Critical analysis of a articles

· FEATURE ARTICLE Continuing Education

Shaping Effective Communication Skills and Therapeutic Relationships at Work The Foundation of Collaboration

by Susan M. Grover, PhD, MS, RN

l1 e study of communication is a vital part of under-

standing human behavior. Indeed, the concept of communication is an integral part of every profession,

academic field, and of society as a whole. It is the basis upon which relationships are established. Despite the emphasis on effective communication, poor communication is often the cause of great misunderstanding and conflict.

Occupational health nurses traditionally have been a part of collaborative interdisciplinary teams including the employer and employees (Wachs, 2005). This emphasis on interdisciplinary practice mandates an appreciation for and understanding of the importance of effective communica- tion. The focus of this article is on effective communication among occupational health professionals, employees, and employers. Therefore, the purpose of this article is to explore the key components necessary for effective communication and therapeutic relationships within the work environment.

COMMUNICATION COMPONENTS What is communication and what are the major com-

ponents? Historically, hundreds of definitions and a variety of paradigms have been developed. What has come to be accepted as a basic assumption by communication experts is that communication is a process with no beginning or end (Heath, 1992). As such, it is continually occurring and constantly changing because no two interactions are ever the same. Communication builds on previous interactions and prompts ongoing communication. Indeed, a commonly accepted maxim is that "people cannot not communicate nor can they uncommunicate" (Heath, 1992, p. 32).

ABOUT THE AUTHOR Dr. Grover is Professor and Chair, Family Community Nursing, East Ten- nessee State University, Johnson City, TN.

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Early communication models viewed communication as a linear process. McQuail and Windahl (1981) discuss these models as a message going through a transmitter to a receiver. This model essentially explored who said what in which channel to whom and with what effect. Subse- quent models described communication as messages that are encoded and decoded to send a signal (McQuail & Windahl, 1981). The emphasis in these models was on the shared experience between encoder and decoder, as well as the importance of feedback. These concepts currently have become key ingredients in the development of inter- disciplinary interactions and communication.

Human communication can best be described as a "two-way ongoing process by which a person or persons stimulates meaning in the mind of another person (or per- sons) through verbal and/or nonverbal messages" (Stone, Singletary, & Richmond, 1999, p. 53). This definition im- plies that there must be an exchange of ideas and an abil- ity to stimulate meaning for the recipient of the message. The sender must transmit the message effectively for the receiver to interpret or decode the message. Through in- terpersonal communication, individuals become aware of, and sensitive to, one another. If the receiver is un- able to receive, misinterprets, or does not respond to the message, communication is flawed (Stone et al., 1999). Indeed, many communication errors occur because the message is not heard accurately. With the number of in- terdisciplinary health care professionals who work on the occupational health team, a lack of common ground is often the direct result of differing patterns of communi- cation. Clear communication strategies that are mutually understandable are critical for optimal outcomes (Mil- ligan, Gilroy, Katz, Rodan, & Subramanian, 1999).

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BASIC COMMUNICATION SKillS Numerous books and articles have been written about

how to avoid flawed communication through the use of basic communication skills (Ellis, 1999; Ledds-Herwitz, 1992). These basic communication skills include: • Listening. • Asking open-ended questions. • Asking closed questions. • Clarifying. • Paraphrasing. • Using facilitators. • Assessing non-verbals. • Silence.

Listening Part of being responsive to an individual in an inter-

action is to listen. Listening requires attending to the other person. Attending skills include maintaining eye contact and attempting to decode or interpret the message. Too often, individuals are thinking of the next question to ask instead of focusing on the present interaction.

Asking Open-Ended Questions Open-ended questions are key to an effective interview.

These are questions that cannot be answered with "yes," "no," or a short phrase. Typically, open-ended questions are worded to gain a wide range of possible responses and infor- mation. In addition, these types of questions help employees feel that the occupational health nurse is listening. Examples of open-ended questions are "How did you feel about that?" and "What helped you deal with that in the past?" It is often difficult not to follow up an excellent open-ended question with a closed one, especially if there is a lapse of time be- fore a response. This can be related to provider concerns that perhaps the question was misunderstood, or even provider insecurity and the need to feel in control.

