Description #
A discussion on communication skills
Learning Objectives #
In this unit, students will learn the fundamental components of interpersonal communication, how and why communication can break down, and how the use of techniques such as active listening and readback/hearback can reduce misunderstandings and improve situational awareness.
Communication #
At its most basic level, communication is the delivery of a message from one person to another. From an operational point of view, we need to communicate in order to achieve task objectives and coordinate team efforts. Effective information exchange is essential for maintaining situational awareness, which in turn helps formulate good strategies.
In short, communication:
– Builds and maintains team structure
– Coordinates process and task execution
– Permits the exchange of information
– Facilitates relationships
Communication should be seen in a much broader context than mere verbal exchange; nonverbal cues (body language, facial expression, eye contact, voice tone, pitch and pacing) have a greater impact on the receiver than words. When in doubt, we believe the tone, facial expression, gestures and body language more than the spoken word. In the absence of non-verbal cues, it becomes much more important to choose words carefully in order to convey a message clearly.
It is also important to keep in mind that communication can never be a mere transfer of information from one person to another. The receivers of the information will always interpret it differently, based on their own experience, language, culture and perception of the situation. While this may not be critical when it comes to day-to- day casual conversations, small misinterpretations that may be tolerated or even intentional (i.e. jokes) can have serious consequences when it comes to patient safety.
Barriers to effective communication #
Good communication occurs only when others receive our message in the manner in which we intended it to be. It is not always as simple as it sounds; many factors interfere with the message we wish to convey. Misunderstandings can arise from both the way we transmit information and in the way we receive it.
Transmission errors #
Speech: Faulty grammar, a strong accent, speaking in a low tone, speaking too quickly, mumbling, mispronunciation, etc can contribute to misunderstandings. Also, the use of jargon, abbreviations and/or slang may create an ‘insider language’ that may be misunderstood by others.
Lack of non-verbal cues: While not technically an ‘error’, the lack of non-verbal cues such as body language, facial expressions, eye contact, etc, can obscure the message we are trying to convey. For example, a surgeon wearing a mask and busy working on a patient might not display any of the non-verbal cues that people normally use to decipher a message. In this case his or her tone of voice and choice of words would carry much more weight than they would in a casual conversation outside the operating room.
Unspecified receiver: Operationally, every message should be directed to a specific person. This is often neglected in high stress/workload situations and can result in diffusion of responsibility; if questions or instructions are put forward with no specific receiver, no one will feel concerned or responsible for answering and/or carrying them out.
Information overload: In time-critical situations there is often a risk of overloading a message with information. When this happens, the receivers have to decide what part of the message is the most important, based on their own experience and mental model (SA) of the situation. This may not reflect the sender’s intent, which may be critical to managing the event. Information overload can be characterized by:
– Rapid sequence of instructions for unrelated actions
– Minimal pause between sentences
– Long lists with numbers or dosage instructions
– Long and detailed instructions
– Multiple questions embedded in a single query
Receiving errors #
Listening
Listening is our most important communications skill, but ironically it is probably also the skill least taught. We tend to think of listening as a passive activity, from childhood we are taught to listen passively while our parents, relatives, teachers, etc., speak to us. We are expected to be a sponge, and absorb the information being given. This is not necessarily a bad thing since for the most part, children tend to be good at passive listening, and are adept at absorbing new information in that way. Unfortunately this ability usually deteriorates as we age.
Poor listening
We hear everything around us, but listening allows us to focus on certain sounds. Effective communication requires skill at both transmitting as well as receiving messages; effective listening takes work and practice, just like any other technical skill.
What often happens when listening is that instead of concentrating on what the other person is saying, we engage in an internal debate, formulating our response before the other person has finished speaking. People often pay little attention to the content of the speakers’ words, waiting instead for an opportunity to make their own case.
Indicators of poor listening:
Interrupting: doing this usually means the person is paying more attention to their own opinion and intentions than to what is being said by the other person. Their responses may be pre-planned and the short pauses caused by interrupting are a way to advance their point of view.
