129 terms

Nursing Communication

Potter Perry Chapter 10 - Overview
Motivates one person to communicate with another.
(Sights, sounds, odors, time schedules, emotions, sensations, perceptions) Considering the referent during an interaction helps the sender develop and organize the message.
[Basic Elements of the Communication Process]
Is the person who delivers the message.
The roles of sender and receiver change back and forth as two persons interact.
[Basic Elements of the Communication Process]
Is the content of the conversation, including verbal and nonverbal information the sender expresses.
(The most effective message is clear, organized, and expressed in a manner familiar to both the sender and the receiver.)
[Basic Elements of the Communication Process]
Is the means of conveying and receiving the message through visual, auditory, and tactile senses.
(Example: Your facial expression sends a visual message, and spoken words travel through auditory channels.)
Usually, the more channels the sender uses to convey a message, the more clearly the receiver will understand the message.
[Basic Elements of the Communication Process]
You send the message to the receiver. The message acts as one of the receiver's referents, prompting a response.
(The more the sender and receiver have in common and the closer the relationship, the more likely the receiver will accurately perceive the sender's meaning and respond appropriately.)
[Basic Elements of the Communication Process]
The physical and emotional climate in which the interaction takes place.
(Make the environment comfortable and suitable to the participants' needs for effective communication. the more positive an environment, the more successful the communication exchange.)
[Basic Elements of the Communication Process]
The message the receiver returns to the sender.
Feedback indicates whether the receiver understood the meaning of the sender's message. Your positive intent is not enough to ensure accurate reception of a message. Seek verbal and nonverbal feedback from the receiver to be sure the receiver understands the message.
[Basic Elements of the Communication Process]
Intrapersonal Communication
(also called "self-talk)
Powerful form of communication that occurs within an individual.
("Talk to ones self" by forming thoughts internally that strongly influence perceptions, feelings, behavior, self-concept, and performance.)
Self-talk is a mental rehearsal for difficult tasks or situations so individuals deal with them more effectively.
(Positive self-talk -- forms such as imagery or meditation, you use it to enhance coping and reduce stress.)
[Levels of Communication]
Interpersonal Communication
Is interaction that occurs between two people or within a small group.
It refers to nonverbal and verbal behavior within a social context and includes the use of symbols and cues to give and receive meaning.
(Effective interpersonal communication includes idea sharing, problem solving, expressing feelings, decision making, goal accomplishment, team building, and personal growth.)
[Levels of Communication]
Public Communication
Is the interaction of one individual with large groups of people.
(You will make special adaptations in eye contact, posture, gestures, voice inflection, and use of media materials to communicate messages effectively.)
[Leveles of Communication}
Verbal Communication
Involves the spoken or written word. Verbal language is a code that conveys specific meaning as you combine words.
[Forms of Communication]
Denotative meaning
Common language for individuals of a specific field or industry. (Example: The word 'code' denotes cardiac arrest primarily to health care providers).
(Verbal Communication]
Connotative meaning
Is the shade or interpretation of a word's meaning influenced by the thoughts, feelings, or ideas people have about the word.
(Example: Families who are told a loved one is in serious condition might believe that death is near, but to nurses the term "serious" may simply describe the nature of the illness.)
[Verbal Communication]
Speak slowly, enunciate clearly, and use pauses to accentuate or stress a particular point or to give the listener time to understand.
[Verbal Communication]
Tone of voice
A simple question or statement can express enthusiasm, anger, or concern.
(Pay attention to a patient's intonation for information about his/her emotional state or energy level.)
[Verbal Communication]
Clarity and Brevity
Effective communication is simple, short, and to the point to minimize confusion.
(AVOID -- "you know" or "OK?" at the end of every sentence.) Give examples to clarify messages for the receiver. Use short sentences and words that express and idea simply and directly.
[Verbal Communication]
Timing and Relevance
Timing is critical in communication. Even if a message is clear, poor timing prevents it from being effective.
(Example: Do not begin routine teaching when a patient is in severe pain or emotional distress. The best time for interaction is when a patient expresses an interest in communication.)
Relevant messages are more effective.
(Example: When a patient is facing emergency surgery, discussing the risks of smoking is less relevant than discussing what the staff will do to prepare the patient for surgery.)
[Verbal Communication]
Nonverbal Communication
Includes messages sent through the language of the body, without using words.
(Examples: Facial expressions, vocal cues, eye contact, action cues -- gestures, posture, touch, odor, physical appearance, dress, silence, and the use of time.)
Nonverbal communication often reveals true feelings, because you have less control over nonverbal reactions.
(Example: A patient who says he feels fine but frowns while moving and holds his body rigidly is probably in pain.)
Nonverbal behaviors add meaning to verbal communication and help you judge the reliability of verbal messages.
Nonverbal behaviors vary in different cultures.
Be sure your (the nurse) nonverbal and verbal messages match.
(Example: If you say a patient is getting better but wear an expression of doubt, you will not relieve a patient's anxiety.)
[Forms of Communication]
Personal Appearance
Physical characteristics, manner of dress and grooming, and jewelry are indicators of well-being, personality, social status, occupation, religion, culture, and self-concept.
First impressions are largely based on appearance.
Your physical appearance influences a patient's perception of care.
(Example: Although your dress may not reflect your abilities, it takes longer to establish trust if your clothing differs from a patient's preconceived image.)
[Nonverbal Communication]
Posture and Gait
The way people sit, stand, and move is a form of self-expression.
Posture and gait reflect emotions, self-concept, and health status.
(Example: An erect posture and a quick, purposeful gait communicate a sense of well-being and confidence.
A slumped posture and slow, shuffling gait may indicate depression or fatigue.
Leaning forward conveys attention.
Leaning backward in a more relaxed manner shows less interest or indicates caution.)
[Nonverbal Communication]
Facial Expression
The face, the most expressive part of the body, reveals emotions such as surprise, fear, anger, happiness, and sadness.
The sender's facial expressions often become the basis for judgments by the receiver. However, because of the diversity in facial expressions, meanings are often misunderstood.
Facial expressions reveal, contradict, or suppress true emotions.
People are often unaware of the messages their expressions send.
When facial expressions are unclear, seek verbal feedback about the sender's intent.
(Example: A patient who frowns after receiving information may be confused, angry, disapproving, or simply concentrating on a reply. In this case, say, "I notice you're frowning," and encourage clarification of the patient's response.)
Patients watch nurses closely.
(Example: Consider the effect your facial expression has on a patient who asks, "Am I going to die?" The slightest change in the eyes, lips, or face will reveal your true feelings.)
Learn to avoid showing overt shock, disgust, dismay, or other distressing reactions in the patient's presence.
[Nonverbal Communication]
Eye Contact
Americans generally maintain eye contact to signal a readiness to communicate, regardless of social class.
