Why good communication skills are important for theatre nurses


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Why good communication skills are important for theatre nurses

  1. 1. Why good communication skillsare important for theatre nurses.6 April, 2004VOL: 100, ISSUE: 14, PAGE NO: 42Sue Saunders, BSc, RGN, is staff nurse, the Royal Bournemouth HospitalSue Saunders, BSc, RGN, is staff nurse, the Royal Bournemouth HospitalTraditionally, the theatre nurses role was not considered by many to be conducive to the developmentof good communication skills. Mardell and Rees (1998), for example, suggest that theatre nursing hasbeen associated with mechanistic interventions on patients who are in no position to respond to, orinteract with, the nurse. Instead of being at the beck and call of patients, like colleagues in otherclinical areas, the theatre nurses main role was seen as providing support for the surgeon and theanaesthetist.However, excellent communication skills have become paramount with the development of theperioperative nurse. Together with government initiatives such as The NHS Plan (Department ofHealth, 2000) and Essence of Care (DoH, 2001), which focus on the need to get the fundamentalaspects of nursing right, this places a new emphasis on the philosophy that underpins the work of thetheatre nurse. Today theatre nurses are required to have a holistic, truly patient-centred approach tocare before, during and after the patients surgical experience (Rees, 1999). Good communication withpatients, theatre colleagues, and other departments is a key element.With an ageing population and the associated risks of general anaesthesia, more surgical proceduresare being carried out under local or regional anaesthetic. The patients remain conscious throughoutsuch operations and this has required theatre nurses to keep in close contact with those who may befeeling anxious and vulnerable (Mardell and Rees, 1998; Walker, 1998). Extended roles for theatrenurses, such as surgeons assistant and carrying out minor operations, are common thereforeincreasing the need for nurses to provide preoperative and postoperative information and healthadvice. The provision of postoperative information and advice will lessen patients anxiety and feelingsof vulnerability.Defining effective communicationCommunication is the essence of social interaction, yet despite its significance Hargie et al (1994)suggest that a precise definition is notoriously difficult. At its simplest, communication may be definedas a means to transmit or pass on by speaking or writing or to impart or share feelings non-verbally. But to be effective it must succeed in conveying information and evoking understanding(Allen, 1991).Communication generally requires a sender, a messenger, a receiver, and a channel ofcommunication. Hargie et al (1994) remind us that the words or language used play only a small partin conveying any message. Meaning is also communicated by the following:- Tone of voice, intonation, speed, and volume;- Posture, body movements, and gestures;
  2. 2. - Facial expressions;- Use of touch.Environmental factors such as choice of furniture, smells and noise are also influential on the outcomeof interpersonal relationships. Active listening and questioning skills are as important as appropriatelanguage. The personal characteristics of the participants sharing a situation contribute to shape theinteraction and determine whether the information is successfully passed on.Communicating with patientsGood communication ranks equally with technical competence in theatre and it is therefore enjoyingan increasingly high profile across many areas of the Royal College of Surgeons of Englands work(RCS, 2003). The RCS clinical guidelines for surgeons regarding communication provide an excellentgrounding for all staff involved in perioperative care (Box 1).The RCS also recognises that an important role of the surgeon is as an educator (RCS, 2003).Westwood (2001) asserts that patients now want to be part of the decision-making process and areentitled to receive accurate information. They are now also much more likely to challenge what healthcare professionals say to them than they were in the past.Informed consentIt is a legal requirement of informed consent that a patient (or the patients parent or guardian) mustbe provided with sufficient information before agreeing to surgery. This includes disclosing significantrisks and describing alternative management (Bates, 2001).Ideally the operating surgeon should be involved and the patient should have ample opportunity todiscuss concerns in advance of admission. But consent is often delayed until the day of surgery whenthe patient may be feeling stressed and vulnerable. So in reality it is nursing staff who may be askedto explain the surgical procedure and pick up on cues from the patient regarding aspects of care sheor he may wish to be clarified.Westwood (2001) and Taylor and Campbell (1999a) agree that open questions should be used toestablish how much the patient understands and how she or he is feeling. It is important to listenattentively to patients. Patient information leaflets are useful as an aid to communication andencourage the patient to ask questions (RCS, 2003).Reducing stressJames (2000) asserts that having an operation is always a cause for some anxiety and fear for mostpeople. Oliver (1999) highlights the numerous causes for concern for the perioperative patient,including:- Expectation of pain and/or risk of disfigurement;- Unknown routines;- Loss of control;- Separation from family and friends;- Unknown prognosis.
