Establishing a connection

The Components of Life model (Jones 1990) is a framework that provides a structure for nursing care. It is based on the belief that humans are individuals with individual needs and are engaged in various self-care activities to maintain a balance between seven ‘components of life’, which incorporate physical, human behavioural and social aspects. An event such as an illness or injury can disrupt the person’s ability to maintain that balance, which adversely affects their quality of life. Jones (1990) theorised that a person in this situation regards ED staff as a resource to help them rebalance these components and to regain independence.

The first of the seven components is communication, while the first aim of the model is to establish a partnership with the patient (Jones 1990, National Emergency Medicine Programme 2021). This not only requires the nurse to possess the requisite knowledge of communication theory, but also requires the ability to convey a welcoming and open attitude and a desire to listen to what the patient wants to say. Effective communication is a dynamic two-way cyclic process, so appearing warm and friendly can encourage the patient to engage in this process, thus establishing a partnership from the outset.

Making a positive first impression is vital, and this can be facilitated by a seemingly simple gesture such as the nurse introducing themselves to the patient, explaining who they are and the purpose of the communication. The #hellomynameis campaign (www.hellomynameis.org.uk/) aims to encourage and remind staff about the importance of introductions in healthcare and to break down barriers, promote understanding and personalise and connect with the patient and their experience within the healthcare system (Health Service Executive (HSE) 2023). This is especially important in an ED where there are many different healthcare professionals who will be unfamiliar to patients.

Some patients, such as people living with dementia or those experiencing a mental health crisis, may exhibit responsive behaviour, for example agitation or aggression, when they are in an unfamiliar environment such as emergency care (Carver and Beard 2021). To engage, communicate with and care for such patients competently, nurses require the relevant knowledge, skills and attitudes, including empathy, respect, authenticity and the use of clear language (Tuohy and Wallace 2022, NHS 2023). There are various resources that nurses can use to enhance their ability to support people to feel safe including, for example, the Star Wards project (www.starwards.org.uk) and Talking with Acutely Psychotic People (Bowers et al 2009), both of which detail the communication skills nurses and other healthcare professionals require when engaging with people with severe mental illness.

Environmental issues

Evidence suggests that the nature of the ED environment, particularly noise, can limit interaction between care providers and patients and is a potential distractor and stressor for both parties (Delmas et al 2020). It is important, therefore, that the nurse considers the effects of the ED environment on the patient before initiating a conversation. Being familiar with the department – for example, the location of private rooms, such as clinical examination rooms, and equipment such as moveable screens and chairs – can help the nurse to quickly create an appropriate space in which to support effective communication.

Patients’ communication, language and cultural needs

Patients like to have frequent contact with staff, to be listened to, to be valued as experts in their own health and to be respected and treated courteously (Walsh et al 2022). However, some patients may have specific communication issues which might affect their ability to communicate their needs and/or the nurse’s ability to understand their needs. Such issues may include hearing or visual difficulties, literary and numeracy issues or developmental or cognitive impairment.

The Nursing and Midwifery Council (2014) Standards of Competence for Registered Nurses state that nurses must ‘communicate effectively using a wide range of strategies and interventions, including the effective use of communication technologies.’ Patients with additional communication needs may require augmentative and alternative communication (AAC) tools, such as a laptop, communication board or speech generating device, and/or support from family members or carers or from a sign language interpreter. Nurses should know where to access AAC equipment and other resources, such as written or picture-based information leaflets. According to Koukourikos et al (2015), play can facilitate communication between nurses and children, therefore contacting the hospital play specialist may support communication with this patient group.

Patients from culturally and linguistically diverse backgrounds may also experience communication challenges in the ED. For example, people whose first language is not English may require the assistance of an interpreter. Family members may be able to assist, however it is vital to consider the patient’s right to confidentiality. To maximise nurse-patient communication, nurses can use resources such as translation apps or multilingual emergency aid packs, which usually comprise a welcome sheet, a language identification sheet, guidelines for interpreters and phrasebooks, and are intended to be used before requesting an interpreter or while waiting for an interpreter to arrive (Tuohy and Wallace 2022). An example of such packs can be found at: www.hse.ie/eng/services/publications/socialinclusion/ema.html

Effective intercultural communication by nurses is underpinned by cultural awareness, sensitivity, knowledge and competence (Tuohy and Wallace 2022). Resources such as the Second National Intercultural Health Strategy (HSE 2018a) in Ireland or the NHS England (2023) Cultural Competence e-learning tool provide information and guidance to support intercultural communication and culturally competent healthcare.