By maintaining eye contact during conversation, you communicate respect and a willingness to listen.
Eye contact also allows you to observe another closely.
(Example: Lack of eye contact indicates anxiety, defensiveness, discomfort, or a lack of confidence in communicating.)
However, some cultures, such as Asian and Indochinese, Native American, and Appalachian, consider eye contact to be intrusive, threatening, or harmful and minimize its use.
Always consider the person's culture when interpreting the meaning of eye contact.
Eye movements communicate feelings and emotions.
(Example: Wide eyes express frankness, terror, and innocence.
Downward glances show modesty.
Raised upper eyelids reveal displeasure, and a constant stare may be associated with hatred or coldness.
Looking down on a person establishes authority, whereas interacting at the same eye level indicates equality in the relationship.
You appear less dominant and less threatening when interacting at the patient's eye level.
Rising to the same eye level of an angry person helps establish your independence.)
[Nonverbal Communication]
Intimate Zone
(0 to 18 inches)
Holding a crying infant
Performing physical assessment
Bathing, grooming, dressing, feeding, and toileting a patient
Changing a patient's dressing
[Zones of Personal Space]
Personal Zone
(18 inches to 4 feet)
Sitting at a patient's bedside
Taking the patient's nursing history
Teaching an individual patient
Exchanging information at change of shift
[Zones of Personal Space]
Social Zone
(4 to 12 feet)
Making rounds with a health care provider
Sitting at the head of a conference table
Teaching a class for patients with diabetes
Conduction a family support group
[Zones of Personal Space]
Public Zone
(12 feet and greater)
Speaking at a community forum
Testifying at a legislative hearing
Lecturing to a class of students
[Zones of Personal Space]
Social Zone
Permission Not Needed)
[Zones of Touch]
Consent Zone
(Permission Needed)
[Zones of Touch]
Vulnerable Zone
(Special Care Needed)
Front of body
[Zones of Touch]
Intimate Zone
(Great Sensitivity Needed)
[Zones of Touch]
(Examples: A salute, a thumbs-up, and a tapping foot)
Hands and feet emphasize, punctuate, and clarify the spoken word.
Gestures alone carry specific meanings, or they may create messages with other communication cues.
(Example: A finger pointed toward a person may communicate several different meanings, but if you frown and have a stern tone of voice, the gesture becomes a sign of accusation or threat.)
[Nonverbal Communication]
Territoriality and Space
Territoriality is the need to gain, maintain, and defend one's exclusive right to space
Territory is separated and made visible to others, such as a fence around a yard. Personal space is invisible, individual, and travels with the person.
During interpersonal interaction, people consciously maintain varying distances between themselves, depending on the nature of the relationship and situation.
When personal space is threatened, people respond defensively and communicate less effectively.
You must frequently move into patients' territory and personal space because of the nature of caregiving.
Convey confidence, gentleness, and respect for privacy, especially when actions require intimate contact.
Knock before you enter a room.
As you leave, ask if the patient wants the door open or closed.
Ask if you can reposition the bed table and what items the patient wants close by.
[Nonverbal Communication]
Psychophysiological Context
The INTERNAL Factors Influencing Communication
Physical helath
Emotional status
Growth and development status
Unmet needs
Attitudes, values, and beliefs
Perceptions and personality
Self-concept and self-esteem
[Contextual Factors Influencing Communication]
Relational Context
The NATURE of the RELATIONSHIP between the Participants
Social, helping, or working relationship
Level of trust and self-disclosure between participants
Shared history of participants
Balance of power and control
[Contextual Factors Influencing Communication]
Situational Context
The REASON for the Communication
Information exchange:
Goal achievement
Problem resolution
Expression of feelings
[Contextual Factors Influencing Communication]
Environmental Context
The PHYSICAL SURROUNDINGS in which Communication Takes Place
Degree of privacy
Degree of comfort and safety
Noise level
Presence of distractions
[Contextual Factors Influencing Communication]
Cultural Context
The SOCIOCULTURAL ELEMENTS that Affect the Interaction
Education level of participants
Language and self-expression patterns
Customs and expectations
[Contextual Factors Influencing Communication]
Is exploration of all factors that influence communications.
(Example: The patient who has had facial surgery tells you, "This scar doesn't look as bad as I thought it would." but is teary and appears apprehensive.
Your nursing experience with facial disfigurement teaches you how anxious people are about a part of the body that everyone can see.
Awareness that the patient's verbal and nonverbal behaviors do not match prompts you to explore the patient's feelings and concerns.)
This analysis of all aspects of communication is metacommunication.
[Factors Influencing Communication]
Therapeutic Communication
The nurse develops a relationship with the patient to meet several purposes.
Creating a therapeutic environment depends on the nurse's ability to communicate, provide comfort, and help the patient meet his or her needs.
Example of Comforting Strategies: gentle humor, physical comfort measures, emotionally supportive statements, and comforting and connecting touch.
Nurses provide information, support patients' active decision making, and offer opportunites to engage in social exchange.
[Nurse-Patient Helping Relationship]
Nurse-Patient Relationship
"Learning experiences whereby two people interact to face an immediate health problem, to share, if possible, in resolving it, and to discover ways to adapt to the situation." -- Imogene King (1971)
the nurse helps patients to clarify needs and goals, solve problems, and cope with situational or maturational crises.
Also the nurse help patients explore the meaning of their illness experience and sort out responses to stressful situations to increase coping skills. (Therapeutic environment)
Preinteraction Phase
Before meeting the patient, you:
Review available data, including the medical and nursing histories
Talk to other caregivers who may have information about the patient
Anticipate health concerns or issues that may arise
Identify a location and setting that will foster comfortable, private interaction
Plan enough time for the initial interaction
[Phases of the Helping Relationship]
Orientation Phase
When you and the patient meet and get to know one another. you:
Set the tone for the relationship by adopting a warm, empathetic, caring manner
Recognize that the initial relationship may be superficial, uncertain, and tentative
Expect the patient to test your competence and commitment
Closely observe the patient and expect to be closely observed by the patient
Begin to make inferences and form judgments about patient messages and behavior
Assess the patient's health status
Prioritize patient problems and identify patient goals
Clarify the patient's and your roles
Form contracts with the patient to specify roles
Let the patient know when you will terminate the relationship
[Phases of the Helping Relationship]
Working Phase
When you and the patient work together to solve problems and accomplish goals, you:
Encourage and help the patient to express feelings about his or her health
Encourage and help the patient with self-exploration
Provide information needed to understand and change behavior
Encourage and help the patient to set goals
Take actions to meet the goals set with the patient
Use therapeutic communication skills to facilitate successful interactions
Use appropriate self-disclosure and confrontation
[Phases of the Helping Relationship]
Termination Phase
During the ending of the relationship, you:
Remind the patient that termination is near
Evaluate goal achievement with the patient
Reminisce about the relationship with the patient
Separate from the patient by relinquishing responsibility for his or her care
Achieve a smooth transition for the patient to other caregivers as needed
[Phases of the Helping Relationship]
A popular communication tool that help standardize communication between health care providers.
