The nurse / patient relationship is arguably the most important part of nursing care and good communication is paramount if a good relationship is to develop. This has been emphasised throughout the nursing texts from Florence Nightingale right up to the present day. (Macilwaine (1978))¹

It has been said that "the major function of the nurse is to help the patient formulate the psychological tasks to be accomplished in facing and recovering from illness." (Macilwaine (1978, p32))¹. Or to put it simply, the nurse is there to help the patient get better. How can this be achieved without some form of interpersonal relationship? A nurse cannot ignore a patient - at the most basic level, he or she will have to find out what is wrong and then communicate to the patient how to put it right. The next step up is to do it with an appropriate level of understanding - a smile, a kind word, and so on. Next come things like using the patient’s name and finding out about them beyond their illness, which leads to a genuine interest in the patient. It is at this level that the nurse should seek to begin a relationship.

The patient will respond in kind. He or she is more likely to be friendly and co-operate with a friendly and understanding nurse, leading to compliance with their treatment. He or she will show no interest in a nurse who is unwilling to show interest in them. (Clarke (1983))²

Communication and nurse / patient interaction, therefore, is a very important part of the nurse’s duty and it is essential that good communication skills are acquired.

In this report, the author has taken some interactions with a patient on his first clinical placement and used them to demonstrate just a few of the many areas within the general heading of "communications".

Mr Mike Lindsay (a pseudonym used to maintain confidentiality) is an 83 year old gentleman who has recently suffered a cerebro-vascular accident (CVA), also commonly called a stroke. The CVA has left Mr Lindsay with a left-sided hemiparesis and he has been on the rehabilitation ward since transferring from Ninewells Hospital in early October.

Communication with a patient after a CVA can be made difficult by any or all of the following factors affecting the normal process of interaction:-

• aphasia:- where the communications centre in the brain has itself been affected by the CVA.
• apraxia:- where the patient develops an inability to compose the actual speech sounds.
• dysarthria:- where weakness in the facial muscles causes speech to be slurred and easily misunderstood.

(based on Hearing, Speech & Deafness Centre. (1997))³.

Mr Lindsay displays dysarthria but no signs of either aphasia or apraxia.

The author first met Mr Lindsay on his first day on the ward placement. The author had previously worked with stroke survivors and believed that he knew how to communicate effectively with Mr Lindsay. Mr Lindsay was sitting beside his bed, having finished shaving, and was waiting to be taken through to the day room for breakfast. The author approached from Mr Lindsay’s good side and asked if he was ready for breakfast. However, Mr Lindsay was more interested in the name label on the author’s uniform and asked what a Dundee University student was doing working as a nurse. The author explained about the recent merger of the School of Nursing with the University, which led into a conversation in which both learned a bit about the background of the other.

As a "first contact" the conversation worked well. It served as an ideal introduction for both parties. Mr Lindsay appeared genuinely interested in the author’s choice of career; likewise the author was keen to learn about Mr Lindsay. The conversation was continued on the way through to breakfast. Unfortunately, this tended towards killing off the conversation as the author was behind Mr Lindsay, pushing his wheelchair.

Reflecting on this, the author believes that lack of eye contact led to a breakdown in non-verbal communication, which eventually stopped the interaction entirely.

Non-verbal communication refers to any and all aspects of interaction that are not spoken. These can include silence, attitude and "body language". In this case, the patient was unable to observe the body language of the author. Where the author would have been nodding, leaning forward or making eye contact in a face-to-face conversation, he was unable to do this while at the patient’s back. This demonstrates well the problems of non-attending (described by Stein-Parbury (1993))⁴. The ideal situation is obviously to properly attend the patient in a face-to-face interaction. However, where this is not possible (for example when pushing a wheelchair), the usual non-verbal responses should be replaced with appropriate verbal responses to show the patient that the nurse is still listening. Examples would be: saying "yes" (or an equivalent such as "aye") instead of nodding and carrying the conversation when there are silences.

Another significant interaction took place about a week later. This was where the author actually asked Mr Lindsay’s permission to use him as the subject of this report; the author later prepared a process recording (see Appendix) for this interaction. A process recording is a record and analysis of an interaction. (as demonstrated by MacIlwaine (1978))¹.

The main problem with this interaction was the author’s use of a closed question in opening the conversation where an open question would have been preferable. Fortunately, this did not affect the rest of the conversation, but it could have done under different circumstances.

A closed question is one of the type that require only a yes, no, or single word answers. Examples could include, "Have you still got that pain?", "Are you going to physiotherapy today?" or, as shown, "Is your wife not here yet?". While closed questions are useful in getting specific information about whether a patient requires further analgesia, or to be ready for the physiotherapist, they are less useful in gaining a more general picture.

For example, is the patient’s pain the same as, similar to, or completely different from last night? Are his physiotherapy sessions useful? In these cases, the questions are far too specific to begin a conversation along these lines, and open questions should be used. "How’s that pain you had last night?" encourages the patient to tell the nurse more about it. Likewise, "How are you getting on at physio[therapy]?" is likely to encourage the patient to talk about his sessions there and the nurse will get a lot more information. "Clients are spontaneous in revealing the needed information" (Pluckhan (1978))⁵.

