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Module 4 Chapter 24
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  1. What are the differences between the levels of communication: Intrapersonal, Interpersonal, Small-group, Public? How would the nurse apply these principles?
    • Intrapersonal communication is a powerful form of communication that occurs within an individual. This level of communication is also called self-talk, self-verbalization, or inner thought. People's thoughts strongly influence perceptions, feelings, behavior, and self-concept. You need to be aware of the nature and content of your own thinking. Self-talk provides a mental rehearsal for difficult tasks or situations so individuals deal with them more effectively and with increased confidence
    • Interpersonal communication is one-on-one interaction between a nurse and another person that often occurs face to face. It is the level most frequently used in nursing situations and lies at the heart of nursing practice. It takes place within a social context and includes all the symbols and cues used to give and receive meaning. Because meaning resides in persons and not in words, messages received are sometimes different from intended messages.
    • Small-group communication is interaction that occurs when a small number of persons meet. This type of communication is usually goal directed and requires an understanding of group dynamics. When nurses work on committees, lead patient support groups, form research teams, or participate in patient care conferences, they use a small-group communication process. Small groups are most effective when they are cohesive and committed and have an appropriate meeting place with suitable seating arrangements
    • Public communication is interaction with an audience. Nurses have opportunities to speak with groups of consumers about health-related topics, present scholarly work to colleagues at conferences, or lead classroom discussions with peers or students. Public communication requires special adaptations in eye contact, gestures, voice inflection, and use of media materials to communicate messages effectively. Effective public communication increases audience knowledge about health-related topics, health issues, and other issues important to the nursing profession.
  2. What are the basic elements of the communication process and how does each impact the communication process?
    • Referent: The referent motivates one person to communicate with another. In a health care setting sights, sounds, odors, time schedules, messages, objects, emotions, sensations, perceptions, ideas, and other cues initiate communication. Knowing which stimulus initiates communication enables you to develop and organize messages more efficiently and better perceive meaning in another's message. A patient request for help prompted by difficulty breathing brings a different nursing response than a request prompted by hunger.
    • Sender and Receiver: The sender is the person who encodes and delivers the message, and the receiver is the person who receives and decodes the message. The sender puts ideas or feelings into a form that is transmitted and is responsible for the accuracy of its content and emotional tone. The sender's message acts as a referent for the receiver, who is responsible for attending to, translating, and responding to the sender's message. Sender and receiver roles are fluid and change back and forth as two persons interact; the more likely they will accurately perceive one another's meaning and respond accordingly.
    • Messages: The message is the content of the communication. It contains verbal, nonverbal, and symbolic language. Personal perceptions sometimes distort the receiver's interpretation of the message. Two nurses can provide the same information yet convey very different messages because of their personal communication styles. Two persons understand the same message differently. You send effective messages by expressing clearly, directly, and in a manner familiar to the receiver.
    • Channels: Channels are means of conveying and receiving messages through visual, auditory, and tactile senses. Facial expressions send visual messages, spoken words travel through auditory channels, and touch uses tactile channels. Individuals usually understand a message more clearly when the sender uses more channels to convey it.
    • Feedback: Feedback is the message the receiver returns. It indicates whether the receiver understood the meaning of the sender's message. Senders seek behavior accordingly.
  3. In what ways do the following aspects of verbal communication impact the communication process: vocabulary, denotative and connotative meaning, pacing, intonation, clarity and brevity, timing and relevance?
    • Vocabulary: Communication is unsuccessful if senders and receivers cannot translate one another's words and phrases. When a nurse cares for a patient who speaks another language, an interpreter is often necessary. Even those who speak the same language use subcultural variations of certain words (e.g., dinner means a noon meal to one person and the last meal of the day to another). Medical jargon (technical terminology used by health care providers) sounds like a foreign language to patients unfamiliar with the health care setting. Limiting use of medical jargon to conversations with other health care team members improves communication. Children have a more limited vocabulary than adults.
