Section 2: Explanation of Key Concepts and Tools

This section contains explanations and illustrations to help you better understand and appreciate the importance of TeamSTEPPS communication concepts and tools. If you teach this content or want additional insights into how the material can be more fully learned, you may find the instructor suggestions in section 3 helpful.

Communication

Communication is one of the four essential skills central to safe, efficient, and patient-centered care.

Communication is the essence of teamwork because teamwork requires coordination and that is achieved through communication. Communication plays key roles in team leadership, situation monitoring, and mutual support, since it is the mechanism through which all those skills are exercised. Conversely, open and effective communication depends on effective leadership, continuous situation monitoring, and a culture of mutual support that fosters information sharing.

Communication involves two or more people continuously sharing information with each other throughout their interaction. This process includes asynchronous exchanges (e.g., by email or inserting comments into an electronic health record [EHR]). In such cases, the interaction includes the other person’s eventual response—not only its content but also its timing (how quickly the person responds) or even its absence (i.e., the person never responds). The information may include facts, emotions, and the communicator’s view of their relationship to the other person, or their view of themselves.

Information may be shared verbally or nonverbally and intentionally or unintentionally. Even when unintended, nonverbal cues are an important form of feedback that can be beneficial or harmful. Sometimes unintended messages can have a larger impact than the intended message because they are more likely to be perceived as reflecting the person’s true feelings.

Listening, making statements (through speaking, writing, or sign language), and using feedback to respond to the messages of others are equally important dimensions of communication. The more different the backgrounds or perceptions of the people involved, the more communication is liable to become challenging and the more potential there is for misunderstanding. As both the healthcare workforce and the patient population have become more diverse, communication challenges in healthcare have grown, and effective communication has become more difficult to attain.

The Transaction Model of Communication¹

Communication is influenced by who the message source is, whom they are communicating with, and how the messages are being exchanged, as shown in the Transaction Model of Communication figure:

• The message source: The same message will be interpreted and responded to differently based on its source. People who are known, respected, and liked are more likely to be believed and complied with than others. Further, messages from patients, their family caregivers, and nonclinical staff are often less attended to. Effective teams recognize these biases and work to ensure that messages from all team members are attended to and carefully considered. 
• Message recipients: As shown in the Transaction Model of Communication above, all individuals in a communication interaction are playing active roles in processing information from others and responding to it. Even a message recipient who says nothing is making sense of what they are receiving and may react to it in the form of nonverbal feedback.
• The mode of communication: In healthcare, messages are exchanged verbally; through nonverbal reactions in in-person or virtual contexts; through text shared in emails, written notes, or instant messages; and in documentation entered (or not entered) into an EHR. Each of these modalities affects how the message will be understood and reacted to by its recipients. Use of acronyms, other abbreviations, and emojis can also affect how communications are perceived.

Nonverbal communication including body language also affects how individuals attend to and interpret messages. Direct eye contact can convey interest and concern. When people communicate in web meetings, sometimes they leave their camera off, or their eye contact is lacking because they are looking at the person on the screen instead of at the camera that is normally above the screen. When one person is positioned (or appears positioned) above another, the need to look down or up also can falsely suggest status differences that will then affect responses to messages. People from different cultural backgrounds also may have differing expectations regarding the appropriateness of eye contact during conversation.

The voice can project interest or energy, but voices frequently sound different when people are masked or when communication is electronic instead of in person. Sometimes contexts have background noise that makes messages hard to hear, particularly for people with hearing loss or those with lower quality equipment. When nonverbal communications convey a different message from the verbal message, people are more likely to believe the nonverbal part.^2,3 For example, if you say you're not concerned but you are visibly shaking and appear extremely nervous, your verbal message will be discounted.

To avoid assumptions that can lead to error, any important communication—either verbal or nonverbal—should be confirmed orally or in writing. The examples in the Communication Examples table provide proven methods for making initial messaging clear and ensuring that it is clearly understood. The rule is, "When in doubt, check it out, offer information, or ask a question."

Communication Examples

Effective communication varies depending on the participants, subject matter, timing, and modality (in person or virtual). It also depends on the cultural context and time period; effective communication in 1970 or even 2000 was not the same as what it would be today or will be in 20 years.

Effective communication is:

• Complete. Communicate all relevant information.
• Clear. Convey information in plain language.
• Brief. Communicate information in a concise manner.
• Timely. Offer and request information in an appropriate timeframe.
• Respectful. Use communication to foster psychological safety and affirm other team members, not just to give instructions or share information.

The information that is relevant and clear can vary considerably depending on whether the participants are nonclinical staff, patients, or clinicians. Conversations that include a mix of these groups create particular challenges to effective communication and make monitoring nonverbal communication and feedback essential.

