Ch. 18 Objectives
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- Communication is a dynamic reciprocal process of sending and receiving messages, which may be verbal, nonverbal, or both. Communication is:
- Sharing or transmitting thoughts or feelings
- A way to meet physical, psychosocial, emotional, and spiritual needs
- A process - the act of sending, receiving, interpreting and reacting to a message
- Content - the actual subject matter, words, gestures, and substance of the message
Identify the three basic levels of communication.
- a) Intrapersonal communication is conscious internal dialogue, sometimes known as self-talk.Constructive affirmations, or positive self-talk promote success in a task. By contrast, negative self-talk may adversely affect the person's ability to complete a task. An example of intrapersonal communication by nurses would be when a nurse enters a room and notices that the patient is pale, diaphoretic, and moaning. At that point, the nurse may ask himself or herself, What's happened? This client appears to be in a lot of pain.
- b) Interpersonal communication is communication between two or more people, such as a face-to-face conversation between two people. In nursing, interpersonal communication is used to gather information during assessment, to teach about health issues, to explain care, and to provide comfort and support.
- c) Group communication is interaction that occurs among several people.
- Small-group communication occurs when you engage in an exchange of ideas with two or more individuals at the same time. Examples of small-group communication include staff meetings, committee meetings, educational groups, and self-help groups. Working with groups requires effective communication skills and a basic understanding of group processes.
- Public speaking is a unique form of group communication. Generally, the speaker addresses a dozen to hundreds of people, and varying degrees of interaction occur. Speakers may deliver a speech, talk directly with a small group of audience members, or have open discussion with the group. Nurses often engage in public speaking to educate groups of people about health issues, to lobby for legislation related to health promotion, and to address professional groups at conferences and conventions.
Discuss the elements of the communication process.
- 1) The sender initiates the conversation to deliver a message (content) to another individual. The sender, sometimes called the source or the encoder, uses verbal and nonverbal methods to transmit the message. Encoding refers to the process of selecting the words, gestures, tone of voice, signs, and symbols used to transmit the message. Encoding is not always consciously intentional, but it is affected by the nature of the message, the relationship between the sender and receiver, and the mood of the sender.
- 2) The message is the verbal and/or nonverbal information that the sender communicates. It might be a conversation, a speech, a gesture, a letter, and so forth. Effective messages are complete, clear, concise, organized, timely, and expressed in a manner that the receiver can understand. The message must be appropriate for the situation and for the developmental level of the person receiving the message.
- 3) The channel is the medium used to send the message. Face-to-face communication is a commonly used channel. Nurses frequently use touch as a nonverbal way to communicate caring and concern. Other channels include written pamphlets, audiovisual aids, recordings, and telephone messages. The type of message, the purpose, and the size of audience influence the choice of what channel is best suited for the communication.
- 4) The receiver is the observer, listener, and interpreter of the message. Interpretation, also called decoding, refers to relating the message to one's past experiences to determine the sender's meaning. The receiver uses visual, auditory, and tactile senses to decode the message. If the decoded meaning matches the intended meaning, then the message was effective. However, messages are sometimes misinterpreted, especially when the receiver is not physically or emotionally ready to receive the message.
- 5) Feedback validates that the receiver received the message and understood it as the sender intended. Feedback may be verbal, nonverbal, or both. Verifying the message avoids confusion.
List the characteristics of verbal and nonverbal communication.
- Verbal Communication:
- Vocabulary - It is your responsibility to deliver messages that the client can understand; therefore, use medical terms only when you are certain the listener understands them. When encoding a message, consider the receiver's age, knowledge, education, and any cultural differences. Encourage feedback to ensure that the recipient understood the message as you intended.
- Denotative Meaning is the literal (dictionary) meaning of a word. Connotative Meaning is the implied or emotional meaning of the word.
- Pacing - the pace must be slow enough for the receiver to interpret one thought before the sender moves on to the next thought. However, the pace must be fast enough to maintain the listener's interest.
- Intonation - reflects the feeling behind the words. This is accomplished by pitch (high or low), cadence (rising and falling of the pitch), and volume (soft or loud). People tend to lose interest when someone speaks in a monotone (does not vary the pitch, cadence, and volume). Before presenting lengthy information, whether as individualized teaching or an address to a group, experiment with these variables to ensure that you maintain the listener's engagement with your topic.
