Communication Skills: A Guide to Practice for Nurses and Midwives

For a nurse, the ability to communicate is a very important skill and a vital part of the job.

Nurses speak to people of varying educational, cultural and social backgrounds and must do so in an effective, caring and professional manner – especially when communicating with patients and their family.

This article will address several aspects of communication to help you navigate and master each interaction you have in your day-to-day practice.

For those who need a quick refresher, this first section offers 10 essential communication skills to remember:

1. Speak Slowly

Certain words sound very similar to one another if they are spoken quickly.

Take the time to speak slowly and carefully, and your words may be less likely mistaken by others.

2. Speak Clearly, Not Loudly

When communicating with some people, especially those who are older, the inclination might be to raise your voice dramatically in an effort to make them understand you. Shouting only tends to make it harder to comprehend what you are saying.

Instead of speaking louder, try speaking with more clarity – especially when communicating with older patients.

3. Avoid Using Slang

A common mistake that many health professionals make is to use bigger and more complicated words. Another common mistake is the use of slang terms that are not fitting or appropriate. Avoid both of these mistakes for better communication.

4. Remember Your Audience

What you say to a doctor or a fellow nurse might be very different to what you would say to a patient and their family.

Use the word ‘medicine’ rather than ‘drug’ when talking to patients. Many people associate the word ‘drug’ with illicit substances, whereas health professionals view the word ‘drug’ as any pharmaceutical.

Choose your words to fit the situation and the audience.

5. Stop and Listen

Communication is a two-way street.

One of the most important communication skills is the ability to stop and listen actively and ethically, to what is being said by the other person.

6. Reflect

To make sure that the communication is flowing, learn the simple trick of reflecting on what the person is saying to you.

To do so, you simply repeat what has been said in your own words, back to the person. If you are wrong, the person can say so before you walk away.

7. Use Body Language

Despite the words you use, the majority of human communication is through the body language in your face, hands, posture etc.

Be conscious of what your body is saying and whether it is in agreement with your words. Do not send conflicting messages.

8. Know Your Communication Roadblock

If you have ever stumbled on a word or found yourself frustrated trying to communicate an idea, then you know your roadblocks.

Everyone has a few of them. Knowing yours can help you to find ways around them. For instance, if you know that a person crying will effectively make your communication skills disintegrate then try to actively practice ways to manage these situations better.

9. Consider Learning a Foreign Language

It might sound strange, but learning a new language puts you in better touch with your native tongue and can open your eyes to the way you use the words you already know.

10. Don’t Forget Other Methods of Communication

In addition to speaking and listening, don’t forget that there are other skills that you should work on, such as reading, writing and technology-based communication.

1. Set the Scene

   Choose an appropriate time to speak with the person (that is, avoid approaching them during a favourite television program, when leaving for work, when stressed about an unrelated issue, and so on) or negotiate a time.

   Do not try to speak about important issues if one or both of the parties are intoxicated. For teenagers, talking in the car or using issues on a contemporary television show might provide a good springboard.

   If the time never seems right, fire a ‘warning shot’ by saying, “There’s something I want to talk to you about. It’s important. I know you have been busy but when could we catch up properly?“

2. Begin to Talk About the Small Things

   Self-disclosure is unfamiliar territory for some. Others might not have the vocabulary to describe how they feel, not see the relevance of telling others, may expect unwanted judgments or fear ‘opening the floodgates’ and overwhelming themselves or others.

   Think about small, less emotionally charged topics as a way of opening the door to more significant conversations. Sometimes, if you talk about what you think and feel, others will slowly follow.

3. Listen and Ask Questions

   Listening without interrupting is powerful; it conveys interest and respect for another’s point of view.

   Spend the time really listening to what is being said (this doesn’t mean you must agree with it). Maintain eye contact and make encouraging remarks such as “I see what you are saying…” and “Go on…” and ask more questions.

   Again, open questions provide the most potent way of understanding another’s position or feelings. Use questions beginning with why, what, when, where and how.

4. Limit the Expressing of Assumptions and Opinions for a Time

   Reverting to old patterns of communication can block new ones. People who have known each other for many years, if not all of their life, will feel as if some (albeit important) discussions are no longer worth having as they always seem to end in the same way.