Asking Closed Questions While open-ended questions are good to use to gain

additional information, closed questions are necessary to gain facts and are essential in emergency situations. In routine interviews, closed questions are most effec- tive when interspersed with open-ended questions or comments. They should not be used as the main inter- view technique.

Clarifying A clarifying question is another type of open-ended

question. The goal is to elicit more from the interaction by reinforcing and encouraging employees to expand and give more details about some information that was shared. For example, "You've shared a great deal about the accident and I appreciate that. How has the accident impacted your abil- ity to perform your job?" This is in contrast to leading ques- tions, which are one of the most frequent errors in managing information. Leading questions suggest an answer and can result in misleading and erroneous information. In the previ- ous example, a leading question would be, "You feel a lot of pain when you lift more than 5 pounds, don't you?"

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Paraphrasing Paraphrasing takes the original message and trans-

forms it by interpreting the meaning. It helps a colleague to elaborate on the cognitive meaning. To use this tech- nique, it is important to listen to the words and check Oul the interpretation of the message by rephrasing. Return- ing to the previous example, the supervisor could use paraphrasing by stating, "It sounds like you have some concerns about how you'll perform your job."

Using Facilitators Facilitators are phrases, questions, or actions that en-

courage a client or colleague to continue sharing information. Examples are nodding; smiling; or saying "umm-hmm,' "go on," "how so?" or "and then?" if appropriate. These facilita- tors are important to use because they do not provide a spe- cific direction or focus, but rather help the client to continue the process of interacting and sharing information.

Restatement. In restatement the interviewer repeats a client's phrase or statement. This is often a good way to enable a continuation of the dialogue or to help the em- ployee refocus. Use of restatement is helpful especially if the client is over-generalizing or rambling in a conversa- tion. In addition, it helps to connect a statement with what is being experienced by the sender. Restatement may feel awkward initially but can be very effective if used spar- ingly. For example, if an employee states, "I'm really afraid to return to work," the occupational health nurse might say, "You're afraid ..." This type of response will al- low the employee to further clarify the fears or concerns.

Reflection. Similar to restatement is reflection. Reflec- tion, however, necessitates an assessment of the feelings that have been shared in the interaction. It focuses on the emo- tional overtones of a message and helps the-receiver to inter- face content and emotional aspects. Light reflections that do not over-analyze the situation can consist of just a few words (van Servellen, 1997). An example is when an occupational health nurse talks to an employee in the clinic about family situations. For example, an employee, a mother of four pre- schoolers, says, "I've had it with my kids! They're sick all the time. I can't take it anymore." By using reflection, the nurse might say, "Sounds like you feel pretty desperate..." Reflec- tions are often difficult to make and may feel "staged" ini- tially. However, as with any communication skill, continued use increases ease and success.

Assessing Non-Verbals One of the most important skills to develop is that of as-

sessing non-verbals because a great deal of communication is gained through subtle non-verbals. It is described as the "con- tent level of a message" (van Servellen, 1997,.p. 24). Examples of these non-verbals are facial expressions, eye movements, gestures, posture, and proxemics (personal space). Facial ex- pressions are cues that help individuals evaluate emotions and determine if the message was received appropriately. Occu- pational health nurses often qualify statements if the receiver looks puzzled or unsure of the message. For example, depres- sion is often assessed by the employee's ability to maintain eye contact, posture, and rapid or slow body movements. Because

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verbal cues are often misread, it is imperative to validate with non-verbalcues.

Silence Another skill to improve communication is the use

of silence. Short, silent pauses of several seconds or more accompanied by eye contact or a slight head nod can en- courage the speaker to continue. It also gives the speaker time to think or share feelings. Silence should be used judiciously and certainly not in threatening situations. It may feel awkward initially and the occupational health nurse may attempt to fill in the silence with closed-ques- tions, as mentioned previously.

VARIABLES THAT IMPACT EFFECTIVE COMMUNICATION Why is it then, given these relatively straightforward

skills, that individuals do not effectively communicate? Perhaps it is because of many other important constructs as well as intervening variables that operate in a communica- tion interaction.

Hierarchy A variable that affects communication is the effect

of the perceived hierarchy of power and authority. Be- cause the occupational health nurse is perceived to have more authority than the employee, the employee may choose not to share important information. The effect of hierarchy can be mitigated by trust.

