Communication in Nursing: The Foundation for Caring

Module 1
Continuing Education Course
2 Contact hours

Instructor:
Marlene V. Obermeyer, RN, MA

Culture Advantage (Marlene Obermeyer) is approved as a provider of continuing

nursing education by the Kansas State Board of Nursing.
Kansas State Board of Nursing: Provider # LT0243-1250.
mobermeyer2006

Nurses major communication tasks are not only to inform the patient
about his/her disease and treatment, but also to create a
therapeutically effective relationship by assessing patients concerns,
showing understanding, empathy, and providing comfort and support.1

Course Objectives:
By the end of this course, the participant should be able to:
1. Define communication.
2. Discuss the development of theories of communication and
examples of each.
3. Describe the 6 elements of communication.
4. List barriers to effective communication.
5. Evaluate two nursing communication encounters using
communication theory.

This module introduces the basic concepts of communication. What

does it mean people say they understand? What are the elements of
effective communication? What are the barriers to effective
communication? How can we use communication theory to improve
our nursing practice?

COMMUNICATION: Introduction
What is communication?
From the Latin communicare, meaning to share, to impart, to partake,
to make things common, communion, community.2

Dictionary definitions:
com

mu

ni

ca

tion

1. the act or process of communicating; fact of being communicated.

2. the imparting or interchange of thoughts, opinions, or information
by speech, writing, or signs.
3. something imparted, interchanged, or transmitted.
4. a document or message imparting news, views, information, etc.
5. passage, or an opportunity or means of passage, between places.
6. communications, used in technology:
a. means of sending messages, orders, etc., including telephone,
telegraph, radio, and television.
b. routes and transportation for moving troops and supplies from
a base to an area of operations.

What is your definition of communication?

________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________

Test yourself
COMMUNICATION: Fact or fiction?
Fact or Fiction?
1. Listening is a passive activity.
2. The audience does not play a role in communication.
3. People who speak the same language do not have problems
with communication.
4. Speaking directly is universally acceptable.
5. The more words used in communicating, the better.
6. Its the speakers job to make me understand.
7. Communication is an inborn talent. Either you have it or you
dont.
8. Nonverbal signals are universally understood.
9. Silence is not feedback.
10. Communication means giving information.

Communicating4 with others is an essential part of our everyday life.

The need to communicate shows itself in many ways. Communication
fulfils several functions that are important for our well-being and
survival. It helps us establish relationships, share information and
ideas, and give meanings to everything we do. In the health care
professions, communication assumes major significance in
demonstrating a caring and a therapeutic approach. Failure to give
accurate and easily understood information, for example, can lead to
anxiety and may have serious consequences where sensitive treatment
are concerned. Communication is a dynamic and complex process.
Miscommunication can lead to conflict and misunderstandings, and
most importantly, can jeopardize patient safety.
When we consider a social encounter, we may become aware of the
many visible and invisible aspects of communication. The spoken
word, the written message and the non-verbal gesture or facial
expressions play an important part in getting the message across.
Similarly, these aspects are part of showing acknowledgement and
understanding of the message.
In effective communication, the shared meaning of the message is
crucial to the outcome of the social encounter. Understanding of the
meanings of what is being conveyed can be achieved through the

congruent interpretation of language and associated non-verbal

gestures and symbols. (6, RCN publication.)
From Drumbeats to Bandwidth: A Short History of
Communication
We know that ancient men communicated and transmitted
messages through their cave paintings, smoke signals and drum
beats.
We have come a long way. Today we communicate across distances
faster and with more accuracy. In todays electronic
communication, we use bandwidth to transmit messages.
Bandwidth is the term for electronic data transfer rate- the amount
of data that a channel can carry from one point to another within a
given time period, usually in one second.5 This term is usually used
to describe the speed of Internet connection.
In this module, we will trace the different models of communication
throughout history and their relationship with technology. We will
discuss how the study of communication theory or models helps us
in understanding the role of communication in the nurse-patient
relationhip.

