CommunicationChapter 1

Communication is a process involving the sorting, selecting and sending of symbols in such a way as to help the listener perceive and recreate in his/her own mind the meaning contained in the mind of the communicator. Communication involves the creation of meaning in the listener, the transfer of information and thousands of potential stimuli. Communication enables us to grow, to learn, to be aware of ourselves and to adjust to our environment.

The scope of communication is very wide and comprehensive. It is a subject of almost unlimited dimensions and is an interdisciplinary one. It is a two—way process involving both transmission and reception. It is a continuous process of exchange of ideas, feelings, attitudes, opinions, figures and interactions with others. Both written 3and oral or verbal media can be used to transmit messages. Written media consist of instructions, orders, letters, memos, journals, posters, bulletins, boards, information racks, hand books, manual, annual reports, union publications, etc. Verbal media may consist of face-to-face conversation, lectures, conference, meetings, interviews, counselling, public address system, telephone, grapevine, etc. Recently, a number of sophisticated communication technologies have emerged, both in oral and written communication on account of technological advancement.

It is obvious that communication contains both the elements those of a science and an art. The science of communication provides a body of principles which can guide the managers to find a solution to the specific problems and objective evaluation of results. Communication is creative like an art. It develops new situations, designs and new systems needed for further improvement. It is true that there is no one best way of communication. Everyone has an individual approach, skill, behavior and techniques in dealing with particular situation. So, communication is the oldest of arts and youngest of sciences. The process of communication is very much related with behavioral aspects of the people at work and their dynamics cannot be predicted in an exact manner.

Action view is the basis for the theory of communication. The whole process of communication is based on one-way action doing something to someone. The sender plays an important role who encodes the message with the help of arbitrary symbols. The demonstration or doing skills of the sender is for the purpose to change the behavior of receiver. The action believes that words have a meaning and there would be no misunderstanding which is the core of effective communication, provided the right words are used to convey the right message. Misperceptions or misunderstandings are bound to occur but according to information theory, the sender has to play effectively and adequately.

This theory is also called interaction or interpersonal view. This approach to the study of human communication is the ping-pong theory of communication. Ping-Pong is the game of table tennis, represents the interaction theory of communication. It is compared with turns at a table tennis match. In communication process, the turns take 4place between the sender and receiver. It is a complex theory of communication than the Bull's theory which recognizes the concept of linear feedback. In this theory, there is linear cause and effect.

The Spiral theory of communication is also called as transactions view of communication. It recognizes more than one interaction between sender and the receiver. A transaction implies independence, mutual and reciprocal causality. Myers and Myers say that human communication is best understood as a system in which senders are simultaneously receivers and senders. Communication is not static but dynamic and life time experience.

The first step towards development of a communication model had been taken by Aristotle. He had developed an easy, simple and elementary model of communication process. According to Aristotle, in a communication event, there are three main ingredients and they are: speaker, speech and audience.

David Berlo's process theory is one of the basic theories for all communication theorists. The various theories of process models indicate the idea persuasively to another person. Berlo's model is of basic importance in developing other communication models and for identifying elements of communication. Berlo's process theory has contributed a great deal to the subject of communication. In this model, he identified essential elements and also other factors affecting them such as five senses. This model does not consider verbal and non-verbal stimuli. The following nine components are included in his model: source, encoder, message, channel, receiver, decoder, meaning, feed back and noise as shown in Figure 1.1.

The model illustrated in Figure 1.2 starts with the thoughts and feelings of the sender to be encoded into message (with some form of behavior) when it have to be 5communicated with the receiver. The message of verbal or non-verbal signs and symbols need to be carried by a means, that is the channels, on to one or more of the senses of the receiver so that receiver can perceive it. The receiver decodes from this sense of data and interprets the message that results in thoughts and feelings. These may or may not match the intended message of the sender. In any interaction the receiver is likely to have thoughts and feelings that he/ she will send back to the original sender. Thus the process of two-way communication proceeds.

The elements of communication process are described below and are given in Figure 1.3.

Referent: The referent motivates one person to communicate with another. In health care setting, sight, sound odor or any other cues initiate communication.

Sender: The sender of message or communicator is a person who transmits the message. He/she conceive and initiate the message. He/she is the driving force to change the behavior of the receiver.

Message: A piece of information, spoken or written, to be passed from one person to another. It is the subject matter of communication. It may involve any fact, idea, opinion, figure, attitude or course of action, including information. It exists in the mind of the communicator.

Encoding (Communication symbol): The process of conversion of subject matter into symbols is called encoding. The message or subject matter of any communication is always abstract and intangible. Transmission of message requires use of certain symbols. The communicator plans and organizes his/her ideas into a set of symbols, signs, etc. Encoding process translates ideas, facts, opinions into symbols, words, actions, pictures, etc. It is left to the sender in the selection of medium he/she feels suitable to communicate effectively to the intended receiver.

