Communication is the exchange of information and meaning between a sender and a receiver. In health care, communication failures are a leading contributor to adverse events, especially during transfers of responsibility.

The basic model: sender → message (encoding) → channel → receiver (decoding) → feedback, all affected by noise (distractions, jargon, emotion, hierarchy, language differences). Feedback is what confirms that the message was understood as intended.

Assertiveness is expressing one's own thoughts, feelings, and rights honestly and directly while respecting the rights and feelings of others. Its three elements are self-expression, respect for others, and appropriateness to the situation.

Endorsement is the Filipino workplace term for the handoff: the formal transfer of information, responsibility, and accountability for clients from one nurse or shift to the next (change-of-shift endorsement), or from one unit to another (transfer endorsement).

Directions of organizational communication

Communication networks

Communication styles

Assertive techniques

• I-message: "I feel [feeling] when [specific behavior] because [effect]. I would like [request]." It describes the effect without attacking the person.
• DESC script: Describe the behavior, Express feelings, Specify the change wanted (or, in the TeamSTEPPS version, Suggest alternatives), state the Consequences.
• Broken record: calmly repeating the request without escalating.
• Fogging: agreeing with any truth in criticism while keeping one's position.
• Saying no politely: acknowledge the request, give a brief reason, offer an alternative if possible.

Safety-speak tools (from team-training programs such as TeamSTEPPS)

• CUS: "I am Concerned… I am Uncomfortable… This is a Safety issue."
• Two-challenge rule: voice a concern at least twice; if it is still ignored, take it to the next level of authority (chain of command).
• Closed-loop communication and read-back: the receiver repeats the order or critical result, and the sender confirms it.

SBAR — structured communication about a client's condition:

• Situation: who you are, the client, the current problem
• Background: diagnosis, relevant history, current treatment, recent results
• Assessment: your analysis (vital signs, what you think is happening)
• Recommendation: what you need, by when

Endorsement on a Philippine ward

• Done at change of shift, ideally at the bedside (walking or bedside endorsement), so both nurses see the client, lines, drains, wound, IV site, and fluids together, and the client can take part.
• Uses the unit's structured tool — the Kardex or its electronic equivalent, an endorsement sheet, or an SBAR-based format.
• Content: client identity and diagnosis; current status and changes during the shift; vital-sign trends; IV fluids (type, rate, amount remaining); medications given, due, or held; pending laboratory results and procedures; new or changed orders; safety risks (falls, pressure injury, suicide, allergies); family concerns; and anything the next nurse must do first.
• The receiving nurse asks questions, verifies with the chart, and does not accept an unclear endorsement. Responsibility transfers only when the endorsement is complete.
• Sensitive information is endorsed in a private manner; health information is sensitive personal information under the Data Privacy Act of 2012 (RA 10173).
• Priority clients (unstable, newly admitted, post-operative, with abnormal results) are endorsed first and checked first by the incoming nurse.

Receiving and giving orders

• Written orders are standard; verbal or telephone orders are limited to urgent situations under hospital policy. The nurse writes the order down, reads it back, and gets confirmation; the prescriber signs it within the time set by policy.
• An unclear, illegible, or apparently wrong order is clarified with the prescriber before it is carried out. Carrying out an order the nurse knows or should know is wrong does not protect the nurse.

Reporting a change in condition. Use SBAR, have the chart and latest vital signs ready, state a clear request, and document the notification, the response, and any orders received.

Difficult conversations

• Angry relative: stay calm, move to a private area if possible, listen, acknowledge the feeling ("I can see you are worried about your father"), then problem-solve. Do not argue or become defensive.
• Colleague's unsafe practice: speak privately and directly using an I-message; report through channels if the risk continues.
• Inappropriate request (e.g., personal errands for another staff member during duty): decline politely, citing client care priorities.
• Interdisciplinary meetings: bring objective, specific observations ("She walks 10 meters with two rest stops") rather than general impressions.

• Communicate clearly, accurately, and on time with clients, families, and the health team.
• Give and receive complete endorsements; verify rather than assume.
• Speak up for client safety, even to seniors or physicians, using assertive and respectful language, and escalate through the chain of command when needed.
• Document communication with prescribers (time, content, response).
• The nurse manager builds a culture where staff feel safe to speak up and where upward communication, including incident reporting, is welcomed.
• RA 9173 Section 28 includes coordination with the health team and health education within the scope of nursing — both depend on effective communication.

• Confidentiality and privacy: disclose client information only to those involved in care or as authorized. Avoid endorsing in hallways, elevators, or group chats not approved for clinical use. Posting client information on social media is a privacy violation.
• Documentation: the chart is a legal record; late entries must be labeled, and records must never be altered.
• Incomplete endorsement that leads to harm (e.g., a missed due dose, a pending critical result not followed up) can be the basis of a negligence claim against both the endorsing and receiving nurses.
• Duty to question orders: following a clearly erroneous order is not a defense.
• The Code of Ethics for Registered Nurses calls for respect and cooperation with co-workers and the health team.

Case 1. During endorsement, the outgoing nurse forgets to mention that a client's potassium result is pending. The incoming nurse notices the pending test in the chart. What should she do?

Answer: Clarify with the outgoing nurse before she leaves, then follow up the result. A calm, specific question ("I see a potassium result pending from 1400 — was the prescriber informed?") closes the gap without blaming.

Case 2. A resident gives a telephone order: "Give the usual dose of furosemide IV now." What is the correct response?

Answer: Ask for the specific dose and route, write it down, and read back the full order for confirmation. "The usual dose" is incomplete and unsafe.

Case 3. A senior nurse repeatedly assigns a new nurse the heaviest clients. The new nurse wants to respond assertively. Which statement is best?

Answer: "I feel overwhelmed when I receive the four highest-acuity clients each shift, and I worry about safety. I would like us to review the assignments together." This is an I-message that states facts, feelings, and a request. Silence is passive; complaining to others is passive-aggressive.

Case 4. A nurse tells the physician twice that a post-operative client's blood pressure is dropping and the client is pale, but the physician dismisses it. What next?

Answer: Escalate through the chain of command (charge nurse, supervisor, consultant as policy allows) and document. This applies the two-challenge rule.

• Choosing "document and wait" when the nurse disagrees with an order. The nurse first clarifies with the prescriber and escalates if needed.
• Treating assertiveness as winning. The goal is honest expression with respect, not forcing one's view.
• Using "you" statements and calling them I-messages.
• Accepting an endorsement "as given" without checking critical items.
• Relying on the grapevine for policy changes. Official information uses formal channels.
• Endorsing sensitive information in public places or through personal messaging apps.
• Mixing up SBAR steps: "blood pressure is dropping" = Situation; "post-operative day 1 after hysterectomy" = Background; "I think she is bleeding" = Assessment; "please see her now and order a CBC" = Recommendation.

• Communication needs feedback to confirm understanding.
• Downward = orders; upward = reports and suggestions; lateral = peers; diagonal = across levels and departments.
• All-channel network suits complex problems; wheel suits simple, fast tasks.
• Assertive = direct, honest, respectful; aggressive violates others' rights; passive avoids.
• I-message: feeling + specific behavior + effect + request.
• CUS words and the two-challenge rule help nurses speak up; escalate through the chain of command.
• SBAR: Situation, Background, Assessment, Recommendation.
• Verbal or telephone orders: write down, read back, confirm; signed later per policy.
• Clarify unclear or wrong orders before carrying them out.
• Endorsement transfers responsibility; bedside endorsement allows joint checking.
• Health information is sensitive personal information under RA 10173.