(Examples: When a patient's pain is no longer adequeantly controlled, the nurse would communicate to the patient's health care provider that he needs better pain control --- situation. Then give the HCP brief information about his history, noting that the patient does not wat to be "out of it" -- background. The nurse would then give an accrate description of the patient's pain -- assessment. And request a modification of the patient's pain regimen -- recommendation.)
[Nurse-Health Team Member Relationships]
Lateral Violence
Sometimes occurs in nurse-nurse interactions and includes behaviors such as withholding information, backbiting, making snide remarks, and nonverbal expressions of disapproval such as raising eyebrows or making faces.
[Nurse-Health Team Member Relationships]
Sentinel events
Unexpected occurrences that result in death or serious injury.
Application to Nursing Practice
Develop common language for critical information for hand-over communications and to communicate changes in a patient's condition.
* Use a communication tool such as SBAR to standardize communication.
* Use a standardized format for shift-change report.
* Use a standardized format for report when patients are transferred to other units or facilities.
* Provide the opportunity for questions and confirmation of understanding of communication.
* Have face-to-face communication when possible.
* Read back all physician or health care provider orders or other pertinent information.
* Allow time for questions and clarification of information.
* Create a culture of patient safety that allows questions and open communication.
* Work in multidisciplinary teams to develop common language.
* Develop skills in assertive communication and conflict management.
[Best Practices]
The patient's acceptance of you as a professional often depends on the manner in which you present a professional and caring image.
(Examples: Verbal and nonverbal behaviors influence the helping relationship. Professional appearance, demeanor, and behavior are important in establishing trustworthiness and competence.)
[Establishing a Therapeutic Relationship]
It conveys respect for others and oneself.
(Examples courtesy techniques: saying hello and goodbye, knocking on doors before entering, introducing oneself, and stating one's purpose. Addressing people by name, saying "please" and "thank you" to team members, and apologizing for making an error or causing someone distress)
[Establishing a Therapeutic Relationship]
Terms of Endearment
AVOID terms of endearment
(Examples: "honey", "dear", "Grandpa", or "sweetheart")
[Establishing a Therapeutic Relationship]
Always safeguard a patient's right to privacy by careful protecting information of a confidential nature.
Reassure the patients that you will keep information private, and then keep that promise.
[Establishing a Therapeutic Relationship]
Trust is an essential building block of the helping relationship.
You foster trust when you communicate warmth and caring and demonstrate consistency, reliability, honesty, and competence.
Trusting another person involves risk and vulnerability, but it also fosters open, therapeutic communication and enhances the expression of feelings, thoughts and needs.
[Establishing a Therapeutic Relationship]
Acceptance and Respect
Acceptance is a willingness to hear a message or to acknowledge feelings. (This does not mean that you agree or approve.)
Conveying acceptance means that you are nonjudgmental (As a nurse you are expected rto provide high-quality care regardless of social or economic status, personal attributes, or the nature of an illness.)
(Examples: Giving positive feedback, making sure verbal and nonverbal cues match, and using touch. Being empathetic, restating, and avoiding arguments also show acceptance and respect.)
[Establishing a Therapeutic Relationship]
Meas being present for the other person when needed and offering your presence even when the patient does not express the need verbally.
(Examples: Showing a caring attitude, demonstrating your willingness to listen and talk, or by just being physically present)
DO NOT be "task oriented" or making a technical procedure (administration of a medication) the focus of an interaction.
You miss opportunities to assess the patient, explore concerns, calm anxiety, demonstrate empathy, teach, or involve the patient in care.
[Establishing a Therapeutic Relationship]
A tool for the patient and nurse to get to know one another and to help people relax.
At the beginning of an interaction use social conversation that is easy and superficial to make connections.
[Establishing a Therapeutic Relationship]
Communication within the Nursing Process
To gather information, develop the nursing diagnosis, plan your care, implement nursing interventions, and evaluate your care.
* Interviewing and history taking
* Physical examination (use of visual, auditory, and tactile channels)
* Observation of nonverbal behavior
* Review of medical records, literature, diagnostic tests
[Communication Through the Nursing Process]
Nursing Diagnosis
* Written analysis of assessment findings
* Discussion of health care needs and priorities with patient and family
[Communication Through the Nursing Process]
* Written care plans
* Health team planning sessions
* Discussions with patient and family to determine methods of implementation
* Making referrals
[Communication Through the Nursing Process]
* Discussion with other health professionals
* Health teaching
* Provision of therapeutic support
* Contact with other health resources
* Record of patient's progress in care plan and nurses' notes
[Communication Through the Nursing Process]
* Acquisition of verbal and nonverbal feedback
* Written results of expected outcomes
* Update of written care plan
* Explanation of revisions to patient
[Communication Through the Nursing Process]
Use communication during the assessment phase of the nursing process to gather information about a patient.
The time you spend assessing patients is a good time to establish the rapport needed for good communication.
(Example, through therapeutic communication techniques, you collect data about the patient's medical history and current problem or concern. To learn more about your patient's pain, you ask him, "How is your pain different than it was last week?" Systematically collect data and then organize the data you collect. Document information you obtain from the patient, family, and significant others.)
Physical and Emotional Factors
Health issues may limit communication.
(Example: Facial trauma, cancer of the larynx or trachea, aphasia after a stroke, breathing problems, Alzheimer's disease, high anxiety, and heavy sedation.)
(Psychoses and depression cause patients to have flight of ideas, constant verbalization of the same words or phrases, or a slow speech pattern)
Review patient's medical record for relevant information describing any physical barriers to speech, neurological deficits, and pathophysiological conditions affecting hearing or vision.
Medication (Examples: Opiates, antidepressants, neuroleptics, hynotics, or sedatives) cause patients to slur words or use incomplete sentences.
communicate directly with patients and family members to fully assess communication difficulties and build a plan to enhance communication.
Developmental Factors
Consider a patient's developmental level when assessing communications.
(Example: An infant's self-expression is limited to crying, body movement, and facial expression. Older children express their needs more directly)
Pay attention to your nonverbal behavior when working with children.
Sudden movements, threatening gestures and loud noises can be frightening.
Include the parents as sources of information about the child's health.
Advancing age influences communication. (Examples: Problems with hearing or speech are barriers to communication.)
Assess the hearing ability of older adults.
Get an older adult's attention before you begin your assessment questions.
Face the patient, and stand or sit on the same level so the patient can read your lips.
Speak slowly and clearly.
Give older adults enough time to ask questions.
Do not assume an older adult has communication impairments.