- Clarity requires that you select words that convey the intended meaning and that you make sure your spoken words and the nonverbal message are congruent. Brevity can be achieved by using the fewest words possible. A conversation that is clear and brief holds the interest of all parties and effectively conveys the message.
- Timing and Relevance - timing is crucial to the communication process. Before starting a conversation, assess your client. A person who is distracted by pain, hunger, or other physiological needs will not receive the message as you intended it. Similarly, a client attempting to cope with stressors, such as limited finances, an upcoming surgery, or a terminal diagnosis, may be unable to listen effectively. Communication is effective when both parties value the interaction and find the discussion relevant.
- Credibility - a pattern of honest and timely response to patient concerns fosters credibility. As a nurse, you will be called on to provide information on a wide variety of topics. Never lie to the patient; lying destroys trust. If you tell the patient you will be right back with pain medication but do not return until she reminds you an hour later, she may doubt your credibility. To be credible, your nonverbal communication must match your spoken words.
- Humor - can have a positive influence on attitude and healing. Laughter can create physiological changes that contribute to well-being and provide an emotional release in a tense situation. However, use humor cautiously. Never direct humor at the client, disease process, or treatment team. Misused humor can have a negative effect on self-esteem, self-confidence, or the client's confidence in the treatment team.
- Nonverbal Communication:
- Facial Expression - expressions of the face and especially the eyes are some of the most demonstrative forms of nonverbal communication. Facial expressions communicate joy, anger, sadness, concern, or fear. Raised eyebrows, staring, squinting, or darting eyes all convey meaning. A mismatch between your verbal message and facial expression may cause the client to doubt your credibility.
- Posture and Gait - body position, gait, and posture offer clues to a person�s attitudes, emotions, physical well-being, and self-concept. In Western culture, an erect posture, head held high, and a quick gait are nonverbal indicators of health and a sense of self-assuredness. In contrast, a slow, shuffling gait may signify someone who is ill, depressed, or has poor self-esteem.
- Personal Appearance - clothing and personal appearance can provide clues to a person�s feelings, socioeconomic status, culture, and religion. A person who is ill, tired, or depressed may not have the energy to invest in hygiene and grooming. Dress and adornments are powerful cultural clues. Does the patient dress in a style that differs from local custom? Are pieces of jewelry or religious medallions visible? These are clues to the patient's values, as well as the patient's socioeconomic status. Pay attention to these clues, but do not make assumptions from them.
- Gestures - hand and body gestures emphasize and clarify the spoken word. They are good indicators of the feeling tone behind the conversation. Gestures vary widely among individuals and cultures, so use them with caution. Gestures can help you communicate with individuals with impaired verbal communication. Be careful, however, that you and the patient agree on the meaning of the gestures.
- Touch - can convey affection, caring, concern, and encouragement. Avoid using touch when dealing with someone who is angry or mentally disturbed, because the touch may be misinterpreted as a sign of aggression or sexual attraction. Although touch can be highly effective, use it with conscious awareness of the situation, environment, and receptivity of the patient.
Analyze factors that influence the communication process.
- 1) Environment - communication is most successful in a favorable environment. A favorable environment is quiet, private, free of noxious smells, and at a comfortable temperature. Think creatively to secure the most comfortable environment possible for communicating with patients and families.
- 2) Developmental Variations - physical and cognitive development, language skills, level of education, and maturity influence the communication process. Thus, you will need to modify your communication strategies to fit your client's developmental level. Infants and young toddlers communicate nonverbally. Older toddlers and preschoolers have more verbal ability. School-age children are usually quite comfortable interacting verbally. Older adults may be affected by sensory alterations, such as hearing loss or vision changes, or any of a variety of healthcare problems that affect cognition.
- 3) Gender - males and females communicate differently and may interpret the same communication differently. Women communicate to form connections and establish relationships. In contrast, male communication styles focus on maintaining independence and favorable positions in a hierarchy. In essence, women want to be connected, whereas men want to be one up.
