Chapter 12 Communication

Jane Stein-Parbury

LEARNING OUTCOMES

Mastery of content will enable you to:

• Define the key terms listed.

• Understand professional obligations to become skilled at communication.

• Recognise the process and content aspects of interpersonal communication.

• Appreciate the importance of communication in the development of therapeutic relationships with clients.

• Identify significant features and therapeutic outcomes of nurse–client helping relationships.

• List nursing focus areas within the four phases of a nurse–client helping relationship.

• Differentiate authoritative and facilitative therapeutic communication techniques.

• Describe qualities, behaviours and communication techniques that affect professional communication.

• Discuss effective communication techniques for clients at various developmental levels.

• Identify client health states that contribute to impaired communication.

Communication and nursing practice

Communication involves the capacity to convey thoughts, feelings and attitudes through spoken, written and non-verbal means in order to exchange ideas and construct human meaning. Most professional people are required to be effective communicators in the conduct of their work, and the nursing profession is no different. However, the content and process of communication varies across professions according to the particulars of context. For example, professional engineers are often required to communicate effectively through technical report writing; computer programmers are required to communicate through symbolic languages unique to the computing world; salespeople must acquire skills of persuasion in order to be successful. Some aspects of communication stand out as more relevant than others; it is therefore important to consider the particular aspects of effective professional communication within the context of nursing practice.

This chapter presents the basic aspects of effective and therapeutic communication within the context of nursing practice. The qualities, behaviours and communication techniques described characterise professionalism in therapeutic relationships. Although the terms ‘client’ and ‘patient’ are often used interchangeably, the same principles can be applied when communicating with any person in any nursing context.

The context of nursing practice

In the particular context of nursing, effective interpersonal communication is required for the exchange of healthrelated information, the promotion of therapeutic relationships with clients and the development of collaborative relationships with other healthcare professionals. Nurses must be competent in the use of effective interpersonal communication skills and knowledgeable about healthcare matters, while simultaneously assuming an attitude of being ‘for’ the client. While the skills of effective communication may be similar to those in other professions, the knowledge and attitudes required for therapeutic intentions are particular to the nursing context. For example, a nurse encouraging a depressed client to engage in physical exercise may use persuasive communication techniques that are similar to those of a salesperson. However, the intention of encouraging a depressed client to be active is based on knowledge that physical movement affects mood; that is, persuasion is used for the purpose of helping the client.

The competent nurse is able to therapeutically adjust and accommodate the use of effective communication skills in response to specific clinical contexts. Context helps to shape client needs. For example, a client who is undergoing diagnostic tests for possible cancer does not need detailed information about managing the possible side effects of radiotherapy (as might a client about to undergo radiotherapy). Such information might increase client anxiety during the diagnostic phase of an illness.

In addition to influencing the content of communication, context also affects the processes of communication. For example, intensive-care nurses rely on non-verbal communication from their patients when interacting with patients who are rendered speechless by mechanical ventilation, and community nurses spend much time enabling client self-care through health education communication. Consideration of context requires critical thinking about what is of benefit in meeting client needs, and such thinking is based on the nurse’s understanding of the therapeutic value of communication.

Therapeutic communication is always for the client; that is, the nurse is morally positioned to communicate in a manner that serves the client’s best interest. Therapeutic communication is goal-directed, with the intention of helping the client and establishing helping relationships. Being goal-directed does not mean that the nurse must always do something for the client. At times, communicating interest by simply being with a client, fully present and attentive, is sufficiently therapeutic. Therapeutic communication demonstrates to clients that nurses not only ‘care for’ them but also ‘care about’ them (see Research highlight, opposite, top).

Why nurses need to communicate

A public expectation that nurses are effective communicators is embedded into competency standards for nurses (Australian Nursing and Midwifery Council, 2006; Nursing Council of New Zealand, 2009a; see also Chapters 9 and 10, and professional codes of ethics and conduct (Australian Nursing and Midwifery Council, 2008 and 2003, respectively; Nursing Council of New Zealand, 2009b; see also Chapter 9). Competency standards include the nurse’s ability to collect relevant information from clients about their functional health status, and effective communication is required to elicit such data during client interactions. Competency standards also require a professional nurse to provide relevant healthcare information to clients in an effort to facilitate their understanding of health events and encourage their active participation in decisions about their healthcare. Effective communication is essential to the provision of such information. Enabling therapeutic relationships with clients through communication is one way that nurses demonstrate expected public standards of professional competency and conduct.

In addition to meeting competency standards and codes of practice, effective interpersonal communication is the main way nurses can meet client expectations of healthcare. Research about client opinion regarding the quality of healthcare is most often explored through client satisfaction surveys (see Research highlight, opposite, bottom). The results of these surveys demonstrate that satisfaction is a reflection of interpersonal communication factors such as receiving adequate information about healthcare (O’Keefe, 2001; Wagner and Bear, 2008). That is, client satisfaction with care is largely a function of the interpersonal communication capabilities of healthcare providers. Although client opinion does not constitute all aspects of quality in healthcare, satisfaction with services that are designed to meet people’s needs does reflect one measure of success in healthcare delivery.

RESEARCH HIGHLIGHT

Research focus

Patients want nurses who are not only skilled at performing physical tasks (‘caring for’) but also want nurses who are able to demonstrate that they genuinely ‘care about’ them. Demonstration of an ability to ‘care about’ patients is achieved through interpersonal communication. Therefore it is important for nurses to understand what is important to patients in feeling ‘cared about’.

Research abstract

This was an observational study carried out in Queensland, Australia. The researchers observed and recorded interactions between nurses and patients in a medical–surgical hospital ward. The findings revealed that what is important to patients was a welcoming, friendly and courteous manner, provision of information and explanations and an ‘expert’ compassion.

Evidence-based practice

• Patients value nurses who get to know them by being friendly and welcoming.

• The provision of explanations and information by nurses was highly regarded by patients.

• Patients value nurses who can actively demonstrate a compassionate approach to care.

• Nurses should neither devalue not diminish the importance of how they approach patients during interpersonal encounters.

Reference

Henderson A, et al. ‘Caring for’ behaviours that indicate to patients that nurses ‘care about’ them. J Adv Nurs. 2007;60(2):146–153.