   Not responding in the same way they always have can help others to be more tolerant and to try to reach new ground.

5. Learn to Walk before you Run

   In some exceptionally difficult circumstances, such as the journey of a patient with cancer or a someone close to death, people may feel pressured to start to talk about meaningful subjects and intimate thoughts and feelings (for example, if someone has received some disappointing news that a treatment hasn’t worked as well as it was hoped).

   For those that have avoided communicating so far, this is confronting and enormously challenging. Communication about difficult issues is much easier if the small steps have been taken first. Try to use the valuable time you have now to open discussion slowly.

6. Be Assertive When You Need to. Use ‘I’ Statements

   Being assertive involves expressing your own thoughts and feelings without dismissing or abusing the rights of others (which is aggression). Particularly when there is concern that a discussion may result in conflict, using ‘I’ instead of ‘you’ statements is a useful skill.

   For example, saying “I feel disappointed when you came home and did not ask me about how my treatment went” is a less accusatory way of expressing your feelings than, “You make me so cross when you don’t even bother to ask me how my treatment went.”

   Use a simple: ‘I think’, ‘I feel’ and ‘I want’ approach. For example, “I think the radiotherapy is taking a lot of time and effort. I feel pretty tired most days. I want you to help around at home by making your own lunches.”

7. Keep Working at it

   When talking to others (especially children or older patients) we do not have only one chance to say things — it doesn’t have to be ‘perfect’.

   Communication evolves and there are nearly always other opportunities to talk. Be realistic in your expectations — set realistic goals for communication and be patient, yet motivated, to create even small changes.

8. Communicate Without Words

   Loving and supportive communication does not need to revolve around words. Simply being there, holding hands, smiling, sharing meaningful eye contact and showing physical affection are all meaningful ways of demonstrating respect, concern and support.

When communicating with family and friends, you can very quickly find yourself entrenched in interfamily politics, put into ethically untenable positions, and generally spending a great deal of time turning people down in their hunt for information.

Although it should be the job of the immediate family to manage the others, this responsibility often falls to the nurse.

Privacy, HIPPA and Families

Technically, the only one with the rights to patient information is the next of kin. Large families, though, pose a problem as there may be a number of next of kin.

Despite being US-centric, the Health Insurance Portability and Accountability Act (HIPPA) — a piece of US legislation — offers advice and guidance that may be useful for health professionals practising globally.

One example is the privacy number concept — something that many US facilities now employ. Think of a privacy number as an access PIN for patient information. If you don’t have the number, then you don’t get any information on the patient. It is simple and easy to turn someone down under those circumstances.

This isn’t always a total fix, though.

That number can very easily be disseminated to numerous people, and this means the nurse has to spend a great deal of time explaining the same information to ten or twelve different people. It takes time to make non-medical persons understand the situation, and the problem can get quickly out of hand.

Managing Large Families

In large family situations, someone should be appointed the main contact. This way, the nurse only has to explain the situation once.

Ideally, it should be the next of kin; but some families may want a member with a medical background to handle updates and check-ins. You don’t need to get into the politics of who becomes the main contact, but you do have to strongly insist that only one person can get the information from the nurse on duty.

Another possible management tool is to tell the next of kin to guard the privacy number closely. Explain to them that it takes away from the care of their family member to have several people with the privacy number.

Even though you are not in charge of the family, you will have to step in and make suggestions that they may or may not comply with. If they don’t comply, it may be necessary to call a family meeting and explain the importance of a contact person. However, even in the best of situations, it may be difficult to get the amount of contacts down to one.

Case Study

Mrs Jones is an 89-year-old woman who has come into the intensive care unit with an acute stroke.

She is the proud mother of five children, all of whom are married, and a grandmother of ten. Some of these grandchildren are old enough to have spouses of their own.

Unfortunately, Mrs Jones’ husband died four years ago and her care has been transferred to her eldest daughter, Lisa. The relationship between Lisa and her siblings is complicated, and all of them have insisted on obtaining the security code for themselves. Lisa, not wanting to start an argument, has given it to her brothers and sisters, who in turn, gave it to a few grandchildren.

Every day on the unit, the nurse assigned to Mrs Jones receives at least five phone calls about their family member’s status. Although the nurse tries to be concise, often these conversations can take up to twenty minutes. After a few days of this, the day nurse brings the family together and explains the difficulties in handling so many calls when their mother’s care is so critical.

