1. Chapter 24 Communication
Communication is a powerful therapeutic tool and an essential nursing skill that influences others and achieves positive health outcomes.
In working with patients and their families, health care professionals must communicate effectively to convey care plans and apply nursing skills and knowledge.
When performing their professional duties, nurses will be required to use nonverbal, verbal, and technological skills to communicate with patients, families, and other health care professionals.

2. Communication and Nursing Practice
A lifelong learning process for nurses
An essential attribute of professional nursing practice
Builds relationships with patients, families, and multidisciplinary team members
•Nurses can not function without communicating with patients, family members, and other health care professionals.
•Oftentimes, nurses communicate with others under extreme stress.
•It is very important that nurses be assertive so they can ask the correct questions and their voices can be heard, especially when acting as their patient's advocate.
•Competent communication will help you maintain effective relationships within the profession and meet legal, ethical, and clinical standards of care.
•Breakdown in communication among the health care team is a major cause of errors in the workplace and threatens professional credibility.

3. Communication and Interpersonal Relationships
Communication is the means to establish helping-trust relationships.
The ability to relate to others is important for interpersonal communication.
Developing communication skills requires an understanding both of the communication process and of
one’s own communication experience.
•Your therapeutic relationship will begin when you first meet your patient. The first eye contact and first interactions will set the stage for you and your patient and family members.
•Gaining experience in communication requires that you learn and use communication theory and also draw on past personal experiences.
•You will need to interpret messages received from others, analyze the content, make inferences about the meaning, evaluate the effect, explain the rationale for the technique used, and examine communication style/pattern.
•Effective interprofessional communication is essential to provide safe transitions and care. Effective communication is critical in promoting collaboration and teamwork in providing patient-centered care.
[See Box 24-1 on text p. 311 Communication Throughout the Nursing Process, and Box 24-2 on text p. 311 Challenging Communication Situations, for further discussion.]

4. Communication and Interpersonal Relationships (cont’d)
Therapeutic communication occurs within a healing relationship between a nurse and a patient.
The nurse’s communication can result in both harm and good.
Skilled communication empowers others and enables people to know themselves and to make their own choices.
•Every nuance of posture, every small expression and gesture, every word chosen, every attitude held—all have the potential to hurt or heal.
•Respect the potential power of communication, and do not carelessly misuse communication to hurt, manipulate, or coerce others.
[Ask the class: What are some ways that nurses with expertise in communication express caring? Then discuss.]
•Nurses with expertise in communication express caring by:
Becoming sensitive to self and others
Promoting and accepting the expression of positive and negative feelings
Developing helping-trust relationships
Instilling faith and hope
Promoting interpersonal teaching and learning
Providing a supportive environment
Assisting with gratification of human needs
Allowing for spiritual expression

5. Developing Communication Skills
Critical thinking
Perseverance and creativity
Self-confidence
Fairness and integrity
Humility
•Nurses who develop critical thinking skills make the best communicators.
They draw on theoretical knowledge about communication and integrate this knowledge with knowledge previously learned through personal experience.
Critical thinking skills can be used to interpret messages received from others, analyze their content, make inferences about their meaning, evaluate their effects, explain rationale for communication techniques used, and self-examine personal communication skills.
•Perseverance and creativity are also helpful because they motivate a nurse to identify innovative solutions.
•Patients respond more readily to a self-confident attitude.
[How could self-confidence help you in making suggestions about nursing interventions to your colleagues?]
•Colleagues sometimes question suggested nursing interventions; having confidence in yourself will help you speak up and offer new ideas.
•An attitude of fairness goes a long way in the ability to listen to both sides in any discussion; integrity allows nurses to recognize when their opinions conflict with those of their patients, review positions, and decide how to communicate to reach mutually beneficial decisions.
•You won’t know everything. Having an attitude of humility is necessary to recognize and communicate the need for more information before making a decision.