Trust One of the most critical concepts of effective com-

munication is trust. The degree of trust existing between individuals is directly related to effective communication. Trust is defined as the ability to "rely on the veracity and integrity of another individual" (van Servellen, 1997, p. 89). One must examine two types of trust: general or global trust and specific trust (Northouse & Northouse, 1992). A nurse possesses global trust by being openly accepting of individuals. Some nurses are more open to trusting others, whereas other nurses are suspicious and distrustful. Specific trust is related to a particular person in the relationship. For example, one may be distrustful of a supervisor if previous experiences have caused conflict and been negative.

Certain behaviors produce feelings of trust in an individual. The focus in occupational health nursing on empowering employees helps generate trust. The more nurses include employees in decision-making and prob- lem-solving, the more trust develops. Individuals who act superior, manipulative, and controlling tend to decrease feelings of trust. Spontaneous, empathic, and problem- oriented behaviors produce feelings of trust. One of the ways to build trust is to use descriptive rather than evalu- ative communication during problem-solving. For ex- ample, saying, "It would be best if we could assess the amount of stress at the production site together" instead of "Your employees are so stressed at that production site ...you need to do something about that" enhances the development of trust between workers.

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Self-Disclosure Another behavior that enhances communication is

self-disclosure. Instances of sharing a personal experience, attitude, or feeling can result in increased dialogue if it is primarily client-centered. However, too much self-disclo- sure on the part of the provider can alter the therapeutic relationship by shifting the focus to the provider's needs.

Empathy Empathy is another variable that impacts effective com-

munication. Arnold and Boggs (1999) described empathy as "the ability of a person to perceive and understand another person's emotions accurately" (p. 110). It is a multidimen- sional concept that includes affective, cognitive, and com- munication components. For health professionals, the out- come of empathic communication is quality interpersonal relationships with colleagues, employees, and management. Empathy is the ability to feel what others feel. It includes the following three components: • To communicate this understanding. • To effectively feel what the other feels. • To cognitively assess the other's point of view. These components can be translated into nursing actions that include listening and hearing, clarification and vali- dation, and analyzing and sharing the understanding (Ar- nold & Boggs, 1999).

Empathy is not to be confused with sympathy. Sympathy involves pity with or sadness for another person-empathy is the process of feeling and under- standing (van Servellen, 1997). Certainly, there are varying degrees of empathic involvement between in- dividuals that relate to type of relationship and amount of power. The more a nurse tries to cognitively under- stand others' feelings, the more likely a relationship will be established. For example, suppose the occu- pational health nurse asks a frightened employee who has been exposed to a hazardous chemical numerous questions and administers a variety of treatments. The nurse notes the frightened look on the employee's face and states, "With all of these questions and procedures, you probably feel very vulnerable and scared." This empathetic statement relays the notion that the nurse is conscious of the subjective experience of fear and, in turn, encourages further discussion.

Mutuality Mutuality is another concept important in communi-

cation. Although it is an interaction style, mutuality is a factor that enhances interpersonal relationships through communication. Attributes that define mutuality include a feeling of connection and understanding of another re- sulting in mutual problem-solving. It is a common shar- ing or a sense of satisfaction that unfolds in the interac- tion (Rosenkoetter, Reynolds, Cummings, & Zakutney, 1993). On a continuum with autonomy on one end and paternalism on the other, mutuality is the central balance between the two (Henson, 1997). The outcome of mutu- ality is a shared sense of control, personal responsibility, and satisfaction (Smith, 1992).

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Although there may be asymmetry in mutual rela- tionships, common sharing makes mutuality a real pos- sibility. A nurse who shares a personal experience (self- disclosure) to help a client understand a particular event demonstrates therapeutic mutuality (Marek, 1990). This understanding of another ultimately increases a dynamic exchange between client and nurse. Thus, they can move toward a common goal (Henson, 1997). For the occu- pational health nurse, mutuality in a team environment among the occupational physician, occupational health nurse, industrial hygienist, ergonomist, and safety profes- sional results in more effective communication as they move toward a quality work environment.