It is decided that all information will flow through Lisa, although this does not make everyone happy. The plan is agreed to, however, and now the nurse need only field one update call per shift and continue to communicate with her elderly patient, Mrs Jones.

Juggling Bad Feelings

In the end, you will inevitably engender bad feelings, even in small families. No one wants to be told that they don’t have a right to information about their loved ones.

Even those without the privacy code may try to bully you into telling them something, and your assertiveness as a nurse has to override that impulse to please. Some families may even go to your manager, so be sure to keep them abreast of the situation and what you are doing to protect the patient’s privacy.

There are no easy answers in cases like this, and the nurse has to make a judgment on a case-by-case basis. You can help minimise bad feelings by actively listening, keeping your cool and assuring callers that you understand they are concerned about the patient. If you have someone who is angry with you, that may be necessary for the good of the patient. If that person goes to your manager, be sure to back up your actions so that you can prove you are merely respecting privacy laws and protecting your ability to care for the patient.

What to Do When Things Escalate

Sometimes, despite our best intentions, things can get a little out of hand and patients may demand to speak to a higher authority — your nurse manager for example.

If this does happen, it’s best to calmly accept the patient’s request and inform them that you will organise a meeting.

 

Crisis Management

Families in crisis may react in ways that they normally would not. The stress and worry over a patient in danger can cause them to say and do things that are offensive, violent, loud, and intimidating. A great deal of the attention will be focused on you because you are at the bedside, caring for their family member.

As in most communication situations, it is important to remain calm in the face of whatever the family may present. If you are in danger or feel you may be in danger, don’t hesitate to call security to get the situation under control. Usually, though, it doesn’t escalate to this level. In that case, you need to work on calming the relative.

Honesty is, once again, very important, and you shouldn’t make empty promises to keep a relative calm. Once you have established that they are privy to the details, tell them the truth about what is going on with their loved one.

Be prepared for a wide range of reactions. Some will react with anger, but most will react with neutrality or sadness. In some cases, this can be more difficult to deal with than hostility. Offer yourself as a sounding board for the relative. Make it a point to be there for them, a presence of peace and understanding. Comfort them and do not betray their trust in you.

Patient Rights v Family Rights

Patients have the right to competent care, protection from reasonable risks, and advocacy from their nurse. Families may feel they have rights too, but the patient’s rights always come first. If the relatives are disturbing the patient, working them up, or causing more stress, the nurse has to step in and remove the family. It is a difficult situation to be put in because no one wants to separate a family from their loved one. However, you have to take the patient’s wellbeing into account. Is this helping them or hurting them?

Most families will not cause stress, but sometimes even the most laid back family may cry, focus only on the negative, or in other ways upset the patient.

In these cases, it is important to talk to the patient and the family member. Ask the patient if they are comfortable with their family and if they would like the family to have restricted access to them. Most will decline, but at least you are offering the opportunity to the patient.

Next, talk with the family. Explain that their behaviours are upsetting the patient and that a different approach is needed. There is no reason to be falsely happy, but tell them to simply be with the patient instead of focussing on the negative.

In the end, talking to a patient may be easier than talking to their family. Patients may not understand what is going on with them, and their relatives are basically in the same position. However, they also have the added stress of not knowing if their loved one will make it through. Acknowledge the fear they are feeling and offer them the same compassion you would offer your patients.

Nurses encounter many older people in the course of their careers. This makes sense, because as a person ages they may require more frequent care. Communicating with patients is a skill that you need to practice. Addressing older patients can be different to talking to other adults; older people may be scared, may not want to bother you, or may not fully understand what you are talking about. Memory and cognitive disturbances can also make talking to this population challenging. Of course, it goes without saying that you should respect the intellectual capacity of the person you’re speaking to regardless of their age.

“Wrinkles should merely indicate where the smiles have been.” – Mark Twain

Give Them Time

One of the most important considerations when talking with older people is time. If you show the slightest amount of impatience or stress, you’re likely to shut them down. It is hard to dedicate the time necessary to talk properly to an older person, but this is the way to open the communication channel. Some elders are afraid to speak out because they don’t want to bother you or be seen as someone who is a complainer. Some don’t have the mental capacity to talk to you or to fully express themselves immediately. It is only over time that you get the whole story.

