Effective Staff Communication and Working Relationships CHAPTER OUTLINE LEARNING OUTCOMES KEY TERI WHAT'S AHEAD COMMUNICATION: Commu WHAT IS IT? ition Systems and Lines of Communication Downward Communication Upward Communication teral Communication Diagonal Communication The Communication Process ‘Communication Component Systems: Verbal, Nonverbal, and Metacommunication Verbal Communication Nonverbal Communication Assessment of Communication Effectiveness Barriers to Communication Information Overload Importance of Feedback: Giving and Receiving Feedback Grapevine: Is le Good or Bad? COMMUNICATION METHOD: Written Communication Face-to-Face Communication Storytelling Information Technology and ‘Communication Telephone E-mail Vi conferencing, Webinar, and Other Web-based C. Web Pages Social Networkin, Resolving Communication Problems and Improving Communication APPLYING LEADERSHIP AND MANAGEMENT MY HOSPITAL UNIT CRITICAL THINKING QUESTIONS AND ACTIVITIES MEDIA LINK REFE erencing Before you begin, take a moment to familiarize yourself with the learning outcomes for this chapter Describe the critical elements of communication. Distinguish between che four lines of communication. Describe the communication process. ‘Assess a team’s communication. amine bartiers to communication and how ads, including the most effective use of the method on problems378 Chapter 13 KEY TERMS + Active listening + Downward communication * Metacommunication + Communication + Encoding # Selective listening + Communication process © Feedback # Sender + Complementary relationship Lateral (hori * Storytelling * Context communication © Symmetrical relationship Decoding + Medium Upward communication, * Diagonal communication Message * Videoconferencing NilaloUie wa tal tal?) Communication is part of everything that is done within the health care system. It ean appear as stafl-to-staff communication and patient-to-staff communication. Communication includes verbal, nonverbal, written, and electronic communication. The major goal of staff communica~ tion is the effective exchange of information that assists staff in meeting outcomes. The survival of each organization is dependent upon the transfer of information and actions taken based on information or communication; therefore, this process serves to integrate the organization's activities. Critical to effective communication is respect for another's values, feelings, opinions, and trust, Typically, when a team or teams work together one of the first signs that productivity is down will be an increase in communication problems. Decreasing communication has a direct negative effect on decision making, collaboration, coordination, and prevention of conflict Communication is expensive as it consumes staff time ancl affects the organization and patient outcomes. When outcomes are not met, this affects costs. New information technology, such as computer hardware, software, information specialists, maintenance, repair and upgrade of hard- ware and software, and staff training in use of information technology (IT), is very costly. This chapter discusses many of these issues concerning communication, and how communication affects the work environment and outcomes. Ie is discussed more fully in Chapter 18. Communication: What Is It? Communication, a key to successful teamwork, is a complex process that should never be ignored. ‘Nurses need this skill daily in their work as they communicate with patients, families, co-workers, physicians and other health care providers, administrators and managers, support staff, case man- agers, utilization management staff, community agencies, and so on, The American Nurses Association (ANA) nursing standards include communication as an important part of nursing practice (2004), and the ANA nursing administration standards integrate the need for effective communication (2009), Although communication cannot be avoided, nurses can provide inade- quate or ineffective communication, The Joint Commission stated that “ineffective communica tion is the most cited category of root causes of sentinel events” (2007, p. 2). Communication is a two-way process that is used to convey a message or an idea between two or more people. This process is used to share thoughts, attitudes, information, and feelings, Effective care, which should be the goal, requires a focused exchange of ideas, feelings, and atti- tudes. Communication is best described as a complementary process with sender and receiver roles and, as such, is a process that happens between people and within people. Organizations ‘must exert considerable effort in ensuring that effective communication occurs within the organ- ization, with other external organizations, and with people who are important to the organization, Key issues are (a) who says what, (b) to whom, (c) in what way, (d) when, and (e) with what effect, Even after focusing on these key issues it is still important to remember that “Interpretation plays a major role; Sometimes interpretation confuses or changes the original message” (Finkelman & Kennet, 2010, p. 343)Effective Staff Communication and Working Relationships 379 |Nusses need to understand the communication process and use it to benefit patient care and + work that needs to be done to reach identified outcomes. With the greater interest on patient- ed care much of communication needs to be focused on the patient. The Institute of “ae includes information about communication in its discussion about the core compe- ovide patient-centered care: “Communicate with patients in a shared and fully open AJiow patients to have unfettered access to the information contained in their medical ‘ommunieate accurately in a language that patients can understand. Offer