Consider the future of respiratory care. Are we sure that our profession is safe from extinction? I would like to think so, but it should be a concern for all respiratory therapists, and should not be taken for granted. As budget constraints tighten, we must take steps to prevent the possibility of hospitals eliminating respiratory therapy departments and allocating those responsibilities to the nursing department, which is all too often understaffed and overworked. What are the steps then that we need to take to help prevent this from happening, and how do we get to the point of being an invaluable, indispensable, contributing part of the health care team? Does your department’s respiratory staff measure up when it comes to being at the bedside of a patient, helping the physician make smart decisions about the appropriate type and amount of therapy; or are they unwilling, afraid, or too intimidated to approach the physician? Schools teach both the didactic and technical skills approach to respiratory care. But is that all we need to teach? I think not. There is one vital step we need to take to help ensure our professional evolution and that is teaching the art of effective communication through simulation.

Literature Review

How many times have you heard the old phrase, “communication is the key to success?” Teaching communication has been shown to improve the overall performance of the health care worker. Huang et al1 studied the effectiveness of a scenario-based communication course to increase the self-confidence of nurses in communicating with their patients. Recognizing that nurses are a vital link between doctor and patient, they concluded that nurses are expected to have keen observation skills to monitor a patient’s condition, and good communication skills are a must to articulate their observations to the attending physician. Should this same standard and expectation also hold true for respiratory therapists? If communication skills are a core competency or attribute for nurses, they should be for respiratory therapists too. The investigators conducted a multisite evaluation to determine if nurses learned communication skills better through a 2-hour standardized course in communications or through a 3-hour scenario-based communications course. Their findings suggested that both courses increased the nurses’ confidence and capabilities in communicating with patients, doctors, and professionals from other disciplines.1

This study shows the importance of using simulation in teaching communication skills. Over the past decade, however, technological advances have changed the modes of communication dramatically. Today it is virtually “faceless,” as digital and wireless platforms seem to be the more popular form of communication in both our personal and professional lives, arguably having a detrimental effect on our ability to verbally communicate effectively. “People may not realize this, but the more they rely on texting to keep in touch, the more they start to drift apart.”2

As leaders in our profession, we must step forward and give our team members all the tools necessary to be successful, and communications training and education is a necessary component. The vital importance of developing high-quality communication skills in health care professionals was expressed by Middlewick et al.3 They posited that these skills can be challenging to develop and that the didactic approach is somewhat limited in that it can impart knowledge but not necessarily the opportunity to practice what was taught. Their research shows the importance of being able to practice communication skills through the use of an experiential theatrical technique, called forum theatre, thus enabling students to experiment with different communication strategies and techniques within a safe, controlled setting. In essence, short scripted scenes are used to develop the learners’ skills by engaging them through an unsatisfactory outcome and then the scenes are rerun to enable the learners to achieve a positive outcome.

Not only will teaching communication skills build confidence when dealing with difficult patients, physicians, or family members; but communication skill development can have a positive effect on patient satisfaction and outcomes, as noted by the research of Sargeant et al.4 Using four 2-hour workshops to develop communication skills based on science (evidence-based practice and teaching) and art (interactive theater), learners were given both positive and negative lessons. This was accomplished through the use of simulation with the nurses playing different roles. Data showed this was well received despite some discomfort with role playing. Overall though, there was a demonstrated improvement in self-reported communication skills when dealing with patients.

Theoretical Framework

Communication theory deals with the technology of the transmission of information (as in the printed word or a computer) between people or people and machines or machines and machines. A key model for communications was introduced in 1949 by Claude Elwood Shannon and Warren Weaver (2009) for Bell Labs.5 Their initial model consisted of three primary parts; sender, channel, and receiver. The strengths of this model are simplicity, generality, and quantifiability. Together, they structured this model based on the following elements:

  • An information source, which produces a message;
  • A transmitter, which encodes the message into signals;
  • A channel, to which signals are adapted for transmission;
  • A receiver, which “decodes” (reconstructs) the message from the signal;
  • And a destination, where the message arrives.
    Shannon and Weaver argued that there were three levels of challenges for communication within this theory, however:
  • The technical problem: How accurately can the message be transmitted?
  • The semantic problem: How precisely is the meaning “conveyed”?
  • The effectiveness problem: How effectively does the received meaning affect behavior?