The study of communication started in ancient Greece and was

resumed after the invention of the telegraph in the 1800s.
I. Aristotles Triad of Communication (350 BC)

According to Aristotle, three elements that ensure

communication are: Speaker, Subject, and Audience.

effective

The credibility, knowledge, skills of speaker; the topic of conversation;

and the interest or benefits to the audience/listener ALL affect the
communication process. However, the listener or audience ultimately
determines whether communication takes place or not.

Elements of communication: Speaker, Subject, Audience

Speaker

According to Aristotle,
The _______ holds the
key to whether or not
effective communication
takes place.
Subject

Audience

Goal: Persuasion
Based on:
Clear,
Linear thinking
Facts

Speaker credibility
Audience readiness/emotion

II. The Telegraph Model (1948)

Linear Model
Message sent

SENDER

Channel

Transmitter

Message received

RECEIVER

Destination

NOISE

In this model, communication is the transfer of information from one

point to the next.
Goal: maximum line capacity with minimum distortion.
Noise is anything that interferes with the transfer of the message.
Noise is any barrier encountered when sending, receiving, or
interpreting messages.
To improve communication, decrease interference or noise.
The technology model of communication is based on the telegraph
model. Human beings themselves have a fixed rate at which
information can be transferred (maximum line capacity).
7

Message
sent:
E=mc

Message
received:
E=mc

In this model, when the information sent is the same as the

information received, communication has taken place.
Example: A nurse receives an order for Lasix 100 mg IV, and
administers Lasix 100 mg IV.
III. Interactional model: 1950s
This is a circular model of communication, in which the message is sent and
received, encoded and decoded, and interpreted, by both the sender and the
receiver.

Message

Encoder
Sender
Interpreter

Decoder
Receiver
Interpreter

Message

In fact, it is misleading to think of the communication process as

starting somewhere and ending somewhere. It is really endless. We
are little switchboard centers handling and rerouting the great endless
current of information.... Schramm 1954
The model emphasizes the ____________ nature of communication.
The participants swap between the roles of
_______________________ and ___________________.
The encoding and interpreting of messages by both sender and
receiver started to get recognized.

For example, a nurse asks the patient, Whats your pain level? On a
scale of 1 to 10? The patient answers, I guess around 5 or 6.
In this communication model, the cycle is not completed until the
nurse responds to the patients feedback. The nurse then becomes the
receiver, and the patient, the sender.

IV. SMCR Model (Berlo, 1960s)

Encoding

Decoding

SOURCE

MESSAGE

CHANNEL

Attitude

Content

Hearing

Attitude

Knowledge

Structure

Seeing

Knowledge

Social
system

Code

Touching

Social

Culture

Symbols

Tasting

Culture

Smelling

Skills

Skills

RECEIVER

In this Source-Message-Channel-Receiver (SMCR) Model by Berlo, the

Linear telegraph model of communication becomes more complex.
According to Berlo8:
The Sender encodes the message through his speaking and writing
skills. The Receiver decodes the message through his listening and
reading skills.
Both sending and receiving are influenced by knowledge, attitudes,
experiences, and skills, and affected by the channel through which the

message is sent. For example, some cultures value direct

communication in order to reduce uncertainty, while some cultures
value indirect communication, in order to preserve harmony.
The sender encodes the message through the use of symbols,
through a channel such as speaking, writing, etc.
The Receiver receives the message (which is encoded in symbols)
through the channels of listening, reading, etc.
Interpretation is the Receivers understanding of the message. The
Receiver is actively listening and decoding or interpreting the
symbols transmitted by the Sender.
Nurse (Sender): Whats your pain level on a scale of 1 to 10?
Patient (Receiver): 4 (Patient grimacing and splinting surgical site
with every movement.)
The nurse encodes the question using the numeric scale without
assessing the patients understanding of what the numbers mean to
the health care team.
The patient decodes the pain scale numbers using his own
interpretation.