patients’ pre- communication channels (e.g., face-to-face, e-mail, other Web-based communication ‘ogies). Explore a patient's main reason for a visit, associated concerns, and need for information” (Institute of Medicine, 2003a, pp. 52-53). As staff members communicate, they become involved in discussions and in dialogue mostly about patients but also about the work effort related to patient care. There is also personal conversation that takes place among co-workers. This, personal conversation is very important in building teamwork—members feel more connected to one another. Effective communication broadens an individual's and a team’s view of issues and how best to work with one another. The result should be better outcomes for patients and the organization. Communication Systems and Lines of Communication ‘Typically, communication is thought of as taking place in a straight line, from the sender to receiver; however, in most situations communication is much more complex. Its direction can be downward, upward, lateral, or diagonal. “Downward communications go from superior to subordi- nate, and consist of messages regarding things like corporate vision, what a job entails, procedures and practices to be followed, and performance appraisals. Lateral, or horizontal, communications go between departments or between people in the same department. Upward communication (from subordinates to superiors) provides management with insights into the company and its employees and competitors” (Dessler, 2002, p. 260). What do these descriptors really mean to nurses? r Communication is downward when a team leader tells « tea member that a specific task must be done. Lines of communication typically relate 10 the onganizational structure. The organizational chart provides the best illustration of these lines of communication. Top level staff communicates to staff in lower levels and so on. Downward communication is the most typical communication flow and is found in the traditional bureaucratic organization, although it is used in many types of structures at some time or another. In fine with this type of organization, this communication is directive and used primarily to coordinate activities to ensure that outcomes are reached. Downward communication might be uused when there are issues related to the onganization’s (a) policies and procedures, (b) position descriptions, (c) employee rules and regulations, (d) written communication from administration, and (e) other forms of organizational communication that come trom above. Performance evaluations traditionally have been primarily downward; however, this type of performance evaluation is less effective, as was discussed in Chapter 9. Most organizations now require that staff participate in its own performance evaluation, thereby changing this communication fine. Changing organizational structures and leadership approaches have required changes in com- munication, Consider what was discussed about Transformational Leadership in Chapter 1. Dictating from above or downward communication is not a communication approach that sup- ports this type of leadership. As a consequence of leadership change, downward commun‘cation is becoming less common as more staff is encouraged to participate in organizational decisions and be innovative and initiate changes. This would encourage more upward communication and other communication forms in which staff interacts in a participatory environment such as shared ‘governance. Downward communication is also not as effective as other communication lines. Why is this, so? Communication really is the act of the message’s receiver. If there is no active receiver, does communication really occus? Downward communication can only send commands or directions. Communication needs to begis with the intended receiver rather than the sender. Downward communication comes after upward communication has been successful. It is a reaction rather than an action, or response rather than an initiative380 Chapter 13 Communication is upward for example when a staff nurse fells @ at the schedule for the month does not meet the staff nurse's needs ot when staff ov making at the unit level. Examples of upward communication, which are cost health care organizations, include staff meetings, staff-to-staff or staff-t0- * uoication, and communication that occurs on a daily basis in the work setting 2s e*e @ manager's use of an “open door” policy so that staff can feel free to come to > socager with issues or concems, shift reports, team or project communication and written cov, evievance procedures, staff development evaluation feedback, exit interviews, use of a ggestion box, staff satisfaction surveys, union communication, and the grapevine. Shared goveriance, a form of organizational process and structure discussed in Chapter 4, requires that staf! pariieipates actively in organizational decision making, which is upward communication; however, if there is limited lateral and diagonal communication, this still limits active staff participation in communication and decision making, Downward and upward communication are similar in that communication goes from one level to another, but only in a different direction from bottom to top or the reverse. Those who receive the message last may not receive the exact original message that was sent. This can be a disadvantage as itis critical that the message is received as sent, This can be an advantage if the message’s content has been improved with the Creative proves of the ideas of more than one staff member, but this still means that not all staff received the same message. The issues of perception and expectations will always be factors in limiting consistent communication, © Lateral