In the author’s case, not only did he use a closed question which could have dried up the conversation, he began by emphasising on the patient’s problems. The patient may have ended up feeling worse. In this case, to encourage the patient to talk, the author should have used an open question, focusing away from his immediate problems.

There will be some cases where the patient is unwilling to elaborate further than single word answers. In these cases, the nurse must be prepared to spend time and ask the right kind of closed questions in order to get the required information.

During a later conversation with Mr Lindsay, he expressed his frustration at not being able to communicate properly. The author asked him what he meant, to which he replied that he wished people would not treat him as if he had "lost his marbles". Having worked with other stroke survivors, the author was able to sympathise.

It is important for the nurse to remember that someone who has had a stroke has not lost any of their intelligence. Mr Lindsay demonstrates dysarthia which is only due to the weakness of the facial muscles. In his case it is merely enough to let him know if you do not understand what he is saying - he will always repeat things if necessary.

Even aphasia is merely the loss of the ability to communicate. In cases like these, the nurse must ask closed questions to which the patient can answer with simple yes / no answers and give the patient time to digest what is being said and form a response. Signals and gestures also often help. Mr Nolan Conley, Sr., a stroke survivor himself, also says "Even if he [the patient] doesn’t speak..., he probably understand more than he can communicate. It is very important not to say anything in front of a stroke survivor that you don’t want him to hear. He probably hears and understands more than it appears." (Conley (1997))⁶

At the time of writing, Mr Lindsay remains on the rehabilitation ward.

From the author’s relationship with the patient, it can be seen that communication is much more than simple words. It can be broken down in many ways. The conversations with Mr Lindsay demonstrated well the differences between verbal and non-verbal communication, and also how important the latter is. When the non-verbal aspects are missing, or do not correspond with the verbal messages, this can lead to a breakdown in communication.

The relationship between the author and Mr Lindsay continued to develop throughout his time on the placement. The first interaction was based primarily on finding out about each other. A week later, the conversation tended more towards more personal things and, finally, the patient felt able to confide subjects of a possibly embarrassing nature. A level of trust appeared to have built up between the author and the patient which had not been there previously.

This demonstrates that a relationship between a nurse and a patient is not an automatic process, but that it must be worked upon and time taken over it. Communication plays a very important part in this - a relationship will never develop if there is poor or no communication between the parties involved. It falls on the nurse to initiate and carry on a level of communication, particularly when the patient may have communication difficulties such as aphasia, or even when a patient is merely uncooperative due to anxiety or disorientation.

While the final conversation was an "organised" one, it actually revealed less than would have been hoped for. This would seem to show that better communication can be derived from spontaneous situations, and it is perhaps to these that the nurse should turn his or her attention. Natural conversation will flow more freely while the patient is dressing or preparing for a meal, and is unlikely to feel forced. Communication, therefore, should be seen as an integral part of the nurse’s duties, and not an "add-on" when the ward is quiet.

The patient was sitting beside his bed waiting for his visitors. He looked fed up.

1. MACILWAINE, H., (1978). ‘Communication in the nurse/patient relationship’. Nursing Mirror, 146(7), pp 32-34.
1. CLARKE, M., (1983). Practical Nursing. 13th ed. London: Baillière Tindall. pp 41-47.
2. HEARING, SPEECH & DEAFNESS CENTRE. ‘Speech after a stroke’. HSDC Communication Update. http://www.hsdc.org/aphasia.htm. (26th November 1997).
3. STEIN-PARBURY, J., (1993). Patient and Person: Developing interpersonal skills in Nursing. 1st ed. Melbourne: Churchill Livingstone.
4. PLUCKHAN, M.L., (1978). Human Communication: the Matrix of Nursing. 1st ed. New York: McGraw-Hill.
5. CONLEY, N., Sr. ‘Post-stroke communication: it just takes time’. The Stroke Newsletter. http://www.nolanconley.com/snlaphasia.htm. (26th November 1997a).

BOSS, B.J., (1991). ‘Managing communication disorders in stroke’. Nursing Clinics of North America, 26(4), pp 985-996.

CARIS-VERHALLEN, W.M.C.M., KERKSTRA A. & BENSING, J.M., (1997). ‘The role of communication in nursing care for elderly people: a review of the literature’. Journal of Advanced Nursing, 25(5), pp 915-933.

CONLEY, N., Sr. ‘Just what does the future hold?’. The Stroke Newsletter. http://www.nolanconley.com/stroke1.htm. (26th November 1997b).

FRANKLIN, B.L., (1974). Patient Anxiety on Admission to Hospital. London: Royal College of Nursing.

MOULES, C., (1996). ‘Communication difficulties’. Nursing Times, 92(7), pp32-33.

PERRY, B. (1996). ‘Influence of nurse gender on the use of silence, touch and humour’. International Journal of Palliative Nursing, 2(1), pp 7-14.

US AGENCY FOR HEALTH CARE POLICY AND RESEARCH. ‘Recovering after a stroke’. National Library of Medicine: Health Services / Technology Assessment Text. http://text.nlm.nih.gov/ahcpr/psr/www/psrptxt.html. (26th November 1997).

WOLFF, L., et al, (1983) Fundamentals of Nursing. 7th ed. Philadelphia: J.B. Lippencott Company.