Essay: Communication in Nursing / Heron’s Model

Communication is predominantly one of the most effective skills explored in nursing and is defined as ‘a transfer of information between a source and receiver,’ (Sheldon, 2009, cited by Dougherty and Lister, 2011, p.191). This simplistic level of communication is largely described through linear models such as Berlo’s expansion of Shannon and Weaver’s theory 1949, (Miller, 2012), known as the SMCR model 1960, (Miller, 2012), representing sender/message/channel/ and receiver. Whilst this model is a foundation for defining communication, focusing on sending and receiving messages, its effectiveness is compromised as the models fail to consider external influences such as noise, (Arnold, 2011). However, such models have expanded and the use of verbal and nonverbal practice to form therapeutic relationships is referred to through John Heron’s Six Categories of Intervention (2001). Heron states that the ability to effectively communicate comes from understanding intentions of interaction and the skilful way it is expressed, either through authoritative or facilitative styles. This essay focuses on Heron’s theory of communication by analysing how its ideologies are applied to practical settings through the study of two videos entitled ‘Persuasion’ and ‘Eliciting’.
The practice of prescriptive and informative language in the ‘Persuasion’ video is used to give advice and provide information in aid of helping the patient to lower their sugar intake. This style of authoritative communication by Heron (2001) is largely emphasised through nonverbal techniques, such as kinesis. The use of open hand gestures from 0.20 to 1.10 promotes confidence in the speaker and enhances the meaning of the conversation, (Bach and Grant, 2009). This is beneficial for the patient by using health promotion to motivate a change in the patient’s lifestyle. McNeill (2005, cited by Kraszewski and McEwen, 2010), suggests that gesturing is an active part of conversation required when speaking, therefore, supporting the idea that gestures facilitate conversations and emphasise the importance of the advice given to the patient. In comparison however, the ‘Eliciting’ video shows a decreased use of hand gestures only expressed when the speaker is verbally communicating (0.39-0.41, 1.18-1.22). This is purposefully done to show empathetic listening towards the patient and is a way of displaying commitment to helping the patient, (Underman Boggs, 2011). As Heron’s model (2001) proposes, this use of facilitative communication supports self-reflection as to why the patient wants to lower their sugar intake, and is a style of communication that would be used in practice.
In addition to hand gestures, posture and proxemics act as indirect communication between both people. Throughout each video the healthcare advisor is sat upright with open arms, suggesting confidence and self-control, (Underman Boggs 2011). This is mirrored by the patient, promoting a comfortable atmosphere and allowing the patient to disclose information about their health. Healthcare professionals should consider nonverbal cues expressed by their patients as a way of identifying emotions. For example a ‘slumped, head down posture might indicate low self-esteem’ states Underman Boggs, (2011, p.104). Equally, distances between communicators act as nonverbal messages but what is deemed socially acceptable varies between cultures. In the video the distance is continuously maintained at an equal level which erases perceptions of a power relationship, (Kraszewski and McEwen, 2010). However, in practice the proxemics between the nurse and patient are often broken, such as when giving physical care. In turn, patients of all cultures could misinterpret the actions of care, (Underman Boggs, 2011). Similarly, this relates back to gestures in that different hand movements and signs could be received in offence by other cultures, (Royal Collage of Nursing (RCN) 2004). Therefore, healthcare professionals should have an understanding of cultural diversity and value the differences, otherwise known as ‘respectful curiosity’, (Giger et al., 2007).
Furthermore, the use of direct eye contact throughout the ‘Persuasion’ video creates a feeling of credibility and confidence in the speaker which is reinforced by Underman Boggs (2011, p.104) who states that ‘maintaining eye contact communicates honesty’. This therefore enables the patient to trust the speaker in the advice given on lowering sugar intake and strengthens the positive therapeutic relationship that has been identified. However, personal use of this communication in practice can be misjudged and for some cultures prolonged eye contact communicates aggression, (Sellman and Snelling, 2010). Similarly, barriers occur when communicating with patients who have sensory learning disabilities and those on the autistic spectrum who are inclined to avoid eye contact. Research carried out by Phoebe Caldwell (2010) has suggested that the observation and replication of body language, including vocal behaviour, can be used to initiate meaningful conversations, otherwise known as ‘Intensive Interaction’. As the interactions develop they support the learner in taking a more active role in communicating, allowing them to understand conversational rules and turn taking in modern society, (Field, 1979, cited by Nind, 1999). It is also suggested that such patient’s should have personalised care around their needs ensuring the best treatment is provided, (National Institute for Health and Care Excellence (NICE), 2015). Similarly, person centred approaches should be used when treating a patient with Dementia who may have difficulty in communicating their needs. James (2011) says that healthcare professionals should ‘recognise behaviours signalled by their patients as feeling distressed or being driven by a belief’. In turn, this reinforces the culturally sensitive understanding nurses should have by providing holistic care and valuing the individual, (Brooker, 2007).