or horizontal commmunication is typically used 10 coordinate activities. This type of communication takes place between staff that isin the same or similar hierarchical level or departmental level in that one does not have formal power over the other (for example, between a staff nurse and another staff nurse or between two nurse manages, cone from the cardiac care unit and the other from a medical unit). Typically, this comammicatiox 4s informal and might involve sharing information about patients, committee communication, and communication among team members, interprofessional, and work team project members AAs organizations begin to incorporate more teamwork and emphasize the value of working in ieams, this type of communication develops and becomes critical for success, co mivisecotes Diagonal communication, another form of communication, is informal. This communication typically occurs when staff members who are from different hierarchical levels are working on a project together, but when they work on the project, they are equal. This form of communication is increasing because more staff from different departments ‘or units are working together increasing collaboration. t also apptics to the relationship between ‘nurse and a physician or a nurse and a patient, For example, if a health care organization is developing a new admission procedure, the project's team ideally should include a physician, several nurse managers, several staff nurses, a patient transportation supervisor, the director of medical records, the director of information system management, a patient cepresentative, an ‘ombudsman or patient advocate, an admission department represemlative, an administrator, and the chief financial officer. In some organizations a patient representative may be included. This team has representatives from different departments, units within departments, management, administration, and an insurer representative; different hierarchical levels; consumers; and external representatives. The goal of diagonal communication is to improve communication so ‘that all can work together to meet the team’s goal. ‘There is also increasing evidence suggesting that clinical errors are often related to ineffec- tive communication pattems between members of the health care team and miscommunication, ‘The Institute of Medicine repor., To Err Is Human, discusses the problem of increasing errors in health care (Institute of Medicine, 1999). (See Chapter 16.) The report defines an error as “the failure of a planned action to be completed as intended of the use of a wrong plan to achieve an aim” Unstitute of Medicine, 1999, p. 3). Considering this definition, itis difficult fo exclude com- ‘munication as a major factor in erors, ineffective communication, problems with communication flow, poor feedback, asi diFficnity ng relevant patient information are all mentioned in the report. The Joint Commission has also commented on communication and errors: “Given thatEffective Staff Ci munication and Working Relationships 381 noncommunication or miscommunication is to blame in many common errors, the central person ‘whom health providers need to communicate—the patient—should be the first priority. storical information on the patient is incomplete and does not include detailed pattent’s allergies, previous diagnoses and lab results, or other medicines that are seing ken, including vitamins, herbs and over-the-counter medication” (Mansur, 2010). he Communication Precess ssion of information and understanding of that information in the message takes coy different levels: individual-to-individual, in small teams, in large organizations, nd berwven organizations. Each level of the process is described in Figure 13-1 and includes the followin; Encoding or translation of the communicator’s ideas into language 2. Message or the result of the encoding process 3, Mediuma or the carrier of the message (e.g., face-to-face, memo, medical record, team meeting, computer, policy statement); it can be an unintended message that is sent by silence or inaction Decoding or the process the receiver goes through to receive and interpret the message Feedback, an important component of two-way communication we ‘The communication process is made up of five elements. It is important to recognize the use of the term process, which indicates that communication is a dynamic interaction. The following are the five elements. 1. The sender is the individual who initiates the message, which may be verbal and/or non- verbal. Comrnunication may also be written, Verbal communication always includes non. verbal communication. There are many factors that affect the sender and the message (¢.g., the sender’s attitude toward self and toward the receiver, the situation in which the message is sent, timing, and purpose of the message). The sender uses encoding when decisions are made about what to include in the message and how to transmit the message, Then the message is sent. “The message includes both verbal and nonverbal information as well as the sender's att tude toward self, receiver, and the message. 