Communicate Effectively with Everyone

The word “communication” is often associated with spoken or written communication. Effective communication is the ability to be sensitive to the other person, their understandings, their interactions, and their social context. All of us as individuals have our unique set of preconceptions, prejudices, and cultural conditioning. Consequently, no one can claim to be wholly neutral in any encounter. The process of developing self-awareness and conscious control of our interpretations and reflections is, therefore, a primary requirement and ongoing professional responsibility for all people working in health and community services.

This is fundamental to our work with families, in our work with teams, with other services. In potentially emotionally charged or tricky situations, enhanced skills and strategies are needed. There are times when we need to raise issues that might be challenging for everyone.

Effective communication is the ability to be sensitive to the other person, their understandings, their interactions, and their social context.

Understanding the primary factors that comprise, influence, and impact upon the communication process is the first step in developing a successful therapeutic relationship with your client. Having this understanding will provide you with a framework that can be applied during client work and will assist you in developing a relationship that is beneficial to your client, helps them to focus on their issues, and facilitates change.

Communication Factors

According to Beebe, Beebe and Redmond (2014), the following factors make up and influence the communication process:

• Participants: All the people involved in a given communication process – that is, the people communicating with one another. Participants are often described as either the source (or encoder) and receiver (or decoder). The source (encoder) forms the messages and communicates them to the receiver or receivers through verbal symbols (words) and non-verbal behaviour. Receivers (decoders) interpret the messages they receive.
• Messages, meanings, and symbols: Messages are the “written, spoken, and unspoken elements of communication to which people assign meaning” (Beebe, Beebe & Redmond, 2014, p. 7). The meaning is the essence of the message that you send – your ideas and feelings. Symbols are the intentional and unintentional verbal and nonverbal words, sounds, and actions that are used to send messages and meanings.
  As messages contain both intentional and unintentional aspects, you need be aware of the underlying components of the client’s communication: the unspoken elements of their message. Observing the client’s non-verbal as well as verbal communication enhances your ability to accurately decode client communication.
• Channels: Channels are the means and pathways by which messages are sent. They can be oral messages (the use of sound); messages we see (written symbols or nonverbal messages); a scent (someone’s perfume may bring back memories); or distance between participants (some people stand very close in our ‘personal space’). Channels also include mediated channels, such as text messaging and phone calls. Our channels of communication are influential in our interpretation of a message.
• Noise: Noise is anything that distracts participants from sharing the meaning of the message. Noises can be external (such as sights, sounds, and other literal distractions within the environment) or internal (such as competing thoughts, feelings, and other psychological occurrences such as stress or trauma).
• Feedback: Feedback involves verbal and nonverbal responses to a person and/or their messages. These responses can be intentional or unintentional and will either reflect back the receiver’s interpretation of the sent message or be a request for more information.
  For example, by nodding and using verbal encouragers, you are feeding back to the client both verbally and non-verbally that you are interested in what they have to say. By using paraphrasing or summarising techniques, you will be reflecting back your interpretation of the sent message. By using a tentative tone and ‘check in’, you will be ensuring that you have decoded the message correctly and you and the client are on the same page.
• Context: The context of the communication comprises the physical and psychological setting in which it takes place. This takes into account what precedes the messaging and what follows the messaging. Context includes “not only the physical environment, but also the people present and their relationships with the communicators, the communication goal, and the culture of which the communicators are a part” (Beebe et al., 2014, p. 8).
• Rules: Rules of communication guide us in understanding what kind of messages and behaviours are acceptable in a given context or with particular people or groups.

It is important to note that rules are not always clear and may change across different situations. Rules may also be implicit or explicit and most of us will learn rules through our experiences, observations, and interactions (Beebe et al., 2014). Additionally, they may change over time and are continually renegotiated within relationships.

As a health worker, there are various modes of communication through which you will operate in order to fulfill the breadth of tasks expected of you. Within the scope of practice for a health worker, you may be required to respond to requests and enquiries; provide explanations and information; listen to complaints and instructions; refer clients to other services; report on problems and issues; and to interact with others on a social level. Some modes of communication include face-to-face interactions, telephone conversations, emails, letters, reports, faxes, visual diagrams or charts/graphs, brochures/pamphlets/fact sheets, and online, such as social media. Each of these will encompass a different method of communication, which is outlined in  this module.