6. Developing Communication Skills (cont’d)
Thinking is influenced by perception
Five senses
Culture
Education
Perceptual bias
Communication is most effective when the receiver and the sender accurately perceive the meaning of one another’s messages.
It is challenging to understand human communication within interpersonal relationships.
•Each person bases understanding of a situation through the filter of her senses (sight, hearing, taste, touch, and smell) and her life experiences (culture, education, past events).
•Perceptual biases are human tendencies that interfere with accurately perceiving and interpreting messages from others.
•People often assume that others think, feel, act, react, and behave as they would in similar circumstances. They tend to distort or ignore information that goes against their expectations, preconceptions, or stereotypes.
•You can overcome perceptual bias by thinking critically, which will help you control these tendencies and communicate effectively.

7. Quick Quiz! 1. Match the levels of communication.
1. Intrapersonal
A. One-to-one interaction between two people
2. Interpersonal
B. Occurs within an individual
3. Transpersonal
C. Interaction with an audience
4. Small group
D. Interaction within a person’s spiritual domain
5. Public
E. Interactions with a small number of people
[Ask the students to match the levels of communication. (Answers are shown on the next slide.)]
Answers:
1. B
2. A
3. D
4. E
5. C
Copyright line.

8. Levels of Communication
1. Intrapersonal
B. Occurs within an individual
2. Interpersonal
A. One-to-one interaction between two people
3. Transpersonal
D. Interaction within a person’s spiritual domain
4. Small group
E. Interactions with a small number of people
5. Public
C. Interaction with an audience
•Note the correct answers. [Discuss each.]

9. Quick Quiz!
2. You are invited to attend the weekly unit patient care conference. The staff discusses patient care issues. This type of communication is
A. Public.
B. Intrapersonal.
C. Transpersonal.
D. Small group.
Answer: D

10. Basic Elements of the Communication Process
•This simple linear model represents a very complex process with its essential components.
•The sender’s and the receiver’s physical and developmental status, perceptions, values, emotions, knowledge, sociocultural background, roles, and environment all influence message transmission.
[Image is Figure 24-1 from text p. 312 Communication as an active process between sender and receiver.]

11. Quick Quiz! 3. Match the basic elements of communication.
1. Referent
A. One who encodes and one who decodes the message
2. Sender and receiver
B. The setting for sender-receiver interactions
3. Message
C. Message the receiver returns
4. Channels
D. Motivates one to communicate with another
5. Feedback
E. Means of conveying and receiving messages
6. Interpersonal variables
F. Factors that influence communication
7. Environment
G. Content of the message
[Ask the students to match the definitions. (Answers are shown on the next slide.)]
Answers:
1. D
2. A
3. G
4. E
5. C
6. F
7. B

12. Basic Elements of the Communication Process
1. Referent
D. Motivates one to communicate with another
2. Sender and receiver
A. One who encodes and one who decodes the message
3. Message
G. Content of the message
4. Channels
E. Means of conveying and receiving messages
5. Feedback
C. Message the receiver returns
6. Interpersonal variables
F. Factors that influence communication
7. Environment
B. The setting for sender-receiver interactions
[Discuss each answer.]

13. Forms of Communication
Verbal aspects of communication:
Vocabulary
Intonation
Pacing
Denotative and connotative meaning
Clarity and brevity
Timing and relevance
•Verbal communication uses spoken or written words. Verbal language conveys specific meanings through the combination of words.
•Each of these aspects conveys meaning to the words you use. [Discuss each.]
•Connotative meaning is the shade or interpretation of the meaning of a word influenced by the thoughts, feelings, or ideas that people have about the word.
•Concerning timing, often the best time for interaction is when a patient expresses an interest in communicating.
•Most important, make sure your communication is culturally competent and respectful.

