Communication is defined asthe imparting or interchange of thoughts, opinions or information by speech, writing or signs. It is the tool which strengthens healthcare provider-patient relationship through which therapeutic goals are achieved (Park et al, 2006). Effective communication occurs when a desired effect is the result of information sharing, while poor communication leads to uncertainty and frustration. There are many situations where poor communication can lead to confusion. It includes not only building rapport but also leading to patients’ queries unanswered, discussing medical issues at patients’ bedside while ignoring them, talking harshly to patients etc. This can result in lack of support, disrespect and especially, harm to the patients.
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During my Mental Health Clinical at a private Hospital, I encountered a patient with diagnosis of Schizophrenia, and his Mental Status Examination (MSE) revealed that he had circumstantial ideas. I asked him a question and he talked irrelevantly about it. The nurse, who was listening to our conversation, scolded the patient saying why was he not answering relevantly. The nurse’s way of talking was very rebuking and lacked empathy. Upon getting scolded, the patient got aggressive and embarrassed, yet left silently. I visited the patient later, continued the MSE politely, and he answered me well.
In my patient’s scenario, the nurse emotionally abused and demoted my patient rather than encouraging him. I believe this lowered my patient’s self-esteem and shattered him psychologically as evident by his gesture of leaving the room in silence due to aggression. Gadit (2011) states that “verbal abuse can cause significant psychological problems in later years and brain damage”. This means that skilled communication of a nurse helps a patient reduce his worries, making him comfortable. Moreover, patient’s verbalization of feelings and thoughts aids a nurse in correctly identifying his problems and performing interventions. Therapeutic communication holds importance as it “contributes to a patient’s emotional growth or reinforce his or her illness.” (Masilani, 2010, p.02). Thus, poor communication shatters the nurse-patient’s therapeutic relationship and acts as a barrier in expression of patient’s feelings which may lead to flawed nursing care. Nurse’s poor communication leaves a negative image in a patient’s mind regarding nurse and the institution, impacting greatly on his treatment. Patient would not express but build on feelings deep inside, which can lead to depression. My patient was not able to answer promptly due to his disease process. Through positive regard, assurance and encouragement, the nurse could have helped the patient. Instead the nurse demoted him and lowered his self-esteem.
A model by Shanon and Weaver (1949) explains where the gap was formed. This model has 8 elements: source is an individual or a group that wants a message to be delivered ; encoder is the specified format for later interpretation; message is the idea that is being communicated; channel is the route that the message travels on; noise is any interference in the communication; decoder is the interpretation of the message from its original form into the one that the receiver understands; receiver is the intended recipient who takes in the message that the source has sent and feedback relates to the source whether their message has been received, interpreted correctly or lost in the noise. In the above scenario, I was the source who put the model into action. Encoding was my speech and expressions. I was doing the Mental Status Examination and it was my message. Noise was the nurse who interrupted and distorted my message. When the noise over rode the source, problem in the decoding occurred, leading the receiver to get aggressive and embarrassed. This gave the feedback that the message that was sent has got an error and needs to be revised. Building on the feedback, I gave patient sometime, and interacted with him later to continue his examination for his benefit
Barriers to effective communication can impede or deform the message. There may be physical barriers that often occur due to the environment. Example of this is the shortage of staff, lack of time, increased workload, improper building etc. In the above scenario, the unit allotted for psychiatry was undersized and less spacious. Nurses and the patients were locked in the small unit, where they could easily listen to each other’s conversations. Second barrier can be the system fault. It refers to problems with the system in an organization. Examples include a lack of clarity in responsibilities, supervision and training. Keeping the scenario in mind, a nurse has the basic responsibility to practice empathy, as studies link empathy with therapeutic relationship (Reynolds & Stewart, 2002; Neumann et al, 2012). Attitudinal barriers occur as a result of problems with staff. Examples include poor management, communication errors, personal attitudes of individual staff due to lack of motivation and insufficient training etc. The above Private Hospital setup reflected that there was no supervision and the staff did not seem much competent.
When looking into the socio cultural context, a news report reveals that “mental health is the most neglected field in Pakistan” (Qasim, 2012). In such conditions, if the communication flaws persist, a patient’s mental health is likely to be devastated. Another survey in Pakistan shows that patient’s satisfaction depends on a healthcare provider’s communication and behavior with them during their length of hospital stay (Danish, Khan, Chaudhry, & Naseer, 2008). As psychiatric patients usually have repeated admissions and prolonged hospitalizations, therefore therapeutic communication can allow a nurse to deliver quality care to the patients, thus satisfying their needs. Moreover, departments of psychiatry in Pakistan are not well equipped specially in terms of psychiatric manpower (Gandit 2006). Literature emphasizes that swift pace and content is required in the field of research.
Poor communication can be attributed to a number of factors. Lack of understanding, which includes value to proper communication and empathy in therapeutic relation, is one of the causes . Sometimes patient factors do not allow healthcare practitioner to communicate properly as it has been observed that harming behavior, emotional blocks and other psychotic symptoms do not allow nurses to continue therapeutic communication (Pfeiffer, 1998). It was also evident in my patients’ case that nurses’ communication can lower self-esteem and promote distress. Excessive poor communication of the nurses can lead to constant aggression and anxiety of communication, ultimately worsening patient’s mental health.
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To sustain a therapeutic nurse-patient relationship I would recommend that institutional management should arrange communication skill workshops for staff, as researches show that workshops help in improving nurses’ communication skills and their sense of preparedness (Lamiani & Furey, 2009). The nursing supervisors should also identify the causes which hinder in communication. Moreover, nurses could reflect daily upon their communication skills, analyze the mistakes and try to work on it, as reflection is a powerful educational tool in nursing that can enhance clinical experience (Bradbury-Jones et al, 2009). They can also take ongoing feedbacks from colleagues and try to improve on their weak points. Since “psychiatric patients have problems in communicating and forming relationships” (Hem & Heggen, 2003, p.102), therefore I would suggest that psychiatric nurses should have profound awareness of when to show empathy during communication. In my opinion medical and nursing students should focus on efficient communication while studying psychiatric course, so they can continue to practice it precisely. Furthermore, as discussed above, a barrier to effective communication is the lack of supervision. For that, ongoing rounds and evaluations should be done by the higher authorities to witness the exact situation and happenings, since it is noticed that in the supervision of the higher authorities, communication is more therapeutic. Thus, I recommend institutions to keep an eye on their staffs’ communication techniques in order to minimize negligence.
In conclusion, nurses may commit errors but practice can make them perfect especially in a skill like communication. Thus, nurses must practice as much as possible and try reducing communication errors. As discussed, there are several causes and effects of poor communication especially in psychiatric nursing. But “nurses should use themselves as a therapeutic instrument” (Hem & Heggen, 2003), so that they can help the psychiatric patients for their early recovery.
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