3. The receiver is the person(s) to whom the message is sent. The receiver decodes the mes- sage So that it can be fully understood. This includes the actions necessary to understand the message (for example, listening, reading a memo or an e-mail message, oF reviewing a chart of data). FIGURE 1 Communication process. RN wo esse — vse Mes Sony FMS. [ cary PUSS [Grane PML Sacaing MEE. racer | oo ca ee Source: Robbins, S., & Deceazo, D. (20080), Findamentals of management. Upper Saddle River, N: Prentice Hall Health 1.377, Reprinied with permission382, Chapter 13 The feedback fs the message or response that the receiver may send back to the sender, Feedback may be verbal, nonverbal, or both, Clearly, the receiver's feelings, attitudes, s, relationship with the sender, the communication climate, cultural factors, and the decision to respond—the message and method chosen for the response. As * carer, the receiver's perception and expectations are important. This is often oor that which might interfere with communication, If response ues, then the process turns around with the receiver becoming the sender and the origi- der becoming the receiver, The receiver may also then communicate with other receivers, Two-way communication has then occurred. ‘The context is the situation or environment in which the communication takes place (for example, the nurse's station, patient's room, patient's home, the hallway, the clinic, the school nurse's office, staff meeting, or during shift report). This aspect of the process is very important and takes into consideration factors such as noise, number of people pres- ent, stress level, emergency or routine, presence of management or supervisors, privacy in the patient care area, organizational culture, morale, ethics and legal requirements, technol- ogy and information systems, and so on (Finkelman, 1996, p. I-1:10; Dessler, 2002). Why should one be concerned about this process? First, the process can be used to ana- lyze communication. Where was communication effective or ineffective? Was there a prob- Jem when the message was developed by the communicator? For example, if a nurse is too tired to be clear when giving directions to an unlicensed assistive personne] (VAP), this then affects the message—instead of telling the UAP to take blood pressures on four patients, one patient is forgotten. Sometimes a less effective medium is chosen; for example, a memo may be sent when it would have been better to call the person to get more immediate feedback. ‘Taking a part in communication by using these levels and elements of the communication process as a framework of analysis can help to identify where the communication process needs to be improved. The communication process is affected by many factors that are external to the environment in which the communication may take place, Managed care health insurance is one of these fac- tors as it has made communication in health care even more complex. Sometimes just trying to get approval for a patient procedure can strain a staff member's patience. There may need to be telephone calls, written documentation of needs, and in some cases, actual face-to-face contact, and the result may still be unsatisfying, Some extemal factors cannot be controlled. An example is state health departments require the reporting of all cases of child abuse. If there is a break~ down in this legally mandated communication, the child may suffer physically, and the health care organization may suffer severe consequences stich as fines and discipline of specific health care providers. In this situation, the health care organization has no choice but to build in a com- ‘munication process to ensure that this information is communicated, Communication Component Systems: Verbal, Nonverbal, and Metacommunication ERBA CAT} Verbal communication is considered to be the most common {ype of communication. It is complex and can be described as written or oral, cone, language, volume, frequency, choice of words, rate, and accent. Verbal communication, like all other types of communication, is affected by a person’s gender, age, culture, stereotypes and biases, education, and impairments such as heating or sight loss. Individuals are highly dependent on verbal communication, and often are less aware of nonverbal communication and metacommunication c OY Nonverbal communication is frequently used in clinical situations wien staf asesses pationts and their responses. Staff members, however, are often not as awate of their own use of nonverbal communication with other staff, patients, and families. The major functions of nonverbal communication are expression of emotion; expression of interpersonal attitudes; maintenance of rituals; support of verbal comrunication; establishment, development, anc maintenance of relationships; and self-presentation. Nonverbal communication is avt somes sways in the awaseness or control of the individual. ToEffective Staff Communication and Working Relationships 383 improve communication a person needs to increase awareness of the impact of nonverbal communication and increase assessment of nonverbal communication during the communication process, Nonverbal communication can consist of facial expressions, body movements or posture, gestures, volume of speech, tone of voice, gait, and physical appearance, Body language cally includes facial expression, eye movements, body movements, posture, gestures, and cies, oF distance between individuals. This assessment must not only include the nonverbal munication that the other party uses but also self-assessment of nonverbal communication. It aoce difficult to be aware of how one is using nonverbal communication while one is using smamunication. For example, when a nurse is discussing a procedure with a patient is the nurse aware of personal facial expressions, body language, and tone of voice, or is the nurse just Focused on the procedure and not the patient’s nonverbal communication? Some nonverbal factors that are important to consider are as Follows » Maintain eye contact and a relaxed manner as this communicates sincerity. = Smile if it is appropriate to the content, but do not smile constantly because this tends to make the receiver distrust the sender and the message. = A neutral environment might be useful in circumstances in which meeting in one’s office or on one’s own tertitory