Client satisfaction with nursing care in particular is a function of technical competence plus interpersonal skills (Johansson and others, 2002), and clients place a value on nurses’ interpersonal skills (Henderson and others, 2007; McCabe, 2004; Williams and Irurita, 2004; Wysong and Driver, 2009). They do want to make interpersonal connections with nurses, and nurses being accessible is considered an act of caring (Chang and others, 2005); conversely, being treated like an object is perceived by clients to be ‘non-caring’ (Wiman and Wikblad, 2004). However, clients are sensitive to the workload demands placed on nurses and are reluctant to make interpersonal connections when nurses seem to be too busy (Chang and others, 2005; McCabe, 2004; Shattell, 2005). This raises questions about how the structure and culture of healthcare environments affect nurse–client communication.

RESEARCH HIGHLIGHT

Research focus

The skills of nurses are a feature of many surveys of patient satisfaction with hospital care. These skills have three domains: interpersonal, critical thinking and technical. Previous research indicates that patient satisfaction with nursing care includes these domains but the skills required are described in general terms.

Research abstract

The purpose of this research was to explore what patients perceive to be nurses’ skills. The researchers interviewed 32 patients in a hospital ward for people with complex medical and surgical needs. The interviews were semi-structured and open-ended, allowing patients to describe nurses’ skills in their own words. All of the patients mentioned interpersonal skills of nurses, while 94% mentioned critical thinking (which included communication skills such as ‘answered my questions’ and ‘provided information’) and 59% mentioned technical skills.

Evidence-based practice

• Patient perception of nurses’ skills is largely interpersonal rather than purely technical.

• Interpersonal attributes of nurses’ skills included taking an interest in the patient as a person, being friendly, happy and cheerful and being a good listener.

• Patients want nurses who can put their mind at ease by answering their questions and providing information.

Reference

Wysong PR, Driver E. Patients’ perceptions of nurses’ skills. Crit Care Nurse. 2009;29(4):24–37.

Communication and interpersonal relationships

At the core of nursing are caring relationships formed between nurses and clients, and communication is the means of establishing these relationships and coming to know the client. The knowledge gained about the client through relational work is at the heart of nursing practice, and the communication skills required are not simply a matter of ‘being nice’ to patients but rather a professional duty (DeFrino, 2009). The nurse’s ability to relate to others rests on effective interpersonal communication, which includes being able to take the initiative in establishing and maintaining communication, to be authentic (one’s self), and to respond appropriately to the other person.

Dynamics of interpersonal communication

Interpersonal communication operates at two levels: content and process. The content level encompasses what is being discussed; that is, the subject matter. For example, when interviewing a client for the first time the content will most likely involve a history of the client’s health status and immediate care needs. The content level of communication is easily identified. The second level, that of process, is more subtle. This level involves how something is communicated rather that what is being communicated. For example, if the nurse conducting an initial interview with a client does so in a cold, clinical manner by simply asking a series of questions that follows a pre-set format, the client may not perceive the nurse to be genuinely concerned and caring. In this way the process level reveals the nature of the relationship between nurse and client.

Content and process go hand in hand. For example, if the nurse is warm and open, demonstrating genuine interest in the client (process level), then clients are likely to be willingly forthcoming with information about their health status and concerns (content level).

Professional nursing relationships

Professional relationships are created through the nurse’s application of knowledge, understanding of human behaviour and communication, and commitment to the moral stance of being ‘for the client’. Having a philosophy based on caring and respect for others will help the nurse be more successful in establishing relationships of this nature with clients. Being responsive to client needs is basic to therapeutic communication. Nurses also communicate in the context of other professional relationships that may require an emphasis on being assertive. For example, when collaborating with a multidisciplinary healthcare team, nurses must be able to assert their views from the perspective of nursing knowledge.

Nurse–client helping relationships

Helping relationships with clients are central to therapeutic nursing practice. In such relationships, the nurse assumes the role of professional helper and comes to know the client as an individual who has unique health needs, human responses and patterns of living. Knowing the client is a central caring behaviour (Swanson, 1999) that also functions as an aid to clinical problem solving and decision making (Curry and Worrall-Carter, 2001; Radwin, 1995) and is also central to client participation in care (Henderson, 1997). Through knowing the client, nurses are able to understand health events from the experience of the client, adapt their care to the unique needs of the individual and judge how a person is responding to healthcare events. This type of knowing requires effective communication between nurse and client so that mutual understanding can be achieved.

Therapeutic and social relationships

Communication involves complex social activity more than other aspects of nursing practice, such as technical proficiency and skills. Through communication, nurses relate to a variety of people during direct client care and within healthcare organisations. However, the social activity in nursing is different from other forms of social activity such as friendships. Communication in nursing is professional and therapeutic, and is thus different from communications in friendships.

In therapeutic nurse–client relationships there is an explicit timeframe, a goal-directed approach and a high expectation of confidentiality. The nurse establishes, directs and takes responsibility for the interaction, and the client’s needs take priority over the nurse’s needs. In acting in the client’s best interest, the nurse maintains professional boundaries.

There are clear legal boundaries, as nurses must practise within the scope of their professional knowledge and skill, while codes of conduct (Australian Nursing and Midwifery Council, 2008; Nursing Council of New Zealand, 2009b) specify ethical boundaries. However, professional boundaries are not always as clearly laid out as geographical ones, for example those between countries. Nurses cross professional boundaries when they do not act in the best interest of the patient (Peternelj-Taylor and Younge, 2003), but rather act in a manner that meets their own needs. Having a sexual relationship with a client is a clear boundary violation, as it is focused on the nurse’s needs. More subtly, nurses can cross boundaries when they burden clients with their own problems, such as being short-staffed and under pressure. The relationship is always ‘for the patient’ and this is the best principle to follow in maintaining professional boundaries.

The relationship is also characterised by the nurse’s non-judgmental acceptance of the client. Acceptance conveys a willingness to hear a message or to acknowledge feelings. It does not mean the nurse must always agree with the other person or approve of the client’s decisions or actions.