Communication channel: Transmitter has to select the channel for sending information. Communication channel means the medium or media through which the message is sent. Media may be auditory (hearing, listening etc), visual (sight, observation, perception and so on), kinesthetic (procedural touch, caring touch and so on).

Receiver: It is the person who receives the message. Effective communication process is not complete without the existence of a receiver of the message. It is the receiver who receives and attempts to interpret, perceive, understand and act upon the message.

Decoding: It is the process of translation of an encoded message into ordinary understandable language. Receiver converts the symbols, words or signs received from the sender to get the meaning of the message.

Feedback: It has been explained that communication is an exchange process. For the exchange to be complete the information must go back to the communicator. The sending back of the knowledge about the message to the transmitter is known as feedback. It ensures that the receiver has received the message and understood in the same sense as the sender meant. Feedback enables the communicator to execute corrections or change the message to be effective.

Interpersonal variables: They are factors within both the sender and receiver that influence communication. They may be perceptions, sociocultural background, developmental levels and illness and so on.

Environment: It is the setting for sender-receiver interaction. The environment should meet the participant needs for physical and emotional comfort and safety.

According to Watzlawick et al (1967), the four basic principles are the following:

The content or the message is usually delivered verbally, non-verbally and/or in written form.

A. Verbal communication: Is an exchange of information using words including both the spoken and the written word. The most important aspects of verbal communication are the following:

Language: is necessary for the complex and abstract ideas needed for the intricacies of social organization and culture. The lexical content of a message which contain words can only convey meaning if the receiver understand in the same context. Patients often clarify the doubts regarding medical jargon used by that attending doctor nurse following doctors’ rounds.

Pacing: The rate of speed while conversing has a great impact in understanding. Nurses should speak slowly to enunciate clearly.

Intonation: The six vocal elements such as tone, pitch, rhythm, timbre, loudness and inflection results in maximum effectiveness in conversation. Further, tone of voice can directly affect the meaning of a message. The nurse must be aware of intonation to avoid sending unintended message.9

Clarity and Brevity: Clarity can be achieved by speaking slowly, enunciating clearly and relating with examples. Emphasizing significant aspects also clarifies communication. Brevity can be achieved by using that sentences and words that express an idea simply and directly.

Timing and relevance: Timing is critical in communication. When patient complaints of severe headache, the attending nurse should not plan for patient education instead wait for that time till the patient gets him/her free from pain. The communication can be effective if the messages given are relevant.

B. Nonverbal communication: Information is exchanged through non-verbal communication in various ways. It is sometimes referred as body language. Duribleby and Brutan (1992) suggest that body language has several elements.

Gesture: While people are speaking they gesture with their hands and they provide useful information as experiments have shown in which people describes shapes or movements with or without using their hands (Argyle 1992). A lively speaking style captures the listener's attention, makes the conversation more interesting and facilitates understanding.

Facial expressions: Whether a listener is pleased, puzzled or annoyed can be detected by observing the eyes and mouth. In crisis situation of teaching a patient, nurse should have control over her facial expressions while communicating to patient's family so as not to provoke anxiety then.

Posture: Numerous messages are communicated while conversing. The way the body is held gives a general indication of confidence, attention, boredom, confrontation and other specific reactions. Posture often provides non-verbal clues concerning pain and physical limitations. Also, speaking with the back turned or looking at the floor or ceiling communicates disinterest.

Gait: Certain gaits are associated with illness. Slow shuffling gait may indicate fatigue, depression or illness.

Body space and proximity: Cultural norms dictate comfortable distance for interaction with others. People need a certain space around them to feel comfortable and this varies depending on age, sex and culture. Zones of personal space are intimate zone (0 to 18 inches), personal zone (18 inches to 4 feet), social zone (4 to 12 feet) public zone (12 feet and greater).

Touch: Touch is a potent carrier of messages as friends and relatives know. This tells a good deal about the nature of a relationship and the degree of friendliness between two people. Though investigations have shown that tactile experiences are shaped by familial, regional, class and cultural influences, touch is viewed as one of the strategy to express comfort, love, affection, security, anger, excitement and so on.

Personal appearance: Nurses observe the general impression of patient's health and emotional status through appearance.

Eye contact: Communication often initiates with eye contact. This helps to regulate the flow of communication. It signals interest in others and increases speaker's 10credibility. It also indicates respect and willingness to keep the conversation open. Nurses interpret its absence as anxiety, or avoidance of communication based on the situation of the patient.