Verbal communication refers to the use of words, language, and speech to convey information and meaning in communication. Effective verbal communication requires clear and concise language, active listening, and appropriate tone and style. It is an essential skill for an allied health worker, as it allows them to communicate effectively with clients, colleagues, and other stakeholders, and to provide quality service delivery.

Two main verbal communication skills are listening skills and interview skills. These are crucial for building effective and respectful relationships with clients, which lie at foundation of the practitioner-client relationship.

Verbal communication is a crucial skill when working with clients, which includes the impact of actual words we use while speaking. Workers must be aware of HOW and WHAT they say in certain situations when with clients.

Verbal behaviour involves factors such as the language we use as well as:

• Tone of voice: This can change the meaning of our message.
• Regularity and pace of speech: This can indicate whether we are comfortable and sure of what we are saying.
• Volume: Is it congruent with our usual volume? If a person speaks louder or softer than usual it may indicate they are angry, in pain, unsure, or even fearful.

Effective verbal communication skills include more than just talking. Verbal communication encompasses both how you deliver messages and how you receive them. Effective communication will automatically engage the use of both verbal and non-verbal communication. Understanding is a critical component of communication in which the recipient comprehends the meaning of the message being conveyed by the sender. It involves active listening, paying attention to non-verbal cues, and trying to comprehend the context, feelings, and intentions behind the message. Understanding in communication allows for effective and meaningful exchange, reduces misunderstandings and conflicts, and enhances the quality of relationships.

The Importance of Grammar, Speed, and Pronunciation in Verbal Communication

Grammar, speed, and pronunciation are important elements of communication as they affect the clarity and effectiveness of the message being conveyed.

• Grammar: Proper grammar helps to convey the intended meaning and avoid misunderstandings.
• Speed: Speaking at an appropriate speed helps the listener to understand and retain the information being communicated.
• Pronunciation: Clear pronunciation helps the listener to understand the message and reduces confusion, especially in situations where there are language barriers or when the listener has limited exposure to a particular accent or dialect.

In conclusion, attention to these elements can enhance the clarity and impact of communication and improve understanding and relationships.

Nonverbal communication refers to the use of body language, facial expressions, gestures, tone of voice, and other nonverbal cues to convey information and meaning in communication. It is often used unconsciously and can influence how a message is received and interpreted by the receiver. Nonverbal communication can communicate emotions, attitudes, and social status, and it can be used to support, enhance, or contradict verbal messages. It plays an important role in interpersonal communication and can be particularly significant in allied health and community services, where nonverbal cues can impact how clients and patients perceive and respond to service providers.

Non-verbal behaviours give clues as to what ‘lies between the lines’ of what the client is actually saying. For example:

• Movement and posture: Behaviours such as foot tapping, making complete body shifts, or suddenly closing arms most often indicate discomfort. Hand and arm gestures may give you an indication of how you and the client are organising things. Random, discrepant gestures may indicate confusion, whereas a person seeking to control or organise things may move hands and arms in straight lines and point fingers authoritatively. Smooth, flowing gestures, particularly those in harmony with the gestures of others, may suggest openness. A client’s posture also offers information about how the client is feeling. A slumped, hunched posture suggests resignation. Crossed arms may suggest defensiveness.
• Facial expressions: Facial expressions are important clues to a client’s experience at the time. Your ability to observe your client’s facial expression and changes in expression will often provide you with additional information the client is not aware of. This is extremely valuable. Facial expressions may also highlight a discrepancy between what someone is thinking and feeling. For example, if a client frowns, tightens their lips, their face becomes flushed, or they smile at an inappropriate time, this could indicate that the client is uncomfortable or experiencing heightened emotions.
• Eye contact: Eye contact conveys meaning. The way in which you look at someone and how you hold or break a gaze adds meaning to what you say. Looking directly at someone suggests that you are listening and open to what they say. An unsteady gaze, looking away frequently, or looking at some point in the middle distance all tend to suggest that your attention is elsewhere, and you are distracted. Similarly, a client’s eye contact communicates messages about their level of comfort and ease. If a client is constantly looking away and seeming uneasy, you might reduce the extent that you make eye contact. However, it is usual for listeners to hold more eye contact than talkers. You should also be careful to consider a person’s cultural background when interpreting eye contact. In some cultures, direct eye contact is not encouraged.
• Silence: There may be any number of reasons why a client is silent. You will need to use your observational skills to assess what is happening for the client and what the most useful course of action is likely to be: whether it is likely to be more helpful for you to allow the silence to continue for some time or to break the silence with a question or reflection. Silence may occur when a client takes time to process something they are feeling or thinking about; thinks about how to express something; or considers their response to a question or suggestion in session. In these situations, and if the client simply needs a break from the conversation, allowing the silence to continue may be the most helpful course of action. Silence may also indicate that the client is considering whether they want to explore a particular area, or that they are uncomfortable with something; here, while also giving the client time to think, it may be helpful to invite them to share what they are thinking and any concerns they have. If the client is quiet because they do not know how to put into words what they want to say, the decision about whether to allow them to simply think it through themselves or to ask questions to facilitate their self-expression may be particularly challenging.