Sociocultural Factors
When caring for patients from diverse cultures, recognize how to adapt your communication approach.
Show respect for all persons whatever their age, gender, religion, socioeconomic group, sexual orientation, or ethnicity.
Recognize and attend to any personal biases or prejudices that might interfere with patients' care.
Take cultural issues into account, and work to be culturally sensitive.
Accept patients' rights to adhere to cultural customs and norms.
Persons of different cultures use different types of verbal and nonverbal cues to convey meaning.
Make a conscious effort not to interpret messages through your own cultural perspective; instead consider the context of the other individual's background.
Avoid stereotyping persons from other cultures or making jokes about them.
Cultural insensitivity in communication takes many forms. (Example: including making fun of another's culture, ethnicity, language, or dress).
Telling jokes that make fun of specific cultures, stereotyping, patronizing, and incorrectly interpreting culturally based behavior are culturally insensitive.
Do not behave in ways that offend the cultural practices of others.
There may be language barriers with foreign-born patients and those who speak English as a second language.
It is essential that you assess the patient's understanding of all communication and obtain a professional interpreter as needed to ensure accurate communication.
Gender influences how we think, act, feel, and communicate.
There are differences in male and female communication patterns.
Males grow up using communication to achieve goals, establish individual status and authority, and compete for attention and power.
Females grow up using communication to build connections and cooperate with others. Females also communicate to respond to, show interest in, and support others and are more likely to discuss feelings and personal issues.
Men tend to communicate in a more task-oriented fashion and more directly express disagreements and what they want done.
A male nurse might say to his colleague, "Help me turn Jeremy."
A female nurse might say, "Jeremy needs to be turned," expecting her colleague to understand the implied request for help.
Men use more banter, teasing, and playful "put-downs."
They sometimes hesitate to ask questions for fear of appearing unknowledgeable, whereas women ask questions to elicit information. Men usually want others to know of their accomplishments; women tend to downplay their achievements.
It is important for you to recognize a patient's gender communication pattern.
Gender-insensitive communication means a nurse of one gender misinterprets or reacts to messages differently from that intended by the other gender.
Being insensitive can block any attempt at forming a therapeutic nurse-patient relationship.
Nursing Diagnosis
Nursing diagnoses for patients with communication difficulties often include the following:
* Anxiety
* Impaired verbal communication
* Compromised family coping
* Ineffective coping
* Readiness for enhanced family coping
* Powerlessness
* Impaired social interaction
Impaired Verbal Communication
Is the nursing diagnostic label to describe the patient who has limited or no ability to communicate verbally.
This diagnosis is useful for a wide variety of patients with special problems and needs related to communication.
It is defined as "decreased, delayed, or absent ability to receive, process, transmit, and use a system of symbols".
A patient with this diagnosis will have defining characteristics such as the inability to articulate words, difficulty forming words, and difficulty in understanding.
The related factor for a diagnosis should focus on the cause of the communication disorder. In the case of impaired verbal communication, a related factor might be physiological, mechanical, anatomical, psychological, cultural, or developmental.
Be accurate in choosing a related factor so that the interventions you select will effectively resolve the patient's problem.
Once you identify the nature of a patient's communication problem, you need to consider several factors to design a plan of care.
(Example: Motivation improves communication. Patients often need encouragement to try different communication strategies.)
Also, select interventions and communication techniques appropriate for the patient's age, cultural beliefs, and practices.
Plan to allow patients adequate time to practice new communication approaches.
It also helps to plan practice sessions in a quiet, private environment.
When possible, involve the family in selecting approaches that will foster communication with the patient.
Goals and Outcomes
A plan of care supporting effective communication will have the ultimate goal of a patient being able to communicate his or her needs.
Select expected outcomes that are specific and measurable.
After you have implemented your interventions, outcomes allow you to determine if your goal was achieved.
(Example: Patient identifies two methods to maintain communication with family in New York. Patient verbalizes his concerns regarding his declining health. Patient initiates conversation about his preferences for care as he becomes weaker.)
Sometimes you will care for patients who have difficulty in sending, receiving, and interpreting messages.
This interferes with healthy interpersonal relationships.
In this case, impaired communication is a contributing factor to other nursing diagnoses such as impaired social interaction or ineffective coping.
Plan interventions in this case to help patients improve their communication skills.
(Example: Role-play helps patients rehearse situations in which they have difficulty communicating.)
Setting Priorities
Always include the patient in setting goals and expected outcomes.
You will not make any progress if the patient is not interested in achieving the goal you chose.
You cannot address all problems at the same time, so consider which is most important. Always maintain an open line of communication so that the patient can express any immediate needs or problems. Keep a call light in reach for the patient restricted to bed, or provide appropriate alternative communication devices such as a message board or Braille computer.
If you plan to have a lengthy discussion with a patient, be sure to take care of the patient's physical needs first to avoid interruptions. Make the patient comfortable by ensuring that any symptoms are under control.
Continuity of Care
Remember to include family caregivers during the planning and implementation phases of the nursing process.
This collaboration supports the family and patient.
When you use collaboration, patients are more likely to comply with plans.
Collaboration also promotes communication among family members to facilitate positive patient-family relationships.
Encourage collaboration by asking others for ideas and suggestions about how to reach goals.
It gives others the opportunity to express themselves and strengthens problem-solving ability.
Also, collaborate with other health care providers who have expertise in communication strategies.
(Examples: Speech therapists help patients with aphasia. Professional interpreters are invaluable when a patient speaks a foreign language.
Mental health clinical nurse specialists help in communicating with angry or highly anxious patients.)
In carrying out any plan of care, nurses need to use communication techniques that are appropriate for the patient's individual needs.
Therapeutic Communication Techniques
Therapeutic communication techniques are specific responses that encourage the expression of feelings and ideas and convey acceptance and respect.
By learning therapeutic communication techniques you become aware of the variety of nursing responses possible in different situations.
Is the ability to understand and accept another person's perspective.
You can never totally know another's experiences because you are not in that person's situation, but you can try to understand what the person is going through.
Empathetic statements reflect an understanding of what the patient communicated and tell the patient that you heard both the feeling and the factual content of the communication.
This allows the patient to validate or clarify feelings and perceptions.
Empathetic responses are neutral and nonjudgmental and foster shared respect.
Use them to establish trust in very difficult situations.
(Example: A patient states he did not want to be "out of it", that he wanted to feel alive. An empathetic response from the nurse is, "It sounds like you don't like to take much pain medication because feeling 'out of it' makes it hard to do the things you want to do. I'm concerned that too much pain might also make it difficult for you to do what you want to do.")
[Therapeutic Communication Technique]
Active Listening
Means being attentive to what the patient is saying both verbally and nonverbally.
Active listening facilitates patient communication.
Active listening enhances trust because the nurse communicates acceptance and respect for the patient.
