Therapeutic Communication Nursing Concepts C. Calzolari

Learner’s Objectives: Define Therapeutic Communication. Describe the importance of therapeutic communication in the nursing process. Explain rapport and its importance in nursing. Differentiate between verbal and nonverbal communication. Give examples of each. Discuss factors that influence the effectiveness of communication. Demonstrate the interviewing and communication skills of questioning, therapeutic silence, and clarifying. Describe communication techniques used with special situations.

What is Therapeutic Communication? Patient- Centered Communication Focuses on the Patient The goal is to promote a greater understanding of patient’s needs, concerns and feelings. The nurse helps the patient explore their own thoughts & feelings, encourages expression of them, and avoids barriers to communication. Communication means the giving, receiving, and interpreting of information through any of the five senses by two or more interacting people. Therapeutic communication is an interaction that is helpful and healing for one or more of the participants; the client benefits from knowing that someone cares and understands, and the nurse derives satisfaction from knowing that he or she has been helpful. A nurse must have self-awareness and interpersonal skills to communicate therapeutically. Successful therapeutic communication encourages client coping and motivation toward self-care. Effective use of communication will play an important role in your nursing career and personal life. It is the foundation on which interpersonal relationships are built. The art of therapeutic communication does not come naturally; it must be learned.

Tell me… Why is it IMPORTANT? Communication and the Nursing Process Communication is related to the nursing process in many ways: • Problem-solving depends on individual and group communication. • The nurse must be able to collect client data accurately by paying attention to both verbal and nonverbal cues and information. • The statement of the nursing diagnosis must be clear and concise. • Planning involves accurate communication among all members of the healthcare team, as well as with the client and the family. During implementation of the nursing care plan, the nurse communicates with the client and family and communicates his or her impressions and observations to other members of the healthcare team. • Ongoing evaluation of the effectiveness of nursing interventions depends on clear and coherent communication among all persons concerned. • Client teaching and preparation for discharge depend on accurate and empathic communication and client understanding. Without accurate and therapeutic communication, the nursing process cannot exist.

The Approach FIGURE 44-1 · This nurse uses principles of therapeutic communication when interacting with his client. He uses appropriate positioning (eye level), does not invade the client’s personal space, makes appropriate eye contact, and generally mirrors the client’s body position. He speaks and then carefully listens to what the client has to say. Personal characteristics of genuineness, caring, trust, empathy, and respect promote harmony among individuals. This feeling of harmony is called rapport. Conveying these attitudes to another person creates a social climate that communicates goodwill and empathy, even when fears or concerns cannot be fully expressed verbally. It is important to be able to provide unbiased nursing care. To be most helpful, the nurse develops the ability to convey a nonjudgmental attitude, especially if another person’s beliefs and values differ from the nurse’s own. Clients must experience a feeling of rapport with the nurse in order to share personal, and sometimes embarrassing, information. The client and the nurse are working toward a common goal. Key Concept In some cases, the nurse has the right to request a different assignment if he or she believes that working with this client may cloud professional judgment. For example, a nurse whose religion forbids abortion may request not to assist in the operating room with this procedure. The client has the right to his or her own beliefs and so does the nurse. In addition, it is usually advisable not to care for a family member or close friend.

The nurse who is using therapeutic communication will: Refer to handout

Components of Communication FIGURE 44-2 · Components in the process of communication. Communication can be carried out in person or by telephone, or by text messaging, alpha paging, AudioVox, Vocera transmission, or other electronic methods. This was already covered in previous lecture with Mr. Hanock.

Types of Communication Verbal Non-Verbal Should be CONGRUENT Nurses communicate with clients often and in various ways. Two types of communication are verbal communication (using words) and nonverbal communication (using facial expressions, actions, and body position). Verbal communication is sometimes differentiated from oral communication. Effective communication occurs when words and actions convey the same message (congruency). This is essential for therapeutic communication to occur. When a “mixed message” is sent, communication is not effective or is confusing (Box 44-1). Key Concept In general, verbal communication is used to communicate information. Nonverbal communication conveys feelings and attitudes. Nonverbal communication occurs whether we want it to or not.

