CommunicationCommunication

Teresa V. Hurley, MSN, RNTeresa V. Hurley, MSN, RN

Communication and the Communication and the Nurse Client RelationshipNurse Client Relationship

• Therapeutic Communication TechniquesTherapeutic Communication Techniques– Assist in the flow of communication Assist in the flow of communication

between the client and nurse with the focus between the client and nurse with the focus on the client and their needson the client and their needs

-It is a holistic approach to the person with a -It is a holistic approach to the person with a therapeutic use of self which has five therapeutic use of self which has five qualities.qualities.

Do you think you can name them?Do you think you can name them?

Qualities Qualities • EmpathyEmpathy is not only the desire but the is not only the desire but the

actual putting of self mentally and actual putting of self mentally and emotionally in the client’s place. This enables emotionally in the client’s place. This enables you to acknowledge their uniqueness and you to acknowledge their uniqueness and adapt your approach to create an effective adapt your approach to create an effective change in them.change in them.

• RespectRespect has to do with you being flexible has to do with you being flexible and adjusting rather than the client adjusting and adjusting rather than the client adjusting to youto you

What happens when a client is stripped of their What happens when a client is stripped of their clothes, separated from loved ones, lost their clothes, separated from loved ones, lost their familiar routines and surroundings etc.?familiar routines and surroundings etc.?

QualitiesQualities

• To preserve self-esteem and power, To preserve self-esteem and power, the nurse must be willing to make the nurse must be willing to make changes as holding off breakfast to changes as holding off breakfast to let a client sleep in the morning.let a client sleep in the morning.

• What other things do you think you What other things do you think you could do?could do?

QualitiesQualities

• GenuinenessGenuineness is being truthful. Do not guess is being truthful. Do not guess at an answer but be honest and say that you at an answer but be honest and say that you need assistance. Also evaluate your need assistance. Also evaluate your interactions to see what was appropriate or interactions to see what was appropriate or what needs improvement.what needs improvement.

• Concreteness and ConfrontationConcreteness and Confrontation: offer : offer responses to client’s questions and concerns so responses to client’s questions and concerns so that he/she understands. You have to express that he/she understands. You have to express clearly what you mean and the client has to so clearly what you mean and the client has to so the same. Thus confrontation is used to clarify the same. Thus confrontation is used to clarify when thoughts are not expressed clearlywhen thoughts are not expressed clearly

Guidelines for Client Guidelines for Client CommunicationCommunication

• Be an active participantBe an active participant• Guide the conversationGuide the conversation• Give broad opening statementsGive broad opening statements• Ask open-ended questionsAsk open-ended questions• Pick-up on cuesPick-up on cues• Follow through on the subject the client Follow through on the subject the client

initiatesinitiates• Utilize body language to convey empathy, Utilize body language to convey empathy,

interest, encouragementinterest, encouragement• Use silence as a therapeutic toolUse silence as a therapeutic tool

Communication Communication

A multileveled process of sending and A multileveled process of sending and receiving messages. receiving messages.

verbally and non-verbally by using:verbally and non-verbally by using:

signs, words, gestures, symbols, spacesigns, words, gestures, symbols, space

Facts, feelings, and meanings are Facts, feelings, and meanings are transmitted through this process transmitted through this process

Primary Bases for all Primary Bases for all SkillsSkills

• AssessmentAssessment• Administration of therapeutic Administration of therapeutic

modalitiesmodalities• Evaluation of skills performedEvaluation of skills performed• InterviewingInterviewing• CounselingCounseling• Health TeachingHealth Teaching

Examples of Therapeutic Examples of Therapeutic TechniquesTechniques

• AcknowledgementAcknowledgement• ClarificationClarification• FeedbackFeedback• FocusingFocusing• Incomplete Incomplete

SentencesSentences• ListeningListening• Minimum Verbal Minimum Verbal

ActivityActivity

• Mutual Fit or Mutual Fit or CongruenceCongruence

• Non-verbal Non-verbal encouragementencouragement

• Open-ended Open-ended questionsquestions

• ParaphraseParaphrase• ReflectionReflection• RestatementRestatement• ValidationValidation

Open-ended QuestionsOpen-ended Questions

• Can not be Can not be answered with a answered with a “yes”, “no” or “yes”, “no” or “maybe”“maybe”

-Ask questions that -Ask questions that need an answer of need an answer of several wordsseveral words

• ““How did you sleep How did you sleep last night?”last night?”

