3.2 Communication

Effective communication is a vital component of proper assignment, delegation, and supervision. It is also one of the Standards of Professional Performance established by the American Nurses Association (ANA).^[1] Research has identified that new graduate nurses are more susceptible to stress and isolation within their job roles due to poor communication and teamwork within the interdisciplinary team.^[2] Strong communication skills foster a supportive work environment and colleagial relationships that benefit both clients and nursing staff.

Consider the fundamentals of good communication practices. Effective communication requires each interaction to include a sender of the message, a clear and concise message, and a receiver who can decode and interpret that message. The receiver also provides a feedback message back to the sender in response to the received message. See Figure 3.1^[3] for an image of effective communication between a sender and receiver. This feedback message is referred to as closed-loop communication in health care settings. Closed-loop communication enables the person giving the instructions to hear what they said reflected back and to confirm that their message was received correctly. It also allows the person receiving the instructions to verify and confirm the actions to be taken. If closed-loop communication is not used, the receiver may nod or say “OK,” and the sender may assume the message has been effectively transmitted, but this may not be the case and can lead to errors and client harm.

Closed-loop communication is vital for communication among health care team members to avoid misunderstandings that can cause unsafe client care. According to the HIPAA Journal, poor communication leads to a “reduction in the quality of care, poor client outcomes, wastage of resources, and high health care costs.”^[4] Parameters for reporting results and the results that should be expected are often left unsaid rather than spelled out in sufficient detail. It is imperative for the RN to provide clear, complete, concise instructions when delegating. A lack of clarity can lead to misunderstanding, unfinished tasks, incomplete care, and/or medical errors.^[5]

Effective communication is at the core of proper assignment, delegation, and supervision. With effective communication at the beginning of every shift, each nursing team member should have a clear plan for their shift, what to do and why, and what and when to report to the RN or team leader. Communication should continue throughout the shift as tasks are accomplished and clients’ needs change. Effective communication improves client outcomes and satisfaction scores, as well as improving team morale by enhancing the collaborative relationships of the health care team.

The RN is accountable for clear, concise, correct, and complete communication when making assignments and delegating, both initially and throughout the shift. These communication characteristics can be remembered by using the mnemonic the “4 Cs”:

• Clear: Information is understood by the listener. Asking the listener to restate the instructions and the plan can be helpful to determine whether the communication is clear.
• Concise: Sufficient information should be provided to accurately perform the task, but excessive or irrelevant information should be avoided because it can confuse the listener and waste precious time.
• Correct: Correct communication is not vague or confusing. Accurate information is also aligned with agency policy and the team member’s scope of practice as defined by their state’s Nurse Practice Act and other state regulations.
• Complete: Complete instructions leave no room for doubt. Always ask if further information or clarification is needed, especially regarding tasks that are infrequently performed or include unique instructions.^[6]

The use of closed-loop communication is the best method to achieve clear, concise, correct, and complete information exchanged among team members. Closed-loop communication allows team members the opportunity to verify and validate the exchange of information. By repeating back information, members confirm the exchange has occurred, understanding is clear, and expectations are heard.

Closed-loop communication should also be used when the RN is receiving a verbal order from a provider. For example, when the resuscitation team leader gives a verbal order of “Epinephrine 1 mg/mL IV push now,” the RN confirms correct understanding of the order by repeating back, “I will prepare Epinephrine 1 mg/mL to be given IV push now.” After the provider confirms the verbal order and the task is completed, the nurse confirms completion of the task by stating, “Epinephrine 1 mg/mL IV push was administered.”

In addition to using closed-loop communication, a common format used by health care team members to exchange client information is ISBARR, a mnemonic for the components of Introduction, Situation, Background, Assessment, Request/Recommendations, and Repeat Back. ISBARR and other communication strategies are discussed in more detail in the “Interprofessional Communication” section of the “Collaboration Within the Interprofessional Team” chapter.