might make the other person feel uncomfortable. ® Ifa person stands over or leans over another, it can make that person uncomfortable and feel a loss of power, = Pulling away or appearing too casual may communicate superiority or disinterest. Cultural issues are also important because there is great variation in nonverbal communication among different cultures and interpretation of nonverbals. Examples of questions to consider with different cultures are (a) Do men look directly at women who are not their wives? (b) How do people greet one another? (c) Does the husband speak for the wife? Answers to these ques- tions and many others are important to know if a nurse is trying to teach a woman and her hus- band is present. The Institute of Medicine supports the need for the importance of cultural communications factors in all communication with patients, families, and staff (workforce diver- sity): “Sociocultural differences between patient and provider influence communication and clinical decision making” (Institute of Medicine, 20036, p. 214). Nonverbal communication frequently causes problems because it is often difficult to asses ‘and interpret. This communication includes anything other than the spoken word. It can be deliber~ ate or unintentional, and when itis unintentional, itis out of the control of the sender or the receiver ‘When there is doubt about the interpretation, the best approach is to ask for clarification about the ‘meaning: however, this is not always easy to do. The receiver may be hesitant, feel incompetent, may be concerned that asking for information may be threatening, or may not know how or what to ask. Comparing the nonverbal with the verbal may assist in greater understanding, but this is not always the case as a person’s nonverbal communication may be different from the verbal. Nurses tend to use comparison of verbal and nonverbal communication more during their communication with patients than with co-workers. Nonverbal communication, however, is very important in ‘work-related communication and should not be ignored, Delegation is a time when asking for clar- ification is critical; both from perspective of delegator and delegatee. (See Chapter 14.) Assessment of Communication Effectiveness Communicators want to have productive communication when the sender sends a message. The goal is that the message will be received and understood as sent. Productive communica- tion can lead to many positive benefits for individual staff, teams, structural units within the organization, the organization, the community, and for the patient and family. Some of these benefits are as follows: A team spirit with a common understanding and staff working toward common goals Participative management providing the staff with the opportunity to express different points of view and develop the best approach to problems ® Quick resolution of misunderstandings A comfortable environment that supports a motivational climate 1 More creative thinking by nursing management and nursing staff384 Chapter (3 Less staff tummover Less evidence of a rumor mill = Scation of responsibilities (Finkelman, 1996, pp. 1-1:13-14) ~ /eacers, charge nurses, and nurse managers need to periodically evaluate the effective- \urication—their own communication, individual staff members, and team winch conkd be a team, unit, department, or entire organization, ‘ght le some indicators of staff communication problems? ! members feel comfortable expressing their feelings and opinions? sie staff members trying to get on the good side of the nurse manager or leader and vamtnicating effectively? ‘During meetings or in shift report, does staff ask questions? aif members contribute their ideas to the discussion when there are problems? Silence ‘may be positive as it can allow time for thinking before responding; however, if staff is silent for long periods without contributing to the discussion, this can be an indicator of @ communication problem, = What happens when messages do not seem to be understood or are misinterpreted? ‘These questions represent some of the many aspects that need to be considered when communi- cation is evaluated Staff-staff communication provides the critical framework in which care oveurs. Imagine how a nurse might provide care without using communication, The care would have to occur on «an isolated island, and even in that situation, the nurse would still have fo communicate with the patient. Problems, however, do occur even in the best communication situations. The following, are some examples: + Discussing patients and their care is part of staff responsibilities. This takes time and needs {0 be considered a critical aspect of each stalf member’s role. This is not to say that in some cases too much time can be spent talking about care rather than providing care. Undoubtedly, every nurse encounters staff members who seem to alle too much, ‘work, interrupt others” work, and cause tension, This may mean that the team fend nurse manager will need to talk to the staff member and determine the reason for this type of communication problem, discuss how it interferes with the work and care of patients and arrive at strategies to improve the staff member's communication and reduce the inter- is, Other staff may even discuss i¢ with the staff member; however, this should be offered as positive criticism and in private. © Competition among staff can interfere with productive communication. It can lead to with- holding of information, distortion of information, and poor morale. Why would staff be competitive? They might be seeking recognition for work, better assignments, better work schedules, or feel that some staff members are treated differently, Clearly, this indicates that there