V. The addition of feedback: Transactional Model

(1960s)

MESSAGE
ASKCE

ASKCE

Speaking, writing
Listening, reading

Speaking, writing
Listening, reading

Feedback loop

Feedback is the Receivers reaction to the message, which he sends

back to the Sender.
Feedback is any message that the receiver sends to the sender. It
could be verbal, nonverbal, or silence. Nonverbal feedback can create
misunderstandings as different cultures interpret nonverbal gestures
differently. A nod in one culture may mean yes, while in other
cultures, a nod of the head means no. Feedback is returned to the
Sender, who in turn becomes the Receiver.

In the final analysis the communication process is not linear, circular

or even interactive. It is transactionalmeaning that encoding,
decoding, receiving and sending feedback, and other components of

the process are all interrelated and all happen simultaneously in at

least two places at once.9
Nurse as Sender: Whats your pain level on a scale of 1 to 10?
Patient as Receiver: (Nurse wants me to give her a number but Im
not sure what she means by pain scale.)
Patient as Sender: About a 4. (Patient grimacing, moaning, and
splinting surgical site with every movement.)
Nurse as Receiver/Sender: 4? You look like you are hurting a lot with
any kind of movement. (Feedback)
Patient as Receiver/Sender: Youre right. I am in a lot of pain right
now!(Feedback)
INTENDED MEANING = RECEIVED MEANING

Intended
meaning

MESSAGE
MESSAGE

Received
meaning

FEEDBACK

Sender

Physical Noise
Semantic Noise
Internal Noise

Receiver

FEEDBACK
ASKCE

ASKCE

MESSAGE

Transactional: give and take of sending and receiving of messages.

Physical, semantic and internal noises distort the messages
transmitted from sender to receiver and vice versa.

Is feedback always beneficial?

The feedback loop may be positive or negative. Negative feedback can
perpetuate an undesirable response as the following illustration shows.

POSITIVE or NEGATIVE Feedback LOOP?

Charmed loop:

Nancy RNs Perspective

Self-concept: Im a nurse.
Perceived message: He thinks Im incompetent. (He doesnt need to
tell me how to change a dressing. Hes rude.)
Feedback given: Im a nurse. I KNOW how to change a dressing! (I
wont ask him anything again!)
Dave MDs Perspective
Self-concept: Im a doctor.
Perceived message: She seems disorganized, and shes rude!
I better make sure she understands exactly what to do. Ill make a
note to keep an eye on her.
Feedback given: Gives very specific orders on how to change a
dressing. (Shes rude! I dont think she knows what shes doing.)

Self-concept:

Nancy, RN
Im a nurse.

Dave, MD
Im a doctor.

Message received:

Hes rude.

Shes rude and

incompetent.

Feedback:

I wont ask him

anything again.

I need to give her

specific directions.

VI. CONVERGENCE MODEL of Communication

(Kinkaid 1980s)
Communication is the convergence of meaning.
Not merely the exchange of information.
ENVIRONMENT OR CONTEXT

Sender

Receiver

My REALITY

My REALITY

ENVIRONMENT OR CONTEXT

SENDER
Pool of shared meaning
And experience.

CONVERGENCE: Where my reality and your reality meet. A pool of

shared meaning between Sender and Receiver.
Goal: Mutual understanding and collective action.10
Each person in an interaction aims to:

Maximize coherence (make sense of the event)

Reduce uncertainty, enhance predictability
Coordinate events (data, symbols) towards a common goal

For example, a patient was given instructions to take his medications

for hypertension. He returns to the office after a month and reports
that he has stopped taking his medications. The patient says he does
not feel hyper anymore, nor is he experiencing any more tension in
his life.
According to the Telegraph model, the information was transmitted
correctly. The patient understood the message that he had
hypertension. However, there was no assessment of his understanding
of the term. There was no shared meaning of the word hypertension.
In order for convergence of meaning to occur, there has to be a
coordination of the symbols used in the communication process, in this
case, the term, hypertension. Both nurse and patient need to
maximize their mutual understanding of is hypertension and the goal
of controlling the patients high blood pressure and preventing its
complications.