    • Denotative and Connotative Meaning: Some words have several meanings. Individuals who use a common language share the denotative meaning: baseball has the same meaning for everyone who speaks English, but code denotes cardiac arrest primarily to health care providers. The connotative meaning is the shade or interpretation of the meaning of a word influenced by the thoughts, feelings, or ideas people have about the word. For example, health care providers tell a family that a loved one is in serious condition, and they believe that death is near; but to nurses serious simply describes the nature of the illness. You need to carefully select words, avoiding easily misinterpreted words, especially when explaining a patient's medical condition or therapy. Even a much-used phrase such as “I'm going to take your vital signs” may be unfamiliar to an adult or frightening to a child.
    • Pacing: Conversation is more successful at an appropriate speed or pace. Speak slowly and enunciate clearly. Talking rapidly, using awkward pauses, or you are hiding the truth. Think before speaking and develop an awareness of the rhythm of your speech to improve pacing.
    • Intonation: Tone of voice dramatically affects the meaning of a message. Depending on intonation, even a simple question or statement expresses enthusiasm, anger, concern, or indifference. Be aware of voice tone to avoid sending unintended messages. For example, a patient interprets a nurse's patronizing tone of voice as condescending, and this inhibits further communication. A patient's tone of voice often provides information about his or her emotional state or energy level.
    • Clarity and Brevity: Effective communication is simple, brief, and direct. Fewer words result in less confusion. Speaking slowly, enunciating clearly, and using examples to make explanations easier to understand improve clarity. Repeating important parts of a message also clarifies communication. Phrases such as “you know” or “OK?” at the end of every sentence detract from clarity. Use short sentences and words that express an idea simply and directly. “Where is your pain?” is much better than “I would like you to describe for me the location of your discomfort.”
    • Timing and Relevance: Timing is critical in communication. Even though a message is clear, poor timing prevents it from being effective. For example, you do not begin routine teaching when a patient is in severe pain or emotional distress. Often the best time for interaction is when a patient expresses an interest in communicating. If messages are relevant or important to the situation at hand, they are more effective. When a patient is facing emergency surgery, discussing the risks of smoking is less relevant than explaining presurgical procedures.
  4. In what ways do the following aspects of nonverbal communication impact the communication process: personal appearance, posture and gait, facial expression, eye contact, gestures, sounds, territoriality and personal space?
    • Personal Appearance: Personal appearance includes physical characteristics, facial expression, and manner of dress and grooming. These factors help communicate physical well-being, personality, social status, occupation, religion, culture, and self-concept. First impressions are largely based on appearance.
    • Posture and Gait: Posture and gait (way of walking) are forms of self-expression. The way people sit, stand, and move reflects attitudes, emotions, self-concept, and health status. For example, an erect posture and a quick, purposeful gait communicate a sense of well-being and confidence. Leaning forward conveys attention. A slumped posture and slow shuffling gait indicates depression, illness, or fatigue.
    • Facial Expression: The face is the most expressive part of the body. Facial expressions convey emotions such as surprise, fear, anger, happiness, and sadness. Some people have an expressionless face, or flat affect, which reveals little about what they are thinking or feeling. An inappropriate affect is a facial expression that does not match the content of a verbal message (e.g., smiling when describing a sad situation). People are sometimes unaware of the messages their expressions convey. For example, a nurse frowns in concentration while doing a procedure, and the patient disapproval. Patients closely observe nurses. Consider the impact a nurse's facial expression has on a person who asks, “Am I going to die?” The slightest change in the eyes, lips, or facial muscles reveals the nurse's feelings. Although it is hard to control all facial expressions, try to avoid showing shock, disgust, dismay, or other distressing reactions in a patient's presence.
    • Eye Contact: People signal readiness to communicate through eye contact. Maintaining eye contact during conversation shows respect and willingness to listen. Eye contact also allows people to closely observe one another. Lack of eye contact may indicate anxiety, defensiveness, discomfort, or lack of confidence in communicating. However, persons from some cultures consider eye contact intrusive, threatening, or harmful and minimize or avoid its use.
    • Gestures: Gestures emphasize, punctuate, and clarify the spoken word. Gestures alone carry specific meanings, or they create messages with other communication cues. A finger pointed toward a person communicates several meanings; but, when accompanied by a frown and stern voice, the gesture becomes an accusation or threat. Pointing to an area of pain is sometimes more accurate than describing its location.