are major problems in the work environment that need to be addressed so that ‘communication can improve. © Confidentiality is an ever present need in all clinical setting interactions. This has been reinforced by the HIPAA law related to privacy and confidentiality. (See Chapter 2.) Discussing staff and patient issues where others who should not hear about them might hear the conversation is very easy to do. Staff gets involved and forgets; however, the prob- Jems that can occur from this can be very serious. Staff members ure busy and so they “reach out” to other staff for these discussions when they can (for example, in the hallway, elevator, cafeteria, etc.) These are not private areas, Even the nursing station must be con- sidered an open area unless itis enclosed. Telephone conversations can also be easily over- heard. Many health care organizations now give staff cellular telephones to use in the clinical setting. These telephones are frequently used where conversations may be over heard. Nurses who work in the community must be particularly aware of this as they fre- ‘quently use cellular telephones where the pablic can overtiear confidential information or misinterpret what might be: said by a health care professional (for example, taking calls while taking a in a public restaurant or telephoning a patient while in another Patient’s home making 2 iorne visit),Effective Staff Communication and Working Relationships 385 = There needs to be greater consideration of staff feelings in the workplace, With heavy workloads itis easy to forget about the feelings of co-workers. Dashing around, communi- cating m short sentences, and moving on creates an environment in which staff forgets to snd fo fisten, A critical element of positive communication is the comfort level ous stalt feet comfortable saying “L need help?” “{ am overwhelmed?” or does staff feel II be seen only in @ negative light? Staff communication may be sharp and caus- ‘hurt feelings or anger, setting up barriers to future effective communication, 2i records and documentation are very important parts of communication in the delivery system, This form of communication must be clear and provide critical at is required. Requirements come from the nursing profession, state boards ning, standards, state and federal laws and regulations, insurers, legal cases, and the organization’s policies, procedures, and quality improvement program. Assessment of this type of communication must include these regulations. It is particularly important today to follow insurer requirements, particularly when describing patient problems, plan of care, and outcomes. This information affects decisions that are made and changes that are insti- tuted, directs care evaluation, communicates responsibilities, identifies outcomes that shonld be met and (if they are met) determines reimbursement, and guides staff. The com- mon response to medical malpractice issues, “If itis not documented, it did not happen,” sayis much about the importance of this documentation. Ifa list was made of health care communication concerns, documentation would be a top pricrity. ® When a staff member does not understand something or what needs to be done, itis impor- lant to ask to have the information or instruction repeated or explained. If itis something that makes the staff member feel uncomfortable, these feelings should be discussed. This is very important in delegation, as is discussed in Chapter 14. Mutual trust is something that is not easy to accomplish or assess today. Poor or ineonsis tent communication, inadequate staff input during the change process, and fears such as job loss or change can damage trust. This trust is a critical component of communication. Developing strategies to build mutual trust is important. Effective timing is somethi should be considered for an important communication and assessment of the commun tion process. Box 13-1 identifies some techniques (o promote trust, ‘At times there seem to be several different “stories” or different versions of information from different staff, This causes major communication and morale problems. Geiting facts from the source and discussing them openly helps to resolve this problem. © Intuition is used by many people, often unconsciously, and when it is used it may predict ‘what will happen within communication or within a situation. This may or may not be helpful as it may cause the sender of receiver to make the wrong assumption, Sometimes itis difficult to know when to use face-to-face communication and when to use the telephone or e-mail. Telephone and e-mail communication usually take less time, but if itis important to have a Face-to-face conversation, then time needs to be taken for this. ie ee » Convey respect that TECHNIQUES DESIGNED TO PROMOTETRUST Be flexible + Consider the person's uniqueness + Be honast and open + Show warmth and caring + Give complete information * Use active listening + Provide consistency * Give sufficient time to answer questions + Plan schedules + Maintain confidentiality * Control distractions + Show congruence between verbal and non- + Set limits verbal behaviors Follow through on commitments + Use @ warm friendly voice Use an attending posture: arms, legs, and + Use appropriate eye contact body relaxed, leaning slightly forward * Smile appropriately + Confirm responses386 Chapter 13 ‘When there is major conflict and miscommunication then blasting with a lot of e-mails is oi effective, This is the time for a face-to-face meeting. Telephone and e-mail offer more atrol: The sender selects the time when it is done; the time it takes is usually shorter; itis ‘0 take notes while in the middle of the communication; and e-mail provides more tone to think about