- 4) Personal space - the distance that individuals engaged in communication maintain between one another is influenced by the relationship of the individuals. Intimate distance is the area immediately surrounding people that they define as their private space. It is the difference between themselves and others during interactions. In Western cultures, this distance is within 18 inches of one another. Personal distance is from 18 inches to 4 feet. Your interactions with clients and healthcare team members will commonly occur in this range. Social distance is a distance of 4 to 12 feet. It is used in more formal interaction or when communicating with a group of individuals at the same time. Public distance is considered to be beyond 12 feet. This distance requires loud and clear enunciation for communication. This distance is characterized by a lack of individuality and a greater focus on the group or community.
- 5) Territoriality - refers to the space and things that an individual identifies as belonging to him. In a hospital setting, many clients consider everything within the curtain boundary to be their territory. Also recognize that hospitalized clients are not in their home territory and are therefore likely to be less at ease during interactions.
- 6) Sociocultural Factors - culture and socioeconomic status strongly influence communication. For example, in some cultures it would be unacceptable for a male nurse to address and provide care to a female patient. Social status also plays a role in communication. For example, you may see impoverished clients being treated with less respect than wealthy members of the community, although this is certainly not ideal.
- 7) Roles and Relationships - relationships affect the choice of vocabulary, tone of voice, use of gestures, and distance associated with the communication. Some patients may view nurses as authority figures. Others may perceive nursing as a lowly occupation and limit conversation with you to matters of comfort and hygiene. If you are working with UAP's or other team members, be sure to clarify their roles with the patient.
Compare and contrast techniques that enhance communication to techniques that hinder communication:
- Communication Enhancers:
- 1) Active Listening - giving undivided attention and allowing the sender the opportunity to complete comments without interruption. As a nurse, you can demonstrate active listening by facing your client, making eye contact, and focusing the conversation on issues of importance to the client. Failure to listen to your client will result in missed messages or misinterpretation.
- 2) Establishing Trust - facilitates disclosure and honesty. To establish trust, always greet the client by name, listen actively, respond honestly to the client's concerns, and provide care competently and consistently.
- 3) Being Assertive - enables you to deal directly with stressful interpersonal communication, for example, with a client who needs to make some lifestyle changes. An assertive nurse also serves as a role model for the client.
- 4) Restating, Clarifying, and Validating Messages - using your own words to summarize the message you received from the client, ensuring that you have accurately interpreted the information, and making sure client concerns are identified and communication is focused. This is especially helpful if the client is unclear or vague with a message.
- 5) Interpreting Body Language and Sharing Observations - be observant of the client's tone of voice, rate of speech, distance, eye movement, facial expressions, and gestures. If there is inconsistency, share your observations with the patient by describing the patient's body language or tone of voice.
- 6) Exploring Issues - ask open-ended questions to obtain a clear understanding of an issue and follow your client's thoughts. Probing comments such as tell me more encourage the client to share information.
- 7) Using Silence - when you remain attentive, silence demonstrates acceptance and allows clients to compose their thoughts and provide further information. This is especially effective if your client is emotionally upset.
- 8) Summarizing the Conversation - at the end of the conversation, summarize what you have heard. Summarizing demonstrates active listening and allows the client to clarify any misunderstandings.
- Communication Hinderers:
- 1) Asking Too Many Questions - asking too many questions, especially closed questions (requiring only a yes or no answer), can make clients feel they are being interrogated. Excessive questioning may suggest insensitivity or lack of respect to the client's issues.
- 2) Asking Why - directly asking for reasons suggests criticism to some people.
- 3) Changing the Subject Inappropriately - abruptly changing the topic of discussion makes you seem uninterested. This often occurs when the nurse is intent on one issue and the client is focused on another. In an ongoing dialogue, changing the subject can stop the flow of conversation cold, and is sometimes used by both patients and nurses to avoid discussing sensitive topics.
- 4) Failing to Probe - can result in incomplete assessment and affect the quality of your care. A thorough assessment requires you to explore issues in detail.
- 5) Expressing Approval or Disapproval - although it may seem supportive, expressing approval can inhibit further sharing it puts you in the position of being the judge of what is right. This often prompts the patient to continue to seek approval.
- 6) Offering Advice - giving the client your solution negates the client's opportunity to participate as a mutual partner in the decision-making process.
- 7) Providing False Reassurance - reassurance is appropriate only if warranted. When clients or family members ask for information or tell you that they are worried, it is easy to reassure them that everything will be okay. However, such responses are uninformed, inaccurate, and may feel dismissive even condescending to the receiver. The best approach is to provide accurate information.