S—Sit facing the patient. This posture gives the message that you are there to listen and are interested in what the patient is saying.
O—Observe an open posture (e.g., keep arms and legs uncrossed). This posture suggests that 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 eye contact. This behavior conveys your involvement in and willingness to listen to what the patient is saying. Absence of eye contact or shifting of the eyes gives the message that you are not interested in what the patient is saying. Be aware of cultural considerations regarding eye contact
R—Relax. It is important to communicate a sense of being relaxed and comfortable with the patient. Restlessness communicates a lack of interest and conveys a feeling of discomfort to the patient.
[Therapeutic Communication Technique]
Using Silence
Allows patient time to collect his thoughts
[Therapeutic Communication Techniques]
Pt: "I have some stuff I need to work out with my uncle so I need to go see him."
Nurse: "You feel it is important to go visit your uncle to address some unresolved issues."
[Therapeutic Communication Techniques]
Pt: "Yeah, and I can't deal with the problems with my uncle when I'm out of it."
Nurse: "When you say 'out of it,' do you mean the medication makes it hard to think straight?"
[Therapeutic Communication Techniques]
Sharing Hope
Pt: "I just don't know if I'll be able to make the trip to see my uncle, and it's really important to work things out with him."
Nurse: "I believe you will find a way to make peace with your uncle."
[Therapeutic Communication Techniques]
Sharing Observations
Nurses make observations by commenting on how the other person looks, sounds, or acts. Stating observations often helps the patient communicate without the need for extensive questioning, focusing, or clarification.
This technique helps start a conversation with quiet or withdrawn persons.
Do not state observations that will embarrass or anger the patient.
(Example: "You look a mess!")
Even if such an observation is made with humor, the patient can become resentful.
Sharing observations differs from making assumptions, which means drawing unnecessary conclusions about the other person without validating them.
Making assumptions puts the patient in the position of having to contradict the nurse. (Examples: the nurse interpreting fatigue as depression and assuming that untouched food indicates lack of interest in meeting nutritional goals.)
Making observations is a gentler and safer technique: (Example: "I see you did not eat any breakfast...," "You look tense...," or a positive observation such as "I see you have been organizing your photos....")
[Therapeutic Communication Technique]
Using Silence
Silence is useful when people face decisions that require much thought.
(Example: If the patient and nurse were discussing the possibility of his needing to move out of his home to get the care he needs, silence could give him time to collect his thoughts and consider the alternatives). Silence is especially therapeutic during times of sadness or grief.
[Therapeutic Communication Technique]
Providing Information
Providing relevant information helps your patients make decisions, experience less anxiety, and feel safe and secure.
Speak in simple language, and translate medical terms.
When offering options, stress that the patient has the right to make decisions.
The nurse also provides information that enables others to understand what is happening and what to expect.
(Example: The nurse explains, "Roberto, this pain medication may make you feel a little sleepy and groggy at first, but those side effects usually go away after 2 or 3 days.")
[Therapeutic Communication Technique]
Clarifying validates whether the person interpreted the message correctly.
Any time a message is unclear or ambiguous, try to restate it, or ask the other person to restate it, explain further, or give an example of what they mean.
(Example: The nurse says, "I'm not sure what you mean; when you say 'out of it,' you mean the medication makes it difficult to think straight?"
[Therapeutic Communication Technique]
Focusing directs conversation to a specific topic or issue when a discussion becomes unclear.
Focusing limits the area to which the sender can respond.
Use it when the sender rambles or introduces many unrelated topics in the same conversation.
(Example: If the patient said, "I had a nice visit with my friend this morning. He's going to stop over tomorrow. I've been able to take care of my dog better. My medications are doing okay, but the pain's still there. I've been looking at my art collection today, and I'm not sure what I want to do with it when I'm gone. You like art—I could recommend a good gallery if you want to buy some."
The nurse focuses the conversation by replying, "You've been thinking about what to do with your special belongings?")
[Therapeutic Communication Technique]
Paraphrasing is restating the sender's message in the receiver's own words to make sure you have received information accurately.
Be careful not to change the meaning when you paraphrase.
Confirm the meaning with the patient.
(Example: The patient states, "I've been walking more, and I'm able to do most of my household chores. I don't need as much help around here now." The nurse replies, "You feel you're getting stronger and more independent. Is that correct?")
[Therapeutic Communication Technique]
Summarizing is a concise review of main ideas from a discussion.
It brings a sense of satisfaction and closure to an individual conversation or during the termination phase of a nurse-patient relationship.
By reviewing a conversation, you focus on key issues and obtain additional relevant information as needed.
(Example: After a session with much discussion about the patient's plans and progress, the nurse summarizes, "Today we talked about your plans to visit your family in New York and some things you can do to help increase your strength. You seem to understand the importance of eating right. Let me know if there is any other information I can get you.")
[Therapeutic Communication Technique]
You may use self-disclosure during the working phase of a helping relationship. Self-disclosures are personal statements intentionally revealed to the other person.
The purpose is to model and educate, foster a therapeutic alliance, validate reality, and encourage autonomy.
Keep self-disclosures relevant and appropriate.
Make these statements to benefit the patient, not you, and use them sparingly so that the patient remains the focus of the interaction.
(Example of an INAPPROPRIATE response: The patient's brother comes to visit and expresses how hard it is to make time for everything. An inappropriate response from the nurse would be, "My mother had cancer and was in hospice too. It was so long and drawn out. I was so sad for so long. Even taking care of the kids was hard.")
(Example of an APPROPRIATE response is, "When my mother was dying, I was torn between wanting to stay with her every moment and trying to meet the needs of my little kids. Is that how it is for you?")
[Therapeutic Communication Technique]
Sharing Hope
Nurses recognize that hope is essential for healing and learn to communicate a "sense of possibility" to others.
You give hope by commenting on the positive aspects of the other person's behavior, performance, or response.
Sharing a vision of the future and reminding others of their resources and strengths also strengthens hope.
You can reassure patients that there are many kinds of hope and that meaning and personal growth can come from illness experiences.
[Therapeutic Communication Technique]
Nontherapeutic Communication Techniques
Hinder or damage professional relationships.
These specific techniques are nontherapeutic or blocking and will often cause recipients to use defenses to avoid being hurt or negatively affected
Nontherapeutic techniques discourage further expression of feelings and ideas and engender negative responses or behaviors in others.
(Potter, Patricia A. . Basic Nursing, 7th Edition. Mosby, 032010. p. 178).
Inattentive Listening
Behaviors and nonverbal expressions such as fidgeting, breaking eye contact, daydreaming during conversation, and "pseudolistening" (pretending to listen when one really is not) convey the message that what the sender has to say is not important.
These behaviors discourage conversation and damage trust.
(Examples: are looking at your watch, tapping your foot impatiently, and gazing out the window as the patient talks.)