A therapeutic relationship between nurse and client does not just happen—it is created with care and skill and is built on the client’s trust in the nurse. Nursing theorist Imogene King (1971) calls the nurse–client 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’. Patricia Benner (1984) prefers not to use the term ‘therapeutic’ because of its association with psychotherapy, yet describes a helping role of the nurse in similar fashion. She states that ‘helping encompasses transformative changes in meanings, and sometimes simply the courage to be with the client, offering whatever comfort the situation allows’ (Benner, 1984:48).

The nurse–client relationship is characterised by a natural progression of four goal-directed phases that often begin before the nurse meets the client, and continue until the caregiving relationship ends (Box 12-1). Even a brief interaction uses an abbreviated version of the same pre-interaction, orientation, working and termination phases. For example, the nursing student may gather client information to prepare in advance for caregiving, meet the client and establish trust, accomplish health-related goals through use of the nursing process and say goodbye at the end of the day.

BOX 12-1 PHASES OF THE HELPING RELATIONSHIP

PRE-INTERACTION PHASE

Before meeting the client, the nurse:

• reviews available data, including the medical and nursing history

• talks to other caregivers who may have information about the client

• anticipates health concerns or issues that may arise

• identifies a location and setting that will foster comfortable, private interaction

• plans enough time for the initial interaction.

ORIENTATION PHASE

When the nurse and client meet and get to know one another, the nurse:

• sets the tone for the relationship by adopting a warm, empathetic, caring manner

• recognises that the initial relationship may be superficial, uncertain and tentative

• expects the client to test the nurse’s competence and commitment

• closely observes the client and expects to be closely observed by the client

• begins to make inferences and form judgments about client messages and behaviours

• assesses the client’s health status

• prioritises the client’s problems and identifies the client’s goals

• clarifies the client’s and nurse’s roles

• forms contracts with the client that specify who will do what

• lets the client know when to expect the relationship to be terminated.

WORKING PHASE

When the nurse and client work together to solve problems and accomplish goals, the nurse:

• encourages and helps the client to express feelings about their health

• encourages and helps the client with self-exploration

• provides information needed to understand and change behaviour

• encourages and helps the client to set goals

• takes actions to meet the goals set with the client

• uses therapeutic communication skills to facilitate successful interactions

• uses appropriate self-disclosure and confrontation.

TERMINATION PHASE

During the ending of the relationship, the nurse:

• reminds the client that termination is near

• evaluates goal achievement with the client

• reminisces about the relationship with the client

• separates from the client by relinquishing responsibility for their care

• achieves a smooth transition for the client to other caregivers as needed.

Socialising is often an important initial component of interpersonal communication. It helps people get to know one another and relax. It is easy, superficial and not deeply personal, whereas therapeutic interactions are often more intense, difficult and uncomfortable. A nurse often uses social conversation to help the client feel comfortable and lay a foundation for a closer relationship. Clients value nurses being ‘friendly and chatty’ (Henderson and others, 2007; McCabe, 2004). An informal and warm communication style helps establish trust, but nurses must get beyond social conversation to talk about issues or concerns affecting the client’s health. During social conversation, clients may ask personal questions about the nurse’s family, place of residence and so on. Students often wonder whether it is appropriate to reveal such information; that is, to self-disclose. In an attempt to ‘be professional’, they sometimes assume it is inappropriate to share anything of themselves. Although a high degree of self-disclosure is characteristic of intimate friendships, it does not fit the context of a therapeutic relationship; however, nurses can use self-disclosure to benefit the relationship with the client, provided they remain professional and do not overstep their professional boundaries (Stein-Parbury, 2009).

Nurses often encourage clients to share personal stories; in doing so, nurses come to understand the context of other people’s lives and learn what is meaningful for them from their perspective. For example, a nurse asked a client to tell about a time in his life when he had to make a hard decision. He related the following story:

When I was a young man, I worked on the family farm. An uncle died and left me some money. All of a sudden I could afford to go to the city for a university education, but Dad didn’t want me to go because he needed me there. I had to decide whether to stay or go, and it was hard, because at first I just wanted to get away. I talked to our priest, and he said it was up to me, to pray about it and then do what my heart told me to. So I stayed. Oh, I’ve thought from time to time what might have been, but I never regretted it. I’ve had a good life on the land.

From this brief story, the nurse understood that it was important to the client to put his family’s needs above his personal desires, and that seeking spiritual guidance was an important component of his decision making.

Nurses also provide information and use strategies that help clients understand and change behaviour. The nurse also acts as an advocate to keep the client informed of healthcare alternatives and give support in decision making. For example, the nurse can ask clients and family members for input and suggestions about goals, interventions and evaluation of the plan of care. This type of mutuality (give-and-take, creative mutual exchanges) has been shown to balance power and respect, and to promote productive provider–client communication (McGilton and Boscart, 2007). It gives the other person a greater sense of purpose and direction, encourages personal responsibility for health, helps establish priorities for care, gives the opportunity for self-expression and strengthens the client’s problem-solving ability. This depends on the vulnerability of the client; that is, the degree to which personal resources are available, adequate and appropriate to the situation at hand. Information is one such possible resource.

Nurse–family relationships

Many nursing situations, especially those in community and home healthcare settings, require the nurse to form helping relationships with entire families. The same principles that guide one-to-one helping relationships apply when the client is a family unit, although communication within families requires additional understanding of the complexities of family dynamics, needs and relationships. Collaboration among nurse, client and family caregivers is especially important. Family members have needs for collaboration and involvement in care when their loved ones are ill (Fry and Warren, 2007; Hart and others, 2006). Receiving adequate and timely information is one way to achieve such involvement, yet nurses often misperceive preferences of family members for such communication (Sobo, 2004). Nonetheless, communication training has been shown to improve the capacity to understand and meet family needs (Hart and others, 2006; Tulsky, 2005).

Nurse–healthcare team relationships

Nurses are members of a larger healthcare community and often function in roles that require interaction with multiple healthcare team members. The basic elements of effective communication that apply to the nurse–client relationship are also relevant in relationships with colleagues. That is, nurses must be responsive in understanding the view of their professional colleagues, and they must also be assertive in stating their views about client care. Communication in relationships with colleagues may be geared towards team building, facilitating group process, collaboration, consultation, delegation, supervision, leadership and management. Various communication skills are needed, including presentational speaking, persuasion, group problem solving, providing performance reviews and writing business reports.