• Do not say:Do not say:

““Did you have a Did you have a good night’s good night’s sleep?”sleep?”

AcknowledgementAcknowledgement

• You do not insert your own You do not insert your own judgments or valuesjudgments or values

• It may be verbal or non-verbalIt may be verbal or non-verbal

• ““I hear what you are saying.”I hear what you are saying.”• ““Yes, go on.”Yes, go on.”• ““Uh huh.”Uh huh.”

ClarificationClarification

• Ascertain or make clear the hidden Ascertain or make clear the hidden meaning of a message. Is the meaning of a message. Is the message sent the message received?message sent the message received?

• ““I do not understand. Can you say it I do not understand. Can you say it in another way.”in another way.”

• ““Are you saying…” [repeat meaning Are you saying…” [repeat meaning of the client’s message]of the client’s message]

FeedbackFeedback

• Relay to the client the effect of Relay to the client the effect of his/her wordshis/her words

• Keep the client on course orKeep the client on course or• Alter the course Alter the course

• ““You did well.”You did well.”• ““When you say that, it makes me feel When you say that, it makes me feel

uncomfortable.”uncomfortable.”

FocusingFocusing

• Focus or refocus on the client’s Focus or refocus on the client’s statement based on the central theme statement based on the central theme or cues givenor cues given

• ““You were telling me about how hard You were telling me about how hard it is to talk to your mother.”it is to talk to your mother.”

• ““You said that the impending surgery You said that the impending surgery is making you feel frightened.”is making you feel frightened.”

Incomplete SentencesIncomplete Sentences

• Encourage the client to go on.Encourage the client to go on.

• ““Then your doctor said…”Then your doctor said…”

Minimum Verbal ActivityMinimum Verbal Activity

• Allow client to lead the conversationAllow client to lead the conversation

• ““Go on.”Go on.”• ““You feel…?”You feel…?”

Nonverbal Nonverbal EncouragementEncouragement

• Use body languageUse body language• NodNod• Lean forwardLean forward• TouchTouch• Sitting down at the bedside facing Sitting down at the bedside facing

the clientthe client

Communication BlocksCommunication Blocks

• Hinders or stops communicationHinders or stops communication• Focus is on the nurseFocus is on the nurse• The nurses needs are being metThe nurses needs are being met

Non-therapeutic Non-therapeutic TechniquesTechniques

• Changing the Changing the subjectsubject

• False reassuranceFalse reassurance• Giving adviceGiving advice• IncongruenceIncongruence• AssumptionsAssumptions

• Over loadingOver loading• Under loadingUnder loading• Value JudgmentsValue Judgments• InvalidationInvalidation• Social ResponseSocial Response

Changing the SubjectChanging the Subject

• New topics introduced New topics introduced inappropriatelyinappropriately

• May be an indicator of anxietyMay be an indicator of anxiety

• ““How many children do you have?” How many children do you have?”

Asked when the client is crying and Asked when the client is crying and afraid of surgery.afraid of surgery.

False ReassuranceFalse Reassurance

• The use of “ pat statements”, The use of “ pat statements”, “cliches”. “cheery” words “cliches”. “cheery” words

• ““It’s going to be all right.”It’s going to be all right.”• ““Don’t worry. This pain medication Don’t worry. This pain medication

always works.” always works.”

Giving AdviceGiving Advice

• Nurse gives advice or opinionNurse gives advice or opinion• Tells the client what to doTells the client what to do• Assumes client can not handle life Assumes client can not handle life

decisionsdecisions

• ““If you are unhappy with your doctor, If you are unhappy with your doctor, you should change doctors.”you should change doctors.”

• ““Don’t have the surgery here. Go to…Don’t have the surgery here. Go to…It’s where I had mine.”It’s where I had mine.”