[Nontherapeutic Communication Techniques]
Using Medical Vocabulary
Technical words can cause confusion and anxiety.
Avoid use of such terms, or translate them into lay terms.
[Nontherapeutic Communication Techniques]
Prying or Asking Personal Questions
Asking irrelevant personal questions simply to satisfy your curiosity is inappropriate and invasive.
If patients wish to share private information, they will.
[Nontherapeutic Communication Techniques]
Giving Approval or Disapproval
Do not impose your own attitudes, values, beliefs, and moral standards on others while in the professional helping role.
People have the right to be themselves and make their own decisions.
Avoid using terms such as should, ought, good, bad, right, or wrong.
Agreeing, disagreeing, or sharing your personal opinion sends the subtle message that you have the right to make value judgments about patient decisions.
Instead, offer options and help the other person anticipate the consequences of decisions.
The problem and its solution belong to the patient, not the nurse.
(Example: Pt: "I really want to go visit my uncles in New York, but I'm not sure I'm up for the trip."
Nurse: "I don't think it's a good idea to try to travel that far."
A better response is, "It sounds like you miss your family. Let's talk about your options for maintaining contact.")
[Nontherapeutic Communication Techniques]
Changing the Subject
Changing the subject is a common problem when you are uncomfortable with a topic, but it is insensitive and tends to block further communication.
[Nontherapeutic Communication Techniques]
Automatic Responses
Clichés or stereotypical remarks such as, "You're never given more than you can handle," tend to belittle the patient's feelings and minimize the importance of his or her message.
These automatic phrases communicate that you are not taking concerns seriously or responding thoughtfully.
[Nontherapeutic Communication Techniques]
False Reassurance
When a patient is seriously ill or distressed, you may be tempted to offer hope to the patient with statements such as, "I'm sure everything will be okay."
Although you may be trying to be kind, false reassurance discounts the patient's concerns or situation and tends to block communication.
[Nontherapeutic Communication Techniques]
Asking for Explanations
Sometimes asking "why" implies an accusation and results in resentment, insecurity, and mistrust.
Try to phrase questions without using "why." Rather than "Why are you not taking the medications the doctor prescribed?" you could say, "Tell me about the problems you are having with your medications."
[Nontherapeutic Communication Techniques]
Challenging or arguing with someone's perception of a situation denies that his or her perceptions are real and implies that they are lying, misinformed, or uneducated.
(Example: If the patient tells the nurse he has no appetite and is not eating, her response of "You must be eating, you have not lost any weight" would block communication. The nurse needs to present information or reality in a way that avoids argument. A better response is, "I see you have not lost any weight; tell me how you are meeting your nutritional needs since you don't have much of an appetite.")
[Nontherapeutic Communication Techniques]
Being Defensive
When patients express criticism, listen to what they have to say.
Listening does not imply agreement.
To discover reasons for the patient's anger or dissatisfaction, you need to listen uncritically. By avoiding defensiveness, you are able to defuse anger and uncover deeper concerns. Rather than saying, "None of the nurses would intentionally ignore you," you respond, "You feel the nurses are ignoring you."
[Nontherapeutic Communication Techniques]
Is the concern, sorrow, or pity you feel for the patient when you personally identify with the patient's needs.
Unlike empathy, which tries to understand the patient's experience, sympathy takes a subjective look at the patient's world.
Sharing sympathy with another feels good, creates a bond, and minimizes differences, but it can prevent effective problem solving and impair good judgment.
When you share the patient's needs, you are assuming the patient's feelings are similar to your own and you are unable to help the patient select realistic solutions for problems. (Example: In response to the patient's statement about his pain the nurse had said, "Oh I know just what you mean, I hate feeling drugged up," the patient would not have had a chance to clarify his feelings and the nurse would miss an opportunity to get a deeper understanding of his perception of the situation.)
[Nontherapeutic Communication Techniques]
Assertive Communication
Is based on a philosophy of protecting individual rights and responsibilities.
It includes the ability to be self-directive in acting to accomplish goals and advocate for others.
An assertive response promotes self-esteem and upholds personal and professional rights. (Examples: Feelings of security, competence, power, and professionalism characterize assertive responses.)
Assertive statements convey a message without resorting to sarcasm, whining, anger, blaming, or manipulation.
Assertive responses are good tools to deal with criticism, change, negative conditions in personal or professional life, and conflict or stress in relationships.
Assertive responses often contain "I" messages, such as "I want," "I need," "I think," or "I feel."
Simple assertive messages are usually stated in three parts, referencing the nurse, the other individual's behavior, and its effect.
(Example: Nurse to nurse: "When you are late for work, I have to stay late and that makes me late picking up my children from the babysitter.")
Difficult Diagnoses or Clinical Situation
* The grieving mother whose baby has died
* A frantic man who was just told his wife was in a serious accident
[Challenging Communication Situations]
Patients and Families Experiencing Strong Emotions
* The anxious, nervous person who cannot cope with what is happening
* The angry, hostile person newly diagnosed with cancer who does not listen to explanations
* The ranting and raving person who blames nursing staff unfairly
[Challenging Communication Situations]
Coping with Personal Feelings While Still Needing to Care for Patients
* Feeling helpless when cancer has progressed
* Grief over the death of a long-term patient
[Challenging Communication Situations]
Formula for Challenging Communication Situations
Action: Describe the action that prompted the need for the message
Subjective: Express a subjective interpretation of the action.
Sensations: Express sensations related to the action.
Effects: Indicate the effects of the action.
Request: Make a request of the other person.
Tell: Tell your intentions if the request is not met.
(Example: Nurse to supervisor -- "When you say I'm not performing well, that sounds serious. I feel surprised and confused, because I had a sense that I was doing a good job. Please give me some examples of what you mean. If there are none, I'll discuss this evaluation with the director of nursing."
Avoid Passive Responses
Passive responses avoid issues or conflict. Some characteristics are feelings of sadness, depression, anxiety, and hopelessness.
(Examples: Nurse to co-worker, hopelessly: "I guess there's nothing we can do about it."
Nurse to spouse during argument: "Whatever you say."
A better response is, "What can we do to make things better?"
Avoid Aggressive Responses
Aggressive responses provoke confrontation at the other person's expense.
Some characteristics of aggression are feelings of anger, frustration, resentment, and stress.
(Examples: Nurse to angry patient: "Who do you think you are? You can't talk to me that way."
A better response is, "I want to hear your concerns and help you have a positive experience. Can we take a deep breath and talk about them now, or should I come back later?")
Humor is a coping strategy that adds perspective and helps you and the patient adjust to stress.
The Association for Applied and Therapeutic Humor defines therapeutic humor as "any intervention that promotes health and wellness by stimulating a playful discovery, expression or appreciation of the absurdity or incongruity of life's situations."