Another challenge you may encounter when communicating with older people is that they don’t feel comfortable “talking back” to the medical professionals. This is especially true of doctors, but they may feel the same reticence when talking to nurses. If you are there and available for their concerns, they may be more willing to talk to you than to the doctor who might only spend five minutes in the room. You may find out something that is vital to the care and comfort of that patient just by spending an extra few minutes with them. Yes, nurses are busy, but older people need time to express their pain, fear, and questions, and you need to allow for that in your schedule.

Explain Things Simply

As with children, it is best to avoid medical jargon when speaking with older people. Medical jargon isn’t really a good way to talk to any patient, but it is particularly detrimental when speaking with the elderly. However, you don’t want to come across as condescending, either. It is a fine line to walk, and you need to base your language on the questions and cognitive ability of the patient you are speaking with.
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Try to use language that is simple, clear, and non-threatening. You should also strive to be as honest as possible. Some older patients need to write down what you are telling them so that they will remember it. Be prepared to repeat yourself and express concepts in different ways so that your patient can grasp what you are trying to say. One of the most important parts of helping your elderly patients is acting as a kind of interpreter for the doctor. Try to be on hand when the doctor talks to the patient so you can explain later what they said. Older people will often be overwhelmed by a doctor and won’t ask questions at the time. They will wait and ask you later to get a better understanding.

Case Study

Carolyn is a 75-year-old female patient with a history of mild to moderate Alzheimer’s disease. Although she is forgetful, she is still able to live a relatively independent life. She experienced an episode of fainting that was witnessed by several people at church, and she was taken to her primary care physician. It took a great deal of talking to her to help her understand that the fainting spell was, in fact, a major problem that needed to be investigated.

In addition to restricting her driving privileges, Carolyn needed several tests to rule out different probable causes of her fainting spell. Each test needed to be carefully explained to Carolyn and the information repeated so that she could grasp what each one required. She wrote down all the key information in a system that she had developed to keep herself from forgetting important points. In the end she had her tests, although she didn’t understand many of them, and doctors are still trying to determine the cause of her fainting spells. It takes careful reminding to keep her from driving her car or performing other actions that may put her in danger.

Include Family in the Conversation

Finally, including family is a big part of communicating with older people. When the patient doesn’t understand, often a family member will step in and take the reins. Again, you shouldn’t begin ignoring the patient to talk to the family member. You should always try to keep your older patient in the conversation, although not much of it may be understood. Often children, spouses and family friends can help the older person understand what is needed from them. Communicating with a patient’s family and friends is always beneficial and should be encouraged.

Family and friends can help you to communicate with an older patient because they know how that person thinks. It may help to have a three-way conversation between the patient, their caregiver, and yourself. When everyone works together to help the patient understand, you stand a much better chance of putting him or her at ease with all that is happening around them.

When communicating with patients, communicating with children is probably the most difficult. Not only are you trying to explain a difficult situation to a child, but you are trying to include the parents in the conversation as well. It is natural for a child to be scared, unreasonable and resistant to medical treatment, and it takes a skilled nurse to work through these roadblocks to achieve understanding. As with most communication, listening and allowing the patient to be heard will serve you well in talking to children.

Communicating with Children

When talking to children you want to avoid medical jargon. For very young children, you have to use words that are as simple as possible. Even then, you may not get them to understand because their fear response is overriding everything else. However, you have to use care when talking to older children. They may be insulted if you treat them like a baby and talk to them as if they can’t understand. You have to make a mental note of the age of the patient and their level of understanding, and tailor your speech to meet their needs.

This isn’t always easy, and it can take some time to get a feel for how much jargon is too much jargon. Certainly, you can’t speak to a child the way you would to an adult or a colleague. You need to moderate your language, get down on the level of the child, and use a soft tone of voice. In showing that you don’t mean them harm, you can start to develop a relationship with the child that will help to calm their fears. Sometimes, though, you need to do something that will cause them discomfort, and you must explain this with honesty and using straightforward language.