IncongruenceIncongruence

• Non-verbal and verbal messages Non-verbal and verbal messages sent contradict one anothersent contradict one another

• Contradiction between time/space or Contradiction between time/space or

Verbal/nonverbalVerbal/nonverbal

““I’d like to talk to you” [but I’m just I’d like to talk to you” [but I’m just too busy].too busy].

AssumptionsAssumptions

• Assume the meaning of client’s Assume the meaning of client’s behavior without him/her validating behavior without him/her validating itit

• A suicidal patient is smilingA suicidal patient is smiling• The nurse reports that the client is The nurse reports that the client is

“happy and feeling much better”.“happy and feeling much better”.

InvalidationInvalidation

• Client’s thoughts, feelings or Client’s thoughts, feelings or presence is denied or ignoredpresence is denied or ignored

• Client: “Hi, how are you today?”Client: “Hi, how are you today?”• Nurse: “I can’t talk now. I am going Nurse: “I can’t talk now. I am going

to lunch.”to lunch.”

Over LoadingOver Loading

• Giving too much data at one time, Giving too much data at one time, talking fast, changing subjectstalking fast, changing subjects

• ““What’s your name? I see you are What’s your name? I see you are 23 years old and you are a nursing 23 years old and you are a nursing student. You hurt your back. Where student. You hurt your back. Where do you come from? do you come from?

Under LoadingUnder Loading

• Fail to give feedback, cues missed, Fail to give feedback, cues missed, silent and unresponsivesilent and unresponsive

Nurse: “What’s your name?” and Nurse: “What’s your name?” and walks away while smiling.walks away while smiling.

Social ResponseSocial Response

• Attention focused on the nurseAttention focused on the nurse

• ““The sunny weather is great for my The sunny weather is great for my tomatoes. I have all varieties. I love tomatoes. I have all varieties. I love to garden.”to garden.”

Value JudgmentsValue Judgments

• Nurse gives his/her own opinion, uses Nurse gives his/her own opinion, uses own values or moralizesown values or moralizes

• ““Nice”Nice”• ““Good”/”Bad”Good”/”Bad”• ““Right”/”Wrong”Right”/”Wrong”• ““Should/”Ought”Should/”Ought”• ““I think she is a very good doctor.”I think she is a very good doctor.”• ““I think it is good that you changed your I think it is good that you changed your

own clothes.”own clothes.”

Non-Verbal Non-Verbal CommunicationCommunication

• Body Language sends a message without Body Language sends a message without wordswords

• Usually occurs on an unconscious levelUsually occurs on an unconscious level• More accurately conveys the true More accurately conveys the true

meaning of your messagemeaning of your message• Facial Expressions Facial Expressions • Posture and GaitPosture and Gait• Personal AppearancePersonal Appearance• Gestures Gestures • TouchTouch

Factors Affecting Factors Affecting CommunicationCommunication

• Environment (quiet, private, free of Environment (quiet, private, free of noxious smells, comfortable temperature)noxious smells, comfortable temperature)

• Developmental (physical, cognitive level, Developmental (physical, cognitive level, language, education, maturity)language, education, maturity)

Infants/toddlers use non-verbal/verbalInfants/toddlers use non-verbal/verbalChildren/adolescents develop abstract Children/adolescents develop abstract

reasoning and those with chronic health reasoning and those with chronic health problems are more knowledgeable than problems are more knowledgeable than their peerstheir peers

Communication FactorsCommunication Factors

• Older AdultsOlder Adults– Sensory alterations (hearing, vision)Sensory alterations (hearing, vision)– Cognitive impairments due to diseaseCognitive impairments due to disease

Gender differences exist Gender differences exist

Research has shown that women Research has shown that women communicate to form relationships and communicate to form relationships and men to do so to be “one up” or hierarchal men to do so to be “one up” or hierarchal positioningpositioning

Communication FactorsCommunication Factors

• Socialization is a major contingentSocialization is a major contingent– Traditional or non-traditional upbringingTraditional or non-traditional upbringing

• Girls engage in one-to-one or fantasy playGirls engage in one-to-one or fantasy play• Boys compete, use strategy to winBoys compete, use strategy to win

Important to realize that gender Important to realize that gender differences between nurse and client will differences between nurse and client will differdiffer