Context It is critical to assess the context in which the com-

munication occurs. Individuals interact in a different man- ner based on the location where the conversation occurs. Sharing information in the middle of a tense meeting is contrasted to that occurring in a hallway on a break. Con- text is critical, and so is the durability of the relationship. Axelrod (1997) describes one of the foundations of coop- eration as the reciprocity, or the "give and take" that occurs in a relationship. Durability is based on the history that two individuals have with each other and the future that makes that reciprocity stable. Cooperation becomes more likely if there is a future for the dyad's ongoing relationship.

INTERVENING VARIABLES There are several intervening variables that affect

success in communication. One of the most important is that of gender. Numerous books have been written about gender's effect on communication (Tannen, 1990, 1994). What is known about gender and communication?

Gender differences in communication have been ob- served even at an early age. Girls talk more indirectly and make requests, while boys talk more directly and make more demands (Tannen, 1990). Women speak to create a sense of harmony and use words to connect emotionally, express feelings, and build rapport. While women talk to maintain intimacy, men attempt to establish independence (Tannen, 1994). Even content topics exhibit differences as men most often talk about sports or business while women discuss relationships and feelings. Similarly, body language has different gender connotations. Women keep close proximity to each other and use non-verbal communication directly, whereas men use non-verbal communication indirectly and keep their distance (Gray, 1992; Tannen, 1994). Although both styles are useful and effective, it is important to recognize and adapt to the dif- ferences typically exhibited by the genders.

Another variable that affects communication is gen- eration. Zemke, Raines, and Filipczak (2000) describe each generation in terms of their life experiences and values, which in tum, are reflected in their different communication styles. Traditionalists (or Veterans), Baby Boomers, Genera- tion X (or Gen X), and Generation Y (or Nexters) each es- pouse differing values and life experiences and, therefore, differing communication styles. These differences in style

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Key Values and Leadership Styles by Generation

Veterans (Born prior to 1943) Respect for authority; sacrifice; take charge; directive; duty

before pleasure

Baby Boomers (Born 1943-1960) Personal growth; involvement; team orientation; collegial

Generation X (Born 1960-1980) Creative but cynical; adaptable; independent; diversity;

fun; informality

Nexters (Born 1980-2000) Confident; teamwork ethic; achievement; sociability;

optimistic

Adapted from Zemke, Raines, & Filipczak (2000).

may lead to misunderstandings in interactions. Some of these misunderstandings may relate to a directive instead of a hierarchical approach to solving a problem. Based on this research, knowing the generation in which a colleague or employee was born can facilitate an understanding of in- teractive styles. The Sidebar depicts key values that affect communication generationally.

CONFLICT RESOLUTION Despite all attempts at effective communication, misun-

derstandings and conflicts can and do develop. When conflict occurs, knowledge of strategies to engage in win-win nego- tiation is key. How does one strive to put a win-win solution foremost in communication strategies? In Dry's (1991) model of conflict management and negotiation, the suggested first step is non-reaction. Dry indicates one should "go to the bal- cony" and take a time-out to get perspective on the situation (p. 147). This step is essential to fully observe self and others. Questions to ask are: • What is going on here? • Are others hearing me? • Am I hearing others correctly? • What behaviors can be observed?

By engaging in the assessment step of the nursing process, a decision can be made whether to negotiate or not. Effective negotiation requires the ability to stay focused and not to engage in stonewall tactics, outright attacks, or manipulations. By "rewinding the tape" effec- tively, one can examine all options for a solution. While doing this, the best alternative to a negotiated agreement is identified (Fischer & Ertel, 1995; Fischer, Dry, & Pat- ton, 1991). Throughout this process, there must be an em- phasis on satisfying interests and not positions.

The beginning of negotiation requires a climate of caring and a commitment to understand the other. This climate of caring is characterized by the acknowledgement of feelings. It entails each of the effective communication skills discussed earlier. This open communication becomes the important component of the negotiation process.

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The next step directs attention back to ail assess- ment of both sides' interests. Problem-solving occurs as each side negotiates the question of "what if." Re- framing the situation is the foundational concept in this stage. To reframe is to change the negotiation to a "we" (How can we resolve this issue? How can we make this fair?). It is important to enlist advice from negotiating colleagues, resulting in their empowerment and sense of ownership.