Definition: Communication is the transfer, exchange, and coordination

of information, to create shared meaning and mutual understanding, in
order to achieve a common goal.

How is the convergence of meaning accomplished?

Convergence of meaning occurs when11:
1. Participants with differing points of view listen to one another by
paraphrasing each others point of view to the others
satisfaction.

2. Each one acknowledges the conditions under which the others

point of view can be accepted as valid.
3. Each one acknowledges the overlap or similarity of both points of
view.
4. Each one assumes accountability for their part in achieving the
desired goal.

Communication convergence can lead to divergence or conflict when:

The participants interests and values are in conflict and they are
not willing or able to engage in dialogue to come to a minimal level of
understanding to achieve a common goal.
Further communication is required to identify the elements that are in
conflict, or elements that do not support achievement of their goals.

Principles of effective communication according to the convergence

model:
Communication is a dynamic process.
It is a system of elements that make up the whole.
The parts interact and influence each other.
The parts are subject to the environment in which they exist.
Communication is a skill that can be learned.
Six Elements of Communication:
Sender
Message
Channel
Receiver
Noise
Feedback
Using a communication checklist to evaluate nurse-patient
communication patterns:
You are teaching two newly diagnosed diabetics how to self-administer
Insulin and how to check blood sugars at home. One patient is a 17year-old female athlete and the other patient is a 74-year-old retired
farmer who lives alone. Using the checklist below, analyze how you as
the Sender, should adjust and adapt your communication patterns
when speaking with these two different patients.

Communication Checklist
Sender:
Knowledge: How much do I know about this topic/subject matter?
Do I need to research or review the topic before this encounter?
Skills: Do I have skills to accomplish the goal?
Attitude: What is my motivation? What attitude do I have toward this
information?
Culture: What are the influences from my cultural background and
experiences that affect how I encode and send the message?
Purpose: Do I want to inform, persuade, inspire, inquire, motivate,
or analyze? Do I have a clear purpose in mind?

Message:
What is the message I want to convey?
Facts or raw data? Motivate?
Interpretation of information?
Answer questions?
Explain a disease process?
Teach a skill?
What is the tone of the message: impersonal, personal, professional,
friendly?
What symbols to use to convey the message?
Channel:
How do I send this information in a way that the receiver would
understand the meaning of the message?
What is the best method to motivate the receiver to listen?
Written instructions versus verbal instructions.
Video or face-to-face demonstration?
Telephone, fax, or email?
Verbal or nonverbal messages?
Environment/noise: communication barriers
Noise is any barrier that interferes with the transmission of the
message.

Consider the following:

Environmental noise: Background noise, poor lighting, poor print
quality, illegible handwriting, static on the phone lines, print that is
too small to read without magnifiers, poor contrast in printed
materials, other distractions, etc.
Physical noise: hunger, pain, exhaustion, etc
Psychological noise: preconceived ideas, previous experience and
knowledge, attitude, current emotional status
Cultural noise: values, knowledge and belief systems, culturallybased health care practices, direct or indirect communication styles.
Semantic: word usage, idioms, metaphors, learning styles
Language: words may have different meaning even when using the
same language.
For example, stress may mean different things to different people.
Speaking the same language is not a guarantee for successful
communication to occur.
The Receiver:
Always have the receiver or listener in mind.
Is the receiver ready to listen?
What is the attitude of the receiver toward this information?
Is the receiver knowledgeable about the subject, or is this the first
time they have ever heard of this subject?
What have they heard about this topic from their friends, family,
significant others?
Are you using a common language? A nurse and a pharmacist may
share a common language or specialized vocabulary that a
layperson might not understand.
Is the receiver a superior, a subordinate, or a peer? Does this affect
how the message is received and interpreted?
Literacy level, language use, generational differences?
Interpretation:
How could I convey the message so that my intended meaning is
clear to the receiver?
Could a word have a double meaning or unintended meaning?
How about your nonverbal message and how the receiver might
interpret this message?
Does the receiver have enough information or background
experience to interpret the message?
Does the receiver have the capacity to receive the message, i.e.,

seeing, hearing, reading, etc?