Female client says: “I feel lousy today.”Female client says: “I feel lousy today.”Female Nurse: interprets as desire to talk Female Nurse: interprets as desire to talk

(connectedness)(connectedness)Male Nurse: Discusses pain control Male Nurse: Discusses pain control

Personal SpacePersonal Space

• Hall in 1969 described four distances Hall in 1969 described four distances influencing communicationinfluencing communication

• Intimate DistanceIntimate Distance: private space is : private space is 18 inches in Western Cultures 18 inches in Western Cultures whereby you can smell, feel body heat, whereby you can smell, feel body heat, hear other speaking, body contact may hear other speaking, body contact may occur.occur.

• NURSES INVADE PERSONAL SPACE NURSES INVADE PERSONAL SPACE WHEN PERFORMING ASSESSMENTS WHEN PERFORMING ASSESSMENTS AND DOING PROCEDURESAND DOING PROCEDURES

SpaceSpace

• PersonalPersonal distance is from 18 inches to 4 feet distance is from 18 inches to 4 feetUsual interactions between clients and other Usual interactions between clients and other health care workershealth care workers

Social Social Distance is 4 to 12 feet and occurs in Distance is 4 to 12 feet and occurs in formal settings, groups and less likely that formal settings, groups and less likely that people will share thoughts and feelingspeople will share thoughts and feelings

Nurse standing at client’s door will more likely Nurse standing at client’s door will more likely receive an impersonal response to their receive an impersonal response to their question of “How are you feeling?” than if question of “How are you feeling?” than if they stood at bedside.they stood at bedside.

TerritorialityTerritoriality

• Space and things that a person Space and things that a person identifies as belonging to them whether identifies as belonging to them whether it be physically bounded or not.it be physically bounded or not.– Health Care Facility everything within Health Care Facility everything within

bounded within the curtain is considered bounded within the curtain is considered their space.their space.

– Do not rearrange furniture, borrow, touch, Do not rearrange furniture, borrow, touch, throw out or invade without their throw out or invade without their permission even if it belongs to the facilitypermission even if it belongs to the facility

Sociocultural FactorsSociocultural Factors

• Facial expressions, non-verbal, and who Facial expressions, non-verbal, and who interacts with whom are factors to interacts with whom are factors to considerconsider

• Culturally it may be prohibited for a male Culturally it may be prohibited for a male nurse to attend a female clientnurse to attend a female client

• Social Status is evident in client--MD Social Status is evident in client--MD interactions; lower income--providers;interactions; lower income--providers;– Do not question MD but nods approvalDo not question MD but nods approval– Nurse gets barraged with questions Nurse gets barraged with questions

afterwards afterwards

Roles and RelationshipsRoles and Relationships

• Interactions are affected by vocabulary, Interactions are affected by vocabulary, tone of voice, gestures, distancetone of voice, gestures, distance

• You will interact differently with your You will interact differently with your instructor than with your fellow classmatesinstructor than with your fellow classmates

• Can you identify some differences?Can you identify some differences?

• Preconceived notions of nurses range Preconceived notions of nurses range anywhere from an authority figure to an “aanywhere from an authority figure to an “a—” wiper.—” wiper.

Roles and RelationshipsRoles and Relationships

• Confusion among clients as to who’s Confusion among clients as to who’s whowho– Medical assistants, nursing aides call Medical assistants, nursing aides call

themselves nurses which is illegal to themselves nurses which is illegal to use such a titleuse such a title

– Dress may be similar and think that the Dress may be similar and think that the nursing assistant is a nursenursing assistant is a nurse

Phases of the Phases of the Communication ProcessCommunication Process

• Pre-interaction Phase occurs before you meet Pre-interaction Phase occurs before you meet the client (Student prepares for clinical and the client (Student prepares for clinical and client identifies need for healthcareclient identifies need for healthcare

• Orientation Phase: Meet the client and Orientation Phase: Meet the client and establish rapport and trustestablish rapport and trust

• Working Phase: majority of work; courteous, Working Phase: majority of work; courteous, confidential, trustworthy relationship achieved confidential, trustworthy relationship achieved by therapeutic communication techniguesby therapeutic communication technigues

