Communication failures are among the most common contributing factors in serious adverse events. Nurses communicate constantly — with clients, families, providers, and each other — and structured communication makes that exchange reliable.

Organizational communication channels

• Downward — from managers to staff: policies, directions, feedback
• Upward — from staff to managers: reports, suggestions, concerns, incident reports
• Lateral (horizontal) — between peers or departments at the same level: coordination
• Diagonal — between people at different levels in different departments (a staff nurse and the pharmacy director)
• Grapevine (informal) — fast and often partly accurate but incomplete, and spreads rumors; leaders reduce its harm by sharing accurate information early

Communication networks — a wheel (information flows through one central person) is fast for simple tasks; a chain passes information step by step and distorts easily; an all-channel (complete) network, where everyone talks to everyone, works best for complex problems and brainstorming but is slower.

Communication styles

Assertiveness has three elements: honest self-expression, respect for the other person, and behavior appropriate to the situation. It is a learned skill.

Assertive techniques

• "I" statements (I-messages): describe the behavior, its effect, your feeling, and what you need. "When report is interrupted, I lose track of details. I need five uninterrupted minutes."
• Broken record: calmly repeat the request.
• Fogging: acknowledge any truth in criticism without becoming defensive.
• Saying no clearly with a brief reason, without over-apologizing.

TeamSTEPPS tools (AHRQ) — used across US health care for speaking up:

• CUS — "I am Concerned… I am Uncomfortable… this is a Safety issue." Any team member saying these words should trigger a stop and review.
• Two-challenge rule — voice a concern at least twice; if it is still unresolved and the risk is serious, take a stronger course of action or go up the chain of command.
• DESC script for conflict — Describe the specific situation, Express concerns, Suggest (or Specify) alternatives, state Consequences (aim for agreement).
• Call-out — announce critical information to the whole team during an emergency ("Blood pressure 70 over 40").
• Check-back (closed-loop communication) — the sender gives information, the receiver repeats it back, and the sender confirms.

SBAR — a structured way to communicate a client concern, especially to a provider:

• S — Situation: who you are, the client, and what is happening now
• B — Background: relevant history, diagnosis, recent treatment, medications, allergies, code status
• A — Assessment: your findings and what you think the problem is
• R — Recommendation (or request): what you need and by when

I-PASS — a validated handoff format:

• I — Illness severity (stable, "watcher," unstable)
• P — Patient summary (diagnosis, history, hospital course, current plan)
• A — Action list (tasks to do, with timeline and owner)
• S — Situation awareness and contingency planning (what might happen and what to do)
• S — Synthesis by receiver (the receiver summarizes and asks questions)

Regulatory framework. Beginning January 1, 2026, The Joint Commission reorganized its hospital and critical access hospital requirements into National Performance Goals, replacing the former National Patient Safety Goals chapter for those programs. The first goal (the right patient receiving the right care) includes patient identification, timely reporting of critical test results, and handoff communication. Organizations must have a handoff process that allows discussion between the giver and receiver of information.

Handoff (shift report, transfer, procedure)

• Use a standardized format (SBAR, I-PASS, or the facility tool) and an up-to-date written or electronic support tool.
• Give report in a quiet place with minimal interruptions; at the bedside when possible, so the client can participate and both nurses can verify lines, pumps, and safety devices.
• Include illness severity, recent changes, pending tests and results, what to watch for, and what to do if it happens.
• The receiver asks questions and summarizes (synthesis). Missing information? Ask for it — without blame.
• Protect privacy at the bedside: ask the client whom they want present; do not share sensitive details in front of visitors without consent.

Calling a provider

• Before calling: assess the client, review the chart, recent vitals, labs, medications, allergies, and code status; have the chart open.
• Use SBAR and state a clear request.
• Write down and read back verbal or telephone orders and critical results; verify them with the prescriber.
• If an order is unclear or seems unsafe, clarify it before acting — "Doctor, the client's potassium is 5.9 mEq/L (5.9 mmol/L) and the order is for potassium chloride 40 mEq. I am concerned. Can we review this order?"

Communicating with an angry client or family

• Stay calm; move to a private area; listen without interrupting.
• Acknowledge feelings ("I can see you are very worried about your father").
• Avoid defensiveness or arguing; focus on what you can do; follow up as promised.
• Maintain safety: keep an exit route; call security if the behavior escalates.

