas (McMurray and Williams 2004), and Carter (2010) encourages managers to provide time and space to listen to staff experiences of care provision and any work-related problems they have.

Good communication should permeate all management tiers, and senior managers must build relationships with their nurse managers by scheduling and keeping regular appointments to listen and provide guidance, keep them informed, articulate performance expectations and give feedback (Parsons and Stonestreet 2003).

Conflict management One cirea in which nurse meinagers’ communication skills are frequently required is conflict management. This can arise as a result of inadequate communication (Brinkett 2010) and result in intrapersonal conflict, that is conflict within oneself, or interpersonal conflict, that is conflict with others. Brinkett (2010) categorises conflict according to its development: within and between nurses; between nurses and other healthcare professioneils; or between nurses, patients and patient’s feunilies.

Physician-nurse conflict, according to Brinkett (2010), commonly accompanies ethical decision making that concerns, for example, end of Ufe care, but is also common in operating theatre departments. Conflicts Ccin arise over facts, methods, goals and veilues, out of difference in professional opitiion or through role changes.

Brinkett (2010) highlights that conflict in healthcare contexts can be costly in terms of care outcomes and can result in errors and poor care, and that persistent conflict can have long-term effects on individual and group morale, job satisfaction and performance. Therefore, from nuise managers’ perspectives, conflict management skills are important in the workplace.

One of the important elements to conflict prevention or management is ensuring workplace environments are such that nurses feel free to speak out when difficulties arise, so nurse managers need to be aware of problems and instigate timely conflict-resolution plans.

Conflict resolution This requires consideration of all factors that have contributed to a conflict and using problem-solving techniques, such as problem identification, brainstorming solutions and asking if solutions are safe, fair and acceptable to others (Arnold and Underman Boggs 2007). The principles

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of conflict resolution (Arnold eind Underman Boggs 2007) include: • Identifying conflict issues, • Knowing your own response to conflict, • Viewing the problem objectively, • Staying focused on the problem and what

motivates people to take the positions they do, • Identifying available options, • Identifying established standards to guide

decision making. Ongoing evaluation, after solutions have been Implemented, is always necessary to monitor conflict and make changes as needed.

Nurse managers have to confront conflict situations directly to be able to manage them and doing this requires moving through several phases, Müstead (1996) describes the three phases as: • Information seeking, in which managers need

to find out more about a situation and what is going on,

• Planning an appropriate venue, • Allowing time for conflict resolution. Resolution of the conflict takes the form of a discussion that focuses on the problem. Specific actions required should then be agreed by all parties. It is also useful to take notes during meetings as a record of what is agreed.

Self-awareness Self-monitoring of communication skills is an important element for nurse managers to consider, not only when resolving conflict, but also when role modelling good communication behaviours.

They need to be aware how the way they communicate can affect others: Rosenblatt and Davis (2009), for excimple, suggest that, because managers are in relative positions of power, they can come across as intimidating. People often act defensively when they feel intimidated, so Rcsenblatt and Davis (2009) advise managers to be aware of how they come across and adjust the way they communicate by being more self-aware, and by evaluating and monitoring their own communication skills.

With regard to the transformation of nurse management in the NHS, Tourish and MulhoUand (1997) suggest that ‘a crucial dimension to this process is how nurse managers evaluate the qucility of their relationships with their staff, how they monitor their own effectiveness as communicators and how they put in place systems which enable them to systematically improve relationships and communication’.

The process of becoming aware of how we communicate as individuals is challenging (McCabe

Describe what happened in a short paragraph.

How does the situation make you feel as a nurse manager?

Evaluate the situation. What sense can you make of it? Why do you think

it happened, or could happen?

Analyse the situation. For example, what important components of effective

management or leadership are missing from the interaction? Why did

the interaction turn out as it did? Did you use effective nurse-manager


Conclude this situation by summarising what happened and why, and

by identifying the important communication issues within the interaction on

which you are reflecting.

Devise an action plan. What would you do differently in this situation,

and to prevent a similar one from occurring?

and Timmins 2006), Bumard (1997) describes self-awareness as ‘a continuous and evolving process of getting to know who you are’ and says that, although humans possess awareness of self, this ability can be explored and developed to improve communication skills.

In this context, nurse managers need to consider their Interactions with colleagues within a formalised reflective cycle such as that proposed by Gibbs (1988), an adapted version of which is shown in Box 3, This reflection can help managers to analyse how they communicate and identify areas for improvement. Managers, Uke anyone using such frameworks, should focus on themselves rather than on other people, and maintain confidentiality,

Rosenblatt and Davis (2009) agree that managers should use self-development to improve their communication skills and suggest rehearsing difficult interactions by videotaping themselves and analysing the recordings to see how they can perform better.

The focus of any analysis, whether a taped communication or a structured reflection, should be to determine whether interactions can be more person-centred. To do this, nurse managers should consider the extent to which they exhibit the following behaviours: approachabüity, respect for the other person, friendliness, appropriate humour, openness, wüUngness to listen, and evidence of having listened and taken the person seriously (Rosenblatt and Davis 2009),

Shared governance Several studies that feature communication as an important management skill suggest that including staff in decision making and shared governance improves commxmication, empowers others and increases staff job satisfaction (Thyer 2002, Notara et al 2010),

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Robertson-Malt and Chapman (2008), for example, report that ‘the trend of increasing health care costs shows no signs of easing. To sustain quality care, amidst the dual and conflicting demands of cost control and consumer “savvy” regarding best practice, a more inclusive style of management, where each employee is held accountable for their contribution to the quality of patient care outcomes, is needed’.

They describe the implementation of a shared governance model in the King Faisal Specialist Hospital and Research Center, in Riyadh, and state that ‘staff nurses are the agents of change who can control costs and improve the quality of care’ (Robertson-Malt and Chapman 2008). To achieve shared governance at the Saudi Arabian hospital, several committees were established with the underpinning ethos of ‘facultative communication and leadership’. The first phase of implementation of shared governance was to develop an open communication system throughout the organisation, and make policies, stEindards and clinical pathways available to nurses.

The authors report that there was an ‘atmosphere of participation’, in that staff nurses participated directly in these committees or could refer matters to them. The committees became ‘central agents for change’, and encouraging open communication on all issues of care was crucial to this. Open

communications systems allowed nurses’ voices to be heard. Nurses were able to have a say in the running of the organisation which fostered empowerment.

Thus nurse managers in the UK and elsewhere might consider setting up similar committees to make communication easier eimong staff and between nurses and other disciplines – and to encourage shared governance.

Conclusion Competence in communication is fundamental to the development of good nurse-patient relationships and many elements of care delivery. The absence of good communication can compromise patient Scifety and care quality, so nurse managers have a responsibility to ensure that communication skuls in clinical environments are developed and maintained.

Managers can use formal support methods, such as education sessions, performance review and competence assessment, to enable this, as well as informal methods such as role modeUing good communication skills.

Above cill, nurse managers must adopt an open meinagement style, ensure that they are available to listen to nurses, pass on relevant information, involve nurses in decision making and deal with conflicts as they arise.

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Fiona Timmins is a senior lectuier at the school of nursing and midwifeiy. Trinity College Dublin


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