Ensuring the effectiveness of communication requires conscious awareness of familiar challenges, including:

• Language barriers: Ensuring equitable language access for patients and staff can be challenging. Patients and staff who do not speak English or who have low levels of proficiency in it may misunderstand messages or not understand them at all and may be reluctant to acknowledge their lack of understanding. Providers may not be proficient in the language of the patient and caregiver or not have effective ways of working with a multilingual population. These factors make LEP patients higher risk for harms and near misses. AHRQ's guidance document for how to support LEP patients and family caregivers provides additional information. 
• Distractions, stress, and fatigue: All these factors can impair willingness and ability to process verbal and nonverbal messages. They can also affect time and attention spent sharing information or eliciting the perceptions of others. 
• Physical proximity: Being too close to or far away from others can make establishing trust more challenging.
• Personalities: Sometimes it is difficult to communicate with particular individuals. Introversion may be perceived as a lack of interest in or desire for additional information. Extroversion may lead people to talk when it is time for listening. Cultural differences may lead to inaccurate perceptions of the personalities of people from diverse cultures.
• Workload: During heavy workload times, all necessary details may not be communicated, or they may be communicated but not verified.
• Varying communication styles: Different types of healthcare workers have historically been trained to use different communication styles. For example, nurses are trained to be descriptive when conveying information and physicians are trained to be succinct.  These communication styles may also differ from those of patients and family caregivers. 
• Conflict: Disagreements may disrupt the flow of information between communicating individuals.
• Lack of verification of information: It is important to verify and acknowledge that information has been exchanged. Unclear units of measure (pounds or kilos) and acronyms or abbreviations with different meanings, as well as unfamiliar accents or dialects, can all cause confusion that leads to patient harm. 
• Shift or staff changes: Transitions in care are the times when most communication breakdowns occur.^5,6 

The TeamSTEPPS curriculum includes many resources that illustrate the significance of communication and challenges to overcome to communicate effectively:

• Three Patient Stories
  Watch one or more of the three patient videos in which patients explain how communication and communication tools positively affected their care. As you watch, consider:
  • Do you have patients who could share positive encounters with you and your teams?
  • How have you seen relationships with patients strengthen and improve over time based on your communication with them?
• Office-Based Care Video Scenario Involving Communication
  After watching the video, consider how you would answer each of the questions below:
  • Were proper communication skills demonstrated in this video?
  • Were these strategies effective? Why or why not?
  • Did you see any other opportunities for better communication in this video?
  • Have you encountered situations similar to the one in the video? If so, how did you resolve them?
  • Think about how this communication would have been more challenging if it had occurred in a series of virtual calls and email exchanges. What cues might have been missed? On the other hand, what advantages might there be to using forms of electronic communication?
• Communication Breakdown With a Patient and Family
  Consider the following scenario:
  An 89-year-old female presents to the hospital and has a history of chest pain. Many tests are being run to determine the cause of the chest pain. The patient and her family decide they no longer want aggressive measures taken and request that the patient’s code status be changed to Do Not Resuscitate. The night shift nurse documents in the progress note that the patient asked not to be resuscitated. But the night shift nurse does not flag the patient’s chart, relay the information during shift change, or notify the attending physician. The morning shift does not read the night shift's notes because of several immediate emergencies.
  • Where did miscommunication occur in this situation?
  • What are the possible outcomes?
  • How could the patient, family, or staff proactively ensure that the change in the patient's wishes would be understood by everyone who needed to know them?
• "Be the Expert on You" Patient Note Sheet
  Review this list and reflect on the following recommendations for how you might use this tool in your setting and teams:
  • Give patients one minute to share their story.
  • Confirm your understanding of the symptoms.
  • Acknowledge the patient’s experience.
  • State your working diagnosis.
  • Communicate uncertainty.
  • Invite the patient’s concerns.
  • Provide clear recommendations and instructions for followup and further testing.
• Reflect on Your Own Experience
  • Can you describe an example in which a communication breakdown was the major contributing factor to an error in care?
  • Can you provide examples from your work setting when nonverbal communication produced a breakdown in teamwork?
  • How have you successfully overcome communication challenges with patients or family caregivers who may be confused or not understand English well?

Notes

1. Lapum J, St-Amant O, Hughes M, Garmaise-Yee J, eds. Introduction to Communication in Nursing. Toronto, CA: Toronto Metropolitan University Pressbooks; 2020. Accessed April 26, 2023.
2. Goleman D. Emotional Intelligence. New York: Bantam Books; 1997.
3. Kuhnke E. Body Language for Dummies. West Sussex, UK: John Wiley & Sons; 2012.
4. Foronda C, MacWilliams B, McArthur E. Interprofessional communication in healthcare: an integrative review. Nurse Educ Pract. 2016 Jul;19:36-40. DOI: 10.1016/j.nepr.2016.04.005. Accessed April 26, 2023.
5. Ong MS, Coiera E. A systematic review of failures in handoff communication during intrahospital transfers. Jt Comm J Qual Patient Saf. 2011 Jun;37(6):274-284. DOI: 10.1016/s1553-7250(11)37035-3. Accessed April 26, 2023.
6. Patel SJ, Landrigan CP. Communication at transitions of care. Pediatr Clin North Am. 2019 Aug;66(4):751-773. DOI: 10.1016/j.pcl.2019.03.004. Accessed April 26, 2023.