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NRMW 1000. Core Skills for Health Care Professionals
Communication Skills for Midwifery Practice
Part B
By Richard Byrt Former Lecturer/Practioner Nursing, De Montfort University and Arnold Lodge
Medium Secure Unit, Nottinghamshire Helathcare Trust.
Adapted for midwifery by Jacqui Williams, Senior Lecturer in Midwifery, DMU.

Examples of women are based on the lecturer’s midwifery experience and are fictitious and not
intended to describe clients in local services or elsewhere.
1.Introduction
This handout considers:

Further aspects of communication in midwifery practice.

Women with specific communication needs, especially individuals with changes to brain structure
and function.

Communication with individuals who are bereaved.
2. Active Listening and Empathy: Two Key Skills in Midwifery
Two key skills are essential:

Active listening: careful attention to the clients’ non – verbal and verbal communication, and

Empathy: attempting to understand the client’s feelings and experiences, communicating this
understanding to her/him; and taking practical action to help the client.
(Arnold and Boggs 2007, Baughan and Smith 2009)
An Exercise on Empathy
Imagine you are a registered midwife and you have to break the news to a woman that the results
from the antenatal screening tests are raised and further investigations are required. .
Consider what communication skills you would use to break this news, and to give the woman
and her partner the information they require.
3.1. Empathy and Sympathy
Several authors have distinguished between empathy and sympathy (Reynolds 2005, White 1997) by
stating that both empathy and sympathy involve attempting to understand the client’s feelings and
experiences, but the person who is sympathetic may be overwhelmed by her/his attempts to feel the
same way as the client.
In contrast, the midwife who is empathetic, whilst trying to understand the woman, would have a
certain amount of objectivity and be able to provide practical help and support, without being
overwhelmed by the client’s feelings and experiences (Arnold and Boggs, 2007, Reynolds 2005).
White (1997) illustrates this by stating that a sympathetic professional might burst into tears to
demonstrate sympathy, which could be difficult for the client; but that an empathetic professional
would be able to translate empathy into being sensitive to the client’s non – verbal and verbal
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communication indicating distress; and by providing practical care and active listening to
reduce this.
4.1. Carl Rogers’s Core Conditions of Client – Centred Communication
Some communication skills are related to Carl Rogers’ core conditions of client – centred
communication (sometimes called person – centred or humanistic communication: Freeth, 2007).
Empathy is one of these core conditions and the others include “congruence [and] unconditional
positive regard (Freeth, 2007, p127).
The three core conditions are described in detail in Rogers (1990). Client – centred principles
appropriate to midwifery are considered in Arnold and Boggs (2007) and Barker (2009).
Each of the core conditions requires self awareness
4.2. Congruence
Congruence includes authenticity: the professional’s “awareness of [her/his] feelings and reactions”
(Byrt and Doyle 2007, p86) in response to the woman.
Congruence also involves being sincere, instead of, for example, pretending interest (Arnold and
Boggs 2007, Barker 2009). The latter would be manifest in a midwife stating to a woman that she/he
is interested in what they have to say, whilst fidgeting and looking out of the window, longing for the
shift to end. This could possibly result in the woman feeling ignored, and perhaps, angry (Arnold and
Boggs 2007). Congruence also involves not being defensive: that is, dismissing what the woman
says. For example, if an aggressive woman complains about the midwife a congruent response
would be to listen carefully to her, and offer an apology, if necessary (Arnold and Boggs, 2007).
4.3. Unconditional Positive Regard
Unconditional positive regard, includes respecting and valuing the client, as a unique
individual, regardless of her/his behaviour. Congruence requires that the midwife is honest about
her feelings about the woman’s behaviour, with unconditional positive regard involving a
determination to work consistently with the woman, despite any difficulties that may be experienced.
It includes caring for a client unconditionally, not caring only if she behaves in the way that the
professional thinks she should behave (Rogers 2004):
“It means that there are no conditions of acceptance, no feeling of “I like you only if you
[behave in particular ways]. ..
“It involves as much feeling of acceptance for the woman’s expression of negative…painful,
fearful, defensive…feelings, as for her expression of…positive…feelings…with permission to
have her own feelings, her own experiences”.
(Rogers 2004, p184)
5.1. Presence
Part of empathy involves presence, which has been defined as “the quality of being open,
receptive, ready, and available to the experience of another person” (Patterson and Zderad
1976, quoted in Engebretson 2004, p235). The latter author indicates that presence involves largely
non – verbal communication skills: what is important for the woman is that, besides practical
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skills, the midwife is there to support and share the woman’s experience; and this may be
more important to her than the midwife’s verbal communication.
An example of presence, involving empathy:
“I was in a side room as I had found out a few days that my baby had died and tomorrow I am going
to be induced. I was very restless and kept waking up and it took ages to ‘get back to sleep again.’
Rashida, a Student [Midwife], noticed my light on at around 3 am and guessed I was awake, and
asked if I wanted a cup of tea. When she brought it, she must have noticed something was wrong
because she asked me how I felt…
“I said to her, “Everyone thinks I’m coping, but I’m not!” She just sat and held my hand…. with me for
a while [as] it was quiet on the ward, and we’d talk about how I was’ trying to overcome some of the
fears I had for seeing the baby and what would happen when I went home. .’I still remember that
time in the middle of the night and how much that Student Midwife presence meant to me”.
(Adapted from Baughan and Smith 2009).
5.2. Caution in the Use of Touch
Although touch can be experienced by some women as comforting or otherwise therapeutic (as
was apparently the case with Rashida’s use of therapeutic touch ), there is evidence that touching
clients who have experienced physical or sexual abuse can be distressing and re – awaken
experiences of their earlier abuse (Gallop and Tully 2009). In addition, some clients object to
touch for cultural, gender and other reasons and may misunderstand the reason for the midwife’s use
of touch (Arnold and Boggs 2007). For these reasons, care needs to be exercising in using
touch to comfort clients or for other reasons.
6.1. Communication in Busy Health Settings
It can be argued that quality, as well as quantity, of communication is of vital importance.
For example, a busy midwife might have only a minute or two to listen to a woman’s fears.
However, giving that client 100% attention for a minute may add considerably to her/his
psychological, physical and spiritual comfort, and ensure that she receives the care needed (Baughan
and Smith 2009).
Morrison (1996) concluded from his research:
“…Just arriving in hospital and settling into the routines to await an uncertain future is a
complicated and anxiety-provoking experience. The physical environment, the technology,
the uniformed staff and the specialist language used by the staff are all influential and
contribute to the feeling of crushing vulnerability experienced by many if not all patients…”
(Morrison 1996, p109)
7. Clients with Specific Communication Needs
Good communication skills contribute to the effective professional care of clients with
particular communication needs, skills and problems. Examples include the following:
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
Individuals who do not understand or speak English. This is not a problem in itself, but the
lack of adequate interpreting or translating services in some health care settings has been
identified as a problem. It has also been found that, within the UK, child and adult clients
sometimes receive poorer services if they do not understand or speak English. It is
essential nursing practice to ensure that all clients receive a high standard of care, whether or not
they understand or speak English (Peckover and Chidlaw 2007, Schott et al 2007, Tribe and
Raval 2006). .

