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Better practice

Communication skills:
revisiting the fundamentals
Fiona Timmins

UK as supplementary and independent.

Abstract The number of prescribers and differences
In the UK, nurses are increasingly involved in medication management with both between the two are described thus: an
independent and supplementary prescribing being common practice. While estimated 1400 supplementary prescribers
specific mandatory training and education exists, there is little development may prescribe from the entire British
by way of continuing professional development, although this is deemed National Formulary, with the exception
important. In this context, nurses who are keen to evaluate or develop their skills of controlled drugs, once a clinical
may appreciate revisiting the key communication requirements of the nurse management plan has been established.
prescribing role. In the first of of a series of three, this article aims to provide Approximately 1800 independent nurse
a brief overview of fundamental theory in relation to communication skills, as prescribers are restricted to items in the
the first step to address knowledge gaps that may exist. This will be followed Extended Nurse Prescribers’ Formulary
in parts two and three with a more in-depth look at information giving and the (ENPF) (Bradley et al, 2007).
communication challenges that may exist.
Education and training
Education and training for nurse

T here has been significant development

in the UK with regard to nurse
prescribing over the last two decades,
circumstances (DH, 1989; 1998; 1999;
2005a; 2005b). Initial evolvements in
this advanced scope of practice meant
prescribers in the UK comprises a
course that takes place over a 3–6 month
period, including 26 taught days in a
with resultant benefits in improved that nurses typically prescribed using university and 12 clinical days under the
patient concordance and clinical the group protocol method, termed as supervision of a medical practitioner (An
decision making, fewer pharmacological patient group directions, which provide a Bord Altranais/NMC, 2005). Currently,
interventions and cost-effectiveness (An multidisciplinary evidence-based directive a minimum of 3 years’ post-registration
Bord Altranais/Nursing and Midwifery pathway for prescribing in a certain client nursing experience is recommended
Council (NMC), 2005). Several reports group. There are currently around 140 before beginning the course or prescribing
issued by the Department of Health medications permitted for prescription by (NHS & DH, 2005) and facilities for
(DH) over consecutive years have nurses in the UK within this framework continuing professional development
paved the way for changes in both (An Bord Altranais/NMC, 2005). This was (CPD) are inconsistent, although strongly
nursing practice and legislation that expanded in 2003 with amendments to recommended (Otway, 2007). While there
provide for nurse prescribing in certain legislation to provide for the prescription are obviously several vital aspects to the
of certain controlled drugs. role of nurse prescriber that need initial
Since 2003 there has also preparation and ongoing development,
been provision to prescribe in a this paper is concerned with one particular
semi-autonomous collaborative fashion area: communication skills.
following an initial assessment of the
patient and a treatment plan is in place. Communication skills
This supplementary prescribing provides Communication skills, including
for registered nurses to prescribe from a information giving and listening, were
broad range of medications and manage ranked the single most important skills
more complex health conditions, without that nurse prescribers must possess
the need for a designated medication
formulary. Discretion is also applied with
regard to dosage alteration and frequency, Fiona Timmins is Senior Lecturer for the School

unlike the group protocols (DH, 2005b). of Nursing and Midwifery, Trinity College, Dublin
Bradley et al (2007) summarize nurse Email: fiona.timmins@tcd.ie
prescribing models currently in use the

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(Bradley et al, 2007), and ranked