Both social and therapeutic interactions are needed between the nurse and other healthcare team members to build morale and strengthen relationships within the work setting. Nurses need friendship, support, guidance and encouragement from one another to cope with the many stressors imposed by the nursing role, and must extend the same caring communication used with clients to build positive relationships with colleagues and co-workers.

Elements of professional communication

Professional appearance, demeanour and behaviour are important in establishing the nurse’s trustworthiness and competence. They communicate that the nurse has assumed the professional helping role, is clinically skilled and is focused on the client. An individual nurse’s inappropriate appearance or behaviour can harm nursing’s professional image.

At work a healthcare professional is expected to be clean, neat, well groomed, conservatively dressed and free of strong scent and other odours. Professional behaviour should reflect warmth, friendliness, confidence and competence. Professionals speak in a clear, well-modulated voice, use good grammar, listen to others, help and support team-mates and communicate effectively. Being on time, organised, well prepared and equipped for the responsibilities of the nursing role also communicate one’s professionalism.

Courtesy and use of names

Common courtesy is part of professional communication. To practise courtesy, nurses need to remain friendly, ask permission to enter the client’s space, address clients by name and always introduce themselves to clients by stating their name and explaining their role and purpose for interacting. This last point is particularly important when students are caring for clients in the clinical setting, as it is important that the student role of learner is understood by clients. The nurse’s failure to give a name, indicate status (e.g. student, registered nurse or enrolled nurse) or acknowledge the client by name can convey an impersonal lack of commitment or caring. More importantly, clients have the right to know who is talking to them and in what professional capacity.

Addressing others by name conveys respect for human dignity and uniqueness. Since using last names is respectful in most cultures, nurses usually use the client’s last name in the initial interaction and then use the first name if requested by the client. The nurse should ask others how they would like to be addressed and let them know personal preference. Using first names is appropriate for infants, young children, confused or unconscious clients and close team members. Terms of endearment such as ‘luv’, ‘dolls’, ‘Grandma’ or ‘darling’ are inappropriate in a professional interaction. Avoid referring to clients by diagnosis, room number or other attribute, which is demeaning and sends the message that the nurse does not care enough to know the person as an individual.

Privacy and confidentiality

Maintaining confidentiality is a sign of respect and a hallmark of professional behaviour. It is essential that the nurse safeguard the client’s right to privacy by carefully protecting information of a sensitive nature. Sharing personal information or gossiping about others violates nursing ethical codes and practice standards. It sends the message that the nurse cannot be trusted and damages interpersonal relationships. Team members directly involved in the client’s care should be given only relevant information about the client’s status.

Trustworthiness

Trust is relying on someone without doubt or question. Being trustworthy means helping others without hesitation when help is needed. To foster trust, the nurse communicates warmth and demonstrates consistency, reliability, honesty and competence. Sometimes it is not easy for a client to ask for help. Trusting another person involves risk and vulnerability, but it also fosters open, therapeutic communication and enhances the expression of feelings, thoughts and needs. Without trust, a nurse–client relationship rarely progresses beyond superficial interaction and care. Avoid dishonesty at all costs. Knowingly withholding key information, lying or distorting the truth violates both legal and ethical standards of practice.

COMMUNICATION WITHIN THE NURSING PROCESS

Each aspect of the nursing process calls for communication skills, as depicted in Box 12-4. In the following section the focus of the nursing process is on providing care for clients who need special assistance with communication. However, the nursing intervention section contains examples of therapeutic communication techniques that are appropriate strategies for use in any interpersonal nursing situation.

BOX 12-4 COMMUNICATION THROUGHOUT THE NURSING PROCESS

ASSESSMENT

• Verbal interviewing and history taking

• Visual and intuitive observation of non-verbal behaviour

• Visual, tactile and auditory data gathering during physical examination

• Written medical records, diagnostic tests and literature review

NURSING DIAGNOSIS

• Intrapersonal analysis of assessment findings

• Validation of healthcare needs and priorities via verbal discussion with client

• Handwritten or computer-mediated documentation of nursing diagnosis

PLANNING

• Interpersonal or small-group healthcare team planning sessions

• Interpersonal collaboration with client and family to determine implementation methods

• Written documentation of expected outcomes

• Written or verbal referral to healthcare team members

IMPLEMENTATION

• Delegation and verbal discussion with healthcare team

• Verbal, visual, auditory and tactile health teaching activities

• Provision of support via therapeutic communication techniques

• Contact with other healthcare resources

• Written documentation of client’s progress in medical record

EVALUATION

• Acquisition of verbal and non-verbal feedback

• Comparison of actual and expected outcomes

• Identification of factors affecting outcomes

• Modification and update of care plan

• Verbal and/or written explanation of revisions of care plan to client

ASSESSMENT

Assessment of a client’s ability to communicate includes gathering data about the many situational factors that influence communication. Situations have several aspects that influence the nature of communication, interpersonal relationships and client needs (Beebe and others, 2007). These include the participants’ internal factors and characteristics, the nature of their relationship, the situation prompting communication, the environment and the sociocultural elements present. Box 12-5 lists the major factors influencing communication within these contexts. Assessing these situational aspects helps the nurse make sound decisions during the communication process.

BOX 12-5 CONTEXTUAL FACTORS INFLUENCING COMMUNICATION

PSYCHOPHYSIOLOGICAL CONTEXT

The internal factors influencing communication:

• physiological status (e.g. pain, hunger, weakness, dyspnoea)

• emotional status (e.g. anxiety, anger, hopelessness, euphoria)

• growth and development status (e.g. age, developmental tasks)

• unmet needs (e.g. safety/security, love/belonging)

• attitudes, values and beliefs (e.g. meaning of illness experience)

• perceptions and personality (e.g. optimist/pessimist, introvert/extrovert)

• self-concept and self-esteem (e.g. positive or negative)

RELATIONAL CONTEXT

The nature of the relationship between the participants:

• social, helping or working relationship

• level of trust between participants

• level of self-disclosure between participants

• shared history of participants

• balance of power and control

SITUATIONAL CONTEXT

The reason for the communication:

• information exchange

• goal achievement

• problem resolution

• expression of feelings

ENVIRONMENTAL CONTEXT

The physical surroundings in which communication takes place:

• privacy level

• noise level

• comfort and safety level

• distraction level

CULTURAL CONTEXT

The sociocultural elements that affect the interaction:

• educational level of participants

• language and self-expression patterns

• customs and expectations

Physical and emotional factors

In client assessment, it is especially important to focus on the psychophysiological factors that influence communication (see Box 12-5). There are many altered health states and human responses that limit communication. People with hearing or visual impairments have fewer channels through which to receive messages. Facial trauma, laryngeal cancer or endotracheal intubation may prevent movement of air past vocal cords or mobility of the tongue, resulting in inability to articulate words. An extremely breathless person must use oxygen to breathe rather than speak. People with aphasia after a stroke or in late-stage Alzheimer’s disease often cannot understand or form words. Certain mental illnesses such as psychoses or depression may cause clients to demonstrate flight of ideas, constant verbalisation of the same words or phrases, a loose association of ideas or slowed speech patterns. People with high anxiety may be unable to perceive environmental stimuli or hear explanations. Finally, unresponsive or heavily sedated people cannot send or respond to verbal messages.

Review of the client’s medical record helps provide relevant information about the client’s ability to communicate. The medical history and physical examination may document physical barriers to speech, neurological deficits, and pathophysiology affecting hearing or vision. Reviewing the client’s medication record is also important. For example, opiates, antidepressants, neuroleptics, hypnotics or sedatives may cause a client to slur words or use incomplete sentences. The nursing progress notes may reveal other factors that contribute to communication difficulties, such as the absence of family members who could provide more information about a confused client.

Communicating directly with clients provides information about their ability to attend to, interpret and respond to stimuli. If clients have difficulty communicating, it is important to assess how they are affected by the problem. People with the nursing diagnosis of impaired verbal communication have described feelings of discomfort, fear and frustration (Carroll, 2004). The client who cannot communicate effectively will often have difficulty expressing needs and responding appropriately to the environment. A client who is unable to speak can be at risk of injury unless an alternative communication method can be found. If there are barriers that make it difficult to communicate directly with the client, family or friends become important sources of data about the client’s communication patterns and abilities.

Developmental factors

Aspects of a client’s growth and development also influence nurse–client interaction. For example, an infant’s self-expression is limited to crying, body movement and facial expression, whereas older children can express their needs more directly. The nurse adapts communication techniques to the special needs of infants, children and adolescents (Box 12-6). The nurse can include the parents, child or both as sources of information about the child’s health, depending on the child’s age. A young child can be given toys or other distractions so the parent can give full attention to the nurse. Children are especially responsive to non-verbal messages, and sudden movements, loud noises or threatening gestures can be frightening. Children often prefer to make the first move in interpersonal contacts and do not like adults to stare or look down at them. A child who has received little environmental stimulation may be behind in language development, thus making communication more challenging.

BOX 12-6 DEVELOPMENTAL ASPECTS OF COMMUNICATION

COMMUNICATING WITH INFANTS

• Use firm touch and gentle physical contact such as cuddling, patting or rocking

• Hold infant so they can see the parents

• Talk softly to the infant

COMMUNICATING WITH TODDLERS AND PRESCHOOLERS

• Interact with parents before communicating with child

• Assume a position that is at the child’s eye level

• Allow children to touch and examine objects that will come in contact with them

• Offer a choice only if one exists

• Focus communication on the child, not on the experience of others

• Don’t use analogies—small children are very literal, direct and concrete

• Use simple words and short sentences

• Keep unfamiliar equipment out of view until it is needed

• Keep facial expression appropriate to activity (don’t smile while doing something painful)

• Communicate through transition objects such as dolls, puppets or stuffed animals before questioning a young child directly

COMMUNICATING WITH CHILDREN

• Allow time for the child to feel comfortable

• Avoid sudden or rapid advances, broad smiles, staring, or other threatening gestures

• Talk to the parent if the child is initially shy

• Give older children the opportunity to talk without the parents present

• Speak in a quiet, unhurried and confident voice

• Use correct scientific/medical terminology

• Give correct reason for why something is done or how equipment works

• State directions and suggestions specifically and positively

• Be honest and let the child know what to expect and how to participate

• Allow the child to express concerns and fears; allow time for questions

• Use a variety of communication techniques such as drawing or play

COMMUNICATING WITH ADOLESCENTS

• Give undivided attention

• Listen, listen, listen

• Be courteous, calm and open-minded

• Try not to overreact. If you do, take a break

• Avoid judging or criticising

• Avoid the ‘third degree’ of continuous questioning

• Choose important issues when taking a stand

• Make expectations clear

• Respect their privacy and views

• Praise good points and tolerate differences

• Encourage expression of ideas and feelings

Modified from Hockenberry MJ and others 2003 Wong’s nursing care of infants and children, ed 7. St Louis, Mosby.

Age alone does not determine an adult’s capacity for communication. However, as people age, their ability to communicate may be affected by many different factors. Normal changes of ageing include decreases in hearing, vision, strength and endurance. Older adults may need more time to recall information during history taking and more time to learn new material during client teaching because of changes in short-term memory. They may repeat themselves or share the same stories over and over without realising it.

Sociocultural factors

Culture is a blueprint for thinking, feeling, behaving and communicating. Culture is something everybody has because it includes values and beliefs systems that are shared by members of a cultural group. These values and beliefs are often taken for granted and assumed to be applicable to all other people. For example, maintaining eye contact is a sign of trustworthiness in some cultures; that is, ‘looking people in the eye’ demonstrates honesty. In other cultures it is disrespectful to make eye contact with a person who is perceived as superior. Clients who avoid eye contact with nurses could be demonstrating respect, not dishonesty. Sensitivity to the culture of other people is needed.

More importantly, nurses should not base their judgments about client behaviour on the basis of their own culture alone. Similarly, it is important to avoid cultural stereotypes that assume all people of a certain background will behave in the same way. Such thinking can lead to misunderstanding and a failure to communicate. An even greater danger of stereotyping is the risk that clients will be rejected or negatively judged because a nurse does not understand their cultural value and belief systems.