Communication is further explored to promote a positive therapeutic relationship by empathising with the patient. Carl Rogers (1957) conditions for a therapeutic relationship largely emphasises empathy as a core skill in communication. The ‘Persuasion’ video offers verbal empathetic responses such as “I do understand” (2.20) which communicates an understanding of the patient’s perspective. However, empathy could be reinforced at this point with the delivery of the message through para-verbal’s such as decreasing the volume of the speaker’s voice and softening their tone, (Kraszewski and McEwen, 2010). Within healthcare the variation of vocalisation and empathy would be particularly important when breaking bad news for example. It is suggested that whilst the nurse advocates the patient they utilise their empathetic skills to continue assessing the patient and deliver care, (Kraszewski and McEwen, 2010). Similarly, the use of touch could be used to provide a comforting and caring mechanism of coping (Sully and Dallas, 2010). This form of nonverbal communication lacked throughout both videos and would therefore be used as an area of development in practice. However, the ‘Eliciting’ video displays empathy through Heron’s (2001) facilitative style of communication by using minimal cues. This is shown at 0.15 by confirming the patient’s response with “yeah” and head nodding in agreement. It is suggested that a patient’s feeling of self-worth is increased when nurses communicate with an empathetic style, (Underman Boggs 2011), and it is more likely a patient will disclose more information about their health, therefore, allowing nurses to provide good quality care. This is supported by the Six C’s (Cummings 2012) released from the Francis Report (2013) which state six core values that should be innate in all nurses, including compassion which establishes relationships built on empathy, (Cummings 2012). However, language barriers can create a problem with communicating empathetically if a patient’s first language is not English. Kraszewski and McEwen (2010) suggest high quality care can still be provided by using non-verbal techniques to relay empathy such as hand gestures or touch and in more complex cases trained interpreters would be available. This is supported by Smith and Field (2011) who recognise that using simple language in such circumstances is a valuable tool for effective communication.
Similarly the use of open and closed questions within both videos demonstrate Heron’s (2001) authoritative and facilitative styles of communication. In the ‘Persuasion’ video authority is shown through the practise of closed questions, “do you tend to snack a lot?” (0.09), which permits the patient to describe health problems in short responses, (Arnold, 2011). Focused questions are particularly used upon assessment of patient’s to gather information, (Arnold, 2011), therefore allowing the healthcare professional to tailor the advice given based on the patient’s response. A verbal weakness noted in the ‘Persuasion’ video was the lack of pauses throughout the speech, which in healthcare is blamed on time pressures, (Kraszewski and McEwen, 2010), however it is also suggested that pauses are a positive form of communication when asking complex questions because it allows the patient time to reflect, (Kraszewski and McEwen, 2010). In contrast, the ‘Eliciting’ video uses all three of Heron’s (2001) facilitative styles, Cathartic, Catalytic and Supportive, allowing the patient to disclose information about their health in their own words. In the video the demonstration of summarising (1.48-2.03) and reflection (2.18-2.20) on the patient’s understanding of wanting to decrease their sugar intake places focus on the emotional intent of their visit, (Arnold, 2011). Although not demonstrated in the video, stereotyping in healthcare can become a risk factor when personal beliefs effect professional standards. It is suggested that practitioners should self-reflect and set aside their beliefs for the benefit of providing good health care, (Sully and Dallas, 2010). In practice, not adhering to this violates the standards set out by the Nursing and Midwifery Council (NMC) in The Code 20.2 (2015) which requires professionals to act ‘fairly and without discrimination’.
Practice of Heron’s model (2001) has been demonstrated as an effective tool for communication in therapeutic relationships, by varying between both authoritative and facilitative roles. Using this model as a foundation for communicating allows for adaptation when overcoming particular barriers that have been identified in healthcare. Reflection of the communication displayed in both videos generally adheres positively to Heron’s model, however, communication is an advancing theme within healthcare and willingness to improve and learn is a core skill for all nurses in developing their communication style.