Interprofessional meetings

• Bring objective, specific data ("walks 30 feet with a walker and needs two rest stops"), not impressions.
• The meeting leader ensures that every member can speak and that one person does not dominate.

Language access. For clients with limited English proficiency, use a qualified medical interpreter (in person, video, or phone), not family members or children, for clinical information.

• Give and receive complete, accurate handoffs; confirm understanding.
• Speak up for client safety using assertive, respectful language — silence is not neutral when a client may be harmed.
• Escalate through the chain of command when a safety concern is not resolved (charge nurse → nurse manager or house supervisor → medical chain as defined by policy).
• Document communications with providers: time, who was notified, what was reported, the response, and actions taken.
• Model civility; address disruptive or bullying behavior directly or through policy.
• Managers keep staff informed (downward), invite feedback (upward), and create a culture where speaking up is safe.

• HIPAA permits sharing health information among the treatment team for care, but nurses must use the minimum necessary information in nontreatment contexts and protect conversations from being overheard where possible.
• Failure to communicate a significant change in condition, or to escalate when a provider does not respond, is a common basis for negligence claims.
• Documentation must be factual and timely; do not document blame or conflict among staff in the medical record — use the incident reporting system.
• Federal civil rights law (including Section 1557 of the Affordable Care Act) requires meaningful language access for people with limited English proficiency in federally funded programs.

Case 1 — Deteriorating client. A postoperative client's blood pressure has dropped from 128/76 to 92/58 mm Hg, heart rate is 118, and the dressing is saturated.

Correct action: after immediate interventions (stay with the client, apply pressure or reinforce the dressing, position, and call the rapid response team per policy), call the surgeon with SBAR: S — "Client in 412 is hypotensive and tachycardic with a saturated dressing"; B — "Four hours after a hip replacement"; A — "I am concerned about bleeding"; R — "Please come evaluate now; do you want a CBC and a fluid bolus?"

Why: SBAR gives the provider the key facts quickly and ends with a clear request.

Case 2 — Order that does not match the client. The nurse receives an order for a medication to which the client has a documented allergy.

Correct action: hold the medication and contact the prescriber assertively with the specific fact: "The client has a documented anaphylactic reaction to this drug. Please clarify the order."

Why: assertive communication states facts respectfully; carrying out the order or silently skipping it are both unsafe.

Case 3 — Unresolved concern. A nurse raises a concern twice to a resident about a client's rising respiratory rate and confusion; the resident says, "Just watch him."

Correct action: apply the two-challenge rule and escalate through the chain of command (charge nurse, rapid response team, attending physician per policy).

Why: the nurse's duty is to the client; failure to escalate is negligent.

Case 4 — Missing information at handoff. The receiving nurse notices that report did not mention a pending potassium result.

Correct action: ask a specific question during synthesis ("Is there a potassium level pending?") and add it to the action list.

Why: closed-loop communication without blame improves safety and team trust.

• Using "you" statements ("You always ignore me") instead of I-messages.
• Treating assertiveness as winning — the goal is mutual respect and solving the problem.
• Starting SBAR without first assessing the client and having data ready.
• Omitting the Recommendation — the provider must know what you need.
• Forgetting read-back for telephone or verbal orders and critical results.
• Giving report in the hallway where others can hear, or at the bedside without considering the client's privacy wishes.
• Stopping after one challenge when a safety risk continues.
• Using family members as interpreters for clinical information.
• Referring to the Joint Commission "National Patient Safety Goals" as the current hospital framework — for hospitals, the 2026 National Performance Goals replaced them.

• Assertive = honest, direct, and respectful of others' rights; I-messages
• Passive → stress and unsafe silence; aggressive → others lose
• SBAR: Situation, Background, Assessment, Recommendation
• I-PASS: Illness severity, Patient summary, Action list, Situation awareness, Synthesis by receiver
• Bedside handoff with read-back and receiver synthesis
• CUS words and the two-challenge rule trigger a stop and escalation
• DESC script for conflict: Describe, Express, Suggest (or Specify), Consequences
• Write down and read back verbal orders and critical results
• Escalate unresolved safety concerns through the chain of command
• Use qualified interpreters, not family
• Joint Commission 2026 National Performance Goal 1 covers identification, critical results, and handoff