It is important to use effectivecommunication skills (e.g., empathy, open-ended questions, affirmations) to encourage mutual satisfaction,problem-solving, and reframing in devel- oping a new and mutually acceptable solution. The process of negotiationis a challenge and requires the ability to step back, listen, openly discuss, and focus on collaboration.

Another way to view conflict situations is to examine the degree to which negotiators satisfy their own, as well as other's, concerns. Rahim (1985) describes five behav- ioral styles: collaboration, avoiding, dominating, oblig- ing, and compromising. The use of collaboration is pre- ferred because it demonstrates concern for both self and other and is described as "balanced power" (Gray, 1989). Dominating and obliging behaviors are the extremes at either end of the continuum.

COMMUNICATION STYLES Van Ess Coeling and Cukr (2000) emphasize behav-

ioral communication styles that enhance collaboration and subsequent satisfaction. They found that an attentive versus a dominant or a contentious style was a way to increase understanding of nurse-physician collaboration. The attentive style includes empathetic and assertive com- munication that exemplifies listening and paraphrasing. In addition, they found that providing verbal feedback to summarize an interaction helps to alleviate misunder- standings. Thus, summarizing is important to clarify an understanding, and, in tum, expand dialogue.

One of the basic principles of collaboration is prac- ticing effective assertiveness techniques. How does asser- tiveness impact effective communication? By being as- sertive, occupational health nurses express their feelings and ideas without judging or hurting others and, in tum, show mutual respect. It is important to use a calm tone of voice and self-expressive or "I" statements. The use of "I" helps individuals take responsibility for what they are about to say and avoids sounding accusatory. Beginning a statement with "you" puts the listener on the defensive and is often perceived as judgmental. For example, say- ing "I feel like I'm being attacked" is better than, "You're being self-righteous and putting me on the defensive."

The acronym CARE is an effective way of remem- bering how to be assertive (Smith, 1992): • Clarify the problem behavior. • Articulate why the behavior is a problem. • Request a change in the person's behavior. • Encourage this behavior change by 'stating positive consequences for that particular change. For example, if a client is resisting changes to a diabetic diet, one may help facilitate change by stating:

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I understand that it must be very difficult to follow these recommendations, but your blood sugars are very high and it is important that we review your diet one more time. Perhaps if we can discuss some of these difficulties, we can draft some changes you could try this week.

These statements are empathetic in acknowledging the situation and identifying why it is important to discuss changes that could result in positive outcomes.

Being assertive is a process and requires constant ap- plication. Assertiveness helps when dealing with difficult or anxious individuals because the nurse can set limits and use consequences to handle potential disruptions. Assertiveness also helps individuals receive immediate feedback on observations or behaviors. Too often behav- iors are ignored until serious consequences occur.

INTERDISCIPLINARY COMMUNICATION For occupational health nurses, communication among

multiple disciplines is often a daily event. Are there specific communication differences among various health science disciplines? Milligan et al. (1999) emphasized the impor- tance of finding common ground between disciplines be- cause there are often differing patterns of communication. Receptivity and respect must be viewed as a process that is dynamic and transforming in the development of common ground. This foundation is critical because individuals iden- tify unique contributions of each discipline. Subsequently, respect for each profession's practice domain can occur.

Collaborative interactions are the result of individu- als working together cooperatively and communicating openly. The individual can contribute to an effective col- laborative process by being active and assertive. Occupa- tional health nurses must feel comfortable in expressions of thoughts and feelings so open communication can oc- cur. During these discussions, negotiation is important and can result in a new way of handling a situation. As a result of clear interdisciplinary communication, client outcomes and quality care can improve.

CASE STUDY The occupational health nurse, employed by a large

local company, noticed an increase in employee visits to the health unit. These employees complained of stiff muscles, low back and/or shoulder pain, and stress. To conduct a complete assessment ofthis problem, the nurse surveyed the work environment and talked to workers in- dividually: The investigation resulted in the identification of a problem area in the plant. Because of a new set of deadlines, the workers were observed lifting heavy boxes of paper from the floor onto the platform instead of us- ing the forklifts. Further dialogue with the supervisors revealed that short cuts were becoming a norm because of time pressures. Workers were becoming increasingly irritable and stressed because of infrequent breaks and the resulting physical problems.