Verbal Communication Sharing information through the written or spoken word Nurses use verbal communication extensively. They converse with clients, write care plans, document information and assessments, input data into the electronic record, and give oral or written change-of-shift reports. Much verbal information is related through vocabulary, sentence structure, spelling, and pronunciation. People reveal their education, intellectual skills, interests, and ethnic, regional, or national background through verbal communication. Voice inflections and sounds reveal messages. Although a client may say what the nurse wants to hear, his or her tone of voice may imply a totally different meaning. (This is an example of noncongruency between verbal and nonverbal communication.) The person may make sounds that indicate true feelings. A snort, for example, may denote disgust. Be aware that some responses stop the communication process. These blocks are called verbal barriers. Table 44-1 gives examples of such barriers and more effective responses that encourage further discussion. Key Concept Remember that how you write or input data indicates information about you, as well as about the client. Try to use correct grammar and spelling in your documentation. This is particularly difficult when English is a second language for the nurse. Characteristics of Speech. It is important to note the volume of the client’s speech. Speaking loudly may be culturally based. However, it may also indicate conditions, such as a hearing impairment, mania, or difficulty in speaking the language. Speaking softly may imply such things as nervousness, paranoia, shyness, or lack of self-confidence. This may also be a reflection of the client’s culture. Consider also the rate and rhythm of the client’s speech. Speaking very fast may imply anxiety, mania, flight of ideas, or impatience. Speaking very slowly may be the result of a brain disorder, mental illness, or minimal knowledge of English. Medications can influence the client’s speech. Hesitation in speaking, thought-blocking, difficulty in finding words, or total aphasia may indicate that the client does not speak English well, has a brain disorder, or is hallucinating (seeing or hearing things that others do not perceive). These are just examples; many other factors influence a client’s speech patterns. Aphasia is a defect in, or loss of, the ability to speak, write, or sign, or of the ability to comprehend speech and communication. Aphasia is usually caused by an injury or disorder of the brain’s speech centers or by a mental illness. Expressive aphasia refers to difficulty in speaking or in finding the correct or desired word. Receptive aphasia refers to a disorder of the brain that interferes with the comprehension or understanding of what one is hearing. Listening. Thoughtful listening is a vital component of communication. The nurse learns a great deal about the client by carefully listening to what the person has to say. Listening skills also include paying attention to nonverbal cues exhibited by the client.

Verbal Barriers Neeb’s book, pp. 21-23 False Reassurance/Social Clichés Minimizing/Belittling Asking “WHY?” Advising Agreeing or Disagreeing Closed-ended Questions Providing the Answer with a Question Changing the Subject Approving or Disapproving

Non –Verbal Communication Sharing information without using words or language It expresses emotions and attitudes, as well as enhancing what is being expressed verbally. NVC is one component of body language and is sometimes more powerful in conveying a message than is verbal communication. If verbal and nonverbal messages are not congruent, the receiver usually believes the nonverbal cues. Several components of NVC are presented in Box 44-1. Box 44-1. Verbal and Nonverbal Communication Verbal Communication Use of words (e.g., speech, sign language, writing, slang) Oral Communication Vocal sounds (e.g., grunt, snort) Nonverbal Communication Personal space Facial expression Eye contact, eye gaze Touch Body gestures and movement (Kinesics): Posture, culturally related gestures, friendly gestures, warning gestures, obscene gestures, secret signals, gang signals Vocal characteristics: Geographic differences and accents, pronunciation, fluency/dysfluency, sarcasm Gender differences: Male/female relationships Cultural mores: Behaviors specific to a cultural group or geographic location (how people behave) Body characteristics: Body art, piercings, branding, plastic surgery, scarification, weight, clothing (cultural differences in what is considered to be beautiful) Messages expressed through body posture and movements, gestures, facial expressions, and other forms of nonverbal behavior provide cues or suggestions to a person’s true feelings or beliefs. This study of body movements and posture, facial expressions, and gestures is referred to as kinesics. The nurse must be aware, however, that nonverbal behavior has different meanings for different people and in different situations. The nurse must be cautious when interpreting nonverbal cues. It is important to check with clients before making assumptions about the meaning of their body language. Remember, NVC includes factors such as clothing, body ornamentation, body shape and size, and gestures.

If the body language and verbal cues are not congruent, confusion occurs. For example, Mr. H., a young diabetic client, begins clenching and unclenching his fists when the nurse asks about his sexual activity. He says, “everything is fine,” through gritted teeth. Later, when he trusts the nurse more, he admits that he has been impotent for the past 6 months. Often, body language provides more powerful clues than verbal language because it points to the person’s true feelings . Key Concept Be sure that your verbal and nonverbal communications give a congruent message to clients. When verbal and nonverbal messages conflict (are not congruent), others are most likely to believe the nonverbal message