Broader contexts of non-verbal behaviour

The context in which non-verbal cues are used is also important, as is their patterns of use and/or any change in those patterns. Culture can also play an important role when observing non-verbal behaviour because different cultures may use different non-verbal cues to convey meaning.

For example, a gesture that is considered positive in one culture may be considered negative or offensive in another. Additionally, non-verbal cues may have different meanings depending on the context in which they are used. For example, a smile may indicate happiness or approval in one context, but in another context, it may be used to mask negative emotions or convey sarcasm.

By considering the broader context, including cultural differences, workers can avoid misunderstandings and misinterpretations that could lead to communication breakdowns and negatively impact the quality of care provided to patients or clients. Additionally, being sensitive to cultural differences in non-verbal communication can help workers build trust and rapport with patients or clients from diverse cultural backgrounds, which is important for promoting effective communication and patient-centred care.

A note on bias

It's important to consider your own values and opinions in situations like this, as stereotyping and prejudice based on cultural differences can lead to negative attitudes and biases, which can create additional barriers to effective communication. Biases can cause individuals to make assumptions about others based on cultural, or other, stereotypes, which can lead to misunderstandings, mistrust, and incidences of discrimination.

As a health worker you should be aware of any biases and prejudices you may hold and avoid making assumptions about clients based on cultural backgrounds, appearance, disability etc.

Written communication refers to any message or information that is conveyed using written or printed words, symbols, or signs. Written communication is an essential aspect of communication in health or community services as it allows for the recording and sharing of information between healthcare providers, patients, and other multi-disciplinary professionals.

Effective written communication requires clear and concise language, appropriate tone and style, and adherence to professional and organisational standards and guidelines.

It is a critical skill for workers as it enables them to document and communicate important information about a client or a patients care and treatment, and to ensure continuity of care across other services. As a health worker, written communication may be used for purposes such as:

• To record personal details
• To keep medical/patient records
• To issue medical prescriptions or referrals
• To create letters, emails, text messages to inform and remind about appointments at the hospital, doctors, dentist, etc
• To draw up care plans
• To issue newsletters and inform notice boards
• To create factsheets, brochures, and reports
• To hand over duties
• To complete documentation and records
• Online communication, such as social media

Clarity, accuracy, and legibility is especially important in written communication, which may contain detailed information concerning, for example, drug dosages, delivery timings, and changes to the current regime. Written communication directed to patients and families should avoid jargon to avoid ambiguity and to ensure it is clearly understood. Written communication should be kept for future reference, stored securely and remain confidential.

Regarding online communication, it should be treated the same as any other form of correspondence. Organisations will usually have specific expectations regarding effective and appropriate electronic communications. The laws and behavioural protocols that affect normal communications also cover cyberspace. Legal protections for example, defamation, copyright, and plagiarism (particularly volatile issues, especially regarding the electronic publishing industry) and privacy laws apply equally to electronic and non-electronic written media.

There are multiple communication tools available in todays’ workplace. Below is a non-exhaustive list of communication tools and their potential uses within the workplace.

