Communication

1. Communication Teresa V. Hurley, MSN, RN

2. 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?

3. 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.?

4. 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?

5. 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

6. Guidelines for Client Communication • 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

7. 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

8. Primary Bases for all Skills • Assessment • Administration of therapeutic modalities • Evaluation of skills performed • Interviewing • Counseling • Health Teaching

9. Acknowledgement Clarification Feedback Focusing Incomplete Sentences Listening Minimum Verbal Activity Mutual Fit or Congruence Non-verbal encouragement Open-ended questions Paraphrase Reflection Restatement Validation Examples of Therapeutic Techniques

10. 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?” Open-ended Questions

11. 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.”

12. 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] Clarification

13. 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.”

14. 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.”

15. Incomplete Sentences • Encourage the client to go on. • “Then your doctor said…”

16. Minimum Verbal Activity • Allow client to lead the conversation • “Go on.” • “You feel…?”

17. Nonverbal Encouragement • Use body language • Nod • Lean forward • Touch • Sitting down at the bedside facing the client

18. Communication Blocks • Hinders or stops communication • Focus is on the nurse • The nurses needs are being met

19. Changing the subject False reassurance Giving advice Incongruence Assumptions Over loading Under loading Value Judgments Invalidation Social Response Non-therapeutic Techniques

20. 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.

21. 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.”

22. 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.”

23. 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].

24. 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”.

25. 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.”

26. 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?

27. Under Loading • Fail to give feedback, cues missed, silent and unresponsive Nurse: “What’s your name?” and walks away while smiling.

28. Social Response • Attention focused on the nurse • “The sunny weather is great for my tomatoes. I have all varieties. I love to garden.”

29. 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.”

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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.

36. 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

37. 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

38. 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.

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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.