Personal Space See FUNDAMENTALS Book, p. 117 for cultural differences regarding personal space Proxemics and Personal Space. Human proxemics or territoriality (the use of space in relationship to communication) varies greatly among individuals and between cultures or ethnic groups. This concept is closely related to the concept of personal space. Each person has an area around himself or herself called personal space. This area is reserved for only close friends or intimates. This culturally learned behavior varies greatly across cultures, although it may also vary from person to person within a culture or ethnic group. Other variables include sex and social status. In traditional Western cultures, the areas of personal space or communication zones are approximately: • Intimate (physical contact to 18 inches): behavior with loved ones,sharing secrets, physical assessment in healthcare • Personal (18 inches to 4 feet): general conversation, interviews, teaching one-on-one, private conversation • Social (4-12 feet): demonstrations, group interactions, parties • Public (>12 feet): lectures, behavior with strangers Although these concepts of proxemics are true for many Americans, they do not necessarily hold true for other cultures. For example, in the Middle East and Far East, the area of personal space is smaller. Consider this concept when working with clients from cultures that differ from your own. An action that would be considered an invasion of personal space by a person from one culture may be considered acceptable behavior by a person from another culture. It is important for nurses not to unnecessarily violate the client’s personal space boundaries. If the nurse comes too close, it is considered an invasion. If the nurse is too far away, the client may feel isolated or ignored. In most cases, you can sense another person’s personal boundaries. Nurses, however, are often forced to invade a client’s personal space to provide care. It is important to be sensitive to the discomfort this may cause. The nurse should alert the client before touching him or her. Be careful to touch the client gently on the arm or hand before further intruding into his or her space; this practice offers comfort and reassurance so the client feels safer. Often, an approach from the side, rather than directly from the front, is perceived to be less confrontational. Nursing Alert Remember that nursing care often involves the invasion of a clients traditional personal space. The nurse must be aware that some clients may react in a violent or assaultive manner when touched. This may be particularly true in psychiatry or with a client who has dementia. Do not touch any client without being alert for this possibility In addition, some clients may invade your personal space. The nurse needs to tell the client this is not appropriate. Seek assistance if this client behavior continues. Sometimes, the client’s use of personal space is not cultural but indicates a mental or physical disorder. For example, the psychiatric client who consistently invades the personal space of others is said to be intrusive and may be threatening. Another client who maintains a very large personal space may be paranoid and afraid of contact with others. On the other hand, the client with a hearing or visual disorder may need to be very close to the speaker in order to determine what is being said. It is important to consider the reasons for variations in expected personal space boundaries when giving nursing care.

Eye Contact Eye Contact. Eye contact or eye gaze means looking directly into the eyes of the other person. Lack of direct eye contact has various meanings among cultures. Sometimes indirect eye contact means that a person is nervous, shy, or lying. However, it may also signify respect, as in Southeast Asian, Hispanic American, and Native American cultures. In these cultures, direct eye contact often signifies defiance or hostility. Staring may be interpreted by many cultures as open hostility, defiance, rudeness, or as a threat. Rolling the eyes is often interpreted as disgust or disbelief. On the other hand, cultures such as those of the Middle East, consider a lack of direct eye contact as inattention, lack of concern, or even rudeness. Eye contact also varies between genders in some cultures. For example, men can have direct eye contact with each other, whereas women are expected to avoid direct eye contact when speaking to men. In Western cultures, direct eye contact or a wink between people is often a part of dating behavior.

Body Movements Facial Expressions. Facial expressions convey messages of many emotions: joy, sadness, anger, and fear. Some people mask their feelings well, which makes understanding what they are thinking very difficult. Nurses learn to control facial expressions if they are experiencing emotions that may offend the client or block effective communication. For example, the nurse remains calm, with a neutral expression, when viewing wounds or smelling body secretions. Body Movements and Posture. A twitching or bouncing foot may indicate anger, impatience, boredom, or nervousness. A slouched appearance may indicate depression or pain. Wringing hands may indicate fear, pain, or worry. Shrugging the shoulders implies, “I don’t know,” in many cultures. Pacing, rocking, and other repetitive movements may be a side effect of medications or may indicate fear or discomfort. Avoid making assumptions about these body language messages, however. You can ask the client what he or she is feeling if there is concern about these or other visual cues. Gestures and Rituals. We use a number of gestures as a matter of course in daily life. Waving may indicate a greeting or “goodbye” or may be used to send someone away. A wink may indicate a mutual secret or may be seen as a flirting gesture. In some countries, people greet each other by kissing on both cheeks. In Western culture, the “air kiss” is a common greeting. Nursing Alert It is very important to realize that some frequently used Western gestures may be interpreted very differently in other cultures. For example, the traditional Western "thumbs up” gesture is interpreted as an obscene gesture in countries such as Iran.

Personal Appearance and Grooming Personal Appearance and Grooming. Personal hygiene, general appearance, clothing, and body ornamentation relate information about clients. These nonverbal messages may convey clients’ true feelings about themselves, or they may be misleading, especially in illness. Individuals who are trying to meet their basic physiologic needs, such as oxygenation, may not have the physical or emotional energy to work on higherorder needs, such as cleanliness or grooming. Lack of personal care may also be a reflection of emotional factors, such as depression. In addition, persons with severe and persistent mental illness or out-of-control chemical dependency often have difficulty managing self-care. Homelessness may also prevent a person from bathing or washing his or her clothing.