• Video conferencing: Video conferencing platforms like Zoom or Skype allow people to have face-to-face conversations even when they are in different locations.
• Instant messaging: Instant messaging allow people to exchange messages in real-time, making it easier to communicate quickly and efficiently. This can be useful for sending quick updates, sharing files, or asking questions.
• Social media: Social media platforms like Facebook or Twitter can be used to connect with individuals or groups, share information, and engage in discussions.
• Email: Email is still a widely used communication tool, especially for formal or business communication. It allows people to send detailed messages, attach documents or files, and organise their communication in a structured way.
• Digital devices: Digital devices like smartphones or tablets can be used to access communication platforms and tools on-the-go, making it easier for individuals to stay connected and respond to messages quickly.
• Translation tools: Translation tools, such as Google Translate, can be used to translate messages between different languages, making it easier for individuals or groups who speak different languages to communicate effectively. While these tools may not be perfect, they can be a helpful supplement to in-person communication or interpretation services.

Uses of Digital Media in Allied Health

Many organisations use a collaborative and person-centred approach when working with clients. This approach places the client at the centre of their own care and assumes that the client is the expert in their own life. The principles of person-centred care are:

Clients, service providers, and even policymakers actively work in partnerships to ensure information, systems, and services meet the needs of clients.

Motivational Interviewing

Motivational Interviewing (Miller & Rollnick, 2002) is an approach based on person-centred care that, as the name suggests, it is focused on increasing the intrinsic (internal) motivation of clients to facilitate behaviour change. It is a collaborative conversation to strengthen a person’s own motivation for and commitment to change, which respects clients’ autonomy and choice. The foundational strategies the worker uses to help clients self-motivate to make behaviour changes include expressing empathy, developing discrepancy, rolling with resistance, and supporting self- efficacy.

Empathy is demonstrated by showing an active interest in making sure they understand what the client is saying, including the client’s perceptions, situation, meaning and feelings. The worker accurately follows or perceives a client’s complex story or statements or probes gently to gain clarity. The practitioner is:

• Respectful and accepting of where the client is in the change process
• Remembers that ambivalence toward change is normal
• Uses reflective listening skills

Developing discrepancy and rolling with resistance are elements involved in a specific technique explained below. Self-efficacy is achieved through highlighting and reinforcing client strengths.

OARS: The Basic Skills of Motivational Interviewing

OARS is a skill-based model of interactions adapted from a client-centred approach used in Motivational Interviewing. These skill-based techniques include verbal and non-verbal responses and behaviours. Both verbal and non-verbal techniques need to be adapted to be culturally sensitive and appropriate.

OARS stands for:

O = Open Ended Questions
A = Affirmations
R = Reflections
S = Summaries

Open and Closed Questions

Composing and asking questions with clients is an essential skill in rapport building and finding out more about the client. Open questions widen the client’s perceptual field. Closed questions narrow the clients focus. Open questions request the client’s attitudes, thoughts, feelings and perceptions. Last, closed questions run the risk of reflecting the workers frame of reference.

Some examples of closed questions are:

• Do you feel sad?
• Do you think things need to change?
• Are you having relationship issues with …

Some examples of open questions are:

• What’s happened since we last met?
• What makes you think it might be time for a change?
• How are you feeling?
• What do you see as being the biggest problem?
• What makes the problem better?
• Can you tell me something about your relationship with….

Types of Open-Ended Questions

Open-Ended questions are likely to feature the typical “who, what, where, when, why and how” in constructing questions, which draws out a more elaborate response from clients.

• Who: Elicits insight into relationships
• What: Most often leads to facts
• Where: Enables discussion about the place the event/situation took place
• When: Brings about the timing of a problem, including what happened immediately before and after it
• Why: Most often brings about a reason
• How: Enables a person to talk about feelings and/or process

When asking open questions with genuine curiosity it transfers both control and responsibility to the client to be the expert in their own life. In comparison with closed questions, they give the client more choice about what to say about themselves and how to say it. Using open questions also demonstrates respect and promotes client self-determination.

Affirmations

Affirmations are statements of recognition about client strengths, as well as acknowledging and exploring the problem. Actively listening to a client who would benefit from having their problem acknowledged.

The problem may or may not involve the counsellor directly. Counsellors may reflect back the client’s feelings and perhaps the content of the problem with a single statement of acknowledgment or during a dialogue over a period of time, exploring the difficulty in more depth.

For example, "You are not quite sure you are ready to make a change, but you are quite aware that your [problem] has caused concerns in your relationships, effected your work, and that your doctor is worried about your health."

Reflections

Reflections feed back to the client the essence of what has just been said. When using reflections, you offer the client an invitation to clarify and expand their stories. Reflections work best when they include the client’s key words and phrases.