People with moderate or severe learning disabilities. These individuals may be very effective
at communicating in certain ways: e.g., non verbally. However, they often have problems with
understanding the content of speech and expressing themselves through speech (Ferris – Taylor
2007). There are now liaison learning disability nurses who work in general hospitals and
who, with adult nurses, explain procedures in ways that the individual can understand
(Jones 2004): e.g., through the use of a sign language or the use of pictures and symbols
(Ferris – Taylor 2007).

Some individuals with mental health problems may experience difficulties in
communication. For example, certain people with severe depression can find it very difficult to
take in what people are saying or to respond to conversation. An individual with
schizophrenia (often occurring in teenagers and young adults) could feel bombarded with
voices (auditory hallucinations), which might make it difficult for her/him to concentrate on
what other people, including the nurse, are saying (Barker 2009). Some mothers (and
fathers) need particular care and support from the midwife in liaison with mental health
professionals, because of depression, excessive stress or schizophrenia precipitated by
pregnancy or childbirth (Parcells 2010).
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Individuals with severe depression and schizophrenia can find it helpful if health care
professionals:

Treat them as an individual, and treat what they say seriously, rather than labelling
them: that is, seeing them only as someone with a mental health problem.

Are prepared to listen and to empathise (attempt to understand) their experiences.
Listening and warm interest are likely to be as important as what the nurse says.

Give small chunks of information at a time if the individual has difficulty in concentrating on
what is being said.
(Barker 2009, Stuart 2009)
In a research study, Bowers (2002) found that some mental health nurses felt able to maintain
therapeutic relationships with clients with aggressive behaviours, partly because they were
able to see “the whole person”, and be prepared to understand the reasons for the behaviours.
(These nurses cared for the minority of people whose mental health problems are associated with
aggression).
8.1 Aids to Hearing, Vision and Speech
Ensure that individuals have the following, if they need them:

Hearing aids – and that these are working.
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Spectacles – and that these are appropriate for near sight or distance.