significantly higher than medication Box 1. The linear model of communication
management. However, in many cases (Miller and Nicholson, 1976)
these skills are already in place. Nurse
prescribers in the UK typically have a Sender Message Receiver
great deal of experience (Avery et al,
2007) and indeed, the highly developed
communication skills of nurses was one Berry et al, 2006) and developing the professional practice of nursing .’
impetus towards nurse prescribing (Jorm, nurse–patient relationship (Brooks,
2000). It might appear, therefore, that a 2001). Another key relationship in the Essential communication skills
paper addressing this fundamental nursing prescribing domain is that of nurse and in nursing are identified as listening
skill may seem redundant. However, doctor (Avery et al, 2007), and nurse and and attending, empathy, information
health professionals, and especially nurses, pharmacist (Pleasance and Brownsell, giving and support in the context of a
place great value on CPD, and revisiting 2004), wherein potential communication therapeutic nurse–patient relationship
the whole area of communication skills difficulties can arise in response to role (Mc Cabe and Timmins, 2006). The
may be seen in light of this. In addition, changes. It is also evident that where focus of communication ought to be
there is also some evidence to suggest this relationship works well, advances in patient-centred, rather than nurse-centred
that while nurses often rate their own the scope of nurse prescribing develop or task-centred, and this is increasingly
communication skills highly, the public to improve practice. However, where forming part of communication models
often come away from situations with the barriers exist in the relationship, progress for nursing practice. Developing a
view that communication could have been is hindered (Avery et al, 2007). There is therapeutic relationship is also considered
improved (Roebuk et al, 2001; Nikoletti evidence to suggest that in some cases essential (Mc Cabe and Timmins, 2006).
et al, 2003). There is also a tendency in doctors were omitted from key planning Although nurse prescribers may not
certain groups of nurses or midwives, stages of nurse prescribing developments always spend long periods of time with
that when confronted by certain groups (Avery et al, 2007) and this may have led patients, Mc Cabe and Timmins (2006)
of patients, to stereotype them and to resistance. Good communication skills argue that developing this relationship
treat accordingly (Kirkham et al 2002, and an understanding of change theory is possible and a requirement for all
Hindle, 2003). For example, in one study may help to alleviate such situations. nurse-patient interactions, regardless of
Somali women perceived that they were A final challenge that emerges for the time period involved. The theoretical
denied information because of negative the nurse prescriber is the health care basis for these skills will now be
stereotyping (Davies and Bath, 2001). In environment, which may prove a barrier considered.
this context, it is useful to revise certain to the progression of new innovations in
key skills and perhaps self-assess the prescribing. Overly complex policies and
Fundamental components
extent to which you are performing. procedures (Avery et al, 2007), a lack of
Communication may be considered
It might also be helpful to examine the understanding or a lack of support may
both a simple and a complex process
particular communication skills that nurse dampen the enthusiasm of qualified nurse
(Rosengren, 2000). The Linear Model of
prescribers require, or the communication prescribers who are eager to begin. Indeed
Communication (Miller and Nicholson,
challenges faced. Research studies on many nurses exit the prescribing course
1976) is an example of how everyday
nurse prescribing indicates that key concerned about how they will implement
communication may be considered at
communication skills include information their new role in practice and unsure of
a very simplistic level (McCabe and
giving (An Bord Altranais/NMC, 2005; what support is available (Bradley et al,
Timmins, 2006) (Box 1).
However, as a model to describe and
understand communication in the health
What is communication? care setting, this is considered overly
Historically, communication is a skill that simple (McCabe and Timmins, 2006).
is valued highly within nursing practice First, it relies on the proficiency of both
(Nightingale, 1992). More recently sender and receiver to give and accept
McCabe and Timmins (2006) suggest that: the message. It also fails to take into
account the many physical, psychological
Communication in nursing as different and social factors that influence
to communication in the other health communication, described as ‘noise’
care professions. It is unique, not because (DeVito, 2000), that serve to distort the
Lee Pettet/iStockphoto.com

of the communication skills required as message being transmitted and distort the
any professional working with the public perception of the receiver. It is worthy to
needs to have effective communications note that this model of communication is
skills, but rather because of the focus one way, and listening to the patient does
and emphasis of communication in the not feature in the interaction. Interestingly,

396 Nurse Prescribing 2007 Vol 5 No 9

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nurses are accused of adopting these

one-way methods, and can adopt this as a
method to avoid listening, possibly owing Distracting Stimuli RECEIVER
to time pressure (Bradley and Edinberg,
1990; Kruijver et al, 2001). Mc Cabe and culture knowledge culture knowledge
Channels of Communication
Timmins (2006) suggest that this: communication vocal visual kinesic previous experiences
abilities values stimuli print internal frame values
‘one-way communication allows internal frame mechanical devices of reference role
nurses to control the interaction and of reference role set factors
when nurses feel that they have a lot set factors Interpersonal Space goals support
of work to do or tasks to complete, needs goals needs system
this is a useful way of communicating.
However, the consequence of this type
of communication is that it does not
recognize the patient as the centre of care Figure 1. Circular transactional model of communication (Bateson, 1979).
but rather the nurses need to complete
the task takes precedence over the needs the understanding of communication Nurse prescribers can identify with these
of the patient.’ processes, this latter model does little processes as they often ‘translate’ the
to advance understanding of specific pharmacological information or doctor’s
Obviously, while imparting information nurse-patient communications. requests to patients, and perhaps are
is an essential feature of nurse prescribing, However, there are very few models of the first to translate directions into a
neglecting the patient through one- communication that relate specifically to language that the patient can understand.
way communication could not only nursing, nonetheless particular authors Trust is also important in nurse–patient
cause patient dissatisfaction, but could (Fosbinder, 1994; Morse et al, 1992; interactions and getting to know a patient
also be detrimental to the developing Morse et al, 1997) have made significant involves being friendly, using humour and
relationship essential to concordance. contributions to this aspect of nursing appropriate personal sharing (Fosbinder,
To examine a more comprehensive (McCabe and Timmins, 2006) which will 1994).
view of communication, McCabe and now be considered. Morse et al (1992) developed a model of
Timmins (2006) put forward the Circular communication to focus on the emotional
Transactional Model of Communication, Specific communication processes engagement of the nurse with the patient
based on the work of Bateson (1979) Fosbinder (1994) highlights the (Figure 2). This model is based on two key
as useful (Figure 1). Following on emphasis that patients place on nurse assumptions:
from the linear model, the concept communication skills and identify four n The nurse is either patient-focused or
of communication is broadened to specific communication processes in the nurse-focused
consider the factors of sender, receiver nurse–patient relationship: n Communication is either spontaneous
and environment that can influence n Translating first-level or learned second-level.
communication (Figure 1). n Getting to know you This model further explains the nature
McCabe and Timmins (2006) n Establishing trust of nurse–patient communication.
point out that while contributing to n Going the extra mile. With regard to patient-focused, first-