Gender

Gender is another factor that influences how we think, act, feel and communicate. Male and female communication patterns tend to differ, which can sometimes create barriers to effective communication (Beebe and others, 2007; Zandbelt and others, 2006).

Males tend to use communication to achieve goals, establish individual status and authority and compete for attention and power. They typically prefer to talk about topics that do not expose personal feelings. Men tend to speak directly when giving criticism or orders. They use more banter, teasing and playful put-downs. Men usually want others to know of their accomplishments.

Women tend to use communication to build connections with others, include others and cooperate with, respond to, show interest in and support others. Women usually enjoy discussing feelings and personal issues and find closeness in dialogue. They tend to downplay their achievements. Women speak indirectly, couching criticism and commands in praise or vagueness to avoid causing offence or hurt feelings.

As with culture, it is important not to stereotype people on the basis of gender. The broad generalisations presented about gender can easily be translated into stereotypes that lack sensitivity for diversity among people, irrespective of gender.

NURSING DIAGNOSIS

Most individuals experience difficulty with some aspect of communication. People who are free of illness or disability may lack skills in attending, listening, responding and self-expression. Most often, the nurse’s care is directed towards those individuals who experience more serious impairments in communication.

The primary nursing diagnostic label used to describe the client who has limited or no ability to communicate verbally is impaired verbal communication. This is the state in which an individual experiences a decreased or absent ability to use or understand language in human interaction. A client will have defining characteristics, such as the inability to articulate words, stuttering or slurring, which the nurse clusters together to form the diagnosis. This diagnosis is useful for a wide variety of clients with special problems and needs related to communication, such as impaired perception, reception and articulation. Although a client’s primary problem may be impaired verbal communication, the associated difficulty in self-expression or altered communication patterns may also contribute to other nursing diagnoses. For example, such persons may experience anxiety, social isolation, ineffective individual or family coping, powerlessness or impaired social interaction.

The related (contributing) factors for impaired verbal communication focus on the causes of the communication disorder. These can be physiological, mechanical, anatomical, psychological, cultural or developmental in nature. For example, a deaf older adult with untreated cataracts who also has expressive aphasia secondary to a stroke has the following nursing diagnosis: impaired verbal communication related to limited vision, absent hearing, and the inability to articulate words. Nursing interventions would then be planned to compensate for the client’s visual and hearing deficits and inability to speak. Accuracy in the identification of related factors is necessary so that the nurse selects interventions that can effectively resolve the diagnostic problem.

PLANNING

Once the nurse has identified the nature of the client’s communication dysfunction, several factors must be considered as the care plan is designed. The nurse needs to make sure basic comfort and safety needs are met before introducing new communication methods and techniques. Adequate time must be allowed for practice, and participants need to be patient with themselves and one another if effective communication is to be achieved. When the focus is on practising communication, the nurse should arrange for a quiet, private place free of distractions such as television or visitors. Communication aids may be needed, such as a writing board for a client with a tracheostomy or a special call system for a client who is paralysed.

The nurse may need to collaborate with other healthcare team members who have expertise in communication strategies. Speech therapists can help clients with aphasia, interpreters may be needed for clients who speak a foreign language, and psychiatric nurse specialists might help angry or highly anxious clients to communicate more effectively.

Expected outcomes for the client with impaired communication are important to identify. In general, effective nursing interventions will result in the client experiencing a sense of trust in the nurse and healthcare team because they are able to be understood. The client will be able to attend to appropriate stimuli, transmit clear and understandable messages and demonstrate congruent verbal and non-verbal messages. The client will demonstrate decreased frustration, or increased satisfaction, with the communication process.

IMPLEMENTATION

In carrying out any plan of care, nurses need to use communication techniques that are appropriate for the client’s individual needs. Before learning how to adapt communication methods to help clients with serious communication impairments, it is necessary to learn the communication techniques that serve as the foundation for professional communication.

The most basic nursing interventions used in communication are therapeutic communication techniques. Therapeutic communication techniques are specific responses that encourage the expression of feelings and ideas and convey the nurse’s acceptance and respect. Learning these techniques helps the student develop awareness of the variety of nursing responses available for use in different situations. Although some of the techniques may seem artificial at first, skill and comfort will increase with practice. Tremendous satisfaction will result as therapeutic relationships and outcomes are achieved.

Therapeutic communication techniques

Heron (2001) offers a useful schema for understanding therapeutic intention through a classification system of two types of communication interventions: authoritative and facilitative. Authoritative interventions take responsibility on behalf of the client. Facilitative interventions promote client autonomy and self-responsibility. When a nurse offers a client new knowledge, makes suggestions or directs the client, authoritative intentions are at play. When a nurse encourages a client to solve problems and express emotions, then facilitative interventions are at play.

The basis for Heron’s intervention analysis is similar to the responsive and assertive dimensions of effective communication (presented earlier in this chapter). Authoritative interventions are assertive in nature and focus on new understandings, such as instructing a client newly diagnosed with diabetes on dietary management. Facilitative interventions are responsive and focus on existing understandings, such as how the client is experiencing a health event. Both types of interventions are potentially therapeutic, depending on context.

Facilitative communication techniques form the backbone of therapeutic communication because they help to build a relationship based on mutual understanding, and this type of mutuality is the basis of therapeutic relationships in nursing practice. In order to be of help, nurses must understand the meaning of a health event from the perspective of the client and their experience of that event.

At times, facilitative communication is therapeutically sufficient. For example, clients often find comfort in another person’s human understanding of their situation; they might gain relief through finding humour in their situation. At other times, authoritative communication techniques are necessary to therapeutic endeavours, such as encouraging and persuading a recently disabled adult client to participate in everyday activities like dressing himself.

• CRITICAL THINKING

Jack Stone is a 78-year-man who has been fit and healthy for most of his life. He was admitted to hospital 3 days ago with a suspected stroke. Thus far, all of the diagnostic tests have been inconclusive. You find that it is difficult for you to communicate with Jack as he complains a lot and gets angry at times. You enter his hospital room in order to conduct a neurological assessment. After asking him ‘What day is today?’, he snaps at you and says, ‘You people just keep asking me the same questions over and over again; what’s wrong with you? I’m not stupid.’