Contact lenses – and that these are correctly and comfortably inserted.
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.Hearing, and visual aids are essential for effective communication, and individuals’
self – esteem and ability to carry out everyday tasks.
(Arnold and Ryan 2007)
8.2. Avoid Speaking Over the Individual and Ignoring Them
It is good practice to avoid speaking to a colleague about matters that don’t involve the woman
whilst providing care. An example would be to talk about your holiday to another midwife, but not
communicating with the woman, whilst you are involved in undertaking observations in labour.
9 “Pregnancy Loss and the Death of a Baby” (Schott et al 2007)
Midwives will sometimes work with parents whose baby has died at birth. Sands (Stillbirth and
Neonatal Birth Charity) (2010) is an organization providing support for parents whose babies have
died during pregnancy or at, or soon after, birth. This organization has published “Pregnancy Loss
and the Death of a Baby: Guidelines for Professionals” (Schott et al 2007). Amongst many topics,
these guidelines consider communication with the parents of children whose baby has died.
Examples of both insensitive and helpful communication are given.
“The [doctor]…knew my baby had died. But he didn’t say anything about it all. Just laughed
and chatted as though nothing bad had happened”.
This contrasted with:
“Everyone we came in contact that night, the midwife, the [doctors]…, they were so fantastic.
They took time to talk to me. And they really showed how upset they were”.
“You need someone to just sit with you and talk you through all these difficult
feelings…One midwife was very good: she’d come and sit with us and talk for a little while”.
(Mothers quoted in Schott et al 2007, p35f)
10. Communication with women and their partners and relatives who are bereaved
The points made by Schott et al (2007) about communication with bereaved parents are

“Listen…and be prepared to listen again and again.

“Treat parents as individuals and accept what they say without judgement.

“Acknowledge their feelings and express empathy.

“Remain calm when they express strong feelings.