- 8) Stereotyping racial, cultural, religious, age-related, or gender stereotypes distort assessment and prevent you from recognizing the patient's uniqueness. Blatant stereotypes are easily recognized, and may create an intense reaction. Subtle stereotypes, however, may be equally disruptive to care. Examples of subtle stereotypes common in healthcare include:
- a) Believing a patient will be calm and know what to expect because he has had previous hospitalizations for the same diagnosis, has had previous surgeries or other procedures, or was given information about his condition.
- b) Assuming that patients will understand their healthcare because of their educational level or work experience, for example, expecting that a physician who has suffered a heart attack needs no explanation of her care.
- c) Expecting all patients with the same surgery or diagnosis to experience similar responses.
- 9) Using Patronizing Language - communicates superiority or disapproval. Statements such as, You know better than that, are patronizing and offensive to the client. The term elderspeak describes ways that healthcare workers may unintentionally show disrespect to elderly patients by using such phrases and speaking to them in a high-pitched, slow, repetitive, childlike voice. Although the intent is communicate caring, many patients are offended because it sounds as though you are speaking to a child. When you first meet your client, use a formal title Mr., Ms, and so on. This conveys respect, which is essential to a therapeutic relationship.
Communicate with clients with impaired hearing, speech or cognition.
- The following guidelines should be used when communicating with clients with impaired hearing or speech:
- 1) Nonverbal communication is the key to communication with clients with impaired speech
- 2) Ask the client to use hand gestures and a picture board, as appropriate
- 3) Solicit family assistance in understanding the client�s speech
- 4) Provide a comfortable environment for the client to practice speaking
- 5) Be positive and patient
- 6) Although the client may have difficulty speaking, you should continue to speak and explain all procedures
- 7) A referral to a speech pathologist may be necessary
- The following guidelines should be used when communicating with clients with impaired cognition or consciousness:
- 1) Always try to communicate - make every effort to communicate, even if you think that the client cannot understand you.
- 2) Don't rush the client - provide adequate time to allow the client to communicate. He needs time to respond to your questions or commands
- 3) Use multiple communication modalities - provide verbal and written discharge instructions. Review the instructions several times with the client before discharge, and include family members in the teaching
- 4) Provide reminders - use memory aids, schedules, and reminder notices to reinforce information
- 5) Orient the client - verbally orient to time, person, and place, and provide visual orientation materials, such as a calendar or schedule
- 6) Stimulate memory - if the client loses his place in the conversation, stimulate memory by repeating his last expressed thought (e.g., We were talking about your back pain. Tell me more about your back pain.)
- 7) Use short sentences - use short sentences, containing a single thought (e.g., Are you hungry?). Avoid complex statements
- 8) Ask yes/no questions ask direct questions that require only a yes or no answer (e.g., Are you hungry?)
- 9) Limit choices - limit choices to avoid confusing or frustrating the patient
- 10) Be concrete and specific - do not use vague comments to indicate that you are listening. The client may be unstable to interpret comments such as, I see Instead, repeat the client's words and directly state your response (e.g., you are cold. I will bring you a blanket)
- 11) Avoid slang and jargon - the client may not understand, and may become anxious
- 12) Use gestures model desired behaviors. You might say Brush your teeth now and then pantomime brushing your teeth
- 13) Don't assume - bear in mind that the client cannot behave differently and that he may be confused about reality. When the person is talking about superficial, routine matters, he may seem more competent than he is
- 14) For clients with expressive difficulties:
- a) If you are sure of the word the person is trying to say, repeat it. Don't guess, though
- b) Pay close attention to nonverbal communication
- c) Assess for and anticipate unmet needs, such as hunger, thirst, and pain
- d) Respond to the emotion, not the words
- e) Do not reprimand the patient if she curses or is aggressive
- 15) For patients who are unconscious:
- a) Touch and speak to unconscious or sedated patients, and advise them of care you are providing. Although the patient may not be able to respond, she may be able to hear your comments
- b) Consult with previous caregivers or the family to determine what the patient responds to
- c) Begin each interaction by identifying yourself and calling the patient by name
- d) Speak calmly and slowly
- e) Explain all healthcare procedures
- f) Provide soothing music and periods of rest
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