1. Should you use an authoritative or a facilitative approach when responding to Jack?

2. What is your intention in selecting the type of response that you think you should use?

The choice between the two techniques depends on the vulnerability of the client. Determining the vulnerability of the client requires assessment of the resources available to meet the demands of a health event. The therapeutic communication techniques that follow are categorised according to therapeutic intention, as listed in Box 12-7.

BOX 12-7 CLASSIFICATION OF COMMUNICATION INTERVENTIONS ACCORDING TO THERAPEUTIC INTENTION

FACILITATIVE COMMUNICATION INTERVENTIONS

Active listening

Sharing observations

Expressing empathy

Offering hope

Sharing humour

Sharing feelings

Using touch

Using silence

Asking relevant questions

Paraphrasing

Clarifying

AUTHORITATIVE COMMUNICATION INTERVENTIONS

Providing information

Focusing

Summarising

Self-disclosing

Confronting

Suggesting

Advising

Instructing

Persuading

Encouraging

Offering direct assistance

Facilitative communication interventions

Facilitative techniques encourage clients to think for themselves and facilitate mutual understanding between them and the nurse. They are considered the backbone of therapeutic communication and are based on a philosophy of patient-centred care. When using facilitative techniques, the nurse follows the client’s lead.

Active listening

Active listening means listening attentively with one’s whole being—mind, body and spirit. It includes listening for conversational themes, acknowledging and responding, giving appropriate feedback and paying attention to the other person’s total communication, including the content, the intent and the feelings expressed (Stein-Parbury, 2009). Active listening allows the nurse to better understand the entire message being communicated, and is an excellent way to build trust. In many nursing situations the other person simply needs someone to listen.

To listen attentively, the nurse faces the client at a distance of about 90 cm, removes any physical barriers if possible, maintains eye contact (if culturally appropriate), assumes a relaxed posture and sits quietly, leans forward slightly and nods in acknowledgment when the client talks about important points or looks for feedback. Fidgeting, breaking eye contact, daydreaming during conversation or only pretending to listen conveys the message that what the other person has to say is not important. These inhibit conversation and undermine trust.

Being available means offering oneself and expressing a willingness to listen, talk or be physically present with another person when the client needs it. By expressing availability, even though the client may not make their needs known, the nurse shows a caring attitude. When clients feel that the nurse is listening they sense a connection that enables the relationship to develop (Kagan, 2008). Therefore, listening is essential to the process element of therapeutic communication.

Availability and active listening are often described as nursing presence, an intersubjective encounter between a nurse and a client in which the nurse encounters the client as a unique human being in a unique situation and chooses to ‘spend’ themself on the client’s behalf (Öhman and Söderberg, 2004; Zyblock, 2010). Presence is the nursing quality of ‘being there’ for the client—not only physically present, but also listening attentively from a caring perspective: ‘I’ll stay with you a while. If you want to talk, I’ll be glad to listen.’ However, the ability to be fully present does not lie simply within the nurse; it requires a healthcare environment that is conducive to the formation of relationships between nurses and clients (Fingeld-Connett, 2008; McMahon and Christopher, 2011).

CHALLENGES AND POTENTIAL PITFALLS WHEN LISTENING

One of the key factors in being able to actively listen to clients is an ability to ‘tune out’ other thoughts in order to fully attend. Often when nurses are attempting to listen they are preoccupied with other matters; for example, they may be thinking about an onerous workload or worrying about a personal matter. More subtle is the tendency to make judgments about what a client is saying; for example, by thinking that the client is being silly or complaining too much. When emotions are being expressed, especially when clients are angry, it is often difficult to hear what they are expressing.

Changing the subject is an indication that the nurse is not listening; for example, saying ‘Let’s not talk about your problems with the insurance company. It’s time for your walk.’ Changing the subject when another person is trying to communicate something important is rude and shows a lack of empathy. It tends to block further communication, and the client may then withhold important messages or fail to openly express feelings.

USING SILENCE

It takes time and experience to become comfortable with silence. Most people have a natural tendency to fill empty spaces with words, but sometimes those spaces give time for the nurse and client to collect their thoughts and consider what has been communicated. Silence also allows the nurse to pay particular attention to non-verbal messages such as worried expressions or loss of eye contact. Remaining silent demonstrates the nurse’s patience and willingness to wait for a response when the other person is unable to reply quickly. Silence may be especially therapeutic during times of profound sadness or grief.

SHARING OBSERVATIONS

Nurses make observations by commenting on how the other person looks, sounds or acts. Stating observations often helps the client communicate without the need for extensive questioning, focusing or clarification. For example, the nurse observes a young client holding his body rigidly erect and his voice being sharp as he says, ‘Going to surgery is no big deal.’ The nurse replies, ‘You say having surgery doesn’t bother you, but you look a little worried. It is natural to feel worry about surgery.’ This approach may result in encouraging the client to further express current concerns.

SHARING FEELINGS

Emotions are subjective feelings that result from one’s thoughts and perceptions. Feelings are not right, wrong, good or bad, although they may be pleasant or unpleasant. If feelings are not expressed, stress and illness can worsen. Nurses can help clients express emotions by making observations, acknowledging feelings, encouraging communication, giving permission to express ‘negative’ feelings and modelling healthy emotional self-expression. At times, clients may direct anger or frustration prompted by their illness towards the nurse, who should not take such expressions personally. Acknowledging clients’ feelings communicates that the nurse listened to and understood the emotional aspects of their illness.

When nurses care for clients they must be aware of their own emotions, because feelings are difficult to hide. Students may wonder whether it is helpful for the nurse to share feelings with clients. Sharing emotion makes nurses seem more human and can bring people closer. It is appropriate to share feelings of caring, or even cry with others, as long as the nurse is in control of how those feelings are expressed and does so in a way that does not burden the client. Feelings are shared with clients in an effort to assist them, not the nurse.

EXPRESSING EMPATHY

Empathy is the ability to understand and accept another person’s reality and to accurately perceive feelings. Empathic communication conveys that the nurse not only has heard what the client has expressed, but also understands what the client means. In expressing empathy, the nurse communicates this understanding to the client. Such empathic understanding requires the nurse to be both sensitive and imaginative, especially if the nurse has not had similar experiences. Statements reflecting empathy are highly effective because they tell the person that the nurse heard the feeling content, as well as the factual content, of the communication. This results in clients feeling accepted and valued, thereby facilitating the therapeutic relationship.