“Avoid platitudes…and empty reassurances…”
(Schott et al 2007, p29)
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Reading List and References
Empathy, Active Listening and Other Communication Skills
Bowers, L. (2002). Dangerous and Severe Personality Disorder: Response and Role of the
Psychiatric Team. Routledge: London.
Byrne, E.J. (1997). Acute and Sub-Acute Confusional States (Delirium) in Later Life. Chapter 10 in:
Norman. I.J. and Redfern, S.J. (Eds.) (1997). Mental Health Care for Elderly People. New York.
Churchill Livingstone.
Byrt, R. and Doyle, M. 2007. Prevention and Reduction of Violence and Aggression. Chapter 5 in:
National Forensic Nurses’ Research and Development Group: Kettles, A.M., Woods, P., Byrt, R..,
Addo, M. A, Coffey, M. and Doyle, M (Eds.). 2007 “Forensic Mental Health Nursing: Forensic
Aspects of Acute Care”. ” London. Quay Books, MA Healthcare, Ltd.
Engebretson, J. (2004). Caring Presence: A Case Study. In: Robb, M., Barrett, S., Komaromy, C.
and Rogers, A. (Eds.). (2004). Communication, Relationships and Care. A Reader. Routledge,
Francis and Taylor Group/The Open University.
Ferris - Taylor, R. (2007). Communication. In: Gates, B. (2007). (Ed.). Learning Disabilities:
Toward Inclusion. Edinburgh. Elsevier.
Forchuk, C. and Reynolds, W. (2001). “Clients’ Reflections on Relationships with Nurses:
Comparisons from Canada and Scotland”. Journal of Psychiatric and Mental Health Nursing.
8, (1), 45-51.
Ford, K., Byrt, R. and Dooher, J. (2010). Preventing and Reducing Violence and Aggression in
Health and Social Care: A Holistic Approach. Keswick. M&K Publishing.
Freeth, R. (2007). Humanising Psychiatry and Mental Health Care. The Challenge of the Person –
Centred Approach. Oxford. Radcliffe Publishing.
Gallop, R. and Tully, T. (2009). ”The Person who Self – Harms”. In: Barker, P. (Ed.). (2nd Ed.).
(2009). Psychiatric and Mental Health Nursing. The Craft of Caring. London. Hodder Arnold.
Keen, T. and Barker, P. (2009). The Person with a Diagnosis of Schizophrenia. In: Barker, P. (Ed.).
(2009). (2nd Ed.) Psychiatric and Mental Health Nursing. The Craft of Caring. London. Hodder
Arnold.
Morris, G. (2006). Mental Health Issues and the Media: An Introduction for Mental Health
Professionals. Routledge, Taylor and Francis Group: London.
Morrison, P. (1997) Patients’ Experiences of Being Cared For. Chapter 6. In: Brykczynska, G. (Ed.)
Caring. The Compassion and Caring of Nursing. London. Arnold.
Parcell, D.A. (2010) Depression, anxiety and stress during pregnancy> Jounrla of Psychiatric and
Mental Health Nursing.17, (9), 813-820.
Rogers, C. (1990). A Client – Centred/Person – Centred Approach to Therapy. In: Kirschbaum, H.
and Henderson, V.L. (Eds.). (1990). The Carl Rogers Reader. London. Constable.
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Rogers, C. (2004). The Necessary and Sufficient Conditions of Therapeutic Personality Change. In:
Robb, M., Barrett, S., Komaromy, C. and Rogers, A. (Eds.). (2004). Communication, Relationships
and Care. A Reader. Routledge, Francis and Taylor Group/The Open University.
Clients with Communication Problems Caused by Changes to the Structure and/or
Functioning of the Brain
Arnold, E. and Ryan, J.W. (2007). “Communicating with Older Adults”. In: Arnold, E. and
Boggs, K. (Eds.). (2007) (5th Ed.). Interpersonal Relationships. Professional Communication
Skills for Nurses. St. Louis, Missouri. Saunders Elsevier.
Baldwin, C. and Capstick, A. (eds.). (2007). Tom Kitwood on Dementia: A Reader and Critical
Commentary. Maidenhead. Open University Press.
Bryan, K. and Maxim, J. (Eds.). (2006). Communication Disability in the Dementias. London. Whurr
Publishers.
Byrt, C. et al. (2003). Making Empowerment a Reality: A Personal Account. Chapter 13 in:
Dooher, J. and Byrt, R. (Eds.) (2003). Empowerment and the Health Service User. Dinton,
Salisbury. Quay Books, Mark Allen Publishing, Ltd.
Cobley, M. (2002). Using Outdoor Spaces for People with Dementia. A Carer’s Perspective.
Working with Older People. 6, (2), 23 – 30.
Hayes, N, and Minardi, H. (2002). Abnormal Psychology in Old Age. In: Woodrow, P. (ed). (2002).
Ageing. Issues for Physical, Psychological and Social Health. London. Whurr Publishers.
Lovegrove, B. (2002). Good Neighbours: Help or Hindrance? Nursing Older People. 14, (6), 10 –
13.
Neno, R. et al. (2007). Older People and Mental Health Nursing: A Handbook of Care. Oxford.
Blackwell Publishing.
Norman, I.J. (2010). Person – Centred Dementia Care. In: Redfern, S, J. and Ross, F.M. (Eds.)
(2010). Nursing Older People. Edinburgh. Churchill Livingstone.
Oddy, R. (2003). (2nd Ed.). Promoting Mobility for People with Dementia. A Problem Solving
Approach. Chapter 2: “Making Communication Easier”. London. Age Concern.
Redfern, S.J. and Ross, F.M. (2010). Nursing Older People. Edinburgh. Elsevier Churchill
Livingstone.
Reynolds, W. (2005). The Concept of Empathy. In: Cutcliffe, J.R. and McKenna, H.P. (Eds.).
(2005). The Essential Concepts of Nursing. Edinburgh. Elsevier Churchill Livingstone.
Richards, D., Clark, T. and Clarke, C. (Eds.). (2007). The Human Brain and Its Disorders. Oxford.
Oxford University Press.
Royal College of Physicians and College of Health. (1998). Stroke Rehabilitation. Patient and
Carer Views. London. Royal College of Physicians of London.
White, S.J. (1997). Empathy: A Literature Review and Concept Analysis. Journal of Clinical
Nursing. 6, 4, 253 – 257.
Comminication with People Who are Bereaved
Kubler-Ross, E. (1970). On Death and Dying. London. Macmillan.
Lugton, J. (2002). Communicating with Dying People and Their Relatives. Abingdon.
Radcliffe Medical Press.
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Sands (Stillbirth and Neonatal Birth Charity) (2010). Website. www.uk-sands.org/
Schott, J. et al. (2007). (3rd Ed.). Pregnancy Loss and the Death of a Baby: Guidelines for
Professionals. Shepperton on Thames. Sands Stillbirth and Neonatal Death Charity/Bosun
Press.
Sweet, A. (1998). Taking the Trauma Out of a Crisis. Nursing Times. 94, (33), 26-28.
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