Listening is often assumed to be a simple skill; however, it is a difficult and complex activity. The physical act of hearing is distinct from listening. Hearing can be considered to be passive, but listening requires active processing and attaching meaning to what is heard. It is difficult to answer the question ‘How do we listen?’ and a procedure on ‘how to listen’ would not do justice to the sophistication and success of good listeners. However, there are ways of describing the constituent parts of listening that, if followed, would make the person speaking appreciate that they were being listened to.

Active listening involves the assimilation of verbal and non‐verbal cues, which are reflected back to the patient using both verbal and non‐verbal responses. Problems can emerge when two people interpret the meaning of the same dialogue differently. For example, if the question asked is ‘How are you?’ and the patient replies ‘Getting by’, is it assumed that they are doing well and coping or that they are struggling and ‘putting on a brave face’? Hopefully, the numerous non‐verbal cues will be attended to, in order to decipher what the patient actually means. If the patient sounds upbeat and smiles, it might be concluded that they are coping. However, if there is incongruence between the words ‘Getting by’ and their delivery – for example, in a low, sad‐sounding voice coupled with a simultaneous lowering of the head – it might be thought that they are struggling. Hargie ([120]) describes four types of listener (Box 5.1).

Non‐verbal communication generally indicates information transmitted without speaking. Included in this would be the way a person sits or stands, facial expressions, gestures and posture, whether the person nods or smiles, and the clothes worn; all will have an impact on the total communication taking place (Hargie [120]). Argyle ([11]) suggested that only 7% of communication between people is verbal. Hargie ([120]) outlines seven non‐verbal signs of listening (Box 5.2).

Egan ([88]) provides the useful acronym SOLER to summarize the constituent elements of non‐verbal communication (Figure 5.4):

By being aware of the above factors and making this behaviour part of your normal demeanour, patients will be encouraged to talk more openly, facilitating emotional disclosure.

It can be argued that non‐verbal information is more powerful than verbal information, for example in the case of incongruence (discussed above), where the verbal message indicates one meaning and the non‐verbal suggests another. There is a tendency to believe the non‐verbal message over the verbal in these instances. This highlights the need to communicate with authenticity. Without this, supportive communication can be severely reduced in its effectiveness.

Non‐verbal communication becomes even more important in the case of people whose verbal communication is impaired, for example by dementia, learning disability, stroke or surgery. Hoorn et al. ([134]) developed an algorithm to help intensive care nurses identify the best communication aid for intubated patients. Patients need to be supported, ensuring, for example, that they have constant access to pen and paper; communication boards can be used to good effect and it is worth considering the use of information technology and communication software, if available. The experience of losing the ability to speak can be very isolating and frustrating, and preparation of the patient and practice with communication aids are important to maximize the success of communication. It is essential that people with a speech deficit are given more time to communicate their needs, so patience and persistence are essential until interaction and understanding are gained at a satisfactory level. Saying nothing can also be interpreted as a communication with meaning, and so there is always communication, however reluctant or silent the nurse or patient.

Non‐verbal behaviour to encourage patients to talk includes nodding or making affirming noises, for example ‘hmmm’. This ‘affirming’ is mostly done naturally, for example at points of eye contact, as specific points are made and during slight pauses in dialogue. It can be especially important to affirm what the patient is saying when they are talking about psychological issues as this will validate that what the patient is saying is an acceptable topic of conversation. Chambers ([44], p.878) suggests that for patients with ‘limited verbal expression’, nurses have a responsibility to build upon and recognize their non‐verbal communication to support the development of a good working relationship with the patient.

The way words and sentences are spoken makes a considerable difference to communication, so attention needs to be paid to the tone and rate of speech. It is important to sound alert, interested and caring, but not patronizing. In general, speech should be delivered at an even rate, not too fast nor too slow (Hargie [120]). However, when presenting difficult or complex information, particularly when someone is upset, talking more slowly will give the patient additional time, thus reducing the cognitive demand required to understand the information.

Questioning is a skill that is used in close collaboration with listening. When specific information is required, for example in a crisis, closed questions are indicated, because they narrow down the number of potential answers (Silverman et al. [254]) and allow the gathering of specific information for a specific purpose. Closed questions, therefore, are ones that are likely to generate a short ‘yes’ or ‘no’ answer, for example ‘Can you hear me?’ or ‘Are you in pain?’.