Therapeutic Use of Touch Therapeutic use of touch is the most potent nonverbal communication technique. A gentle and reassuring touch tells the client the nurse cares and is there to help. Be sure to use touch in this manner only if it is nonthreatening to the client. Therapeutic Use of Touch. Touch, referred to as haptic communication, can say “I care” (Fig. 44-4). A firm touch can discourage a child from doing something dangerous; a light touch can encourage a person to walk down the hall. Touches can involve such movements as holding hands, a “high five,” or a pat on the shoulder. In some cases, touch by another person makes people anxious. Some people do not like to be touched, feeling that it invades their personal space. Be sensitive to the feelings of all clients. Sometimes, a nurse may need to touch a client to carry out a nursing procedure. In such a case, the nurse should verbally convey understanding of the client’s discomfort. * Key Concept Nursing care revolves around communication: giving, receiving, and interpreting information. Communication is both verbal and nonverbal. Listening is an important communication tool as well.

Factors Influencing Communication Attention Culture & Ethnicity Age Gender Social Factors Many factors influence the effectiveness of communication. Some factors enhance communication. Other seemingly harmless factors create barriers between people. Attention A listening or attention barrier can occur because of lack of concentration. Selective listening may also be the culprit. In such a case, a person hears only what he or she wants or expects to hear. The nurse may not be paying attention and may not hear because of emotional responses to what the client is saying. Or, the nurse may be mentally framing the next question or thinking of something else. Sometimes, a client is experiencing pain or discomfort (physical or emotional) so great that he or she cannot listen or concentrate. The client may also be preoccupied with internal stimuli (e.g., auditory hallucinations). If both the sender and the receiver do not give, or are not able to give, full attention to the current communication, an effective nurse-client relationship may not occur. It may be necessary to postpone the interaction. Special Considerations :CULTURE & ETHNICITY Age Age can be an advantage or disadvantage to effective communication. Very young or very old clients may be unable to communicate fully because of physical or intellectual capacity. Some clients are uncomfortable with caregivers much younger or older than they are. A young nurse may have difficulty working with a client near the same age. On the other hand, age can be an advantage. An older client may prefer to receive care from an older nurse, or a younger client may be more willing to accept instructions from an older nurse. An older client may also be energized by the presence of a young nurse. Gender Gender roles may influence nurse-client interactions. For example, a man who is accustomed to being in charge may resent being told what to do by a female nurse, particularly if she is much younger than he. A nurse who believes men should be tough may find it difficult to see a male client cry. A female client may be embarrassed by a male nurse performing personal care procedures. It is also important to consider the client’s ethnic background; in some cultures, interactions between men and women are specifically prescribed. Approaching a personal situation matter-of-factly or professionally may eliminate embarrassment. Culture and Subculture Cultural norms and traditions influence the behaviors and perceptions of all people, including nurses.Each nurse would be well-advised to develop an awareness of his or her own personal beliefs and practices, based on culture and ethnicity. Cultural differences are significant, for example, in relation to concepts such as personal space, eye contact, and interactions between men and women. Understanding and accepting differences is the key to developing therapeutic communication. The effective nurse actively seeks and maintains the client’s sense of self-worth by acting in a non-judgmental manner. Key Concept Remember: A smile is part of the universal human language. It is understood by all. Social Factors Social acceptance of a particular illness plays a role in a person’s reaction to the illness. For example, a sexually transmitted infection or psychiatric disorder may be more difficult or embarrassing for the client than a disorder such as glaucoma or diabetes, because of society’s attitudes. The person with an arm or leg amputation or a colostomy may feel more self-conscious than the person who has had some type of surgery that is not visible to others.

Difficult Client Behavior Difficult Client Behaviors Inappropriate behavior on the part of clients creates a barrier to communication. Sexual Harassment. If a client sexually harasses you, consult with your instructor or team leader to handle this inappropriate behavior correctly. Sexual harassment is defined as any unwanted sexual activity. This includes any inappropriate or unwanted touching, as well as sexual statements, or lewd jokes or comments. The use of profanity and name-calling is also included. If a client continues these inappropriate actions after being warned, the nurse may consider pressing charges. (It is important to consider the client’s physical condition. For example, the client who has Alzheimer’s disease may not be totally responsible for his or her actions.) Key Concept A nurse is never required to allow inappropriate behavior from a client.This includes verbal or physical abuse, as well as sexual harassment. Aggressiveness. Some clients are very anxious or angry when admitted to a healthcare facility. They may respond with aggression, which may be directed toward the nurse or the situation in general. It is important for the nurse to remain objective and to practice assertiveness (confidence without aggression or passivity). Box 44-2 gives a brief description of aggressive and assertive behaviors and an introduction to assertiveness training for nurses. Key Concept Remember that any aggressive behavior toward clients by a nurse, whether physical or verbal, constitutes assault on the part of the nurse. Nursing Alert It is important to maintain your own safety If you feel that a client is threatening you and you are in danger.If you are in doubt, withdraw from the situation and ask for help.