Diverting: Changing the direction of a conversation by picking up on irrelevant issues. If the listener has not perceived the core problem, they may pay more attention to surface details rather than on the substance of the conversation.
Debating: Instead of asking questions in order to clarify what a person means, they are used to argue or play devil’s advocate. Rather than understand the other person’s point of view, the goal is to win the argument, sometimes just for the sake of arguing.
Quarrelling: This occurs when the listener stops focusing on the subject of the conversation and instead goes on a personal attack on the speaker; the conversation then focuses on offending the other person.
Reactive behavior: To protect one’s feeling of freedom, an opinion is dismissed; feeling pressured to accept another person’s opinion can lead to rejection of both the opinion and the person.
Tuning out: This occurs when the listener feels their communication partner is not worth listening to, either because they fell they already know what will be said, or they are preoccupied with their own position.
Questions, questions, questions
Gathering information often requires asking questions. The types of questions asked have a bearing on the quantity and quality of the information received. There are two basic types of questions: open and closed. Each has its advantages and drawbacks.
Closed questions are those that only require a short answer, i.e. a short sentence or single word. Closed questions are good for gathering precise information quickly however overuse may cause the listener to feel like they are under interrogation. When this happens people tend to become more tight-lipped, which reduces communication, possibly at a critical time.
Open questions are more general in nature, requiring longer answers. Open questions are useful in gathering background information on a situation. Care should be taken when using open questions since there is a risk that important information may not be received in a timely manner.
Improving communication #
The implications for patient safety resulting from poor communication are obvious; the techniques of ‘active listening’ and ‘readback/hearback’ are effective in reducing the risk of misunderstandings in critical situations.
Active Listening
As mentioned earlier, nonverbal cues have more impact than words. They can be misinterpreted or sometimes absent, i.e. radio communication, facing away from the intended receiver, wearing a surgical mask, etc. Safe operation of complex technical systems such as transport category aircraft, nuclear power plants and operating rooms require the accurate, timely, and sometimes rapid exchange of information in an often fluid situation. Active listening means taking responsibility for understanding another person’s point of view, request, or message. It takes practice since it requires more than just incessant attention. In 1997, Transport Canada identified the following habits and behaviors associated with being an active listener:
Patience: This is often the hardest skill to put into practice. Wait until the other person has finished speaking, and do not interrupt. While the other person is talking, try to hear what his or her position is.
Ask questions: Once the other person has finished speaking, ask for clarification, details and explanations. An appropriate combination of open and closed questions is the most effective strategy here.
Observe and hold eye contact: Observe body language and listen closely to other nonverbal signals. You can learn a lot about what the other person is really trying to communicate.
Paraphrase and mirror: Repeat important details (doses, names, times) literally; otherwise, repeat in your own words what you understood. This can help to clarify your own thoughts as well as let the sender know how well he/she has been understood.
Be supportive: Encourage, show respect, and say thank you; This will help to create a supportive team climate.
Readback/Hearback
Active listening is an effective technique for reducing the risk of misunderstandings, however we should acknowledge that there might not always be enough time for it. ‘Readback/Hearback’ is an efficient process that is used a great deal in aviation; it helps ensure that messages are clearly received and understood. Ideally, the sequence of communication should be as follows:
1) The ‘sender’ concisely states information to the ‘receiver’.
2) The receiver then reads back or says what he/she has just heard.
3) The sender then provides a hearback, acknowledging that the readback was correct, making corrections if required.
4) The readback/hearback process continues until a shared understanding is mutually verified.
5) The instruction is then carried out and the task execution is announced.
This closes the information loop. This process may seem cumbersome at first but it can become a seamless part of messaging and decision-making in critical situations, if practiced repeatedly in everyday situations.
Conclusion #
Communicating effectively is a basic building block of situational awareness. Like any other skill, it needs to be practiced on a regular basis and should become part of everyday practice, not only used in critical situations. The use of simulation is an effective method of training individuals and teams to communicate more clearly and efficiently, thereby increasing patient safety.