Talking to Parents

Part of communicating with children is communicating with their parents. Again, you are likely to be dealing with someone who is in a great deal of distress and fear. It is helpful to try to allay their fears, answering all their questions as honestly as possible. Some parents may get emotional and you need to be aware of possible outbursts of anger or sorrow. Either of these can upset your patient and that can go against what you are trying to accomplish. Try talking to parents away from the child and use active listening techniques, as you would for any other patient, family and relatives.

Case Study

Daniel was a two-year-old heart patient who was preparing for his second open-heart surgery. He didn’t understand what was to happen to him, and the atmosphere of the hospital room made him scared. Already, starting the IV line had been a traumatic event. Then one of the nurses from the OR came into the room the night before the operation with a bag of items. She got down on her knees with Daniel and showed him the hairnet he would wear, the tubes that would come out of him, and the mask that would be placed over his face.

Instead of being afraid, Daniel was fascinated with the new toys in front of him and played with them all. During this time, the nurse took the time to talk to the parents about their concerns. She helped them to understand what would happen, explaining the procedure, the heart-lung machine, and the estimated time of the surgery. When the nurse prepared to leave after half an hour of talking, both Daniel and his parents were much more at ease. Although all of them were still afraid of the surgery, it helped to know a little bit about what would happen so not everything would come as a shock.

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Including the Child

Finally, it is important to include the child when talking about procedures or their health. It is so much easier to talk to the parents that you may have a tendency to ignore the child. Children are very sensitive to this, and they do not appreciate being ignored. You should address the child at the beginning of your explanation and try to focus your talk on them and their needs. At the end, you should also ask the child if he or she has any questions. They may not, but it helps them to feel included if you treat them like more than just a parcel to be taken here and there. Talk to the child as much as possible, and then take the parents out of the room for more adult conversation, if needed.

Among the most difficult scenarios that can arise for caregivers when communicating with patients is talking with a patient who is dying. It is challenging and often awkward to face the person. You might be too professional and distant, or you may go the other way, and be more emotional and connected than you should be. Remember, you have a roster of patients, and the wear and tear from becoming too emotionally involved can lead to burnout. How do you successfully balance all of the emotional roadblocks that can arise when dealing with a patient who has a poor prognosis?

It is important for you to be mentally healthy when working as a nurse, but especially when working with a population of patients who are in the process of dying. This means taking care of yourself and having ways to de-stress and unwind. When you go home you need to leave the sadness and emotion of the job at work. If you take it home you could end up becoming a victim of compassion fatigue—a syndrome that can lead to anger, depression, substance abuse, and other problems. Communicating with dying patients is difficult and taking care of yourself emotionally should always come first.

Honesty

Pretending the problem doesn’t exist is insulting to the patient. Most people who are dying are aware of what is happening. If you don’t acknowledge what you know it may make the person feel like you are infantilizing them. However, if you enter the room tongue tied and sad the patient could feel as if you pity them. Neither of these approaches will make your patient feel supported through this difficult time. Instead, you should approach the patient with neutrality. You are an open, loving caregiver. You tend to their needs and answer their questions with honesty.

It can be challenging to be open. When a patient asks a difficult question you may be tempted to pass the buck to other caregivers or to gloss over it. However, your patients have the right to know what their condition is. That is part of ethical nursing. Your patient may also need to open up to someone and trusts you because you are their nurse. Don’t betray your patient’s trust by closing yourself to their emotional needs and their need to know. Although it may be difficult, always tell your patient the truth when they ask questions.

Being Present

Sometimes, in this situation the best communication is not saying anything at all. This is not always easy; one part of you may want to draw the person out to explore their feelings while another part of you would just like the distraction of talking to avoid awkwardness. Neither of these approaches is helpful to a dying person. You just need to be present. In some cases, silence is more helpful than talking. Maybe your patient has been talked to so much that the quiet helps to finally give them a chance to talk. They could also be tired of talking because everyone wants to know everything about what they are feeling.

Helping Families

Families of dying patients are also suffering, and it can be challenging to communicate with them as well. Honesty is always the best course of action to take with families. They will know you are hiding the truth and may resent you for telling them something false. One of the best ways to talk to families is through active listening. Since these people may be highly emotional they have the need to be heard as much as the patient.

