Core Communication Competencies in Patient-Centered Care
Abstract: Effective communication between the patient and nurse is an essential requirement for nursing practice and for patient-centered care. Nursing faculty that teach in undergraduate and graduate nursing programs play a signiflcant role in preparing the nursing workforce to communicate effectively and provide patient-centered care. Patient-centered care, interprofessional collaboration, and informatics are necessary knowledge, skills, and attitudes for nurses across educational levels in order to meet the needs of patients, and improve the quality and safety of the health care system environment. The focus of this article is to provide information on core nursing competencies for effective communication and to discuss communication tools used in patient-centered care, interprofessional collaboration, and informatics.
Key Words: Communication, Nurse, Patient-Centered Care, Interprofessional Collaboration, Informatics
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In the last decade the Institute of Medicine (IOM) hasreleased reports that address quality and safety in healthcare systems, health professions and nursing (IOM, 1999, 2001,2003a, 2003b, 2010). A core component of quality care is patient-centered care. Patient centered care is care based on a partnership between the patient, their families, and the health care provider that is focused on the patient’s values, preferences, and needs. Effective communication between the patient and health professionals is an essential requirement for patient- centered care (IOM, 2001). Furthermore, health professions education should include core competencies in patient-centered care in order to meet the needs of patients and the changing health care system (IOM, 2003a). Nursing faculty play a significant role in preparing the nursing workforce to provide patient-centered care and to communicate effectively. Patient- centered care, interprofessional collaboration, and informatics are necessary knowledge, skills, and attitudes (KSAs) for pre- licensure nurses and nurses returning for graduate education in order to communicate effectively and to improve the quality and safety of the health care system environment (Cronenwett, et al., 2007; Cronenvvett,et al.,2009; Massachusetts Department of Higher Education Nurse of the Future Competency Committee, 2010)). This article will synthesize core nursing competencies
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for effective communication and patient-centered care and discuss communication tools used in patient-centered care, interprofessional collaboration, and informatics. Existing communication competencies from nursing and health professional resources are interrelated and important for nursing faculty in curriculum development, and it is equally important for nursing students to comprehend the concept of communication when providing patient-centered care.
EFFECTIVE COMMUNICATION The American Nurses Association (ANA, 2010)
delineates standards of professional nursing practice. Professional competence in nursing practice includes not only psychomotor and clinical diagnostic skills, but also proficiency in interpersonal and communication skills. The registered nurse is expected to communicate in various formats and in all areas of practice. Communication is one of the standards of professional nursing practice (see Table 1). Communication is also addressed in four other standards of professional nursing practice: Assessment; Implementation; Collaboration; and Environmental Health (ANA, 2010).
Skill in communication has been described as communication that is effective, appropriate and therapeutic (Massachusetts Department of Higher Education Nurse of the Future Competency Committee, 2010). Effective communication is the creation of meaning in communication in which patients and health care providers exchange information so that patients are able to actively participate in their care. The communication involves a two-way process of expressive and receptive communication so that the message and resf)onsibilities of both the patient and health care provider is understood (The Joint Commission, 2010). Therapeutic communication is mutually respective communication and has a health related purpose. Examples of nursing core competencies for effective, appropriate, and therapeutic communication knowledge and skills are listed in Table 2 (Massachusetts Department of Higher Education Nurse of the Future Competency Committee, 2010). Nursing students must demonstrate therapeutic communication knowledge and skills prior to graduation. One of the core competencies is that the nurse must use clear, concise, and effective written, electronic, and verbal communication (Massachusetts Department of Higher Education Nurse of the Future Competency Committee, 2010).
Table 1. American Nurses Association Standards of Professionai Nursing Practice
Assesses communication format preferences of healthcare consumers, families, and colleagues
Assesses his or her ov(/n communication skills in encounters with healthcare consumers, families, and colleagues
Seeks continuous improvement of communication and conflict resolution skills
Conveys information to healthcare consumers, families, the interprofessional team, and others in communication formats that promote accuracy
Questions the rationale supporting care processes and decisions when they do not appear to be in the best interest of the patient
Discloses observations or concerns related to hazards and errors in care or the practice environment to the appropriate level
Maintains communication with other providers to minimize risks associated with transfers and transition in care delivery
Contributes her or his own professional perspective in discussions with the interprofessional team
American Nurses Association. (2010). Nursing: Scope and standards of practice, p. 54.