Types of Reflections

• Content: Reflecting content involves repeating back to a client a version of what they just told you. Reflecting content shows the client you understand and are listening to them.
• Emotions: Reflecting a client’s emotions is often useful for heightening the client’s awareness of and ability to label their own emotions.
• Meaning: Reflecting a client’s meaning can increase their self-awareness while encouraging emotional depth in the session.

Summaries

Summaries are brief statements of longer excepts from the client thoughts, actions, and feelings. Summarising is a specialised form of reflective listening and an effective way to draw attention to salient elements of the discussion. In summarising, the worker attends to verbal and non-verbal comments from the client over a period of time, and then pulls together key parts of the extended communication, restating them for the client as accurately as possible.

A check-out, phrased at the end of the summary, is an important component of the statement, enabling a check of the accuracy of the counsellor’s response. Summaries are similar to reflections; except they are used less frequently and encompass more information.

Overall, Motivational Interviewing as a model of communication fosters a collaborative and respectful relationship between the worker and the client. Other approaches to communication are explored below.

Coercive Approach

A coercive approach is one where behaviour change is forced upon a client through coercion. In this approach, the motivation to change is external, rather than intrinsic. This limits the effectiveness and longevity of any positive change as the person is not the centre of the process nor are they provided with empathy or the skills to continue enacting positive change themselves. A coercive approach can damage the therapeutic relationship and create resistance, distrust, and defensiveness in the client. It can also increase the client’s stress and anxiety levels, may lead to short-term compliance but not long-term change, and ignores their autonomy which goes against person-centred care.

Confrontation Approach

According to the American Psychological Association (2023, para. 1) the confrontational method of communication aims to change individual’s behaviour by “aggressively compelling them to acknowledge their failures and weakness.” Confrontational communication approaches are most often used in drug programs and research has shown that people tend to respond to this type of approach with an increased resistance to change, which is antithetical to treatment.

Choosing an Approach

As mentioned above, utilising Motivational Interviewing can draw out the client’s own thoughts and ideas. This is a collaborative effort. Lasting change is more likely to occur when the client discovers their own reasons and determination to change. The worker’s job is to "draw out" the person's own motivations and skills for change, not to tell them what to do or why they should do it. Confrontation or coercion can create defensiveness and resistance to change. While there is a time and a place for some of these models of communication, in an allied health setting collaborative approaches are most appropriate.

It is important to confirm other people’s understanding of the information you communicate, and that you listen to requests, using the active listening skills described below. You should then clarify meaning and respond appropriately.

Active listening is a communication skill where the listener seeks to understand the intent and meaning of another’s words – to be fully immersed in the conversation -- beyond merely hearing what they are saying. This skill keeps you engaged and makes the speaker feel valued and heard which is important for ensuring a positive practitioner-client relationship. The following is an overview of useful techniques:

The purpose of clarification in effective communication is to ensure that the message being communicated is understood correctly by the receiver. Clarification is important in many situations, especially when what is being communicated is difficult in some way. Communication can be ‘difficult’ for many reasons: perhaps sensitive emotions are being discussed, or you are listening to some complex information or instructions. Clarification can involve asking questions, paraphrasing, or summarising to confirm the accuracy of the message.

In allied health, clarification is particularly important as it helps to ensure the needs and preferences of clients receiving care are clearly understood and addressed. By seeking clarification, care professionals can promote open and effective communication, build trust, and ultimately provide better care to those they serve. Clarification also helps to ensure the communication is person-centered and the client receiving care is actively involved in the communication process.

Working in an allied health environment can lead to many conversations where the information discussed is difficult or hard to understand. Information may be hard to understand because the person speaking to you has memory loss or difficulty with speech, or perhaps English is not their first language. It is important for all workers to acknowledge they won’t always understand the needs and requests of the people who they provide care for and will need clarification. Barriers to communication will be discussed in more detail in Section 2. Once you have clarified meaning you may respond to the client that you have understood what they have communicated. Clarifying and responding is an ongoing process to ensure everyone understands each other.

This section of the module provided you with an introduction to the principles of effective communication. You learned about the components of communication and how learning styles can affect the way in which we communicate. This section also explored when and how to use and recognise non-verbal communication, as well as using verbal and non-verbal communication to enhance understanding and demonstrate respect. Finally, techniques on how to work collaboratively with clients was also demonstrated in this section.

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