In care situations with significant life‐changing implications, a broader assessment of the patient's perspective is required and there is also a need to show compassion and identify any underlying psychosocial issues. Open questions and listening are therefore required. Open questions do the opposite of closed questions; they broaden the number of potential answers (Silverman et al. [254]), giving the agenda and control of the conversation to the patient. For example, instead of asking ‘Are you all right?’, an open question would be ‘How are you today?’ or ‘What has your experience of treatment been like?’. A question that enquires about a patient's emotional experience indicates that this is also of interest to the nurse – for example, ‘How did you feel about that?’ or ‘What are your main concerns?’.

Open questions cannot be used in isolation as the opportunity for open discussion can easily be blocked by failing to ensure that the rest of the fundamental communication elements are in place. Attention must therefore be paid to providing sufficient time, verbal space (not interrupting) and encouragement (in the form of non‐verbal cues, paraphrasing, clarifying and summarizing), so that the patient and/or relative can express their feelings and concerns.

Open questions may not be the most appropriate way of communicating with people who have an acquired communication problem, such as changes to the oral cavity following head and neck surgery, as it may be too difficult or frustrating for them to answer questions at length. However, it is important to provide an opportunity for such patients to express themselves verbally and non‐verbally, and a combination of open and closed questions may be appropriate.

Asking one question at a time is important. It is easy to ask more than one question in a sentence, but this can make it unclear where the focus is and lead the patient to answer only one part of the question.

Open questions can also be helpful to respond to cues that the patient may give about their underlying psychological state. Cues can be varied, numerous and difficult to define, but essentially these are either verbal or non‐verbal hints of underlying unease or worry. Concerns may be easier to recognize when they are expressed verbally and unambiguously (del Piccolo et al. [61]).

This technique involves telling the patient what they have told you using different and often less words that retain the same meaning. For example:

Reflecting, sometimes referred to as ‘mirroring’, includes a reflection of emotion as well as words. When it is used, it needs to be done with thought and authenticity. For example:

The aim of this technique is to reduce ambiguity and help the patient to define and explore the central or pivotal aspect of the issues raised. Nurses can be reluctant to explore psychological issues in too much depth for fear that the issues raised will be too emotional and hard to deal with (Perry and Burgess [222]). However, if the principles of good communication are applied and a focus on the patient's agenda is maintained, distressing and difficult situations can be heard and support offered to the patient.

The use of open questions is likely to raise certain issues that would benefit from further exploration. Clarification encourages the expression of detail and context about situations, helping to draw out pertinent matters perhaps not previously considered by either the patient or the nurse. A mixture of open and closed questions can be used in clarification (Box 5.3).

It is sometimes necessary for the nurse to clarify their own position, perhaps acknowledging that they do not know something and cannot answer certain questions. For example: ‘I am not in a position to know if the treatment will work.’ Sometimes not knowing can be a valuable position, as it prompts an enquiry about the patient's experience rather than making assumptions. The knowledge and experience gained through a nursing career may mean that the experience of the patient or relative is familiar; however, patients and relatives will benefit from the opportunity to share their experience in their own words and to feel ‘heard’ (Williams and Iruita [290]).

This technique can be used as a way of opening or closing dialogue. An opening can be facilitated by recapping a previous discussion or outlining your understanding of the patient's position. Summarizing can be used to punctuate a longer conversation and highlight specific issues raised. This serves several purposes:

For example:

Summarizing can be a useful opportunity to plan and agree what actions are necessary. However, if summarizing is used in this situation, it is important to avoid getting caught up with planning and solution finding; the patient will gain the greatest benefit from empathetic, attentive listening. Nurses are familiar with ‘doing’ and correcting problematic situations, and, although interventions can be helpful in psychosocial issues, sometimes it is necessary not to act and to just ‘be’ with the patient, accepting their experience as it is, however difficult this may be. If it helps you to ‘be’ with the patient and/or relative, remember that what you are ‘doing’ is ‘being’.

Recognizing when to act and when to sit with distress can be difficult. However, it is important to develop this awareness and to accept that sometimes there are no solutions to difficult situations. The temptation to always correct problems might only serve to negate the patient's experience of being listened to (Connolly et al. [52]). Sometimes all the patient may want in that moment is to be listened to and heard.