The nursing interventions included modifying the use of the lifts and relocating the sites for box storage. Group

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2 Effective communication is shaped by basic tech-niques (e.g., listening, asking open-ended questions, clarifying, paraphrasing), and affected by several variables (e.g., hierarchy, trust, gender, generation).

SUMMARY Effective communication is essential to practice and

can result in improved interpersonal relationships at the workplace. Effective communication is shaped by basic techniques such as open-ended questions, listening, em- pathy, and assertiveness. However, the relationship be-

Shaping Effective Communication Skills and Therapeutic Relationships at Work The Foundation of Collaboration

Grover, S.M.

tween effective communication and successful interper- sonal relationships is affected by intervening variables. The variables of gender, generation, context, collegiality, cooperation, self-disclosure, and reciprocity can impede or enhance the outcome of quality communication. It is essential for occupational health nurses to qualitatively assess the degree to which each of these concepts affects communication and, in tum, relationships at work.

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Axelrod, R. (1997). The complexity ofcooperation. Agent-based mod- els of competition and collaboration. Princeton, NJ: Princeton University Press.

Ellis, D. (1999). Crajiing society: Ethnicity, class, and communication theory. Princeton, NJ: Lawrence ErlbaumAssociates.

Fischer, R., & Ertel, D. (1995). Getting ready to negotiate. The getting to yes workbook. New York: Penguin Books.

Fischer, R., Ury, w., & Patton B. (1991). Getting to yes: Negotiation agreement without giving in. New York: Penguin Books.

Gray, B. (1989). Collaborating: Finding common groundfor multiparty problems. San Francisco: Jossey-Bass.

Gray, J. (1992). Men are from Mars, women are from Venus. New York: Harper Collins.

Heath, R. (1992). Human communication theory and research: Concepts, context, and challenges. Hillsdale, NJ: Lawrence Erlbaum Associates.

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Ledds-Herwitz, W. (1992). Forum introduction: Approaches to interper- sonal communication. Communication Theory, 2(2),131-136.

Marek, P. (1990). Therapeutic reciprocity: A caring phenomenon. Ad- vances in Nursing Science, 13(1),49-59.

McQuail, D., & Windahl, S. (1981). Communication models for the study of mass communications. New York: Longman Inc.

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Northouse, L.L., & Northouse, P.G. (1992). Health communication: Strategies for health professionals (2nd ed.). East Norwalk, CT: Appleton and Lange.

Rahim, M.A. (1985). Referent role and styles of handling interpersonal conflict. Journal of Social Psychology, 126, 79-86.

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Van Ess Coeling, H., & Cukr, P.L. (2000). Communication styles that promote perceptions of collaboration, quality, and nurse satisfac- tion. Journal of Nursing Care Quality, 14(2), 63-74.

van Servellen, G. (1997). Communication skills for the health care professional: Concepts and techniques. Gaithersburg, MD: Aspen Publishers, Inc.

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Because of the emphasis on interdisciplinary practice, effective communication is essential to occupational health nurse practice.

By improving their communication skills and assess- ing the intervening variables affecting communication in their workplaces, occupational health nurses can improve interpersonal relationships at work.

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meetings were organized with the supervisors to allow a forum for discussing ways to decrease stress in the small work environment. Recommendations were made for ap- propriate rest breaks and relaxation strategies.

During the implementation phase, the nurse was called to the manager's office. He was irate that the nurse was suggesting changes in the environment that were per- ceived to slow down the process. He suggested that this was not the nurse's role and that he was the sale manager of the work environment. His perception was that there were no stress problems in the plant.

What important components of effective communica- tion could be used with the manager to resolve this con- flict? The first step is to acknowledge feelings and use "I" statements. Beginning the interaction with "I can see that you're very concerned about this. I'd like to talk with you about what was happening so that we can resolve the is- sue." By focusing on the "we" resolution, the nurse can enlist advice from the manager. Using open-ended ques- tions such as, "I'm interested in hearing from you how we can relieve some of the problems with lifting," the negotia- tion becomes a challenge to both the nurse and the manger to collaboratively explore opportunities for improvement. Finally, providing verbal feedback to the manager about what the nurse has heard may help to solve the problem.

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