14. Forms of Communication (cont’d)
Nonverbal
Personal appearance
Posture and gait
Facial expressions
Eye contact
Gestures
Sounds
Territoriality and personal space
•Nonverbal communication involves all five senses.
•All types of nonverbal communication are important, but interpreting the meaning can cause problems. [Discuss each form.]
•Problems can occur when culturally diverse patients, family members, and health care workers misinterpret nonverbal communication.
[See Box 24-3 on text p. 314 Zones of Personal Space and Touch for further discussion.]

15. Forms of Communication (cont’d)
Symbolic
The verbal and nonverbal symbolism used by others to convey meaning
Metacommunication
A broad term that refers to all factors that influence communication
•Art and music are forms of symbolic communication.
•Metacommunications send messages that oftentimes present incongruence between the word and body language.
•Awareness of the tone of the verbal response and of nonverbal behavior warrants further exploration of the patient's feelings and concerns.

16. Nurse-Patient Relationship
1. Preinteraction phase: occurs before meeting the patient 2. Orientation phase: when the nurse and the patient meet and get to know each other 3. Working phase: when the nurse and the patient work together to solve problems and accomplish goals 4. Termination phase: occurs at the end of a relationship
•The nurse-patient relationship has four phases.
[See Box 24-4 on text p. 315 Phases of the Helping Relationship for further discussion.]

17. Professional Nursing Relationships
Nurse-patient helping relationships
Nurse-family relationships
Nurse-health team relationships
Nurse-community relationships
The same principles that guide one-on-one helping relationships apply when the patient is a family unit, although communication within families requires additional understanding of the complexities of family dynamics, needs, and relationships.
Evidence-based practice has identified some of the nursing actions that increase the effectiveness of nurse-to-nurse interaction and interprofessional communication.
[See Box 24-5 on text p. 316 Evidence-Based Practice for an evidence summary and applications to nursing practice.]
•Communication within the community occurs through many channels. [Ask the class for examples of these channels: neighborhood newsletters, health fairs, public bulletin boards, newspapers, radio, television, and electronic information sites.]

18. Case Study
Roberto Ruiz is a 44-year-old man of Puerto Rican descent, suffering from HIV/AIDS. He was near death and in hospice, but his condition has improved and he is now home.
Suzanne is a 54-year-old nurse dedicated to hospice and committed to maximizing quality of life in end-of-life care.
[Ask the class: What are some important communication areas for Suzanne and Roberto? Possible answers include
“What are your needs at this time?”
“What are your concerns at this time and for the future?”]
[Discuss.]

19. Quick Quiz!
4. Helping relationships serve as the foundation of clinical nursing practice. Contracts for a therapeutic helping relationship are formed during the A. Orientation stage. B. Working stage. C. Termination stage. D. Preinteraction stage.
Answer: A

20. Elements of Professional Communication
Appearance, demeanor, and behavior
Courtesy
Use of names
Trustworthiness
Autonomy and responsibility
Assertiveness
[Why are these aspects important when establishing a relationship with patients, family members, and health team members?]
[Be sure to stress the importance of cultural diversity and respect for age.]
•Professional appearance, demeanor, and behavior communicate that you have assumed the professional helping role, are clinically skilled, and are focused on your patients.
•Common courtesy is part of professional communication.
•Always introduce yourself. Failure to give your name and status or to acknowledge a patient creates uncertainty about the interaction and conveys an impersonal lack of commitment or caring.
•Trustworthiness includes maintaining confidentiality. Nurses strengthen helping relationships by establishing trust, empathy, autonomy, confidentiality, and professional competence.
•Autonomy is being self-directed and independent in accomplishing goals and advocating for others.
•Assertiveness allows you to express feelings and ideas without judging or hurting others.

21. Case Study (cont’d)
As Suzanne works with Roberto, she develops a helping relationship. Suzanne knows that posing questions for the patient’s reflection helps her assess his needs and support his self-care strategies.
•A helping relationship between you and your patient does not just happen. You create it with care and skill, and build it on the patient’s trust in you as a nurse.
•You help patients to clarify needs and goals, solve problems, and cope with situational or maturational crises.
•Creating this therapeutic environment depends on your ability to communicate, provide comfort, and help the patient meet his or her needs.