Sufferer-focused (patient) Self-focused (professional)
Characteristic Response Response Characteristic

First Engaged with sufferer’s emotion Pity Guarding

level Genuine Sympathy Shielding/steeling/bracing Anti-engaged
Reflexive Commiseration Dehumanizing
Compassion Withdrawing (against
Reflexive reassurance Distancing embodiment;
Labelling protective)

Second Pseudo-engaged Sharing self Rote behaviours

level Humour ‘professional style’
Reassurance Legitimizing/justifying Anti-engaged
Learned Therapeutic empathy Pity (false/professional) (embodiment
Professional Confronting Stranger absent or
Comforting Reassurance removed)

Figure 2. Model of communication (Morse et al, 1997).

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level communication, this is unconscious Peplau’s (1952) seminal work heralded an strategies, such as touch and listening,
and includes responses such as pity, increasing emphasis on nurses developing and patterns of learned professional
sympathy and simple reassurance ordinary a therapeutic relationship with patients behaviours
but often undervalued skills (McCabe (Peplau, 1988). This aim (Timmins and n Patient actions consist of: signals of
and Timmins, 2006). Patient-focused, McCabe, 2006): discomfort; indices of distress and patterns
second-level communication includes of relating.
responses such as providing comfort ‘is not to treat or cure a disease or n The evolving relationship describes
and professional reassurance (McCabe disorder. It is to provide a sense of well- nursing and patient actions as the means
and Timmins, 2006). Patient-focused being for patients by making them feel by which the nurse–patient relationship is
communication responses ultimately relaxed and secure. This helps to establish negotiated and develops.
benefit patients; however, this is less rapport and trust between the nurse and Nurses respond to patient signals of
apparent with nurse-focused responses. the patient. The key characteristics of discomfort and indices of distress using
Nurse-focused, first-level responses therapeutic nurse-patient communication comforting strategies, styles of caring and
include withdrawing, distancing, labelling include a perception of caring, openness, patterns of relating on an ongoing and
and stereotyping, often manifested by warmth, genuineness, empathy and changing basis.
the appearance of a ‘busy’ nurse; nurse- purpose on the part of the nurse.’ This model (Morse et al 1997) is a
focused, second-level communication useful model with which to consider the
includes rote or mechanical responses These are essential ingredients for the health-care environment and the context
(Mc Cabe and Timmins, 2006). Clearly an development of a positive nurse–patient of the nurse-patient relationship therein.
approach that is patient-centred is more relationship. One model greatly enhances The presence and development of a nurse
appropriate and places the patient as the our understanding of this relationship patient relationship is key to providing
focal point of all interactions. Although in the context of communication quality care to patients, regardless of
there is work to be done in the health (Morse et al, 1997). ‘The Comforting the duration of the interaction. The
care environment, it is also important Interaction-Relationship Model’ is based relationship is fostered by maintaining a
that the need to perform tasks does on nurse–patient interaction as a strategy patient-centred approach, being genuine,
not supercede the need to maintain an for the nurse and the patient to establish friendly and empathetic. The relationship
individualized approach to each patient, a therapeutic relationship. Morse et al can evolve to one that provides benefit for
one that considers them as unique human (1997) identified three components to the the patient by considering the patient’s
beings with unique needs. One of the model: individual needs, a factor which will be
earliest proponents of this approach n Nursing actions consist of comforting further developed in the second part of
is Rogers (1951), who put forward the
‘person-centered’ theory. He identified
three core components of this theory:
warmth, empathy and genuineness.
Warmth indicates respect for people
as individuals; empathy displays non-
judgmental understanding of the other
Doctor Hospital Environment Nurse Physiotherapist Dietician
and genuineness is a about being open and
honest (Timmins and McCabe, 2006):

‘These qualities are imparted through

the use of congruent behaviour, that is,
the verbal language that a person uses
Nurse-Patient Relationship
matches their non-verbal language; and is
(sic) the foundation stone of a therapeutic
Coordination of Care ‘Knowing’ the patient
nurse–patient relationship.’

Increasingly, there is great emphasis

placed on the development of the Pharmacist Community Care Occupational Therapist Ancillary Staff
nurse-patient relationship (McCabe and
Timmins, 2006), more recently termed
the ‘therapeutic’ relationship in the
nursing climate. The term therapeutic is
associated primarily with counseling or
psychotherapy, and generally relates to a
curative role, assisting others to feel better Figure 3. A model of nursing within the context of collaborative and patient-centred
(McCabe and Timmins, 2006). However, care (McCabe and Timmins, 2006).

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