Until the 20th century, the focus of study was the art of communication rather than the process of communication. The art of communication can be observed through language, visual representation, drama and music. After the Second World War, the Bell Laboratories, a division of the Bell Telephone Company, proposed the first model of communication (Shannon & Weaver, 1949). Not surprisingly, it was the development of radio and telephone communication technologies that gave rise to the model. The basic model proved too simplistic for most people and was progressively developed from a simple process to describe communication using telephony to a model applicable in the much broader realm of human social relations. In the early 1960s, based on the work of David Berlo (1960), the model was expanded and clarified to what is now widely accepted as the basic model of communication: that of source, message, channel and receiver.

Understanding of communication and its impact has grown rapidly in recent years, beginning with the modernist premise that preceded the growth in advertising communications in the 1960s. The idea that ‘the medium is the message’ was promoted by Marshall McLuhan (1964) and has been further developed in modern understanding that communication can be initiated by the inanimate. For example, the structure of an organisation, the architecture or a building, the clothing people wear (such as blue or pink uniforms or white coats) are all media for a message. And the media may be the message. This is further complicated by notions of identity and ideas about self. Self-awareness as people, which preferences personalities contain, even mood: all form part of the source of messages that are sent.

Essential elements of communication

Sender

The sender of human communication (usually but not always a person) retains the belief that whatever techniques they employ, their message and the information contained therein are always received in the detail and context with which it was intended. Messages rely heavily on language, and of course the language used must be understood. When sending a message it is important to ensure that the language used is simple, clear and to the point. Messages constructed carefully will have the best chance of being understood. Think about a simple request like ‘I would like you to make a cup of coffee for me, please’. When messages are clear they contain a reference to the source (‘I’ and ‘for me’), the subject (‘you’), the object (‘a cup of coffee’) and an emotive adjunct to the phrase to support the desired behaviour (‘please’).

When messages are ambiguous, receivers may start to look for other meanings than that which was originally intended. For example, if the message was simply ‘I would like a cup of coffee’, the receiver may assume it has nothing to do with them, because the subject (‘you’) is not identified. Of course, if the sender said, ‘Fais-moi un café, s’il te plaît’, they would be assuming the subject could speak French. Language and its careful construction, tone and use are often critical to communication.

Emotion

When messages are loaded with emotion, such as anger or happiness, the meaning can also become unclear. In fact, an angry or happy message will most likely convey the emotion rather than the message itself: emotion can cloud a message to the point where no part of the message is retained save for the emotional impact. How people send a message – the language, tone and medium – is critical to what message will be received.

Distortion

Ambiguity is only one of the possible distortions that result in a message being lost or a communication being ineffective. Message distortion, or noise, can have several causes. Sometimes it is accidental, but sometimes a deliberate and disruptive act by the receiver or a third-party stakeholder with an interest in skewing the message.

A distortion effect can occur in a workplace when a communication between one person and another, or one person and many other people, becomes skewed by external interference. If communication is to be clear, understood and acted upon, sources of distortion must be eliminated or minimised. A critical skill in communication leadership is establishing an intuitive alert mechanism for distortion.

Feedback

One way in which it is possible to test if a message is getting through is by asking for feedback from the receiver. Feedback is essential if the sender is to achieve confirmation that a message is heard and understood. Without feedback, even in the most straightforward of personal communications, the sender can have no idea whether the message has been received, let alone understood.

Non-verbal communication

A smile, a happy disposition, an open stance or a warm handshake or greeting immediately indicates a positive disposition between a communication sender and receiver. Folded arms, clenched teeth, hands covering the face and an agitated disposition have the opposite effect. Non-verbal acts can communicate vividly or undermine all attempts to communicate with equal and stunning effect. More subtle clues lie in interpersonal behaviours, such as the use of eye contact and shuffling in one’s seat, or perhaps in the choice of clothing for a particular situation. Any of these factors can enhance or detract from the effectiveness of communication. Good communicators pay a lot of attention to non-verbal cues; understanding them in their cultural, social and workplace contexts is critical to successful communication (Dwyer & Boyd, 2003).

Receiver

The situation of the receiver of a message or group of messages is completely dependent on their reading comprehension, listening or perceiving skills – that is, their situational awareness. If the receiver is not aware or listening, they will not receive the message. Given that they are not the initiator of the message, it is highly likely that the sender may need to first gain their attention. With a telephone call this is relatively simple: the sender dials a number, the phone rings, and the receiver answers. Most cultural protocols would include some identifying language and confirmation that the receiver is ready to listen.

When this is translated into a workplace situation it can be either simpler or more complicated. For example, we should assume that in the earlier example someone would not ask another person to make them a cup of coffee unless the subject could hear the request and there was some idea or evidence that they were listening or taking it in. In other situations, such as a speech or instructions to a group, it is difficult to guarantee that an individual in the receiving group is alert and listening. In more complex situations, the true message may be so couched in neutral or inoffensive language, in order not to offend members of an audience, that comprehension of the actual request becomes very difficult. If the receiver is not skilled, capable or ready to receive a message, the communication will be lost.

Healthcare and communication

Communication in health services settings can be broadly grouped into three streams: administrative (financial, human resources and organisational), clinical (medical and interprofessional) and client (patient and family). This chapter focuses on the second two; many good texts about organisations are available which describe the nature and importance of sound administrative communications, while special skills and structures are needed to lead clinical and client communications successfully.

Formal and informal communication

In health management settings, understanding when a communication should be formal or informal is critical. For new team leaders, it can be embarrassing to have written a formal memorandum-style email to a team member and colleague and afterwards discover that a personal conversation would have been more appropriate. An important part of managers’ and leaders’ armoury is a consistent set of formal and informal protocols for communication.

Upward communications (reports, proposals, requests for approval) are often formal. Most managers respect, however, that subordinates may need to talk over an idea in an informal setting. Downward communications (procedures, requests, memorandums, meeting minutes) are also often formal, whereas peer or sideways communications are more likely to be informal in most instances, except where a structured communication is called for due to an administrative requirement or clinical situation.

Clinical communication

In any health service context, strong communication skills can literally be a matter of life and death. The lore of human health experience is littered with examples and anecdotes of situations in which poor communication led to a terrible health outcome, escalating illness or even causing unnecessary loss of life (see, for example, Mid Staffordshire NHS Foundation Trust Public Inquiry, 2013). A challenging issue in healthcare is the unintended silo effect of having experts from many differently focused fields of healthcare advising on a single situation without first communicating with each other. This can and has led to many unfortunate outcomes in which information was conveyed without the correct context and a tragic result occurred.

Structured communication

New developments derived from experiences of the US military have led to a popular model for structured communication in clinical practice: the formalising of communication protocols for situations in which information and context must be conveyed with as much accuracy as possible – for example, the clinical handover of information from one daily rostered shift to the next or from one health service location to the next. The ISBAR model is one such framework and is commonly in use in many health settings. Figure 9.1 describes the protocols involved and the core questions required to establish the critical clinical information. It is not only useful in clinical settings but can be used to manage any organisational communication in which the use of a formal protocol is likely to be well known and understood. Whenever communication is of a critical nature and distortion must be minimised, following this structured method will assist in ensuring clarity.

Figure 9.1 The ISBAR model. ISBAR. (2011). NSW Ministry of Health / New South Wales and South Australian Department of Health (Version 1.0) [Mobile application software]. Retrieved from https://itunes.apple.com.

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