    • Sounds: Sounds such as sighs, moans, groans, or sobs also communicate feelings and thoughts. Combined with other nonverbal communication, sounds help to send clear messages. They have several interpretations: moaning conveys pleasure or suffering, and crying communicates happiness, sadness, or anger. Validate nonverbal messages with the patient to interpret them accurately.
    • Territoriality and Personal Space: Territoriality is the need to gain, maintain, and defend one's right to space. Territory is important because it provides people with a sense of hospital room. Personal space is invisible, individual, and travels with the person. During interpersonal interaction, people maintain varying distances between each other, depending on their culture, the nature of their relationship, and the situation. When personal space becomes threatened, people respond defensively and communicate less effectively. Situations dictate whether the interpersonal distance between nurse and patient is appropriate.
  5. What is the difference between a social relationship and a professional relationship?
    • In a therapeutic relationship, the aim is to help the client. Social relationships are for companionship and aren't goal oriented.
    • Social relationship: Defined as relationship initiated for the purpose of friendship, socialization, enjoyment or accomplishment of a task. Mutual needs are met during social interaction (e.g. participants share ideas, feelings, and experiences).
    • Professional Nursing Relationships: A nurse's application of knowledge, understanding of human behavior and communication, and commitment to ethical behavior help create professional relationships. Having a philosophy based on caring and respect for others helps you be more successful in establishing relationships of this nature. Helping relationships are the foundation of clinical nursing practice. In such relationships you assume the role of professional helper and come to know a patient as an individual who has unique health needs, human responses, and patterns of living. Therapeutic relationships promote a psychological climate that facilitates positive change and growth.
  6. What is the difference between social communication and therapeutic communication?
    • Socializing (Social communication) is an important initial component of interpersonal communication. It helps people get to know one another and relax. It is easy, superficial, and not deeply personal; whereas therapeutic interactions are often more intense, difficult, and uncomfortable. A nurse often uses social conversation to lay a foundation for a closer relationship. “Hi, Mr. Simpson, I hear it's your birthday today. How old are you?” A friendly, informal, and warm communication style helps establish trust, but you have to get beyond social conversation to talk about issues or concerns affecting the patient's health. During social conversation some patients ask personal questions such as those about your family or place of residence. Students often wonder whether it is appropriate to reveal such information. The skillful nurse uses judgment about what to share and provides minimal information or deflects such
    • Therapeutic communication between you and your patients allows the attainment of health-related goals. The goals of a therapeutic relationship focus on a patient achieving optimal personal growth related to personal identity, ability to form relationships, and goals. There is an explicit time frame, a goal-directed approach, and a high expectation of confidentiality. A nurse establishes, directs, and takes responsibility
  7. How does a nurse apply the following elements of professional communication?
    • Courtesy: Common courtesy is part of professional communication. To practice courtesy, say hello and goodbye to patients and knock on doors before entering. State your purpose, address people by name, and say “please” and “thank you” to team members.
    • Use of Names: Always introduce yourself. Failure to give your name and status (e.g., nursing student, registered nurse, or licensed practical nurse) or acknowledge a patient creates uncertainty about the interaction and conveys an impersonal lack of commitment or caring. Making eye contact and smiling recognizes others. Addressing people by name conveys respect for human dignity and uniqueness. Because using last names is respectful in most cultures, nurses usually use a patient's last name in an initial interaction and then use the first name if the patient requests it.
    • Privacy and confidentiality: my answer; helps build trust and shows respect (didn’t find in book)
    • Trustworthiness: Trust is relying on someone without doubt or question. Being trustworthy means helping others without hesitation. To foster trust, communicate warmth and demonstrate consistency, reliability, honesty, competence, and respect. Sometimes it isn't easy for a patient to ask for help. Trusting another person involves risk and vulnerability; but it also fosters open, therapeutic communication and enhances the expression of feelings, thoughts, and needs. Without trust a nurse-patient relationship rarely progresses beyond social interaction and superficial care. Avoid dishonesty at all costs. Withholding key information, lying, or distorting the truth violates both legal and ethical standards of practice.
    • Autonomy and Responsibility: Autonomy is being self-directed and independent in accomplishing goals and advocating for others. Professional nurses make choices and accept responsibility for the outcomes of their actions. They take initiative in problem solving and communicate in a way that reflects the importance and purpose of the therapeutic conversation. Professional nurses also recognize a patient's autonomy.