More on Behavior… Passivity Aggressiveness Assertiveness Passivity: This person does not seem to care what happens and may be forgetful and/or inefficient. Body language displays indifference. (Example—shrugging the shoulders, looking the other way saying “whatever”) Aggressiveness: This person seems angry and hostile, argues and disagrees with everything that is said, and displays angry body language. This person is often inflexible and argumentative, and may be very intrusive. Passive-Aggressive: This person seems passive and pleasant on the surface, but does things to undermine or sabotage care (or the work environment). Actions include intentional disregard for physicians’ orders, intentional inefficiency, saying one thing and doing another or saying different things to different people, and engaging in other manipulative or obstructive behaviors. Aggressive Communication – uses the defense mechanism of projection; puts the responsibility on the other person. Uses the “you “ word. Assertive behavior/Assertiveness: This is an important skill for nurses to learn. The assertive person is able to make statements without conveying either aggressiveness (overdominance) or passivity (submission). The assertive person makes confident statements of fact, without making judgments. Assertiveness training is a helpful tool for the nurse to use in all interactions, whether with clients or peers. This training assists the nurse to express personal feelings freely, to speak up nonjudgmentally for his or her rights, to communicate comfortably and clearly, and to express appropriately and nonaggressively a legitimate complaint. This helps all persons involved to negotiate mutually satisfying solutions to interpersonal situations. Uses “I” word. Suggested Approach Involve the client and family in decisions about his or her care. Explain what is being done. Answer questions thoughtfully. Ask the client to repeat back to you, in his or her own words, what was said, to make sure he or she understood what was said. Remain calm. Do not argue or become angry. Keep your voice low, although the client may be yelling at you. Reinforce what is expected of the client in a firm, nonjudgmental way. Repeat, as necessary (the “brokenrecord approach”). Protect yourself from assaultive behavior; Document having given instructions to the client, along with the client’s actions or exact words (in quotes). Give the client a written list of instructions or expectations, to avoid confusion and to reinforce the care plan. Remain calm. Practice assertiveness, but not aggressiveness.

“You make me angry when you don’t help.” “I feel angry when you don’t help with the housework.”

Using Unbiased Language When Documenting Client Behaviors The nurse objectively describes eye contact, rather than applying judgments. For example, “The client looks at the floor when speaking” is descriptive and nonjudgmental. (A judgmental statement such as “good eye contact” implies that all clients should behave like most Western Europeans or Caucasian Americans.) Using Unbiased Language When Documenting Client Behaviors • The nurse objectively describes eye contact, rather than applying judgments. For example, “The client looks at the floor when speaking” is descriptive and nonjudgmental. (A judgmental statement such as “good eye contact” implies that all clients should behave like most Western Europeans or Caucasian Americans.) The nurse might go on to state that (in the nurse’s opinion) the client is “insecure and afraid.” However, this assessment may be incorrect if, for example, the client is Native American and looking down is considered a sign of respect. • The nurse objectively describes behavior related to personal space. For example, “client maintains approximately 3 feet of personal space and moves away when approached.” In the nurse’s opinion, the client might be described as “staff-avoidant.” However, this assessment may be incorrect, depending on the cultural background of the client. • The nurse describes the tone and volume of the client’s verbalizations in objective terms. An objective statement might be, “client speaks very loudly.” The judgment that the client is “hostile” may be incorrect, however, when the nurse considers that in some cultures, all people speak very loudly. (On the other hand, the client may be hearing-impaired and may speak loudly as a result.) A male nurse may write about a female client, “client refuses to speak.” However, it might be incorrect to say that the client is “paranoid” or “aphasic.” It is important for this nurse to remember that in some cultures, women are not permitted to speak to men outside their families. Objective documentation may be, “client speaks softly.” However, rather than stating that client is “shy” or “afraid,” it is important to remember that in some cultures, women are expected to speak softly at all times. • The use of profanity is common in some cultures and is considered part of everyday language. Documenting what the client says, in quotation marks, rather than making judgments, is objective. • Many people of the world consider folk medicine or mystical beliefs to be a normal part of life. Therefore, if a client talks about the “evil eye” or a “cold disease,” documentation of the actual statement is appropriate and objective. A nurse might wrongly determine that this client is “delusional,” for example, when these beliefs are common to most members of that client’s culture. The preceding are examples. The nurse uses the same general guidelines when documenting other nonverbal behaviors, such as reaction to pain, body posture, and general attitudes about health and illness. The nurse will be objective if he or she documents exactly what the client says and does, rather than making judgments based on the interpretation of those statements or actions. (Formal nursing assessments are made using NANDA guidelines. Unit 6 of this topic, The Nursing Process, describes these guidelines in more detail.)