PATIENT-CENTERED CARE AND COMMUNICATION The IOM report (2001 ), Crossing the quality chasm: A new health system for the 21″ century, targets improving the health care system, structure and processes for changing the health care environment, and principles for redesigning the health care system. Patient-centered care is one of the aims for improvement of the health care system; using information technology and preparing the workforce are areas recognized to change the health care environment; and patient-centeredness is one of the principles for redesigning the health care system. Patient-centered areas for redesign include:
1. Care is based on continuous healing relationships 2. Care is customized to patient needs and values 3. The patient is the source of control 4. Knowledge is shared and information flows freely 5. Decision making is evidence-based 6. Safety is a system priority
7. Transparency is necessary 8. Needs are anticipated 9. Waste is continuously decreased 10. Cooperation among clinicians is a priority
In order to improve, change, and redesign the health care system and meet standards of professional nursing practice, the nurse has to assess barriers to communication. Barriers to communication between the patient and the nurse may be related to language, developmental level, medical condition/disabilities, learning styles, psychosocial, literacy, financial and cultural factors (ANA, 2010; Massachusetts Department of Higher Education Nurse of the Future Competency Committee, 2010). In addition, communication barriers may be experienced by the nurse with other health care professionals and within the health care system. The nurse has to be willing and capable of understanding the different styles of communication used by patients, families, and other health care professionals; communicate with the patient, family and systems during transitions in care; and use information technologies for health teaching and promotion to patients in a variety of settings. The nurse also communicates environmental health risks and strategies to reduce exposure to these risks to patients, families, and communities (ANA, 2010). The nurse continuously advocates disease prevention, Wellness, and promotion of healthy lifestyles, including a focus on population health when providing patient-centered care (IOM, 2003a).
Patient-centered care is addressed in the Healthy People 2020 topic area, health communication (HC) and health information technology (HIT), as it relates to the objective, satisfaction with health care providers’ communication skills and health literacy (U.S. Department of Health and Human Services |USDHHSl,n.d.). Table 3 displays the objectives in the Healthy People 2020 HC and HIT topic area. Health communication is defined as the study and use of communication strategies to inform and influence individual and community decisions that affect health. One communication strategy is the use of plain language to cleariy communicate health information and improve health literacy (USDHHS, n.d.). Literacy is a part of language and is important in patient-centered care and when working with teams. Literacy encompasses reading and health literacy (Interprofessional Education Collaborative Expert Panel, 2011).
Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions (USDHHS, n.d.). Individuals that experience health literacy problems receive less preventive care and have poor understanding of health problems and care, increase use of emergency and inpatient services and increase rates of rehospitalization, decrease adherence to medication schedules, decrease participation in medical decision making, higher medical costs, and inefficient mix of health care service use (Berkman et al., 2004; Berkman et al., 2011). Health literacy is also a tool that is used in health promotion, disease prevention, management of chronic illnesses, and quality of life (American Association of Colleges of Nursing |AACN],2011). Social marketing, one of the objectives in the Healthy People 2020 HC and HIT topic area (USDHHS,n.d.), is another tool for health promotion and disease prevention. Social marketing is the use of marketing techniques (product, price, place, promotion) to promote health behaviors of a specific target audience in order to improve health or benefit society (Andreason, 1995).
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Table 2. Therapeutic Communication Knowledge & Skills
Nurse of the Future: Nursing Core Competencies
• Uses clear, concise, and effective written, electronic and verbal communica
• Understands visual, auditory, and tactile communication
• Impact of ones’ own communications style on others
• Understands the physiological, psychosocial, developmental, spiritual, and
• Understands tbe nurses role and responsibility in applying principles of acti
• Chooses the right setting and time to initiate conversation
• Assesses the patient’s readiness/willingness to communicate
• Assesses the patient’s ability to communicate
• Assesses barriers to effective communication (language, developmental lev
anxiety, learning styles, etc )
• Makes appropriate adaptations in own communication based on patient anc
• Assesses the impact of use of self in effective communication
• Establishes rapport
• Actively listens to comments, concerns, and questions
• Demonstrate effective interviewing techniques
• Provides opportunity to ask and respond to questions
• Assesses verbal and nonverbal responses
• Adapts communication as needed based on patienf s response
• Able to distinguish between effective and ineffective communication with ps
cultural influences on effective
rel, medical condition/disabilities,
i family assessment
itients and families
Used with Permission: Massachusetts Department of Higher Education Nurse of the Future Competency Committee. (2010). Nurse of the Future Nursing Core Competencies. Boston: Massachusetts Department of Higher Education, pp. 27-28.