Laughter is a diversion from stress-related tension.
It provides a sense of well-being and more of a feeling of control or mastery.
Humor helps provide emotional support to patients and humanizes the illness experience.
Laughter provides both a psychological and physical release for you and the patient; promotes open, relaxed interaction; and illustrates our shared experience in being human.
You assess whether humor is appropriate by noticing if patients use humor in their conversations.
Start with small doses to see if this is helpful. To offer positive humor, share humorous incidents or situations, offer a clown nose to someone who could use a laugh, or share puns or simple jokes that are not offensive. Positive humor is associated with hope, love, and joy with the intent to bring people closer. Avoid negative humor, which is inappropriate. Ethnic, religious, sexist, ageist, or put-down humor creates distance.
Realize that humor sometimes backfires; not everyone will appreciate a humorous approach because of negative moods, stress, or physical discomfort.
Humor is often a signal for closer attention. When a patient preparing for surgery quips, "Well, I won't die from it," gently explore concerns of the patient.
Sometimes health care providers use dark, negative humor after difficult or traumatic situations to survive a situation intact and to relieve tension and stress.
This "coping humor" may seem callous or uncaring by those not involved in the situation.
Avoid using "coping humor" within earshot of patients or their loved ones.
Understand that humor is a release, but timing, content, and receptivity are important in the use of therapeutic humor.
Is one of the nurse's most potent forms of communication.
Nurses are privileged to experience more of this intimate form of personal contact than almost any other professional.
Touch conveys many messages, such as affection, emotional support, encouragement, and personal attention.
Comfort touch, such as holding a hand, is important for vulnerable patients who are experiencing severe illness with its accompanying physical and emotional losses.
(Example: A nurse rubbed a patient's shoulders to soothe and comfort her.)
The nurse enjoyed providing this comfort and savored this moment of caring connection. She valued this as part of the art of nursing, which is sometimes left out due to the emphasis on the high-tech nature of our work.
Sometimes touch is misinterpreted.
Always be sensitive to the patient's response to touch.
(Examples of inappropriate and appropriate use of touch:
Inappropriate touch: In a cancer support group, the wife of a patient had her arms wrapped around herself as if she were "holding herself together." The nurse moved too quickly and tried to hug the wife without permission. The wife backed off and struggled to hold back tears.
Appropriate touch: The nurse says, "I see you are distressed. Would a hug help?" The woman is then free to decline this well-intended act that might trigger tears that would embarrass this very private person.)
Another concern is the confusion about the use of touch with culturally diverse patients. Some risk is involved.
You must look for cues that a patient would welcome touch.
We use touch to awaken patients, to get their attention, or to add emphasis to explanations. Touch may also convey understanding better than words or gestures.
Therapeutic touch is a special form of alternative touch therapy used by specially educated nurses for health assessment, pain reduction, and relaxation by influencing a patient's body energy fields.
In therapeutic touch, specially educated nurses pass their hands over the body without actually touching to balance the energy fields and provide an environment for optimal health.
Because much of what you do involves touching, learn to use touch wisely.
Touch delivered in the social or consent zones is less anxiety producing than touch delivered in the vulnerable or intimate zones. Students initially find giving intimate care stressful, especially with patients of the opposite sex.
Shift your focus from personal discomfort to your role as a caregiver with the intent to provide sensitive nursing care.
Trust that you will become more comfortable with experience.
Remember that the patient who is ill and dependent must permit closer physical contact than is normally tolerated and may be uncomfortable with touch.
Remain sensitive to your own responses and to patients' feelings.
If a patient refuses to hold your hand while in pain or pulls away from physical contact, this signals that the patient is uncomfortable with being touched.
People perceive touch negatively when it is given without consent; used within a hostile or mistrusting relationship; and delivered to a vulnerable, intimate, or painful area of the body.
Your touch should never be angry, rough, violent, overly stimulating, threatening, overly tentative, sexual, or unnecessarily painful.
Cultural Focus
The nurse works with patients from a variety of cultures. She likes to use touch to communicate caring and compassion, but finds some patients are uncomfortable with her touch. When she holds their hand or puts her arm around their shoulder, some patients become very quiet or pull back. The nurse explores how different cultures perceive touch in order to provide more culturally sensitive care. She learns that among people from Africa and Southeast Asia the head is considered the seat of life and should not be touched except by close kin and that touching the head of a patient by a nonrelative may predispose to loss of one's spirit and power. She also learned that Amish patients consider touching taboo between unrelated males and females.
Implications for Practice
* Ask permission before touching a patient of another culture.
* Use same-gender caregivers for female and older patients from Asian, Middle Eastern, Hispanic, African, and Amish cultures, especially when touch is involved.
* Avoid touching the head of a patient from Africa or Southeast Asia.
Communicating with Patients with Special Needs
(Examples of special needs patients: hearing and visually impaired, persons suffering from a stroke or late-stage Alzheimer's disease, and persons with autism or schizophrenia who respond to internal stimuli and misinterpret external stimuli.)
The person who does not speak or understand English and the patient with learning disabilities and limited vocal skills will challenge you to accommodate their special needs.
In addition, unresponsive or heavily sedated patients are sometimes unable to send or receive verbal messages.
The patient who cannot communicate effectively has difficulty expressing needs and responding appropriately to the environment and requires special thought and sensitivity.
Such persons benefit greatly when you adapt communication techniques to their circumstances.
When caring for a patient with impaired verbal communication related to a language barrier, you may provide a table of simple words in the patient's language.
The patient's use of the table will meet the expected outcome of the patient communicating basic needs such as food, water, toileting, rest, and pain relief. Collaborate with team members to design the best communication strategies.
Good communication improves the quality of your patient's interpersonal relationships and well-being.
If the patient uses ineffective communication techniques that interfere with coping or interpersonal relationships, intervene to help your patient send, receive, and interpret messages more effectively.
Be a communication role model and teacher to help patients express needs, feelings, and concerns.
Help patients develop social interaction skills and communicate thoughts and feelings clearly.
This will help them interpret messages sent from others, increasing their autonomy and assertiveness.
Providing Alternative Communication Methods
Patients with physical communication barriers (e.g., those with a laryngectomy or endotracheal tube) may be unable to speak, or the clarity of speech may be so poor that they need alternative methods of communication.
To decrease frustration, provide simple communication methods and allow the patient time to respond.
The patient must be physically able to use the method you provide (e.g., communication boards or pencil and pad).
Patients who are unable to speak are at risk for injury unless they are able to communicate personal needs quickly.
Communicating with Children
Communication with a child requires special considerations to develop a working relationship with the child and family. Because contact between parent and child is usually close, assume the information communicated by parents is reliable, although some parents may exaggerate. Offer a child toys or materials so the parent gives full attention to your information gathering.