22. Nursing Process: Assessment
Through the patient’s eyes
Gather information, synthesize, apply critical thinking
Physical and emotional factors
Developmental factors
Sociocultural factors
Gender
•Assessing contextual factors will help you to make sound decisions during the communication process.
•Contextual factors include your patient’s physiological status, as well as relational, situational, environmental, and cultural contexts.
[See Box 24-6 on text p. 317 Assessment: Factors Influencing Communication for further discussion.]
•Remember that context refers to all the parts that help to determine the meaning of something.
•When communicating with patients, it will be important to deal properly with your patient’s physical, emotional, developmental, gender, and sociocultural issues.
•Patients need to be treated respectfully with regard to age and culture.
[See Box 24-7 on text p. 318 Focus on Older Adults for tips on improved communication with older adults who have hearing loss, and Box 24-8 on text p. 318 Cultural Aspects of Care for tips on communicating with non–English-speaking patients.]

23. Case Study (cont’d)
Suzanne learns that Roberto wants to travel to New York to see his extended family.
Even though Roberto is in poor health and the trip will be difficult, Suzanne expresses her understanding of the importance of the trip. She understands how important extended family is in the Puerto Rican culture.
[What is Suzanne demonstrating?]
•Her understanding of the importance of the extended family in the Puerto Rican culture helps her appreciate the importance of the trip to New York. Expressing an understanding of the importance of the trip, even though he is in poor health and it will be a difficult trip, demonstrates cultural sensitivity.
•In the example above, Suzanne did not question why he felt it important to see more distant relatives.

24. Nursing Process: Diagnosis
Nursing diagnosis for communication
Many patients experience difficulty with communication:
Lacking skills in attending, listening, responding, or self-expression
Inability to articulate, inappropriate verbalization
Difficulty forming words
Difficulty with comprehension
•Remember that impairment of communication can be physiological, mechanical, anatomical, psychological, cultural, or developmental.
•The primary nursing diagnostic label used to describe a patient with limited or no ability to communicate verbally is impaired verbal communication.
•Although a patient’s primary problem is impaired verbal communication, the associated difficulty in self-expression or altered communication patterns may contribute to other nursing diagnoses:
• Anxiety
• Social isolation
• Ineffective coping
• Compromised family coping
• Powerlessness
• Impaired social interaction
Related factors for a nursing diagnosis focus on the causes of the communication disorder.

25. Nursing Process: Planning
Goals and outcomes
Specific and measurable
Setting of priorities
Teamwork and collaboration
[Ask the class: What are some examples of specific and measurable communication goals and outcomes? Possible outcomes include:
•Patient initiates conversation about diagnosis or health care problem.
•Patient is able to attend to appropriate stimuli.
•Patient conveys clear and understandable messages to health care team.
•Patient expresses increased satisfaction with the communication process.]
•Setting priorities: Always maintain an open line of communication; ensure the patient is comfortable and that all physical needs have been met.
•Teamwork: If patients have problems with communication, you may need to seek the services of a speech therapist or an interpreter.

26. Case Study (cont’d)
During her visit, Roberto tells Suzanne, “I really want to go visit my uncles in New York, but I’m not sure I’m up for the trip.”
Suzanne is understanding: “It sounds like you miss your family. Let’s talk about your options for maintaining contact.”
As they talk, Suzanne helps Roberto to identify two methods of communicating with his family in New York.
[Suzanne identifies two outcomes from her conversation with Roberto. What are the outcomes that Suzanne identifies?]
•Outcomes for Roberto include the following:
Patient identifies two methods to maintain communication with family in New York.
Patient verbalizes his concerns regarding his declining health.