  3. 3. It is recognised that stress and anxiety can produce an imbalance in the bodys natural homeostasis.This can lead to an increased cardiac workload and suppression of the immune system (Gross, 1996).Such changes are detrimental to postoperative recovery and should therefore be minimised.Patients are often most nervous immediately before the administration of the anaesthetic. At thistime, noise levels should be kept to a minimum, all stages of the process should be explained to thepatient and reassurance given. For patients undergoing surgery under local anaesthetic, music can beused to aid relaxation (Oliver, 1999).The use of appropriate touch, such as a comforting touch on the arm, can sometimes be rewarding,giving encouragement during anxious moments.Styles of speech should be adapted to allow for possible hearing difficulties or language differences. Inan increasingly multicultural society the use of interpreters may be useful. Sometimes adaptation ofspeech styles, such as speaking slowly, using short words, avoiding jargon, and using simplegrammatical constructions is sufficient to aid understanding (Hogg and Vaughan, 1995). Often thereare facial expressions, gestures and postures that can cross international barriers (Box 2).Communicating with other staffBonnington (1994) asserts that good teamwork provides the solid foundation for achievement andwhen taking into account the variety of staff making up the multidisciplinary team in an operatingtheatre it becomes apparent that effective communication is an essential skill. Hogg and Vaughan(1995) discuss the way in which individuals occupying different roles in a group need to coordinatetheir actions through communication, though not all roles need to communicate with each other.The concept of efficient group performance using a communication network functioning around a hubperson relates well to an operating team. The scrub nurse is central to receive, integrate, and pass oninformation to and from the surgeon while allowing peripheral members to concentrate on theirallotted tasks. Verbal communication is often hampered by surgical masks, which muffle speech. Eyecontact and modifications of speech style should by made to ensure that the listener understands whatis being said. This is important when there may be several team members for whom English is nottheir first language (Hogg and Vaughan, 1995).Taylor and Campbell (1999a) explain that the interpretation of a message can differ for each recipient.The listener should respond through expressions and gestures, and check for non-verbal clues thatconfirm or contradict what is being said. Communication is a two-way process that requiresclarification and reinforcement, and should be reflected back by repetition to confirm understanding.The swab count between scrub nurse and circulator illustrates this perfectly. The count should beundertaken aloud, with both participants confirming numbers of swabs and sharps in use or discarded.A running total should be kept on a whiteboard in clear view of the scrub nurse to record the count.The scrub nurse is then able to confirm to the surgeon, when necessary, that nothing has been lost.As a general rule, unnecessary noise and movement should be kept to a minimum as it can distractthe operating team from concentrating. Any background music should be stopped when totalconcentration is required (Oliver, 1999; Taylor and Campbell, 1999a).Written forms of communication are also useful as a one-off aid to communication or as a permanentrecord for different teams of staff using a theatre. The operating list, for example, provides a wealth ofinformation about a patient in order to allow safe preparation for a planned operation and surgeons