Sounds: Sounds such as moaning, gasping, crying communicate feelings and thoughts. Sounds can be interpreted in several ways, nurse validates with the patient to interpret accurately.

Silence: Periods of silence during conversation carries nonverbal messages. Silence between two people reveals complete understanding of each other or anger.

C. Symbolic communication: It involves the verbal and nonverbal symbolism to convey meaning. Art and music are forms of symbolic communication used by nurses to facilitate understanding and healing for patients. (Siegel, 1989)

D. Metacommunication: It is ‘communication about communication’ so that the deeper ‘message within a message’ can be uncovered and understood (Wood 1999). When a patient tells the nurse that he is cool to undergo surgery with his body rigid and sharp voice, a nurse can interpret that he is anxious as evidenced by the body language.

E. Written communication: Another important form of communication is written communication. It is the best method when the communicator and the recipient are beyond oral communication media. This form of communication ensures exchange of facts, ideas, opinions through a written instrument by which the individual come in touch with each other and share meaning and understanding with another.

Objectives of written communication: All the listed objectives can be applied in health care setting and in colleges of nursing:

Communication can be one-way and two-way process. Both the patterns are followed in various circumstances efficiently and effectively by the people globally. There is also a horizontal and vertical movement of information from one source to another. The horizontal flow keeps individuals of same status and peer groups informed of what others are doing and what is expected of them. The vertical communication is both downward and upward movement since mere downward flow is like conversing to a person continuously without giving a chance for the listener to respond. In such situation, the pattern will be given in one-way communication and when mutual chance is given to the listener, the pattern is similar to two-way communication.

One-way communication: One way communication or one-directional communication is explained in linear model (Figure 1.4) of communication. According to this, a speaker encodes a message and sends it to a listener through one or more of the sensory channels. The listener then receives and decodes the message. This is called one-way or one-directional communication.

Two-way communication: This is explained in interaction model (Figure 1.5) of communication. In this model, the source encodes a message and sends it to the receiver through one or more sensory channels. The receiver then decodes the message received. The receiver then encodes the feedback and then sends the feedback to the source, making it two-way or interaction communication.

This two-way communication could be classified into two: one to many and many to one.

One to one communication: There is only one sender and one receiver where in the sender passes the information to the receiver and receiver passes on to the sender in return. Such kind of communication is one to one communication in two-way communication pattern.

One to many communication: There is only one sender and one or more receivers wherein the sender passes information to all the receivers and each of the receiver passes on or replies to the sender in return. Such kind of communication is one to many communication in two-way communication pattern.

Many to one communication: There are several senders and one receiver wherein all sender passes on information to the receiver and receiver replies for them. Such kind of communication is many to one communication in two-way communication.

Nurses use different levels of communication in their daily practice.

Intrapersonal communication is a powerful form of communication that occurs within an individual. This level of communication is also called self-talk, self-verbalization and inner thought (Balzer Riley 2000). Nurses and patients can use intrapersonal communication to develop self-awareness and a positive self-concept by positive self-talk and defeating negative thoughts.

Interpersonal communication is one to one interaction that occurs face to face. This level of communication is frequently used in nursing situations. It results in expression of feelings, exchange of ideas, decision making, team building, goal accomplishment, problem solving and personal growth when happens meaningfully.

Transpersonal communication is interaction that occurs within a person's spiritual domain. Nurses who value human spiritually use this level for patients and for themselves.

Small group communication is interaction that takes place with gathering of small number of persons. It is usually goal-oriented and requires an understanding of group dynamics. Nurses use this form for committee work, to lead client support group, form research team and so on.13

Public communication is interaction with an audience. Nurses use this form for group health education, class room discussion with students or peers.

Organizational communication is interaction between an individual and groups within an organization in order to achieve established goal.

The following are the benefits of communication:

The American Management Association has given excellent essentials of good communication. They are popularly called Ten Commandments of good communication and they are the following:

It is shown in Figure 1.6 and description is given below.

Credibility: Communication starts with the climate of belief which is built by performance on the part of the practitioner. The performance reflects an earnest desire to serve the receiver and receiver must have confidence in the sender.

Content: The message must have meaning for the receiver and it must be compatible with his/her value system. The content determines the audience.

Context: A communication program must square with realities of its environment. The context must provide for participation and play back, the context must confirm, not contradict the message.

Channels: Different channels have different effects.

Clarity: Complex issues should be compressed into themes that have simplicity and clarity.

Capability: Communication must take into account the capability of receiver. Communication is most effective when they require the least effort on the part of the receiver.15

Continuity and consistency: Communication is an unending process. Repetition with variation contributes to factual and attitude learning, the content must be consistent.

The functions of communication are shown in Figure 1.7 and are described below.