Active listening means that you reflect back to the person what they are communicating to you. If the family member is screaming and shouting you can respond with, “It seems like you are very angry. Can you tell me more about that?” You can also mirror them with, “I hear you saying that your mother isn’t being cleaned enough. Is that what you are trying to say?” Keep eye contact, nod, and use encouraging words, such as, ‘go on’ or ‘tell me more’. This can help with any emotional situation from anger to sorrow to apathy. Using this method, you can help the family come to terms with the truth of their loved one’s prognosis.

Conclusion

Nursing isn’t always about talking. Nurses teach and help patients communicate their needs, but something about silence is therapeutic too. Once again, openness and the willingness to be with the patient will either help them to talk or give them a much-needed rest. Communication isn’t always about finding out how a person feels. It can be about quietly projecting the energy that you are here, you are willing to listen, and you won’t judge. That is the best therapeutic gift you can give your patient.

Your patient’s condition is deteriorating and you need to tell the doctor. You have your vitals, your chart, and a full head of information that you want to blurt out as soon as their voice crackles across the line. Chances are, this strategy of communicating with doctors is not going to get you far.

The shotgun method of nurse-doctor communication – double-barrelled, give ’em everything you’ve got – is only going to make them confused and you frustrated. What’s worse, you may not make your point effectively, and the patient could suffer because of it. You have a very busy, often impatient, person listening to you. You have to make the most of your time, and the best way to do that is with organisation.

One such method of organisation is the ISBAR method. It stands for identify, situation, background, assessment, and recommendation. Merely having this structure in your head when picking up that phone to the doctor can make the call flow a bit more smoothly.

The doctor on the other end will get a clear picture, you will get all of your information out concisely, and the patient will get the treatment they need.

Identification

First, identify who you are, your role and who you are talking about (your patient or client).

Situation

The situation part of ISBAR seems self-explanatory, but it can often throw you off when dealing with a patient you are not sure about or just have a bad feeling about.

If the patient fell or has a low blood pressure, it’s easy to state the situation, but what if the patient is diaphoretic, complaining of ‘just not feeling right’, and their vitals are fine? It gets a little more difficult to state the situation when the patient is not presenting something black and white, so you should take some time to think about what is prompting your call to the doctor. What exactly is it that is bothering you? What do you think the doctor can do for you?

In this section of the report, state concisely whom you are calling about and what prompted the call.

Background

The background section of this approach has the most variability built into it. If the doctor you are speaking to is an on-call doctor and doesn’t have the slightest idea of who the patient is, you are going to have to give them the basics of the patient’s history.

However, if the patient has been going to this doctor for 30 years, you probably wont need to give as much background.

The timeline leading up to the situation is important. What was the patient doing earlier in the day that may have an impact on the current situation? Did they have some incident or event that has some bearing on how they are acting now?

This type of information is critical in giving the doctor a complete clinical picture of the patient’s condition.

Assessment

All doctors will ask for them, regardless of the reason you are calling. Pathology, recent test data and any other collected information from the history can also be given at this time. Included in this section is other data that may not fit anywhere else. You can insert how the patient looks to you personally.

Do not be afraid to let the doctor know where your concerns lie. If you do not express that your patient is worrying you, then the doctor will not know enough to be worried themselves. They are basing all of their decisions on what you are telling them. If you leave off your gut feelings that prompted you to call, they are not going to understand the severity of the situation.

Trust yourself and your assessment skills, and tell the doctor what you see.

Recommendation

Recommending a solution to a problem might feel a bit awkward to a nurse, especially newer ones, but doctors are often open to collaboration and do not mind working in tandem with a nurse. However, you do not want to be demanding. Often phrasing your thoughts as a question can be a great way of asking for something you think might help your patient.

For instance, you could say that since the patient is so short of breath, would it be possible to get them a stat portable chest x-ray? This allows the doctor to understand your line of thinking and opens the lines of communication between the two of you. If they agree, you got what you wanted. If they disagree, they will likely explain why. By recommending a course of action, you put the ball in the doctor’s court and give them a clear line of action that is going to help your patient.

After all, you know your patient best because you are with them (see Communicating with Patients). The doctor knows the medicine. Collaborating with ISBAR, you can come up with a plan to get the patient healthy.