What cultural background and life experiences does the receiver
have that might affect how he/she interprets the message?
Feedback:
What is the intended result of your communication?
What kind of feedback do you want to see from the communication?
What kind of verbal and nonverbal feedback are you receiving?
What do you want the receiver to be able to do as the result of this
communication?
Verbal? Demonstration?
Is the received message the intended message?
What is the intended short-term result, end-term result?
How do you know that the receiver has understood the message?

Complete the worksheet below using the Communication

Checkist.
Communication Worksheet for teaching patient self-administration of
insulin.
Patient: 17-year-old female athlete

Sender (nurse)
Message (selfinjection of insulin)

Channel

Noise

Interpretation

Feedback

What may be the communication barriers with a 17-year old diabetic learning about
self-injection of insulin?

a. Attitudes of friends about diabetes?

b. Believing that insulin shots can cure diabetes?
c. Talking on the cell phone while watching a demonstration on drawing up insulin?
d. Any other communication barriers?
What may be the communication barriers for a 74-year-old learning about diabetes?
a. Hearing loss?
b. Vision impairment?
c. Crowded and noisy room?
d. Fine print?

Communication Worksheet for teaching self-administration of insulin

Patient: 74-year-old retired farmer

Sender
Message

Channel

Noise

Interpretation
Feedback

In this module, we discussed several communication theories in order

to give us a better understanding of the dynamics in the nurse-patient
interaction. We explained that communication is not only the transfer
of information, but also the exchange of meaning. We described
noise and listed barriers to effective communication. And we used a
communication checklist to evaluate our communication patterns with
two different listeners or Receivers.

Communication: The Foundations

Review Questions
To take the exam, log in at:
http://www.culture-advantage.com/etraining/
1. According to Aristotle, the three elements of communication are:

a. audience
b. speaker
c. message
d. desires
e. all of the above
f. a,b, and c only.
2. In the Communication Triad, the _____ determines the success of
communication.
a. audience
b. speaker
c. message
d. desires
e. all of the above
3. The Telegraph Model of communication is:
a. Linear
b. Circular
c. Negotiable
d. Verbal
e. Noisy
4. According to the Telegraph Model, the __________
transmits the message through a __________
and is received by the __________.
5. Noise includes:
a. Poor lighting
b. Loud rock music
c. Illegible handwriting
d. Cold room
e. All of the above
6. A nurse receives an order for 50 units of Regular Insulin subq,
and administers 50 units of Regular Insulin subq. This is an example of
a successful communication according to:
a. Aristotle
b.Telegraph Model
c. Analysis Model
d. Meaning Model
7. Encoding a message means:
a. receiving the message
b. sending the message through the use of symbols
c. using technical language
d. using a "secret code"
8. What factors influence how the message is sent and interpreted?
a. attitudes, knowledge and skills of the sender and receiver
b. environmental noise
c. cultural backgrounds of both sender and receiver
d. all of the above.
9. What is the best description for "transactional communication?"