what will be said, Although physical nonverbal communication cannot ve observed with these methods, tone and use of words communicated in an e-mail can © some aspects of nonverbal communication. showld not be left hanging. Feedback and follow-up are necessary for the develop- :eintenance of trust and to encourage two-way communication. It takes time to provide feedback, but itis time well spent {nterdepartimental/unit commumication helps the nurse manager and staff see problems fom the other departmend/unit’s point of view. Without this communication, itis easy to be isolated and only see one viewpoint. «There are times when communication in the nursing station, desk area, or the work area (uch as in a clinic) is impossible or undesirable. If it is very busy, the message may be lost amid the confusion. If a sensitive topic needs to be discussed, this location is too public. Never assume that this area is private ® Selecting the appropriate time to discuss a sensitive issue or even to communicate daily work-related information can make a critical difference. If a staff member is busy with patient care or documentation, this is not the best time, There are times, such as immedi- ately after a critical clinical incident, that staff is not able to discuss fully what has occurred due to emotions or fatigue. Often the first response is to discuss the situation; however, the best approach is (o identify another time within a reasonable time frame to discuss the inci dent. Putting off'a discussion is not always negative if itis done thoughtfully and follow-up action is actually taken (Finkelman, 1996, p. 1-I:14-15). crcies and procedures should be followed. Security within the organization's e-mail wnt concern, Using passwords, not sharing passwords, and remembering that eges ate deleted they may stay on the server and thus are accessible are factors “viewed with all staff. Organizations have policies about who may access Sor, and these policies must be followed. Some organizations have policies ganization’s e-mail system for personal messages. Thought needs to be taken ‘ages, remembering that once they are sent they cannot be retrieved. E-mail is @ ccnce Sur sending routine messages. The following are some e-mail etiquette guidelines, ‘ber that e-mail may not be read quickly so when the message is urgent a telephone cali muy o© 8 beter method, At a minimum, indicate the message is “urgent” or “priority” and request receipt reply. E-mail should be used thoughtfully. Sending too many messages that ate unimportant may ‘mean that important messages are ignored. Specify the subject in the subject ine, thas become more acceptable to attach formal letters or resumes to an e-mail, but the sender should first inquire if this is acceptable such as contracts, Acronyms and emoticons (symbols) should not be used in business e-mails, Break up content by using paragraphing, This makes it easier to read. Use bulleting or ‘numbering to highlight information, Put the most important information at the beginning of the message (0 ensure that itis read, Color can also be used for emphasis, bat it should be used carefully. Some colors do not show ap well on the screen, When printed, the message probably will be printed in black and white. Complex. graphics should be avoided as they take fonger fo download such as graphic letterheads, ‘When forwarding messages, include only relevant information from the original message to reciuce the amount of reading required and length of time for receiving the message, The forwarded message should be clearly distinguished from the original message, When a snessage is forwarded consideration should be given as to who are the appropriate peoy receive the message, The sender may not have intended for the message to be sent to others ‘When using reply, check to make sure that the reply message should go fo all recipients automatically or just one recipient. A common error isto click “reply all” when really one only wants the message to go €o one sender. There are times when a recipient may need more time to respond to a message: for example, 0 obtain more information. When this occurs, the recipient should acknowledge receipt of the message and indicate when a more detailed message will be sent. Not all messages sent via e-mail are received, and messages stating that there was a problem sending the message are not alway’s sent. Its a good idea to ask the recipient to acknowl- ‘edge receipt of important messages so that the sender can be sre the message was received. Use of virus protection is critical. Downloading messages, attachments, and information from the Intemet is a good way for an entire system to get a virus, 50 it is important to make it a practice to check for viruses first. + When an attachment is sent, double-check to see if the correct attachment is attached before hitting the send bution. Another common problem is to say a document is attached and then forgetting to attach it, Extremely long attachments should be avoided unless the receiver has been consulted about the length. ‘There is a tendency to ignore graimar, spelling, and so on in e-mails, but this should be considered in business related e-mails. + Do not use all caps, as this indicates shouting (Milgram, Spector, & Treger, 1999). rp . Bebe ‘The advantage to videoconferencing is iis a live interaction with visual images while the communication takes place. It also can reduce costs and time as staff do not have to travel to another physical location, Hower. nitia: cost of che equipment must be considered. Staff requires some training im the use of the equipment, but it is aot difficult, Videoconferencing is also used in telehealth. One example in saedical consultations between rural health