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Communication
Teresa V. Hurley, MSN, RN
Communication and the Nurse
Client Relationship
• Therapeutic Communication Techniques
– Assist in the flow of communication between the
client and nurse with the focus on the client and
their needs
-It is a holistic approach to the person with a
therapeutic use of self which has five qualities.
Do you think you can name them?
Qualities
• Empathy is not only the desire but the actual putting
of self mentally and emotionally in the client’s place.
This enables you to acknowledge their uniqueness and
adapt your approach to create an effective change in
them.
• Respect has to do with you being flexible and adjusting
rather than the client adjusting to you
What happens when a client is stripped of their clothes,
separated from loved ones, lost their familiar routines
and surroundings etc.?
Qualities
• To preserve self-esteem and power, the nurse
must be willing to make changes as holding off
breakfast to let a client sleep in the morning.
• What other things do you think you could do?
Qualities
• Genuineness is being truthful. Do not guess at an
answer but be honest and say that you need assistance.
Also evaluate your interactions to see what was
appropriate or what needs improvement.
• Concreteness and Confrontation: offer responses to
client’s questions and concerns so that he/she
understands. You have to express clearly what you
mean and the client has to so the same. Thus
confrontation is used to clarify when thoughts are not
expressed clearly
Guidelines for Client
Communication
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Be an active participant
Guide the conversation
Give broad opening statements
Ask open-ended questions
Pick-up on cues
Follow through on the subject the client initiates
Utilize body language to convey empathy, interest,
encouragement
• Use silence as a therapeutic tool
Communication
A multileveled process of sending and receiving messages.
verbally and non-verbally by using:
signs, words, gestures, symbols, space
Facts, feelings, and meanings are transmitted through this
process
Primary Bases for all Skills
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Assessment
Administration of therapeutic modalities
Evaluation of skills performed
Interviewing
Counseling
Health Teaching
Examples of Therapeutic
Techniques
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Acknowledgement
Clarification
Feedback
Focusing
Incomplete Sentences
Listening
Minimum Verbal Activity
• Mutual Fit or
Congruence
• Non-verbal
encouragement
• Open-ended questions
• Paraphrase
• Reflection
• Restatement
• Validation
Open-ended Questions
• Can not be answered
with a “yes”, “no” or
“maybe”
-Ask questions that need
an answer of several
words
• “How did you sleep last
night?”
• Do not say:
“Did you have a good
night’s sleep?”
Acknowledgement
• You do not insert your own judgments or values
• It may be verbal or non-verbal
• “I hear what you are saying.”
• “Yes, go on.”
• “Uh huh.”
Clarification
• Ascertain or make clear the hidden meaning of a
message. Is the message sent the message
received?
• “I do not understand. Can you say it in another
way.”
• “Are you saying…” [repeat meaning of the
client’s message]
Feedback
• Relay to the client the effect of his/her words
• Keep the client on course or
• Alter the course
• “You did well.”
• “When you say that, it makes me feel
uncomfortable.”
Focusing
• Focus or refocus on the client’s statement based
on the central theme or cues given
• “You were telling me about how hard it is to talk
to your mother.”
• “You said that the impending surgery is making
you feel frightened.”
Incomplete Sentences
• Encourage the client to go on.
• “Then your doctor said…”
Minimum Verbal Activity
• Allow client to lead the conversation
• “Go on.”
• “You feel…?”
Nonverbal Encouragement
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Use body language
Nod
Lean forward
Touch
Sitting down at the bedside facing the client
Communication Blocks
• Hinders or stops communication
• Focus is on the nurse
• The nurses needs are being met
Non-therapeutic Techniques
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Changing the subject
False reassurance
Giving advice
Incongruence
Assumptions
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Over loading
Under loading
Value Judgments
Invalidation
Social Response
Changing the Subject
• New topics introduced inappropriately
• May be an indicator of anxiety
• “How many children do you have?”
Asked when the client is crying and afraid of
surgery.
False Reassurance
• The use of “ pat statements”, “cliches”.
“cheery” words
• “It’s going to be all right.”
• “Don’t worry. This pain medication always
works.”
Giving Advice
• Nurse gives advice or opinion
• Tells the client what to do
• Assumes client can not handle life decisions
• “If you are unhappy with your doctor, you
should change doctors.”
• “Don’t have the surgery here. Go to…It’s
where I had mine.”
Incongruence
• Non-verbal and verbal messages sent contradict
one another
• Contradiction between time/space or
Verbal/nonverbal
“I’d like to talk to you” [but I’m just too busy].
Assumptions
• Assume the meaning of client’s behavior
without him/her validating it
• A suicidal patient is smiling
• The nurse reports that the client is “happy and
feeling much better”.
Invalidation
• Client’s thoughts, feelings or presence is denied
or ignored
• Client: “Hi, how are you today?”
• Nurse: “I can’t talk now. I am going to lunch.”
Over Loading
• Giving too much data at one time, talking fast,
changing subjects
• “What’s your name? I see you are 23 years old
and you are a nursing student. You hurt your
back. Where do you come from?
Under Loading
• Fail to give feedback, cues missed, silent and
unresponsive
Nurse: “What’s your name?” and walks away while
smiling.
Social Response
• Attention focused on the nurse
• “The sunny weather is great for my tomatoes. I
have all varieties. I love to garden.”
Value Judgments
• Nurse gives his/her own opinion, uses own values or
moralizes
• “Nice”
• “Good”/”Bad”
• “Right”/”Wrong”
• “Should/”Ought”
• “I think she is a very good doctor.”