• Termination Phase: Bring relationship to an Termination Phase: Bring relationship to an end; prepares nurse/client for future end; prepares nurse/client for future interactions, helps client achieve health interactions, helps client achieve health outcomes and contributes to nurses’ outcomes and contributes to nurses’ satisfactionsatisfaction

Impaired Verbal Impaired Verbal CommunicationCommunication

• Language Barriers (language not of dominant Language Barriers (language not of dominant culture)culture)

• Cognitive skills (developmental, physiological Cognitive skills (developmental, physiological effects on CNS) Short/long term memory loss, effects on CNS) Short/long term memory loss, functioning at or below age levelfunctioning at or below age level

• Sensory perceptual changes/loss: hearing, Sensory perceptual changes/loss: hearing, vision, post CVA or neurological diseasevision, post CVA or neurological disease– Receptive aphasia: Client does not have ability Receptive aphasia: Client does not have ability

to receive or interpret verbal/non-verbal to receive or interpret verbal/non-verbal messagesmessages

– Expressive aphasia: Client does not have ability Expressive aphasia: Client does not have ability to express verbal/non-verbal messages to express verbal/non-verbal messages

Impaired Verbal Impaired Verbal CommunicationCommunication

Dysarthria: speech slurred, difficult Dysarthria: speech slurred, difficult to understand due to inability to to understand due to inability to produce sounds; breath control produce sounds; breath control lacking, coordination of lips, lacking, coordination of lips, tongue, palate, larynx (Parkinsons, tongue, palate, larynx (Parkinsons, MS, CVA, accidents).MS, CVA, accidents).

Voice: Removal of larynxVoice: Removal of larynx

Physiological Barriers: tubes, cleft Physiological Barriers: tubes, cleft palate palate

Nursing DiagnosesNursing Diagnoses

• Impaired Verbal Communication Impaired Verbal Communication Assess: inability to speak, difficulty Assess: inability to speak, difficulty

forming words or sentences, difficulty forming words or sentences, difficulty expressing thoughts verbally, expressing thoughts verbally, inappropriate verbalization, inappropriate verbalization, physiological barriers to communication physiological barriers to communication as artificial airway, tubes, loose fitting as artificial airway, tubes, loose fitting dentures, cleft palate; short or long dentures, cleft palate; short or long term memory loss; disorientation; term memory loss; disorientation; dyspneadyspnea

Impaired Verbal Impaired Verbal CommunicationCommunication

• Related to (What is the reason why they Related to (What is the reason why they can not communicate?)can not communicate?)

• Physical barrier (artificial airway, Physical barrier (artificial airway, anatomical defect as a cleft palate, anatomical defect as a cleft palate, broken jaw)broken jaw)

• Circulation to brain diminishedCirculation to brain diminished• Shortness of breathShortness of breath• Cultural or language differencesCultural or language differences• DevelopmentalDevelopmental

Impaired Verbal Impaired Verbal CommunicationCommunication

• Related to: hearing lossRelated to: hearing loss• Goal: Client will communicate effectively.Goal: Client will communicate effectively.• 1. check to see if hearing aid is in place and 1. check to see if hearing aid is in place and

turned onturned on• 2. turn off radio, or tv set2. turn off radio, or tv set• 3. face the client3. face the client• 4. speak in a normal tone at normal pace4. speak in a normal tone at normal pace• 5. provide pen and paper to aid in 5. provide pen and paper to aid in

communicationcommunication

Evaluation: Client was able to communicateEvaluation: Client was able to communicate

Impaired Verbal Impaired Verbal CommunicationCommunication

• r/t visual lossr/t visual loss

1. when speaking look directly at client1. when speaking look directly at client

2. use normal tone and normal pace2. use normal tone and normal pace

3. let the client know when you are entering 3. let the client know when you are entering and leaving the roomand leaving the room

4. use clock hours to orient client to the 4. use clock hours to orient client to the immediate environmentimmediate environment

5. ask client if you may touch them 5. ask client if you may touch them

Outcome: Client able to communicate Outcome: Client able to communicate effectively.effectively.