  4. 4. preference cards provide a permanent record of an individual surgeons requirements for setprocedures so as to minimise delays (Box 3).Bonnington (1994) explains that an atmosphere where the team as a whole is valued as well as theinput of individuals contributes towards an attitude of optimism and trust, which will help to overcomeproblems. A study by Livesley (2000) found that the major factor causing unhappiness within anoperating department was poor communication. The study recommended that team meetings,preferably weekly, should be undertaken to discuss problems, appraise staff, generate new ideas, andintroduce changes in order to raise morale. Taylor and Campbell (1999b) agree that opportunitiesshould be provided to debrief staff after difficult events.Communicating with other departmentsFor an operating theatre to run smoothly, it is essential that there is clear communication andcoordination between managers, surgeons, anaesthetists, preoperative assessment, wards, and bedmanagers.Davidson (1999) identifies a need for improved communication links between ward staff and theatres.It is suggested that a named theatre nurse should act as a liaison nurse. This nurse would be the firstpoint of contact for ward staff, addressing issues that may arise regarding perioperative care. Theliaison nurse is ideally placed to be responsible for the booking of ward staff and/or students who wishto visit theatre. Such visits provide a useful insight into theatre business, and can be complementedby an explanatory handout.Additionally, Davidson (1999) recommends that theatre staff become involved in preoperative visiting,so that the patients see a familiar face when they come in for treatment. This helps to minimise stressleading up to and during surgery. Simple gestures such as telephoning a ward 10 minutes before apatient is due to be collected or immediately when it is known that an operating order is to bechanged, allow the final preparations of patients to be undertaken calmly and efficiently.Patient care plans are a valuable source of information to be passed from one clinical area to another,and effort should be made by all staff to take ownership of the section relevant to their clinical areaand to complete it comprehensively, accurately, and legibly. This will ensure safe continuity of care forthe patient throughout the perioperative experience.Overall planning and management should be directed by a theatre management group, for which oneof the key roles is to analyse theatre utilisation and to anticipate problems that could arise. Relativelysmall steps, such as communicating when surgeons will be taking annual leave, help to reduce theneed for operations to be cancelled (DoH, 2003).ConclusionNurses should remember that any operation, from minor planned procedures to major emergencyoperations, is an anxious time for most patients. Good communication, especially the use of openquestioning techniques and active listening with patients and their families or friends can help toaddress any fears and ease tensions, which in turn is beneficial to postoperative recovery. Health Care’s Growing Complexity Causing Greater Nursing Stress
  5. 5. Print Page Send to a Friend ShareBy Debra Wood, RN, contributorMarch 25, 2012 - More than 75 years ago and long before health reform, endocrinologist Hans Selye defined stress as“the nonspecific response of the body to any demand for change.” Today, with a rapidly evolving health careenvironment, nurses are facing additional stress, but there are ways to mitigate the effects.Vitug Garcia, DHEd, DNS, MA, RN, FACLNC, suggests organizational and departmental approaches to managing nurses’ stress.“The demands of health care in this day and age are absolutely high,” said EM Vitug Garcia, DHEd, DNS, MA, RN,FACLNC, director of perioperative and perianesthesia services at Mission Community Hospital in Panorama City, Calif.“With changes in policies and organizations moving toward the competitive edge, expectations become higher, broaderand more complex. Nurses in the era of health care reform have more involvement in the treatment planning andcollaboration with interdisciplinary practice. There is more responsibility. The roles have expanded. Nurses are prone tostress as health care became a stressful environment.” Lisa Irvin, RN, MSN, NEA-BC, said transparency and data collection is adding to nurses’ stress levels.Lisa Irvin, RN, MSN, NEA-BC, vice president of nursing at Roper Hospital in Charleston, S.C., added, “Nursing is gettingmore complex, because there is so much transparency and public reporting on everything from a patient‟s experienceand satisfaction to the number of adverse events that happen in a hospital.”