Difficult people are everywhere in the world of the nurse. It isn’t just patients who can be difficult, either; families, doctors and co-workers are often a significant source of stress too. With all of the difficult personalities that go into making up a working medical facility, nurses need to know how to navigate the waters of prickly relationships while remaining professional and retaining their sanity.

What should a nurse do when confronted with a difficult person? It is best to remain calm and cool while dealing with the person carefully. To use an apt metaphor, the skills required are akin to defusing a bomb. If you say the wrong thing, the situation with a difficult person can escalate very quickly. You need to focus on staying professional and being assertive, rather than aggressive. This also means enduring personal attacks without losing your cool.

Here are just a few strategies for dealing with difficult people as a nurse.

Retain Professionalism

Nurses always need to maintain their professionalism when dealing with doctors, patients, families and co-workers. This doesn’t mean they can’t let off steam in the breakroom or with a trusted friend, but on the floor professionalism is expected of a nurse. You may feel like the other person is walking all over you, but your calm, professional attitude may just show them how idiotic they are being.

Professionalism is required in these situations, but what exactly does it mean? To be a professional means not to forget yourself. You aren’t in the street or arguing with your kids. You are a representative of your facility and nursing in general. That means you shouldn’t raise your voice, you shouldn’t attempt to ridicule the person you are sparring with and you shouldn’t have the conversation in public.

Professionals never attack. They listen. They try to find ways of amicably solving the problem so that all parties are satisfied. If there is no solution, a professional finds ways to make the difficult person see that there is no other course of action. In the real world, you may lose your temper, say things you shouldn’t and storm away. Professionals can’t do this.

Be Assertive, Not Aggressive

Some nursing schools are now teaching students how to be assertive. Assertive means that you get your point across, no matter how difficult, in a calm yet direct way. When you are assertive, you can tell a doctor that you don’t agree with their order. You can even tell the patient that non-compliance is only going to make their situation worse. Although you always remain professional, assertiveness allows you to say what needs to be said to a person who is being difficult.

The problem with assertiveness is that it can sometimes slip into aggression. Aggression is the point where you lose your temper, raise your voice and insist on your way. Most difficult people are aggressive. But aggression will not help you to deal with aggressive people. It is a fine line, but one that can be easily recognised.

To be assertive, a nurse needs to disconnect from their emotions. Emotions will make the situation explode, so staying calm is a primary facet of assertiveness. You still get to say what the difficult person needs to hear, but you say it in a way that doesn’t ignite a further argument.

Avoid Personal Attacks

It goes without saying that you should not resort to personal attacks against a difficult person. Attacks like these are both aggressive and unprofessional.

If you feel yourself losing control, on the brink of swearing or saying something about the person, walk away. Let someone else step in, because if you are not calm you risk making this situation worse.

Most nurses are not short-sighted enough to hurl a personal attack at a difficult person, but sometimes the heat of the moment can make us say things we wouldn’t normally say. If you feel yourself losing control, on the brink of swearing or saying something about the person, walk away. Let someone else step in, because if you are not calm you risk making this situation worse.

Another aspect of personal attacks is when the difficult person starts hurling them at you. They can call you stupid, worthless and the ‘worst nurse they have ever encountered’. This is a time when you may feel the need to hurl the insults back, but that is exactly what the difficult person wants. They want a screaming match, but you cannot give it to them.

Don’t take personal attacks to heart. This is a person who is reacting out of anger and it really has nothing to do with you. It is more about their feelings and their problems, and not a reflection of you or your work. When you stay calm in the face of a difficult person’s anger, you can often talk them down and resolve the situation before it gets out of control.

The 10 Tips

Here are ten tips to assist nurses to communicate effectively at handover, ensuring brief yet accurate information is shared to encourage safe continuity of patient care:

1. Use a structured format to organise your reporting – e.g. the care plan or other system
2. Review the patient’s chart just prior to the end of your shift
3. Talk with other care providers who saw the patient that day. Get a mini-report from them with their views and observations
4. Make dot-point notes throughout your shift and compare these with the information recorded on the patient’s record
5. The off-going and oncoming nurses should share a verbal report about each patient
6. Consider a bedside report between the off-going and oncoming nurse
7. Design a patient safety checklist suitable for use on your unit that can be reviewed by both nurses at change of shift
8. Always include allergies, code status, and other relevant involved care providers (the patient’s doctor, etc.) in your handover report
9. Provide a brief report of the patient’s care plan (home tomorrow, surgery)
10. Don’t rush. That extra minute or two speaking with the on-coming nurses will make little difference in the time you return home, but will make huge differences in the quality of patient care.