This communication theory clearly demonstrates that simply because a signal is transmitted does not necessarily mean it is received as it was intended. Respiratory therapists must be able to communicate an idea concisely and convincingly—sometimes to a somewhat cantankerous, egotistical physician who really does not want to hear the therapist’s ideas or appreciate the therapist’s perspectives. This can pose a problem for both the therapist and the patient. Therapists must perfect verbal skills to be effective during these situations. As Shannon and Weaver’s communication theory elucidates, there are also barriers to ensuring one’s message is received and understood. Figure 1 outlines some of these barriers, or variables, that must be overcome to ensure that the final outcome of improved communication is achieved.

Each independent variable (education, culture, language, and experience) of these barriers should be addressed and analyzed in detail so that the proper forum or technique for practice can be used to improve communication. Further defining these variables will show the key factors that influence each one.

Throughout the history of respiratory therapy, each of the variables (Figure 2), either alone or in combination with others, has played a role in the overall quality or abilities of the respiratory professional. One-year programs, which no longer exist, were traditionally shown to draw students who might otherwise not fit into a longer, more structured program or have the means to do so. Cultural barriers can be as simple as how a man or woman is seen in the hierarchal status of that culture. Language issues may arise when, even though someone speaks English fluently, the accent from their native country might be so strong that it makes it very difficult to understand the concept or idea they are trying to convey. Also, words convey different meanings from language to language, and sentence structure might play a role as well. Screening applicants for their verbal acuity has never been a consideration for most schools, and looking for cultural or learning barriers was never addressed early on to see if the student or employee could overcome these barriers. Experience is another variable of effective communication. Whether a respiratory professional is a new graduate or has several years of experience, it will play a significant role in how effectively they are able to communicate. Overcoming these barriers with practice in a safe environment may help to mitigate the fear and intimidation so that these variables are no longer obstacles on the road to improved communication.

Why Now?

Respiratory therapists face a multitude of challenges today; one being the basic fact that we need to be at the bedside of our patients offering solutions and challenging physicians to step out of their comfort zone by trusting us when we recommend a new or different therapy. This is possible only if we have the communication skills necessary to convey our point, as communication is the number one skill for critical thinking.6 If one cannot convincingly and concisely get a point across, the battle is lost. Communication skills, as the literature shows us, support adding communication training to the current educational curriculum and practicing those skills in a safe, controlled environment. Respect is earned, but if communication is unperfected, the value of the respiratory therapist might be quickly lost if one comes across as being intimidated, scared, uncertain, unable to debate a point, or inferior. Through the use of scenario-based simulation, learners can practice the art of communication by engaging in verbal banter with others from different disciplines. Addressing the individual needs of the learner by making the scenario specific to those needs, such as cultural barriers where a woman might feel intimidated by approaching a man or vice versa, will be the key factor to success. Learning to get past those cultural stereotypes can be a mammoth step in learning to approach someone. Through the years, I have learned the verbiage or phrasing you use can make all the difference in the world in how someone interprets what you are trying to convey and, more importantly, be understood. Through simulation, practicing how to say something to make your point heard and understood is crucial in helping someone overcome a language barrier, thus helping them to learn correct sentence structure or word choice. Practice will facilitate getting past the fear and intimidation variable and achieving improved communication.

One approach that is a must for the current educational curriculum is the incorporation of cooperative learning,7 a successful teaching strategy in which small groups of students from different levels of ability use a variety of learning activities to improve their understanding of a subject. Simulation is such a strategy, and through such tools as simulation scenarios, theater, and phone calls, wherein learners can practice the verbal skills necessary to convey their thoughts and ideas, they will gain confidence when speaking with people they perceive as intimidating or difficult. What are the ways to achieve this?

  • Build it into the core educational curriculum by requiring one of the students’ elective classes to be a speech or debate class.
  • Use standardized patients or patient simulators. These are great methods to practice verbal communications. Along with teaching a technical skill scenario, include a situation during which the patient is failing on one mode of therapy, and the learner must explain to a difficult physician role player why a different mode would be better for the patient. This not only has the potential to increase the learner’s confidence in relating to a difficult participant, but also may increase the learner’s understanding of the procedure or mode of therapy they are explaining.
  • Mock telephone calls made by the learner to a difficult physician, played by a role player, also are very effective in learning to speak and convey ideas.