  6. 6. Roper shares its quality data and opportunities for improvement with staff nurses and explains how the metrics will affectreimbursement.“Staff [members] are pretty acutely aware,” Irvin said. “Communication is critical.”In home care, family dynamics and other factors outside a nurse‟s control produce stress, said Tiffany LaSister, RN, NP,providing long-term care at CenterLight Health System in Brooklyn.Stress among nurses is not new. In the 1960s, Isabel Menzies identified four nurse stressors: patient care, decision-making, taking responsibility and change, according to Patient Safety and Quality: An Evidence-Based Handbook forNurses, a 2008 report from the Agency for Healthcare Research and Quality (AHRQ). However, one of the report‟sauthors, Bonnie M. Jennings, DNSc, RN, FAAN, said stress may be escalating due to rising health care costs,technology and “turbulence within the work environment.”Stacey Purcell, RN, MSN, and colleagues studied 197 registered nurses providing direct patient care and reported in2011 in the Journal of Nursing Management that age, patient work load and day of the week were factors affecting nursestress levels.Also in 2011, the American Nurses Association (ANA) Health and Safety Survey indicated that 74 percent of nursesreported concern about the effects of stress and overwork.Patrick R. Coonan, EdD, RN, NEA-BC, recommends striking a balance between work and family responsibilities.“An inability to balance work and life causes people the most angst, and it‟s harder for nurses, because they „take theirpatients home‟ and think about them,” said Patrick R. Coonan, EdD, RN, NEA-BC, dean and professor of the AdelphiUniversity School of Nursing, in Garden City, N.Y. “Change also comes at the top of the list. It creates an imbalance inwork and life. The majority of people say change is bad, because it takes people out of their comfort zone.”Mitigating stressorsGarcia suggested developing organizational and departmental approaches to managing nurses‟ stress, since every unitdiffers. Organizations can provide employee-assistance and employee-health programs, and on individual units, chargenurses must equally balance assignments, develop staff nurses‟ coping skills (such as how to de-escalate a hostilesituation), and monitor nurses for signs of stress.“A spirit of collaboration and being supported are very important in a day-to-day practice,” Garcia said.Garcia recommends starting with an organization-wide survey of nurses to learn what they feel stressed about and thenaddress those issues.When nurses at Roper Hospital voiced concern about rotating shifts, the facility‟s leaders listened, stopped the rotationand added a weekend program, which helps staff balance family and work obligations. The hospital also installed lift
  7. 7. equipment in response to nurses‟ requesting it. It also funds professional development, offers employee assistanceprograms and wellness coaches, and is serving more healthy fare in the cafeteria.“Organizations have to have a whole host of tools in their toolkit to minimize the stress on nursing, because it‟s a hardprofession, physically and emotionally,” Irvin said.Joyce J. Fitzpatrick, Ph.D., RN, FAAN, the Elizabeth Brooks Ford Professor of Nursing at the Frances Payne BoltonSchool of Nursing at Case Western Reserve University in Cleveland, Ohio, reported that for nurses to providerelationship-based care, putting the patient at the center of decision making, nurses must take care of their own health,including reducing stress.“Intellectually, nurses know they should do something to take care of yourself, but we all get so busy,” Fitzpatrick said.“Demands for nurses in acute settings are great.”Fitzpatrick mentioned hospitals are beginning to create places where nurses can go to unwind and others are startingstress-reduction programs.The American Holistic Nurses Association (AHNA) suggests organizations institute stress management programs, holdregular staff meetings to discuss feelings and provide counseling opportunities.Stressors that can impact nurses may include helping patients and families with end-of-life issues or hearing difficultnews.“Sometimes, we get too close to our patients and are affected by it,” Garcia said. “To be emotionally exposed to yourpatients, that is the nature of nursing. It‟s a caring science.”Nurses should develop relationships with colleagues they can talk with when something distressing happens.“They don‟t have to be friends, they are work friends, people to have a conversation with and help you get through whatyou have to get through,” Coonan said.Employee health nurses and nurse leaders could also talk with nurses about patient issues and create a culture ofsupport, Garcia added.LaSister said she finds interdisciplinary team meetings to discuss patient problems and stressors are helpful.“Everyone has valuable input into care,” LaSister said. “We work together to decrease the stress.”Individual initiativesNurses also must take responsibility for seeking assistance and learning how to reduce stress. AHNA recommendsidentifying sources of stress and working to resolve them. Proper nutrition, exercise, rest and healthy relationships oftenare helpful.Yet, Fitzpatrick said, nurses often skip lunch, while some food and a five- or 10-minute walk would help clear the mind.“Every small break makes a difference in your energy level,” Fitzpatrick said.In addition, she said, “Nurses can learn to reduce their stress through relaxation techniques or centering techniqueswhere you teach them to focus on the present.”Additional modalities AHNA suggests to deal with stress include yoga, tai chi, biofeedback, art, music, dance, massageand journal writing.Coonan recommends nurses develop other interests, so when they are away from the job, they have hobbies, friendsand activities that help them take their mind off work. He also advocates for turning smartphones off and taking a breakfrom computers.
  8. 8. “We have more information and data on patients and our profession than we ever had before. The question is: do wehave more knowledge?” he asked. He pointed out, “Information overload causes stress, too.”