Handover, or change of shift, is a critical time for patients, as the accuracy of the information communicated between nurses at shift change could result in a change in patient care – for better or worse.

What the Research Says

Research has shown that poor or missed communication has led to events that affect the quality of patient care. In 2003, the Joint Commission on Accreditation of Healthcare Organisations (Alvarado et al. 2006) reported almost 70% of sentinel events are caused by a breakdown in communication. For example, missing identification armbands or misidentified intravenous solutions could cause serious problems. In fast-paced areas like the emergency room or neonatal ICU, proper and accurate communication at handover could mean the difference between life and death.

Pass it On

When handover is inadequate it can also be detrimental to the nurse’s state of mental health. How often have you arrived home only to worry or wonder if you had forgotten to pass on something to the oncoming nurse? It can make for a very restless night’s sleep, or stretch of days off.

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References:

• Alvarado, K, Lee, R, Christoffersen, E, Fram, N, Boblin, S, Poole, N, Lucas, J & Forsyth, S 2006, ‘Transfer of Accountability: Transforming Shift Handover to Enhance Patient Safety’, Healthcare Quarterly, vol. 9, pp. 75-9, viewed 26 October 2016, http://www.longwoods.com/content/18464
• Hodgkinson, K & Gilchrist, J 2008, Psychosocial Care of Cancer Patients: A Health Professional’s Guide to What to Say and Do, Ausmed Publications, Melbourne, Victoria.
• Lower, SE 2008, ‘Communication Between the Nurse and Family Caregiver in End-of-Life Care: A Review of the Literature’, Journal of Hospice and Palliative Nursing, vol. 10, no. 1, pp. 35-45.
• Lautrette, A, Darmon, M, Megarbane, B, Joly, LM, Chevret, S, Adrie, C, Barnoud, D, Bleichner, G, Bruel, C, Choukroun, G, Curtis, R, Fieux, F, Galliot, R, Garrouste-Orgeas, M, Georges, H, Goldgran-Toledano, D, Jourdain, M, Loubert, G, Reignier, J, Saidi, F, Souweine, B, Vincent, F, Barnes, NK, Pochard, F, Schlemmer, B & Azoulay, E 2007, ‘A Communication Strategy and Brochure for Relatives of Patients Dying in the ICU’, vol. 356, pp. 469-478, viewed June 2018, https://www.nejm.org/doi/full/10.1056/NEJMoa063446#t=abstract
• National Institute on Aging, National Institutes of Health & Deparment of Health and Human Services, Talking With Your Older Patient: A Clinician’s Handbook, viewed June 2018, http://memoryworks.org/PUBS/NIA…0Handbook.pdf
• Robinson, TE, White, GL Jr & Houchins, JC 2006, ‘Improving Communication with Older Patients: Tips from the Literature’, Family Practice Management, vol. 13, no. 8, pp. 73-8, viewed  June 2018, https://www.ncbi.nlm.nih.gov/pubmed/17022433
• The Gerontological Society of America n.d., Communicating with Older Adults, GSA, viewed June 2018, https://www.geron.org/publications/communicating-with-older-adults
• PBS Parents 2018, Talking with Kids, PBS, viewed  June 2018, http://www.pbs.org/parents/talkingwithkids/
• Worden, JW 1991, Talking to Children About Death, Hospice, viewed June 2018, https://www.hospicenet.org/html/talking.html
• Milford, PC 2018, ‘3 Tips for Talking to Children about Traumatic Events’, PsychCentral, viewed June 2018, https://psychcentral.com/blog/3-tips-for-talking-to-children-about-traumatic-events/
• Cancer: Talking to Children About a Parent or Guardian’s Cancer Diagnosis
• Sleeman, KE & Collis, E n.d. ‘Caring for a Dying Patient’, Medscape
• Grohol, JM 2018, ‘Become a Better Listener: Active Listening’, PsychCentral, viewed June 2018, https://psychcentral.com/lib/become-a-better-listener-active-listening/

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