These ideas are designed to help the learner become better at communicating thoughts and ideas to team members to the benefit of the patients. Respiratory therapists are continually made aware of new modalities to facilitate better patient outcomes and being good patient advocates. Therefore, we must make available to our patients every possible mode of therapy feasible, even if it is a mode, device, or procedure the physician is not familiar with. Proper verbal vernacular, banter, and how to stand one’s ground are all very valid skills that can, and should, be taught and practiced in the simulation environment as part of regular skill scenarios. Challenging a physician to implement a procedure or mode they may not be familiar or comfortable with is definitely a challenge. But if one has practiced ahead of time, the chances of success are vastly improved.

Using Simulation

Getting school or hospital administrators on board with simulation can be a major task in and of itself. So if the task seems overwhelming, here are some possible solutions to work around having all the “upscale,” costly simulation tools at your disposal. Schools have more patient simulators than most hospitals, and most schools use them for training purposes more than hospitals do; but I feel that is changing and will continue to change as more and more hospitals invest in patient simulators. Pushing yourself or your administrators to find grants, foundation money, or private donors, or adding it in the budget, are all ways to find financial support for simulation. Data showing how simulation improves patient safety and increases patient satisfaction can be great support for getting administrators on board. Respiratory programs usually are accompanied by a nursing program at the same school, so I encourage you to approach the nursing instructors and partner with them to use their simulators and conduct multidiscipline scenarios. This is a great team building opportunity and a way to learn to work together early on. After all, that is what it’s all about in the work setting. Furthermore, learning to communicate with one another through multidisciplinary scenarios helps to create confidence in future interactions.

Patient simulators that function as living, breathing people are great, but for instilling or teaching effective communication are not entirely necessary. Low-fidelity (refers to the reality of the simulation) simulations are equally effective and for the hospital setting maybe a little easier to set up and run. Low-fidelity simulations can be anything from a basic lifesaving (BLS) mannequin to just simulating a conversation in a hallway. Phone calls made randomly to therapists during their shift and engaging them in a conversation are also great practice. Medium-fidelity simulations could use a BLS mannequin and have a couple of role players (confederates) play the roles of a nurse, physician, or family member. This exercise could lead the learner down a path in which they are required to communicate a therapy change to one of the other role players. High-fidelity simulations could incorporate the use of fully functioning patient simulators that can talk, breathe, and perform every other bodily function imaginable. These scenarios are typically set up to absolutely resemble a true patient setting and are run to the fullest extent of a real situation. One of the components of high-fidelity simulations is that they should be videotaped, and, after the simulation is over, a debriefing is held where the participants are allowed to watch themselves in action. This leaves no doubt in anyone’s mind as to how they performed and offers a great method for the learner to see just how their communication skills measure up. I would encourage you to videotape or record even your low- and medium-fidelity simulations so learners have a chance to review their performances. As you review the tape with them, stop it periodically to have the participants make suggestions as to how they might improve verbally or handle the situation differently, which is another great learning tool. Random phone calls, if you have the capability, can be recorded and played back also as a learning improvement tool.

Competencies are done in the hospital once or twice a year, so start introducing competencies that include, as part of the check off, a verbal communication skill. This can be as simple as having the therapist explain a mode of therapy to you and why it would be beneficial for a certain patient. This will help teach the therapist the proper way to communicate effectively.

We can no longer be the knob turner who simply does what a physician orders; we must elevate our profession by being at the bedside communicating what is best for the patient.


Linda M. Ward, RRT, NPS, certified simulation educator, is education coordinator for respiratory care services, St Joseph Hospital, Tampa, Fla. For further information, contact [email protected]

References
  1. Huang YC, Hsu LL, Hsieh SI. The effect of a scenario-based communications course on self-confidence in novice nurse communications [in Chinese]. Hu Li Za Zhi [The Journal of Nursing]. 2011;58:53-62.
  2. Zhang D. Texting: loss of communication. Available at: [removed]voices.yahoo.com/texting-loss-communication-4770732[/removed]. Accessed April 2, 2012.
  3. Middlewick Y, Kettle TJ, Wilson JJ. Curtains up! Using forum theatre to rehearse the art of communication in healthcare education. Nurse Educ Pract. 2011;12:139-42.
  4. Sargeant J, MacLeod T, Murray A. An interprofessional approach to teaching communication skills. J Contin Educ Health Prof. 2011;31:265-7.
  5. Griffin EA. A First Look at Communication Theory. New York: McGraw-Hill; 2009.
  6. Mishoe SC, Welch MA Jr, eds. Critical Thinking in Respiratory Care. New York: McGraw-Hill; 2002.
  7. Snowman J, McCown R, Biehler R. Psychology Applied to Teaching. 12th ed. Boston: Houghton Mifflin Co; 2009.