THERAPEUTIC COMMUNICATION TECHNIQUES Therapeutic communication techniques are strategies to encourage clients to express their thoughts and feelings more effectively. These techniques are tools for building and maintaining rapport with others. Some techniques are verbal; others are nonverbal (Fig. 44-5). Nontherapeutic communication is that which stops the communication process or is perceived as a threat by the client. Examples of nontherapeutic actions include the nurse who talks too much, uses only closed-ended questions, or demonstrates impatient or threatening body language.

THERAPEUTIC COMMUNICATION TECHNIQUES Interviews Offering Self Using Empathy Closed vs. Open Ended Questions (Handout) Use of Silence Clarification Reflection/Repeating/Parroting Paraphrasing Summarizing Using Unfinished Statements Giving Information Stating Implied Thoughts and Feelings Interviewing An interview is a goal-directed conversation in which one person seeks information from another. In nursing, the interview is the communication technique used to evaluate the client’s understanding of his or her health concerns and to acquire valuable information from and concerning the client. The effectiveness of the interview depends on the selection of suitable questions for which the client can provide answers. Sometimes, questions require simple responses (e.g., “What medications are you taking?” or “Do you have children?”). This type of question is called a closed-ended question because only brief and predictable responses are required. A question that elicits a “yes” or “no” answer is a closed-ended question. An open-ended question encourages longer and more thorough answers. Table 44-2 compares these two types of questions. Nonverbal Therapeutic Techniques Just as the client’s body language provides cues in communication, the nurse’s body language indicates a great deal about how the nurse is feeling. It is important to use effective NVC techniques, such as maintaining an openly accepting facial expression and appropriate eye contact, or mirroring what the client says or does. It helps to lean toward the client to express acceptance. The nurse who is an effective communicator learns to avoid gestures such as crossing the arms over the chest, pointing fingers, or holding the hands on the hips. (The client may interpret these gestures as judgmental or threatening.) Be sure to listen carefully OFFERING SELF - key component makes this patient centered. Portrays caring and empathy Using EMPATHY – Neeb’s page 26 Use of Silence, also NEEB’s p.26 Silence gives the nurse and the client an opportunity to collect their thoughts and to prepare to continue the conversation. It is very difficult for many people to cope with silence; they feel they must say something. Many clients will respond verbally to silence. If the nurse pauses for a few seconds, the client will often answer a question or make a statement that he or she would not have made before. Learning to use silence effectively is a valuable communication tool. Key Concept Practice waiting in silence for a client to speak.This is a very effective communication tool, but is difficult for many nurses. Clarification. Also NEEB’s p.24 Clarification is necessary if the client answers a question and the nurse does not clearly understand the answer or wants additional information. The nurse can ask the client to repeat what was said, or may say, “Tell me more about it” or “Explain that to me” or “What do you mean by____?” Reflection ALSO READ NEEB”S , 4th ed., page 24 Reflection can be used in two ways. First, the nurse may echo the client’s words, allowing the client to hear what he or she has just said. In this way, the client can re-evaluate the words to determine if they expressed what he or she actually meant. CLIENT: “My life has been one frustration after another.” Nurse: “Your life has been full of frustrations?” The second way to reflect is to point out the client’s behavior or attitude that seems to be underlying his or her words. Client: “I’m just a worthless old man, and no one cares about me!” Nurse: “You say that as if you were very angry.” CLIENT: “I am angry. I raised six children and gave them the best years of my life. If they cared about me, they would come to visit me.” Paraphrasing Use of paraphrasing helps the nurse to clarify the interpretation of the message by restating it in other words. CLIENT: “It was really noisy here last night. It was like Grand Central Station.” Nurse: “You didn’t get a very good night’s sleep? What can we do to help you sleep better?” Summarizing If the nurse tells the client what he or she heard, it helps the nurse to make sure it was what the client meant. Often the person adds more to the statement or clarifies the nurse’s interpretation. CLIENT: “I was in the hospital 2 years ago and I swore I would never come here again.” Nurse: “You were dissatisfied with your stay?” Client: “The food was so tasteless. I couldn’t eat. My roommate died. The noise at night kept me from sleeping. I went home in worse shape than when I came in.” Nurse: “Sounds like you were very uncomfortable when you were here and are apprehensive about being admitted to the hospital again. How can we help improve the situation?” Another example of summarizing is as follows: Client: “I don’t eat meat. My son says I should, but I don’t.” Nurse: “You don’t eat meat?” Client: “That’s right. I can’t chew it any more.” Or, Client: “That’s right. I can’t afford meat.” Or, Client: “That’s right. I have become a vegetarian.” Or, Client: “That’s right. I’m afraid of the cholesterol.” Or Client: “I don’t eat meat on Fridays and on religious holidays.” Or Client: “My religion forbids me to eat pork.” Or Client: “I cannot eat the meat here because it is not Kosher.” By allowing the client to continue talking, the nurse can find the real reason that he or she does not eat meat. Using Unfinished Statements also NEEB’s p. 27 (using general leads) Sometimes, if the nurse makes an unfinished statement, the client finishes it. For example: Nurse: “You’re going to live with your daughter . . .?” Client: “Well, I don’t know. She really wants to put me in a nursing home, but I don’t want to go!” GIVING INFORMATION Neeb’s page 27. Stating Implied Thoughts and Feelings, Neeb S p28