    • Assertiveness: Assertiveness allows you to express feelings and ideas without judging or hurting others. Assertive behavior includes intermittent eye contact; nonverbal communication that reflects interest, honesty, and active listening; spontaneous verbal responses with a confident voice; and culturally sensitive use of touch and space. An assertive nurse communicates self-assurance; communicates feelings; takes responsibility for choices; and is respectful of others’ feelings, ideas, and satisfying interpersonal relationships, and increases goal attainment. Assertive individuals make decisions and control their lives more effectively than nonassertive individuals. They deal with criticism and manipulation by others, learn to say no, set limits, and resist intentionally imposed guilt. Assertive responses contain “I” messages such as “I want,” “I need,” “I think,” or “I feel”
  8. How do the following relate to the assessment phase of the nursing process: physical and emotional factors, developmental factors, sociocultural factors, and gender?
    • Physical and Emotional Factors: It is especially important to assess the psychophysiological factors that influence communication. Many altered health states and human responses limit communication. Eg Persons with hearing or visual impairments often have difficulty receiving messages. Review of a patient's medical record provides relevant information about his or her ability to communicate. Assessment includes communicating directly with patients to determine their ability to attend to, interpret, and respond to stimuli.
    • Developmental Factors: Aspects of a patient's growth and development also influence nurse-patient interaction. For example, an infant's self-expression is limited to crying, body movement, and facial expression; whereas older children express their needs more directly. Age alone does not determine an adult's capacity for communication. Hearing loss and visual impairments are common changes that occur during aging that contribute to communication barriers. Communicate with older adults on an adult level and avoid patronizing or speaking in a condescending manner.
    • Sociocultural Factors: Culture influences thinking, feeling, behaving, and communicating. Be aware of the typical patterns of interaction that characterize various cultures. For example, European Americans are more open and willing to discuss private family matters; whereas Hispanics, African Americans, and Asian Americans are sometimes reluctant to reveal personal or family information to strangers. Hispanics and Asian Americans value a quiet demeanor and self-restraint; to be open or argumentative reflects negatively on family honor. Native Americans also value silence and are comfortable with it. Foreign-born persons do not always speak or understand English. Those who speak English as a second language often experience difficulty with self-expression or language comprehension.
    • Gender: Gender is another factor influencing how we think, act, feel, and communicate. Men tend to use less verbal communication but are more likely to initiate communication and address issues more directly. They are also more likely to talk about issues. Women tend to disclose more personal information and use more active listening, answering with responses that encourage the other person to continue the conversation.
  9. What are examples of nursing diagnostic labels used that reflect the communication process?
    • • Anxiety
    • • Social isolation
    • • Ineffective coping
    • • Compromised family coping
    • • Powerlessness
    • • Impaired social interaction
  10. How does the planning step of the nursing process relate to nurse-patient communications?
    Once you have identified the nature of a patient's communication dysfunction, consider several factors when designing the care plan. Meet basic comfort and safety needs before introducing new communication methods and techniques. When the focus is on practicing communication, arrange for a quiet, private place that is free of distractions such as television or visitors. Communication aids such as a writing or picture board for a patient with a tracheostomy or a special call system for a paralyzed patient enhance communication.
  11. How can the nurse demonstrate active listening?
    • Active listening means being attentive to what a patient is saying both verbally and nonverbally.
    • S—: Sit facing the patient. This posture conveys the message that you are there to listen and are interested in what the patient is saying.
    • O:— Observe an open posture (i.e., keep arms and legs uncrossed). This posture suggests that you are “open” to what the patient says. A “closed” position conveys a defensive attitude, possibly provoking a similar response in the patient.
    • L:— Lean toward the patient. This posture conveys that you are involved and interested in the interaction.
    • E:— Establish and maintain intermittent eye contact. This behavior conveys your involvement in and willingness to listen to what the patient is saying. Absence of eye contact or shifting the eyes gives the message that you are not interested in what the patient is saying.
    • R:— Relax. It is important to communicate a sense of being relaxed and comfortable with the patient. Restlessness communicates a lack of interest and a feeling of discomfort to the patient.