27. Nursing Process: Implementation
Therapeutic communication techniques are specific responses that encourage the expression of feelings and ideas and convey acceptance and respect.
Active listening means being attentive to what a patient is saying both verbally and nonverbally.
Use “SOLER”: Sit facing the patient; observe an open posture, lean toward the patient, establish and maintain intermittent eye contact; relax
•Communication techniques need to be used to prevent barriers when rendering care to patients.
•Effective communication techniques are facilitative and tend to encourage the other person to openly express ideas, feelings, or concerns.
•Active listening mnemonic means:
S—This posture (sitting) conveys the message that you are there to listen and are interested in what the patient is saying.
O—Observe an open posture (i.e., keep arms and legs uncrossed). This posture suggests that the you are “open” to what the patient says. A “closed” position conveys a defensive attitude, possibly provoking a similar response in the patient.
L—Lean toward the patient. This posture conveys that you are involved and interested in the interaction.
E—Establish and maintain intermittent eye contact. This behavior conveys your involvement in and willingness to listen to what the patient is saying. Absence of eye contact or shifting the eyes gives the message that you are not interested in what the patient is saying.
R—Relax. It is important to communicate a sense of being relaxed and comfortable with the patient. Restlessness communicates to the patient lack of interest and a feeling of discomfort.
[Ask the class for other therapeutic techniques in addition to active listening. Discuss the following: active listening, sharing observations, sharing empathy, sharing hope, sharing humor, sharing feelings, using touch, using silence, providing information, clarifying, focusing, paraphrasing, asking relevant questions, summarizing, self-disclosure, and confrontation.]

28. Nursing Process: Implementation (cont’d)
Therapeutic communication techniques
Nontherapeutic communication techniques
Adapting communication techniques
•Unlike therapeutic communication techniques, nontherapeutic communication hinders or damages professional relationships: asking personal questions, giving personal opinions, changing the subject, automatic responses, false reassurance, sympathy, asking for explanations, approval or disapproval, defensive responses, passive or aggressive responses, and arguing.
•Ineffective communication techniques are inhibiting and tend to block the other person’s willingness to openly express ideas, feelings, or concerns.
•Communication techniques often must be adapted for patients with special needs. Such patients include aging persons, those who have problems speaking and understanding, the hearing impaired, the visually impaired, and those who do not speak English.
•Blend social and informational interactions with therapeutic communication techniques to help your patients explore feelings and manage health issues.
[See Box 24-9 on page 324 Communicating with Patients Who Have Special Needs for further discussion.]
[Image is Figure 24-2 from text p. 321 The nurse uses touch to communicate.]

29. Adapting Communication Techniques
Patients who cannot speak clearly
Cognitive impairment
Hearing impairment
Visual impairment
Unresponsive
Patients who do not speak English (or your language)
Older adults with sensory, motor, or cognitive impairments require adaptation of communication techniques to compensate for their loss of function and special needs.
[Ask the students to consider how they would adapt communication techniques for patients with each of the situations listed. Discuss.]
Patients with impaired verbal communication require special consideration and alterations in communication techniques to facilitate sending, receiving, and interpreting messages.

30. Quick Quiz!
5. While admitting a patient, during the initial interview, a family member tells you, “My mom really means that she does not understand her medical diagnosis.” The communication form used by the family member is A. Focusing. B. Clarifying. C. Summarizing. D. Paraphrasing.
Answer: B

31. Nursing Process: Evaluation
Through the patient’s eyes
Patient outcomes
Nurses and patients need to determine whether the plan of care has been successful.
Nursing interventions are evaluated to determine which strategies or interventions were effective.
If expected outcomes are not met, the plan of care needs to be modified.
•Does the patient perceive having difficulty communicating? Have the patient’s needs been met?
•Videotaping practice sessions with peer or process recording can help students assess their communication style.
•Desired outcomes for patients with impaired verbal communication include increased satisfaction with interpersonal interactions, the ability to send and receive clear messages, and attention to and accurate interpretation of verbal and nonverbal cues.
[See Box on text p. 325 Sample Communication Analysis for an example of process recording.]