Communicating in Special Situations Communicating With Different Age Levels Communicating With the Client Who Has Sensory Problems The Unconscious Client The Person With Aphasia The Client Who Is Not Able or Who Refuses to Speak The Client Who Speaks a Different Language The Person Who is Anxious The Person with Severe Mental Illness Communicating in Special Situations Not all communication can be handled in the same way. Modifications to communication techniques are often necessary when working with children, older adults, mentally ill people, or people with special sensory or behavioral problems. Communicating With Different Age Levels The Young Child. When working with small children, keep normal developmental stages in mind and communicate at an appropriate level for the child’s age. Remember that children often regress (revert) to an earlier stage of development when ill. Role playing or drawing pictures may be helpful to determine what a child is feeling. Key Concept It is important to remember that play is often the most effective means of communicating with a child The Older Adult. It is important to respect and treat the older adult as you would expect to be treated. The effective nurse tries to communicate with older adults at an appropriate level and to be considerate of personal dignity. It is important not to “talk down to” any of your clients, whether younger or older. Show respect by addressing the person as “Mr.” or “Ms.” and adding the client’s last name. It is disrespectful to refer to an older person by such names as “Grandpa” or “Sweetie.” (If the client asks to be called by his or her first name, it may be acceptable to do so.) Think how you might feel if a younger person did not treat you with respect. Communicating With the Client Who Has Sensory Problems The Visually Impaired or Hearing-Impaired Person. Communication with sensory-impaired people is discussed. Remember these important points: • Do not frighten the person. The visually impaired person cannot see you coming; the hearing-impaired person cannot hear you. Make sure the person knows you are in the room before you touch him or her. • Remember, the person with a sensory impairment is normal, not abnormal. Take a little extra time to stop and communicate with this client. • utilize the services of a sign language interpreter, if the client is able to communicate in this way. Key Concept When communicating with a client who has a visual or hearing impairment, remember that this person is normal and has strengths, likes, and dislikes, just as does anyone else. FUNDAMENTALS , 127 The Unconscious Client. use these guidelines for communicating with the unconscious client: • Always assume the client can hear you. • Introduce yourself. • Explain what you are going to do. • Talk to the client. • Describe what the client can expect (cold, wet, pressure). • Do not talk about the client or the client’s family in his or her presence. (Also, be sure the client’s family does not do so either.) Many people who have been unconscious for some time remember—when they recover—everything that occurred while they were unconscious. The Person With Aphasia. Aphasia commonly involves the inability to communicate verbally. However, aphasia may also include the client who cannot communicate via writing or by sign language or who cannot comprehend what is being said. Aphasia often results from a neurologic disorder or injury or a psychiatric disorder. Clients who have experienced a cerebrovascular accident (stroke) or traumatic brain injury (TBI) may have some type of aphasia. This is very frustrating for clients, because their intelligence is often unaffected. The client often takes this frustration out on the nurse and family by showing anger, swearing, ignoring others, acting argumentative, or displaying assaultiveness and other disruptive behaviors. Develop some system or method of communication to help prevent withdrawal and social isolation. See Box 44-3 for examples of communication skills to use when working with people who have speech or communication difficulties. Key Concept It is important to establish some sort of communication system for all clients. The Client Who Is Not Able or Who Refuses to Speak ♦ Provide the client with a “magic slate,” pencil and paperi or word and picture cards (see Fig. 44-7). Encourage him or her to write or use a computer to indicate requests and comments Establish hand signals or eye signals that are understood by both client and staff. It is most important to establish signals for “yes” and “no” if at all possible. ♦ Remember that most clients can hear and can often understand, even if they are unable to speak or are not fluent in the language spoken. ♦ Treat each person with respect. Do not “talk down to” the client or talk about the client. ♦ Talk to the client, even if he or she is unable to answer ♦ Many clients who cannot speak can use a computer Assist the person to try this. ♦ Allow the client time to formulate words. Do not rush. ♦ Encourage the client to read. This may help the aphasic person to find more words. The Client Who Speaks a Different Language ♦ Provide a client’s language-to-English language dictionary at the bedside. ♦ Make sure to schedule a qualified interpreter for physician’s visits, team conferences, and so forth. (Telephone or video interpreters may be used if an on-site interpreter is not available.) ♦ Try to learn a few words of the client’s language. ♦ Ask the client to repeat back and explain what was said. Many people who do not speak the language being spoken will say they understood, even if they did not. It is important to check to make sure that the client understands questions and instructions. ♦ Computer programs and translation devices are available to assist people to communicate in a language other than their own. ♦ Try to assign staff who can speak some of the client’s language. Introduce the client to others who speak the same language. ♦ Encourage family members and friends to visit. They can provide encouragement to the client and may be able to give information to the staff. Both the Client Who is Unable to Speak and the Client Who Speaks a Different Language ♦ Design a picture board showing commonly requested items. The client can point to items requested. Put the English word under each picture (see Fig. 44-7). ♦ If a client is not English-speaking, put the English word and the corresponding word from the client’s language under each photo. ♦ Remember that everyone understands a smile. ♦ Be conscious of body language. Make sure it is not misunderstood. Do not touch the client until you are sure the client understands what you are going to do. ♦ Consider cultural differences. ♦ Encourage the person to speak. Reinforce attempts to speak. ♦ Be patient. Give the person a chance to communicate. ♦ Remember that hesitation before speaking or avoiding direct eye contact may be a sign of respect. ♦ Make liberal use of hand gestures. Be aware that some gestures used in the United States mean something entirely different in another country. ♦ Speak slowly and clearly. ♦ Avoid slang. Keep statements simple. ♦ Do not raise your voice—the person is not hearing-impaired. Saying something louder will not help the person to understand. ♦ Do not repeat the same thing over and over. Try to phrase it in a different way. Use simple language. Do not use slang terms. Remember that many of these clients can understand more than they can speak For more technical communications, find official interpreters to speak to the client. Often a family member volunteers to help, but there are risks involved: the family member may add his or her own interpretation to what the client says or may not be able to translate medical terms correctly. The nurse has no way of knowing the accuracy of the layperson’s translations. In addition, the use of a family member or friend as an interpreter violates the client’s privacy. Key Concept All interpreters must be approved by the facility before becoming involved in a client’s care. Health Insurance Portability and Accountability Act (HIPAA) regulations require special training for interpreters. The interpreter must have documentation of this training and must be an approved volunteer or employee of the healthcare organization. Dealing With Specific Client Behaviors Some clients may be anxious. They may be afraid of being hospitalized, fear dying, or feel generally depressed. Some people do not trust anyone and are suspicious. Some clients will question everything the nurse does. Other clients regress and become dependent on the nursing staff. Others become isolated and reject everything the nurse tries to do. Some people may be very fearful or may react with false bravado or become threatening or assaultive. Be patient and open-minded with all clients. Reassure them and make sure that the client is not a danger to self or others. Let all clients know you care, but do not allow them to participate in dangerous or threatening behavior. Encourage independence in all clients.