  12. What is it about each of the following techniques that is considered therapeutic?
    • Sharing observations: Stating observations often helps a patient communicate without the need for extensive questioning, focusing, or clarification. This technique helps start a conversation with quiet or withdrawn persons.
    • Sharing Empathy: Empathy is the ability to understand and accept another person's reality, accurately perceive feelings, and communicate this understanding to the other. To convey empathy, accurately perceive the patient's situation, communicate that understanding to the patient, and act on your understanding to help the patient. To express empathy, you reflect that you understand and feel the importance of the other person's communication.
    • Sharing Hope: Nurses recognize that hope is essential for healing and learn to communicate a “sense of possibility” to others. Appropriate encouragement and positive feedback are important in fostering hope and self-confidence and for helping people achieve their potential and reach their goals. You give hope by commenting on the positive aspects of the other person's behavior, performance, or response.
    • Sharing Humor: Humor is an important but often underused resource in nursing interactions. It is a coping strategy that adds perspective and helps a “any intervention that promotes health and wellness by stimulating a playful discovery, expression or appreciation of the absurdity or incongruity of life's situations.”
    • Sharing Feelings: Emotions are subjective feelings that result from one's thoughts and perceptions. Feelings are not right, wrong, good, or bad, although they are pleasant or unpleasant. If individuals do not express feelings, stress and illness may worsen. You help patients express emotions by making healthy emotional self-expression. At times patients will direct their anger or frustration prompted by their illness toward you. Do not take such expressions personally. Acknowledging patients’ feelings communicates that you listened to and understood the emotional aspects of their illness situation.
    • Using Touch: Because of modern fast-paced technical environments, nurses are required more than ever to bring the sense of caring and human connection to their patients (see Chapter 7 ). Touch is one of the most potent forms of communication. Historically physical touch played a central role in healing
    • Using Silence: It takes time and experience to become comfortable with silence. Most people have a natural tendency to fill empty spaces with words, but sometimes these spaces really allow time for a nurse and patient to observe one another, sort out feelings, think about how to say things, and consider what has been communicated. Silence prompts some people to talk. It allows a patient to think and gain insight. In general, allow a patient to break the silence, particularly when he or she has initiated it.
    • Asking Relevant Questions: Nurses ask relevant questions to seek information needed for decision making. Ask only one question at a time and fully explore one topic before moving to another area. During patient assessment questions follow a logical sequence and usually proceed from general to more specific. Open-ended questions allow patients to take the conversational lead and introduce pertinent information about a topic.
    • Providing Information: Providing relevant information tells other people what they need or want to know so they are able to make decisions, experience less anxiety, and feel safe and secure. It is also an integral aspect of health teaching. It usually is not helpful to hide information from patients, particularly when they seek it. If a health care provider withholds information, the nurse clarifies the reason with him or her. Patients have a right to know about their health status and what is happening in their environment.
    • Paraphrasing: Paraphrasing is restating another's message more briefly using one's own words. Through paraphrasing you send feedback that lets a patient know that he or she is actively involved in the search for understanding. Practice is required to paraphrase accurately. If the meaning of a message is changed or distorted through paraphrasing, communication becomes ineffective.
    • Clarifying: To check whether understanding is accurate, restate an unclear or ambiguous message to clarify the sender's meaning. In addition, ask the other person to rephrase it, explain further, or give an example of what the person means. Without clarification you may make invalid assumptions and miss valuable information.
    • Focusing: Focusing centers on key elements or concepts of a message. If conversation is vague or rambling or patients begin to repeat themselves, focusing is a useful technique. Do not use focusing if it interrupts patients while they are discussing an important issue. Rather use it to guide the direction of conversation to important areas.
    • Summarizing: Summarizing is a concise review of key aspects of an interaction. It brings a sense of satisfaction and closure to an individual conversation and is especially helpful during the termination phase of a nurse-patient relationship. By reviewing a conversation, participants focus on key issues and add relevant information as needed.
    • Self-Disclosure: Self-disclosures are subjectively true personal experiences about the self that are intentionally revealed to another person. This is not therapy for a nurse; rather it shows patients that the nurse understands their experiences and their experiences are not unique. You choose to share experiences or feelings that are similar to those of the patient and emphasize both the similarities and differences.