• “I think it is good that you changed your own clothes.”
Non-Verbal Communication
• Body Language sends a message without words
• Usually occurs on an unconscious level
• More accurately conveys the true meaning of your
message
• Facial Expressions
• Posture and Gait
• Personal Appearance
• Gestures
• Touch
Factors Affecting Communication
• Environment (quiet, private, free of noxious
smells, comfortable temperature)
• Developmental (physical, cognitive level,
language, education, maturity)
Infants/toddlers use non-verbal/verbal
Children/adolescents develop abstract reasoning
and those with chronic health problems are
more knowledgeable than their peers
Communication Factors
• Older Adults
– Sensory alterations (hearing, vision)
– Cognitive impairments due to disease
Gender differences exist
Research has shown that women communicate to form
relationships and men to do so to be “one up” or
hierarchal positioning
Communication Factors
• Socialization is a major contingent
– Traditional or non-traditional upbringing
• Girls engage in one-to-one or fantasy play
• Boys compete, use strategy to win
Important to realize that gender differences between
nurse and client will differ
Female client says: “I feel lousy today.”
Female Nurse: interprets as desire to talk
(connectedness)
Male Nurse: Discusses pain control
Personal Space
• Hall in 1969 described four distances influencing
communication
• Intimate Distance: private space is 18 inches in
Western Cultures whereby you can smell, feel
body heat, hear other speaking, body contact
may occur.
• NURSES INVADE PERSONAL SPACE
WHEN PERFORMING ASSESSMENTS
AND DOING PROCEDURES
Space
• Personal distance is from 18 inches to 4 feet
Usual interactions between clients and other health care
workers
Social Distance is 4 to 12 feet and occurs in formal
settings, groups and less likely that people will share
thoughts and feelings
Nurse standing at client’s door will more likely receive an
impersonal response to their question of “How are you
feeling?” than if they stood at bedside.
Territoriality
• Space and things that a person identifies as
belonging to them whether it be physically
bounded or not.
– Health Care Facility everything within bounded
within the curtain is considered their space.
– Do not rearrange furniture, borrow, touch, throw
out or invade without their permission even if it
belongs to the facility
Sociocultural Factors
• Facial expressions, non-verbal, and who interacts
with whom are factors to consider
• Culturally it may be prohibited for a male nurse
to attend a female client
• Social Status is evident in client--MD
interactions; lower income--providers;
– Do not question MD but nods approval
– Nurse gets barraged with questions afterwards
Roles and Relationships
• Interactions are affected by vocabulary, tone of
voice, gestures, distance
• You will interact differently with your instructor
than with your fellow classmates
• Can you identify some differences?
• Preconceived notions of nurses range anywhere
from an authority figure to an “a—” wiper.
Roles and Relationships
• Confusion among clients as to who’s who
– Medical assistants, nursing aides call themselves
nurses which is illegal to use such a title
– Dress may be similar and think that the nursing
assistant is a nurse
Phases of the Communication
Process
• Pre-interaction Phase occurs before you meet the client
(Student prepares for clinical and client identifies need
for healthcare
• Orientation Phase: Meet the client and establish rapport
and trust
• Working Phase: majority of work; courteous,
confidential, trustworthy relationship achieved by
therapeutic communication technigues
• Termination Phase: Bring relationship to an end;
prepares nurse/client for future interactions, helps
client achieve health outcomes and contributes to
nurses’ satisfaction
Impaired Verbal Communication
• Language Barriers (language not of dominant culture)
• Cognitive skills (developmental, physiological effects on
CNS) Short/long term memory loss, functioning at or
below age level
• Sensory perceptual changes/loss: hearing, vision, post
CVA or neurological disease
– Receptive aphasia: Client does not have ability to receive
or interpret verbal/non-verbal messages
– Expressive aphasia: Client does not have ability to
express verbal/non-verbal messages
Impaired Verbal Communication
Dysarthria: speech slurred, difficult to
understand due to inability to produce
sounds; breath control lacking, coordination
of lips, tongue, palate, larynx (Parkinsons, MS,
CVA, accidents).
Voice: Removal of larynx
Physiological Barriers: tubes, cleft palate
Nursing Diagnoses
• Impaired Verbal Communication
Assess: inability to speak, difficulty forming words or
sentences, difficulty expressing thoughts verbally,
inappropriate verbalization, physiological barriers to
communication as artificial airway, tubes, loose
fitting dentures, cleft palate; short or long term
memory loss; disorientation; dyspnea
Impaired Verbal Communication
• Related to (What is the reason why they can not
communicate?)
• Physical barrier (artificial airway, anatomical
defect as a cleft palate, broken jaw)
• Circulation to brain diminished
• Shortness of breath
• Cultural or language differences
• Developmental
Impaired Verbal Communication
• Related to: hearing loss
• Goal: Client will communicate effectively.
• 1. check to see if hearing aid is in place and turned on
• 2. turn off radio, or tv set
• 3. face the client
• 4. speak in a normal tone at normal pace
• 5. provide pen and paper to aid in communication
Evaluation: Client was able to communicate
Impaired Verbal Communication
• r/t visual loss
1. when speaking look directly at client
2. use normal tone and normal pace
3. let the client know when you are entering and leaving
the room
4. use clock hours to orient client to the immediate
environment
5. ask client if you may touch them
Outcome: Client able to communicate effectively.