FIGURE 44-7 · A word-and-picture card can assist in communicating with a person who has difficulty hearing or speaking or with one who speaks a language different than that of the nurse. Sometimes, each word is also written in the client’s language so the staff can learn some key words.

FACILITATING COMMUNICATION IN HEALTHCARE Nurses facilitate communication between clients and members of the nursing team in various ways FACILITATING COMMUNICATION IN HEALTHCARE Nurses facilitate communication between clients and members of the nursing team in various ways, including: • Skillfully interviewing clients to determine their healthcare needs • Listening attentively to what the client is saying • Teaching clients and their families certain aspects of care • Documenting information on the nursing care plan and in the client’s record • Reporting the condition of the client to other members of the healthcare team • Participating in team conferences and client care conferences • Maintaining the confidentiality of all information about clients. Be sure to have a signed Release of Information (ROI) before disclosing any information about a client to any unapproved person. • Treating each client as a unique individual; it is important to consider each person’s age, sex, ethnic and religious background, state of health, life experiences, body image, feelings about being in the healthcare facility, language preference, and other personal factors • using both verbal and nonverbal means of communication and observing clients’ verbal and nonverbal reactions • using touch as a therapeutic modality, but not invading the client’s personal space or threatening the client All aspects of communication influence the quality and effectiveness of client care. How the nurse handles this responsibility will directly influence the client’s recovery.

Key Points Effective communication is the cornerstone to competent nursing care. This is true in any setting. Effective communication is the cornerstone to competent nursing care. This is true in any setting. • Communication involves a sender, a receiver, a channel, a message, and feedback. • Developing rapport with the client is a basic ingredient of the nurse-client relationship. • All communication has verbal and nonverbal components. NVC is very powerful. • The nurse must consider all personal and cultural factors about each client when communicating. • Nurses conduct interviews to learn information about clients and to teach. • The nurse can make many important observations, in addition to what the client says when communicating. • Nurses use techniques other than words to communicate with clients who have special communication difficulties. • Competent nursing care requires caring, accurate, and ethical communication with clients and the healthcare team. • It is critical to maintain each client’s confidentiality when communicating, whether verbally, by computer, or in writing.