a. It is a linear process.
b. Negative loop
c. All the elements are interrelated and happen simultaneously.
d. The sender and receiver take turns speaking.
10. What describes the "Convergence" theory of communication:
a. Sender sends message. Receiver receives message.
b. A pool of shared meaning is created between the sender and the receiver.
c. Persuading others to your point of view.
d. When verbal and nonverbal signals are understood.
11. When does convergence of meaning occur?
a. When both sender and receiver speak the same language.
b. Participants with differing points of view listen to one another.
c. Each one acknowledges the other person's point of view can as valid.
d. Each one acknowledges the overlap or similarity of both points of view.
e. Each one assumes accountability for their part in achieving the desired goal.
f. All except a.
12. When does conflict occur?
a. When interests and values are in conflict.
b. Participants are not willing to engage in dialogue.
c. Participants not willing to come to a minimal understanding to achieve a common
goal.
d. all of the above.
13. What are the six elements of communication?
a. sender/speaker, message, motivation, information, language, feedback
b. sender/speaker, receiver/listener, message, verbal, nonverbal.
c. sender/speaker, message, channel, noise, receiver/listener, feedback
d. sender/speaker, message, goal, implementation, environment, interpretation.
14. The Sender of a message should consider the following except:
a. Own knowledge, skills and experience with the subject.
b. Own cultural background and life experiences
c. Personal motivation and attitude
d. Clear purpose
e. The listener's job is to follow directions.
15. Creating the message to be sent to the Receiver requires consideration of the:
a. Tone of the message.
b. Content of the message: facts, data, interpretation,etc.
c. Use of symbols to convey the message.
d. Possible interpretation of the message.
e. All of the above.
16. What may be the communication barriers with a 17-year old diabetic learning
about self-injection of insulin?
a. Attitudes of friends about diabetes.
b. Believing that insulin shots can cure diabetes.
c. Listening to cellphone while watching a demonstration on drawing up insulin.
d. All of the above.

17. What may be the communication barriers for a 74-year-old learning about
diabetes?
a. Hearing loss
b. Vision impairment
c. Crowded and noisy room
d. Fine print
e. All of the above.
18. When teaching a patient about signs and symptoms of hypoglycemia, which
of the following words may have different meanings?
a. "shocky"
b. hypoglycemia
c. sugar
d. meals
e. All of the above.
19. When planning a teaching session with a patient, which of the following
do you need to assess:
a. Patient's socio-economic status
b. Patient's knowledge and experience of the subject
c. Patient's physical and emotional needs at the moment
d. Environmental noise
e. All of the above.
f. All except a.
20. Which is a form of feedback?
a. Receiver asks questions about the topic.
b. Receiver does not answer.
c. Receiver repeats the major points of the conversation.
d. All of the above.
e. None of the above.

REFERENCES
1

Kruijver I, Kerkstra A, Francke A, Bensing J. (2000) Evaluation of communication

training programs in nursing care: a review of the literature. Patient Education and
Counseling Volume 39, Issue 1 , Pages 129-145.

ARTFL Project, Webster Dictionary, 1913. Accessed October 7, 2006 at :

http://machaut.uchicago.edu/cgi-bin/WEBSTER.sh?WORD=communicate
3

communication. (n.d.). Dictionary.com Unabridged (v 1.0.1). Retrieved October 30,

2006, from Dictionary.com website:
http://dictionary.reference.com/browse/communication

Husband C, and Torry B. (2004). Transcultural Health Care Practice:

An educational resource for nurses and health care practitioners. Published by the
Royal College of Nursing. Online:
http://www.rcn.org.uk/resources/transcultural/foundation/sectiontwo.php Accessed
December 28, 2006.
5

Bandwidth. (2006) Encarta World English Dictionary [North American Edition]

& (P)2006. Retrieved October 30, 2006 at:
http://encarta.msn.com/dictionary_1861588703/bandwidth.html
6

Griffin, E. (1997). A First Look at Communication theory (3rd ed.), McGraw-Hill.

Information theory. (n.d.). The Columbia Electronic Encyclopedia. Retrieved

October 30, 2006, from Reference.com website:
http://www.reference.com/browse/columbia/inform-th
8

Underwood, Mike, (2003). Introductory Models and Concepts. Retrieved online

October 26, 2006 at:
http://www.cultsock.ndirect.co.uk/MUHome/cshtml/introductory/smcr.html
9

C. Windley M. Skinner, (2006).

http://www.class.uidaho.edu/comm101/chapters/selecting_topic/selecting_topic4.ht
m
10
Figueroa, M., Kincaid, L., Rani, M., Lewis, G. (2002). Communication for Social
Change Working Paper Series. Retrieved online October 21, 2006 from:
http://www.comminit.com/strategicthinking/stcfscindicators/sld-1500.html
11

Ibid.