Table 3. Healthy People 2020
Objectives in Health Communication and Health Information Technology Topic Areas
Health Literacy Satisfaction with health care providers’ communication skills Individuals involvement in their health care decision making Receipt of providers’ recommendations for personalized health care resources Social support
Health Information Technology Internet access Electronic personal health management tools
Quality of internet health information sources
Electronic health records in medical practices
Access to online health information Users of health information technology Best practices in health protection messages Social marketing in health promotion and disease prevention
U.S. Department Health and Human Services Office of Disease Prevention and Health Promotion, (n.d.). Healthy People 2020.
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Nurses assess factors that influence the patient and family’s ability to learn including readiness to learn, preferenees for learning, and levels of health literacy. The nurse also has to demonstrate qualities of mutual respect, compassion, and collaboration when communicating with the patient, family, and other health professionals regarding the patient’s care and the nurse’s role in providing care (ANA, 2010).
INTERPROFESSIONAL COLLABORATION AND COMMUNICATION
Interprofessional collaboration in the professional work environment has been recognized by nursing, dentistry, medicine, doctor of osteopathy, pharmacy, and public health professional organizations as a vital component to safe, high, quality, accessible, patient-centered care (Interprofessional Education Collaborative Expert Panel, 2011). Interprofessional collaboration is working across healthcare professions to cooperate, collaborate, communicate, and integrate care in teams to ensure that care is continuous and reliable (IOM, 2003a). The nurse should be able to build communication and leadership skills in praetice settings, to function effectively within nursing and other interprofessional teams, to foster open communication, to demonstrate mutual respect, and to engage in shared decision making to achieve quality care (American Association of Colleges of Nursing [AACNI, 2008: Cronenwett, et al., 2007; Cronenwett,et al., 2009). Most importantly, the patient should participate in their eare through shared decision making (IOM, 2003b).
Table 4. American Nurses Association Principles for Social Networking
• Nurses must not transmit or place online individually identifiable patient information.
• Nurses must observe ethically prescribed professional patient — nurse boundaries.
• Nurses should understand tbat patients, colleagues, institutions, and employers may view postings.
• Nurses sbould take advantage of privacy settings and seek to separate personal and professional information
• Nurses should bring content that could harm a patient’s privacy, rights, or welfare to the attention of
• Nurses should participate in developing institutional policies governing online conduct.
American Nurses Association. (2011 ). Principles for social netwotkitig and the nurse: Guidance for the registered nurse.
One of the core competencies for interprofessional collaborative practice is interprofessional communication. Teamwork and collaboration requires that the nurse is able to communicate effectively with the healthcare team, patients, and caregivers to integrate safe and effective care within and across settings (AACN, 2008; ANA, 2010). Health professionals and health care systems should also actively collaborate and communicate to ensure an appropriate exchange of information and coordination of care (IOM, 2001).
Examples of communication that involves appropriate exchange of information and coordination of care are hands-off communication, chain-of-command, and error discIosure(AACN, 2008). SBAR (Situation-Background- Assessment-Recommendation) is a technique for communicating critical information that requires immediate attention and action concerning a patient’s condition It is used as a communication technique, shift report hand-off, critical situation call to a provider, in specialty nursing areas, and as process/ quality/improvement.
1. Situation- Briefly describe the current situation. Give a clear, succinct overview of pertinent issues.
2. Background-Briefly state the pertinent history. What got us to this point?
3. Assessment-summarize the facts and give your best assessment. What is going on? Use your best judgment.
4. Recommendations-What actions are you asking for? What do you want to happen next (Institute for Healthcare Improvement, n.d.).