Give periodic attention to infants and younger children as they play to include them.
An older child can be actively involved in communication.
Consider the influence of development on language and thought processes.
Children, particularly the young, are especially responsive to nonverbal messages.
Sudden movements or gestures can be frightening.
Remain calm and gentle, and, if possible, let the child make the first move.
Use a quiet, friendly, confident tone of voice. The child feels helpless in most situations involving health care personnel.
When it is necessary to give explanations or directions, use simple, direct language and be honest.
To minimize fear and anxiety, prepare the child by explaining what to expect.
Avoid staring, and meet the child at eye level.
Drawing and playing with young children allows the child to communicate nonverbally (making the drawing) and verbally (explaining the picture)
Use a child's drawing as a basis for beginning a conversation.
Communicating with Older Adult Patients
The majority of older adults experience some loss of sensory function.
Sensory alterations prevent receiving messages clearly.
Many older adults adapt to sensory losses and learn to communicate effectively.
When obvious deficits exist, maximize existing motor and sensory function to help the patient communicate more effectively. You can make some simple modifications in your approach and the environment to improve communication with older adults. Identify these challenges, and work with the patient to enhance effective communication.
Patients With Difficulty Hearing
* Avoid shouting.
* Use simple sentences.
* Punctuate speech with facial expression and gesture
[Communicating with patients who have special needs]
Patients with Difficulty Seeing
* Communicate verbally before touching the patient.
* Orient the patient to sounds in the environment.
* Inform the patient when the conversation is over and when you are leaving the room.
[Communicating with patients who have special needs]
Patients Who Are Mute or Cannot Speak Clearly
* Place a sign by unit call system to answer call light in person.
* Listen attentively, be patient, and do not interrupt.
* Do not finish patients' sentences for them.
* Ask simple questions that require "yes" or "no" answers.
* Allow time for understanding and responses.
* Use visual cues (e.g., words, pictures, objects) when possible.
* Allow only one person to speak at a time.
* Do not shout or speak too loudly.
* Encourage the patient to converse.
* Let the patient know if you do not understand.
* Use communication aids as needed:
* Pad and felt-tipped pen or Magic Slate
* Flash cards
* Communication board with words, letters, or pictures denoting basic needs
* Computer toy ("speak and spell" type)
* Call bells or alarms
* Sign language
* Use of eye blinks or movement of fingers for simple responses ("yes" or "no")
[Communicating with patients who have special needs]
Patients Who Are Unresponsive
* Call the patient by name during interactions.
* Communicate both verbally and by touch.
* Speak to the patient as though he or she could hear.
* Explain all procedures and sensations.
[Communicating with patients who have special needs]
Patients Who Do Not Speak English
* Speak to the patient in a normal tone of voice (shouting may be interpreted as anger).
* Establish a method for the patient to signal the desire to communicate (call light or bell).
* Provide a professional interpreter/translator as needed:
* Use a person familiar with the patient's culture and with biomedicine if possible.
* Allow plenty of time for the interpreter to transmit messages.
* Communicate directly to the patient and family rather than the interpreter.
* Ask one question at a time.
* Avoid making comments to the interpreter about the patient or family (they may understand some English).
* Develop a communication board, pictures, or cards using words translated into English for the patient to make basic requests (e.g., pain medication, water, elimination).
* Have a dictionary (e.g., English/Spanish) available if the patient can read.
[Communicating with patients who have special needs]
Patients Who Are Cognitively Impaired
* Reduce environmental distractions while conversing.
* Get the patient's attention before speaking.
* Use simple sentences, and avoid long explanations.
* Avoid shifting from subject to subject.
* Ask one question at a time.
* Allow time for the patient to respond.
* Include family and friends in conversations, especially in subjects known to the patient.
[Communicating with patients who have special needs]
Improving Communication
In communicating with older adults, the primary goal is to establish a reliable communication system that all health care team members easily understand. Ideally, an interdisciplinary model delivers effective care for older adults.
Communication with older adults requires special attention.
Be aware of the physical, psychological, and social changes of aging.
Use the following interventions to assist with impaired communication with older adults:
• During conversation, maintain a quiet environment that is free from background noise.
• Avoid shifting from subject to subject; allow time for conversation.
• Be an attentive listener. Use explorative questions to facilitate conversation (e.g., "How do you feel?").
• Avoid long sentences to explain the subject. Try to keep it short, simple, and to the point.
• Allow the older adult the opportunity to reminisce. Reminiscing has therapeutic properties that increase the sense of well-being.
• If you are experiencing problems understanding the patient (e.g., dysarthria), let the patient know and facilitate methods that help the patient speak more clearly. Consult with a speech therapist if necessary.
• Include the patient's family and friends in conversations, particularly in subjects known to the patient.
• Be aware of cultural differences among patients.
Together, you and the patient determine the success of the plan of care by evaluating patient communication outcomes.
Ask yourself if you understood what your patient communicated, if your patient had the opportunity to express feelings and concerns, and if your patient has unresolved needs.
Patient Care
Evaluate whether communication interventions were effective.
Compare the expected outcomes you established in the plan of care with the actual outcomes you observe when interacting with patients.
If you meet your outcomes, you have resolved the goals of care and the nursing diagnosis.
When outcomes remain unmet, you may revise the existing plan with new goals, outcomes, and/or interventions.
(Example: If using a pen and paper proves frustrating for a nonverbal patient whose handwriting is shaky, you revise the care plan to include use of a picture board instead.)
In this case, observing the patient's handwriting and asking other caregivers about the patient's success in communicating needs would be your evaluation measures. Remember, careful evaluation requires you to make observations similar to those in your original assessment.
(Example: After initially assessing the extent of a patient's ability to hear the spoken word and providing various interventions to promote hearing, you then return to evaluate the patient's ability to hear any interaction or instruction. It is also helpful to question the patient about whether needs were adequately met.)
Patient Expectations
Review the patient's expectations of care and determine if the patient achieved expectations.
This is an important part of the evaluation process.
Ask patients and their families for input about goal achievement, factors that affected outcomes, and suggestions for changes in the plan of care.
(Example: The nurse consistently asked the patient if the pain medications were relieving his discomfort. He was pleased that she was open to working with him to balance pain management with the clarity of his thinking.)
Avoiding patient input during evaluation and care plan modification will lead to a task-oriented rather than a critical thinking, patient-centered approach to nursing.
It denies the patient's right to see the total picture of care and to be involved in all phases of the nursing process.
(Example: A goal of total pain relief for the patient was incompatible with his own goals of being alert enough to care for his dog and work with his art collection. The nurse's willingness to consistently reevaluate the plan of care affected the patient's quality of life. She used her therapeutic communication skills to engage the team in holistic care to address his goals for body, mind, and spiritual well-being. They focused on helping the patient live every moment of his life the way he wanted to live it.)