    • Confrontation: When you confront someone in a therapeutic way, you help the other person become more aware of inconsistencies in his or her feelings, attitudes, beliefs, and behaviors ( Stuart, 2009 ). This technique improves patient self-awareness and helps him or her recognize growth and deal with important issues. Use confrontation only after you have established trust, and do it gently with sensitivity: “You say you’ve already decided what to do, yet you're still talking a lot about your options.”
  13. Why are each of the following techniques considered non-therapeutic?
    • Asking personal questions: “Why don't you and John get married?” Asking personal questions that are not relevant to the situation simply to satisfy your curiosity is not appropriate professional communication. Such questions are nosy, invasive, and unnecessary. If patients wish to share private information, they will. To learn more about a patient's interpersonal roles and relationships, ask a question such as: “How would you describe your relationship with John?”
    • Giving Personal Opinions: “If I were you, I'd put your mother in a nursing home.” When a nurse gives a personal opinion, it takes decision making away from the other person. It inhibits spontaneity, stalls problem solving, and creates doubt.
    • Changing the Subject: “Let's not talk about your problems with the insurance company. It's time for your walk.” Changing the subject when another person is trying to communicate their story is rude and shows a lack of empathy. It tends to block further communication, and the sender then withholds important messages or fails to openly express feelings.
    • Automatic Responses: Making stereotyped remarks about others reflects poor nursing judgment and threatens nurse-patient or team relationships. A cliché is a stereotyped comment such as, “You can't win them all,” that tends to belittle the other person's feelings and minimize the importance of his or her message. These automatic phrases communicate that you are not taking concerns seriously or responding thoughtfully. Another kind of automatic response is parroting (i.e., repeating what the other person has said word for word). Parroting is easily overused and is not as effective as paraphrasing. A simple “oh?” gives you time to think if the other person says something that takes one by surprise.
    • False Reassurance: “Don't worry, everything will be all right.” When a patient is seriously ill or distressed, you may be tempted to offer hope to the patient with statements such as “You’ll be fine” or “There's nothing to worry about.” When a patient is reaching for understanding, false reassurance discourages open communication. Offering reassurance not supported by facts or based in reality does more harm than good.
    • Sympathy: “I'm so sorry about your mastectomy; it must be terrible to lose a breast.” Sympathy is concern, sorrow, or pity felt for a patient. The nurse takes on a patient's problems as if they were his or her own. Sympathy is a subjective look at another person's world that prevents a clear perspective of the issues confronting that person. If a nurse overidentifies with a patient, objectivity is lost, and the nurse is not able to help the sometimes prevent effective problem solving and impair good judgment. A more empathetic approach is: “The loss of a breast is a major change. How do you think it will affect your life?”
    • Asking for Explanations: “Why are you so anxious?” Some nurses are tempted to ask the other person to explain why the person believes, feels, or has acted in a certain way. Patients frequently interpret “why” questions as accusations or think the nurse knows the reason and is simply testing them. Regardless of patient perception of your motivation, “why” questions cause resentment, insecurity, and mistrust. If you need additional information, it is best to phrase a question to avoid using the word “why.” “You seem upset. What's on your mind?” is more likely to help the anxious patient communicate.
    • Approval or Disapproval: “You shouldn't even think about assisted suicide; it's not right.” Do not impose your own attitudes, values, beliefs, and moral standards on others while in the professional helping role. Other people have the right to be themselves and make their own decisions. Judgmental responses often contain terms such as should, ought, good, bad, right, or wrong. Agreeing or disagreeing sends the subtle message that you have the right to make value judgments about patient decisions. Approving implies that the behavior being praised is the only acceptable one. Often a patient shares a decision with you, not in an effort to seek approval but to provide a means to discuss feelings. Disapproval implies that the patient needs to meet your expectations or standards. Instead help patients explore their own beliefs and decisions. The response, “I'm surprised you're considering assisted suicide. Tell me more about it,” gives the patient a chance to express ideas or feelings without fear of being judged.