The nurse coordinates care by communicating with the patient, family, and systems during transitions of care (ANA, 2010). An example of coordination of care is reflected in The Joint Commission National Patient Safety Goals (2013) for health care settings. Improving communication and medication safety are two goals where the nurse has to coordinate care through communication with the patient, family, and systems. Regardless of the health care setting (ambulatory, behavioral health care, critical access hospital, home care, hospital, long term care, office-based surgery), one of the ways identified to ensure medication safety is recording and passing along correct information about a patient’s medications. The nurse should consistently maintain and communicate accurate patient medication information. An example of the patient safety goal, improvement in communication, in hospital and laboratory settings involves getting the important test results to the right
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staff person on time. Another example of the patient safety goal, improving communication, is identified as improving the effectiveness of communication among caregivers (The Joint Commission National Patient Safety Goals, 2013). Being competent in interprofessional communication requires that the nurse communicate with patients, families, communities, and other health professionals in a responsive and responsible manner that supports a team approach to the maintenance of health and the treatment of disease (Interprofessional Education Collaborative Expert Panel, 2011).
INFORMATICS AND COMMUNICATION Informatics is a core competency for all health
professional’s education and incorporates mastery of new communication technologies including integrating and coordinating care (IOM, 2003a). Informatics is the use of information and technology to communicate, manage knowledge, mitigate error, and support decision making (Cronenwett et al., 2007; Cronenvvett et al., 2009; IOM, 2003a). The Technology Informatics Guiding lîducation Reform (TIGER, 2009) initiative in nursing was formed to improve nursing practice, education, and the delivery of patient care through the use of health information technology. Basic computer competencies, information literacy, and information management are competencies of the TIGER model. The nurse is expected to have knowledge and skills in information management in order to deliver quality patient care (AACN, 2008). The nurse also uses information technology to provide health teaching and health promotion and disease prevention information to patients in a variety of settings (AACN, 2011) and coordinates continuous care through information technologies. Evaluation of health information resources for laypersons and health professionals should be conducted by the nurse in order to translate scientific evidence to practice (AACN, 2008).
Health information technology (IT) or electronic health (E-health) is the use of information and communication technologies to improve health and health care (Office of Disease Prevention and Health Promotion [ODPHPl, n.d.). Information and communication technologies, resources, and principles of learning are also used to teach patients and others (AACN, 2011). Health care professionals can provide patients access to care over the Internet, by telephone, and other means other than face-to-face visits (IOM, 2001). E-health provides patients internet access to online communities and support groups, health information, health self-management tools,
personal health records and is a means of communication with health professionals. The nurse is expected to engage in an array of technologies that support patient care including electronic health and medical records, patient monitoring systems, and medication administration systems (AACN, 2008). The Electronic Medical Record (EMR) or Electronic Health Record (EHR) used in health care systems is not only used to provide patients access to their personal health record but it is a clear, concise documentation of care and improves communication and collaboration with other health care professionals. Information technology is not only used to communicate patient specific clinical information but is also used to communicate with other health professionals through e-mail.
HIT is also used in the exchange of health information among health professionals in an electronic environment and is a regulated by laws that protect health information and health information messages under the 2000 Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. Online social networks is one the most recent modes of social media in the health care arena. Social networking sites are online communities where individuals can interact with others with similar interests. Interactions can occur in various settings including chat, email, video, file-sharing, blogging, and discussion groups (Center for Disease Control and Prevention, [CDC], n.d.). The American Nurses Association (ANA, 2011) and the CDC (n.d. ) recently implemented principles, guidelines, and best practices for social networking. Likewise, the National Council of State Boards of Nursing (2011) has issued a white paper on the use of social media. Best practices in health protection messages and identifiable patient information and other privacy issues are addressed by the national agencies. The ANA principles for social networking are in Table 4. Interprofessional communication through information and communication technologies requires the health care professional to choose effective tools and techniques to facilitate discussions and interactions that improve interprofessional teams functioning (Interprofessional Education Collaborative Expert Panel, 2011).
SUMMARY In summary, the IOM report (2003a) addressed changing
the work environment and defined attributes of patient centered care. Key aspects of patient centered care are that the nurse or health care professional identify, respect, and care about patients differences, values, preferences, and expressed needs; relieve pain and suffering; coordinate continuous care; continuously advocate disease prevention, Wellness, and promotion of healthy lifestyles including a focus on population health; listen to, cleariy inform, communicate with, and educate patients; and involve patients in decision making and management. As nursing faculty prepare nurses to work in various roles and settings, core competencies in communication should be met by the nursing student regardless of educational level. Communication tools including patient-centered care, interprofessional collaboration, and informatics are important for improving patient outcomes and delivering high quality and safe care.