There are many factors that influence communication and they are illustrated in Figure 1.8.

Ambiguity: Using words in current use is important and to avoid words which convey vague meaning, as it can lead to confusion in communication.

Audience: The communicator should know his/her audience or listeners and accordingly ideas have to be put across.17

Avoid extremes: It is desirable to avoid extremes in speaking as some subject matters may be too good or too bad.

Conditions: An ideal infrastructure and environment are to be provided to both speaker and listener.

Cultivate speaking: Listening and understanding require a lot of reasoning and attitude. The reasons of non-listening are boredom, bias, fear, interruption, etc.

Clarify ideas: The communicator has to clarify his/ her ideas himself/herself before and then think on the message clearly and clarify ideas to ensure effective communication.

Emphasis on purpose: The subject matter and its theme should be greatly emphasized to draw attention to the listener.

Feedback: It is probably the most significant method of improving communication. Two-way process ensures feedback.

Gestures and tones: The style in which message is conveyed is equally important as what is being said. There must be integration between facial expressions, voice, gestures, mood to the action of what is said about.

Ideas: One must be clear about the ideas, opinions, and facts to be communicated to have a clear communication.

Not to talk and talk: A verbal communication should be short, clear, and simple to pass the message.

Physical and human setting: An atmosphere of mutual trust is to be created in the process of communication. The informal relations are the best weapon to promote physical and human setting in an institution.

Purpose: The purpose of communication is to make others understand the subject matter. The communication is ineffective if the purpose is not achieved.

The word ‘barriers’ means hindrances or hurdles or difficulties or problems. Any difficulty which partly or fully prevents any activity is called a barrier. Barriers with reference to communication imply hurdles or problems on the way which adversely affect the transmission of information from sender to the receiver.

Reasons for occurrence of barriers in communication:

These barriers arise when duties and line of authority are not clearly defined. They arise on the account of distance communication, more layers of communication, heavy communication load etc. Various types of organizational barriers are:

Problems of language are called ‘semantic barriers’. They arise on account of linguistic background and ability of the communicator. Linguistic barriers occur in both oral and written communication. Common types of semantic barriers are:19

The aforementioned barriers can be thought of a filter, that is, message leaves the sender, goes through the aforementioned filters and is then received by the receiver which may muffle the message. The following strategies can be adopted to overcome such filters.

Suitable language: The appropriate language and tone definitely minimizes linguistic barriers to communication. Use of technical terms should be avoided as far as possible and the message should be direct, simple and meaningful language. Different people perceive the message differently. The team should use a common language to avoid semantic distortions.

Active listening: Hearing and listening is not the same. Hearing is the act of perceiving sound. It is involuntary and simply refers to the reception of aural stimuli. Listening is a selective activity which involves the reception and the interpretation of aural 22stimuli. It involves decoding the sound into meaning. Listening is divided into two main categories: passive and active. Passive listening is little more than hearing. It happens when the receiver of the message has little motivation to listen carefully such as when listening to music or when being polite. People speak at 100 to 175 words per minute (WPM) but they can listen intelligently at 600 to 800 WPM. Since only a part of mind is paying attention, it is easy to go for mind drift thinking about other things while listening to someone. The cure for this act is active listening which involves listening with a purpose. The following are the few traits of active listeners:

Ten rules for good listening: Ten rules for good listening are given in Table 1.1.

Feedback: When you know something, say what you know. When you do not know something, say that you do not know. That is knowledge—Kung Fu Tzu. The purpose of feedback is to alter messages so the intention of the original communicator is 23understood by the second communicator. It includes verbal and non verbal responses to another person's message. Carl Rogers listed five categories of feedback:

Actions and deeds: Communication through actions and deeds is the principle of effective communication. A message is one to be acted upon. Otherwise it tends to distort the current and also the message henceforth from the individuals involved in communication. A meaning to a message is achieved only when it is acted upon. Action and words must walk hand in hand.

Clarity: Every communication should have skills to have clarity of the message. The greater part relies on the sender of the message to achieve clarity. The message should be as clear as possible in the mind of the sender. The content or the message should be encoded in a direct and simple language. The purpose of the communication is to make the receiver understand the message which can be achieved through clarity.

Knowing the receiver: The importance of understanding the receiver and the needs of the receiver cannot be overlooked. The message content is to meet the needs of the receiver. Sender of the message should have full knowledge about the receiver, his or her capabilities, background, and level of intelligence, social climate, receptiveness, temperament and attitudes and so on.

Interpersonal relationships: Developing optimum interpersonal relationships can be more helpful in overcoming the barriers in communication. Lack of cooperation among people results in non-accomplishing their goal. Principles of personal contact, appreciation, recognition and so on help in eliminating the barrier.