Using Roper et al’s (1996) nursing process (assess, plan, implement and evaluate) as a framework can support nurses to maximise communication through:

Accurate verbal and written communication between staff

Maximising nurse-patient communication extends beyond direct interaction with the patient and encompasses effective and accurate verbal and written reporting and documentation between ED staff and other members of the multidisciplinary team. Patient assessment, history taking and the planning, implementation and evaluation of care delivery requires clear and accurate written and verbal communication between ED team members, as well as with the patient and their family.

The use of standardised communication systems such as the Situation, Background, Assessment, Recommendations (SBAR) tool promotes effective transmission of information between ED staff in emergency care settings (Martin and Ciurzynsk 2015, Moi et al 2019). SBAR is a structured form of communication that enables accurate transfer of information in healthcare settings and supports patient safety by prompting staff to formulate information with the appropriate level of detail and by reducing the need for repetition and the likelihood of errors (NHS England and NHS Improvement 2021).

Formal handovers at shift changes are another opportunity for effective communication of information between staff and to support continuity of patient care (Petersen et al 2013). Additionally, a ‘safety pause’ during a shift – which typically lasts no longer than five minutes and involves staff asking: ‘What patient safety issues do we need to be aware of today?’ – can enhance communication between staff and support them to proactively identify patient safety issues or risks related to the delivery of quality patient care (HSE 2013).

ED staff must be familiar with documentation and reporting practices within their clinical setting. Clear and accurate documentation is important in providing optimal patient care and requires contemporaneous, factual and legible written information (Nursing and Midwifery Board of Ireland (NMBI) 2015). Accurate written documentation and verbal information exchange between staff supports maximisation of nurse-patient communication through the provision of continuity of care and by informing subsequent nurse-patient dialogue (NMBI 2015).

Quality control and audit

In a systematic review of patients’ experience in the ED, Sonis et al (2018) identified that patients’ satisfaction and dissatisfaction was related to staff-patient communication, ED wait times and staff empathy and compassion. One way of evaluating effective communication is by using quality care metrics, which provide a framework by which to measure, monitor and track the processes in place to support communication (HSE 2018b). The HSE (2019) recommends service providers undertake local clinical audits of a range of parameters, including communication in acute settings. An audit involves gathering information and measuring the data against local and/or national standards (HSE 2019); in the context of communication, this might include requesting patient feedback on their care experience (Fox et al 2019).

Education, mentorship and reflection

Effective nurse-patient communication can be maximised through mentorship of new staff by senior staff and/or clinical facilitators, as well as training, education and reflection supported by performance review and staff appraisal. Training and education may involve orientation to the unit and ongoing mentorship by a more experienced member of staff and/or in-service online or face-to-face training programmes in, for example, communication theory and techniques, use of body language or intercultural awareness.

Reflection enables the nurse to make sense of their clinical practice, therefore using a reflective model can support the nurse to examine their knowledge base, skills competence and personal attitudes, beliefs and values and how these affect their communication with patients and colleagues (Gibbs 1988, Johns 2022). In a study by Pangh et al (2019), ED nurses were asked to reflect on their practice by writing down their patient-related clinical experience of communication issues over a period of eight weeks. The researchers reported a significant positive difference in these nurses’ verbal, non-verbal and patient safety-related communication skills following the intervention and recommended that reflective writing should be encouraged as a tool for improving communication competency among ED nurses.

Alongside self-reflection, regular appraisals with a line manager can support assessment of staff’s communication skills and help to identify education needs (Norman et al 2022).

Conclusion

Effective communication with patients is crucial for planning and delivering care, supporting optimal outcomes and increasing patient satisfaction, but it can be challenging to achieve within the unpredictable environment of an ED. Maximising nurse-patient communication can be supported through various measures. These range from simple acts such as the nurse introducing themselves to the patient and addressing environmental challenges such as noise and privacy, through ensuring the effective and accurate transfer of verbal and written information between ED staff, to conducting audits and engaging in reflection. Nurses of all levels and experiences can engage in these practical and strategic measures.