Sharing time and physical space with other people demands the development of a relationship. In nursing, the relationship with patients is defined by many factors, for example physical and medical care. In clinical roles, it is possible to be emotionally detached and to exist behind a ‘professional mask’ (Taylor [265], p.74); however, when working in a supportive role, a shared experience and bond are generated, inclusive of feelings.

Rogers ([245], p.2) seminally described the skill of empathy as ‘the ability to experience another person's world as if it were one's own, without losing the “as if” quality’. This means allowing ourselves to step into the patient's shoes and experience some of what they might be experiencing, without allowing ourselves to enter the experience wholly (it is not our experience). Empathy allows for an opportunity to ‘taste’ and therefore attempt to understand the patient's perspective. Understanding emotions and behaviours in this way encourages an acceptance of them.

Nurses demonstrate empathy when there is a desire to understand the patient as fully as possible and to communicate this understanding back to them (Egan [88]). This means attempting to gain an appreciation of what the patient might be going through, taking into consideration their physical, social and psychological environment. This inferred information can be used to ‘connect’ with the patient, all the time checking that the interpretation of their experience is accurate. Even if the nurse has experienced similar events, it is important to determine the patient's thoughts and feelings as they can be very different.

Empathy may not always come easily, especially if a patient is angry. Learning the ability to step back from a situation and reflect upon what it is that you, as the nurse, feel and how this relates to what is happening for the patient can be useful in the development and use of empathy.

Maintaining Egan's ([88]) ‘as if’ quality protects nurses from adopting too great an emotional load. Having too much of a sense of loss or sorrow may prevent us from offering effective support, as we are drawn to focus on our own feelings more than is necessary or helpful for ourselves or the patient. Recognizing our own feelings is important to allow us to understand and to ‘tolerate another person's pain’ (McKenzie [173], p.34).

Poor communication with patients can negatively affect decision making and quality of life (Dwamena et al. [86], Fallowfield et al. [97], Thorne et al. [268]). The environmental conditions in which nurses work, with competing professional demands and time pressures, can reduce the capacity to form effective relationships with patients (Hemsley et al. [130], Henderson et al. [131]).

There is a personal, emotional impact when providing a supportive role to patients with psychological issues (Botti et al. [25], Dunne [83], Turner et al. [273]) and it is therefore likely that blocking or avoidance of patients’ emotional concerns (Box 5.4) relates to emotional self‐preservation for the nurse. Young ([292]) states that in caring for patients who have dementia, professional caregivers are likely to avoid communication, which can result in further isolation and frustration in the patient, which in turn may lead to angry behaviour.

When communicating and assessing patients’ needs, nurses may be anxious about eliciting distress and managing expressed concerns. They may lack confidence in their ability to clarify patients’ feelings without ‘causing harm to the patient or getting into difficulty themselves’ (Booth et al. [23], p.526). As a consequence, nurses can make assumptions, rather than assessing concerns properly (Booth et al. [23], Kelsey [143], Schofield et al. [250]). To illustrate this point, Kruijver et al. ([147]) demonstrated how nurses verbally focus upon physical issues, which in their study accounted for 60% of communication with patients. Nurses often recognize this bias, with the evidence suggesting that they feel greater competence discussing physical rather than psychological issues; many nurses desire better skills to help them to manage challenging situations (McCaughan and Parahoo [171]).

Intercultural communication and competence require the ability to recognize different cultural identities and meanings. Barriers to intercultural competence are similar to those described above but also include anxiety, stereotyping, non‐verbal misinterpretations and language (Roebuck [244]).

Institutions, work environments and the nature of the senior staff within them can influence the nature of communication (Booth et al. [23], McCabe [169], Menzies‐Lyth [181], Wilkinson [289]). Approaches to patients who have additional communication needs require consideration and planning. Being supported practically and emotionally by supervisors and/or senior staff can help to decrease blocking behaviours (Booth et al. [23], Connolly et al. [52]). Clinical supervision can aid the transfer of communication skills into practice (Heaven et al. [127]).

Nurses may improve their own practice by identifying where environmental barriers lie and attempting to mitigate the features of the clinical environment that inhibit psychological care. These barriers to communication may be particularly significant for patients who have cognitive or physical impairment, such as dementia, a learning disability, or a hearing or sight impairment.

Despite the difficulties outlined above, nurses can communicate well when they are supported to provide individual patient‐focused care (McCabe [169]).