    • Defensive Responses: “No one here would intentionally lie to you.” Becoming defensive in the face of criticism implies that the other person has no right to an opinion. The sender's concerns are ignored when the nurse focuses on the need for self-defense, defense of the health care team, or defense of others. When patients express criticism, listen to what they have to say. Listening does not imply agreement. You need to listen uncritically to discover reasons for a patient's anger or dissatisfaction. By avoiding a defensive attitude you are able to defuse anger and uncover deeper concerns: “You believe that people have been dishonest with you. It must be hard to trust anyone.”
    • Passive or Aggressive Responses: “Things are bad, and there's nothing I can do about it.” “Things are bad, and it's all your fault.” Passive responses serve to avoid conflict or sidestep issues. They reflect feelings of sadness, depression, anxiety, powerlessness, and hopelessness. Aggressive responses provoke confrontation at the other person's expense. They reflect feelings of anger, frustration, resentment, and stress. Nurses who lack assertive skills also use triangulation, complaining to a third party rather than confronting the problem or expressing concerns directly to the source. This lowers team morale and draws others into the conflict situation. Assertive communication is a far more professional approach for the nurse to take.
    • Arguing: “How can you say you didn't sleep a wink when I heard you snoring all night long?” Challenging or arguing against perceptions denies that they are real and valid to the other person. It implies that the other person is lying, misinformed, or uneducated. The skillful nurse gives information or presents reality in a way that avoids argument: “You feel like you didn't get any rest at all last night, even though I thought you slept well since I heard you snoring.”
    • Defensive Responses: “No one here would intentionally lie to you.” Becoming defensive in the face of criticism implies that the other person has no right to an opinion. The sender's concerns are ignored when the nurse focuses on the need for self-defense, defense of the health care team, or defense of others. When patients express criticism, listen to what they have to say. Listening does not imply agreement. You need to listen uncritically to discover reasons for a patient's anger or dissatisfaction. By avoiding a defensive attitude you are able to defuse anger and uncover deeper concerns: “You believe that people have been dishonest with you. It must be hard to trust anyone.”
  14. Give an example of each non-therapeutic communication technique?
    See above
  15. How can the nurse adapt communication techniques for the client with special needs (Box24-10)?
    • Patients Who Cannot Speak Clearly (Aphasia, Dysarthria, Muteness)
    • • Listen attentively, be patient, and do not interrupt.
    • • Ask simple questions that require “yes” or “no” answers.
    • • Allow time for understanding and response.
    • • Use visual cues (e.g., words, pictures, and objects) when possible.
    • • Allow only one person to speak at a time.
    • • Encourage patient to converse.
    • • Let patient know if you have not understood him or her.
    • • Collaborate with speech therapist as needed.
    • • Use communication aids:
    • Patients Who Are Cognitively Impaired
    • • Use simple sentences and avoid long explanations.
    • • Ask one question at a time.
    • • Allow time for patient to respond.
    • • Be an attentive listener.
    • • Include family and friends in conversations, especially in subjects known to patient.
    • Patients Who Are Hearing Impaired
    • • Check for hearing aids and glasses.
    • • Reduce environmental noise.
    • • Get patient's attention before speaking.
    • • Face patient with mouth visible.
    • • Do not chew gum.
    • • Speak at normal volume—do not shout.
    • • Rephrase rather than repeat if misunderstood.
    • • Provide a sign language interpreter if indicated.
    • Patients Who Are Visually Impaired
    • • Check for use of glasses or contact lenses.
    • • Identify yourself when you enter room and notify patient when you leave room.
    • • Speak in a normal tone of voice.
    • • Do not rely on gestures or nonverbal communication.
    • • Use indirect lighting, avoiding glare.
    • • Use at least 14-point print.
    • Patients Who Are Unresponsive
    • • Call patient by name during interactions.
    • • Communicate both verbally and by touch.
    • • Speak to patient as though he or she can hear.
    • • Explain all procedures and sensations.
    • • Provide orientation to person, place, and time.
    • • Avoid talking about patient to others in his or her presence.
    • Patients Who Do Not Speak English
    • • Speak to patient in normal tone of voice.
    • • Establish method for patient to ask for assistance (call as interpreters.
    • • Use communication board, pictures, or cards.
    • • Translate words from native language into English list for patient to make basic requests.
    • • Have dictionary (e.g., English/Spanish) available if patient can read.

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