CHALLENGES AND PITFALLS IN EXPRESSING EMPATHY

There is a difference between empathy and sympathy. An example of a sympathetic expression is ‘I feel so sorry about your amputation, it would be terrible to lose a leg.’ Sympathy is concern, sorrow or pity felt for the client generated by the nurse’s personal identification with the client’s needs. Empathy is imagining what it would be like to be in the circumstances of the client; sympathy is assuming that the nurse knows what it is like (Stein-Parbury, 2009). Sympathy is a subjective look at another person’s world that prevents a clear perspective of the issues confronting that person. Although sympathy is a compassionate response to another’s situation, it is not as therapeutic as empathy. The nurse’s own emotional issues can prevent effective problem solving and impair good judgment. Stuart (2009) explains that sympathy can cause problems in a helping relationship, because helpers who share the client’s needs may be unable to help the client select realistic solutions for problems. A more empathic approach would be: ‘Losing your leg has been a major change. How has it affected your life?’

• CRITICAL THINKING

Helen Simpson has had a resection of her bowel for cancer and now has a colostomy. You have been asked to begin assisting her with learning how to care for her colostomy when she is discharged. You read about how to instruct patients and feel confident that you know how to explain colostomy care. When you enter Helen’s hospital room she is quiet and withdrawn, and tells you ‘There’s no need to bother with all of that. I’ll be fine’. What should you say to Helen that would express empathy for her situation?

OFFERING HOPE

Hope is productive to healing, and offering hope communicates a ‘sense of possibility’ to clients (Fitzgerald Miller, 2007). Appropriate encouragement and belief that the client can cope, along with concrete feedback about how the client is progressing, are important in fostering hope by boosting self-confidence and helping clients achieve their potential. Sharing a vision of the future and reminding others of their resources and strengths can also strengthen hope. Clients can be reassured that there are many kinds of hope and that meaning and personal growth can come from illness experiences (Fitzgerald Miller, 2007).

SHARING HUMOUR

Humour is an important therapeutic resource in nursing interactions. Dean and Gregory (2005) found that humour was used pervasively in palliative care. It serves to build relationships by conveying respect for the personhood of the patient and creates a sense of cohesiveness between nurses and their clients. It helps decrease client anxiety, depression and embarrassment. According to Christie and Moore (2005), humour can promote a sense of wellbeing by alleviating stress and improving pain thresholds. Laughter can be good medicine when nurses use humour to help clients adjust to stress imposed by illness. Humour can increase the nurse’s effectiveness in providing emotional support to clients and can humanise the illness experience. Laughter provides both a psychological and a physical release for both nurse and client. Humour can help others to interact more openly and comfortably and can make nurses’ own humanity more apparent.

USING TOUCH

Touch 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. Many messages, such as affection, emotional support, encouragement, tenderness and personal attention, are conveyed through touch. Comfort touch, such as holding a hand, is especially important for vulnerable clients who are experiencing severe illness with its accompanying physical and emotional losses.

Since much of what nurses do involves touching, nurses must learn to be sensitive to others’ reactions to touch and use it wisely. There are times when touch should be withheld; highly suspicious or angry people may respond negatively or even violently to the nurse’s touch.

ASKING RELEVANT QUESTIONS

Asking questions allows nurses to seek information that is vital to client care. Nurses should ask only one question at a time, and fully explore one topic before moving to another area. During client assessment, questions follow a logical sequence and usually proceed from the general to the more specific. Open-ended questions allow the client to take the conversational lead and introduce pertinent information about a topic: ‘What happens when you and your husband argue?’ Focused questions are used when more-specific information is needed in an area: ‘What do you argue about most often?’ The nurse should allow clients to fully respond to an open-ended question before asking more-focused questions. Closed-ended questions elicit a yes, no or one-word response: ‘How many arguments did you have last week?’ They are generally less useful during therapeutic exchanges, although they are often essential to client assessment.

CHALLENGES AND POTENTIAL PITFALLS IN QUESTIONING

Asking too many questions can be dehumanising, because clients can feel as though they are being treated like an object. A useful exercise is to try conversing without asking the other person a single question. By giving general leads (‘Tell me about it …’), making observations, paraphrasing, focusing, providing information and so on, nurses can discover much of importance that would have remained hidden if questions alone had been used during the communication process.

A nurse may be tempted to ask clients to explain why they believe, feel or have acted in a certain way. Asking for explanations, for example ‘Why are you so anxious?’, is not helpful to clients; people often do not know why they feel the way they do, and a question such as this can put them on the defensive. Moreover, clients frequently interpret ‘why’ questions as accusations, and this can cause resentment, insecurity and mistrust (Stein-Parbury, 2009). They are best avoided and replaced with open-ended questions that explore the situation further.

Asking personal questions that are not relevant to the situation simply to satisfy the nurse’s curiosity, for example ‘Why don’t you and John get married?’, is not appropriate professional communication. Such questions are intrusive and unnecessary. If clients wish to share private information, they will. If the nurse needs to know more about the client’s interpersonal roles and relationships, a question such as ‘How would you describe your relationship with John?’ can be asked.

PARAPHRASING

Paraphrasing is re-stating another’s message briefly, using one’s own words. Through paraphrasing, the nurse sends feedback that lets others know whether their messages were understood. If the meaning of a message is changed or distorted through paraphrasing, communication may become ineffective. For example, a client may say ‘I’ve been overweight all my life and never had any problems. I can’t understand why I need to be on a diet’. Paraphrasing this statement by saying ‘You don’t care if you’re overweight or not’ is incorrect. It would be more accurate to say ‘You’re not convinced you need a diet because you’ve stayed healthy’.

Paraphrasing is an effective way to clarify what a client is communicating. By putting their words into the nurse’s own words, clients can not only correct any misunderstandings, e.g. ’That’s not exactly what I meant’, but can also expand and elaborate on what they are meaning. A paraphrase is a useful way to encourage further interaction by demonstrating that the nurse is trying to understand the client’s experience.

• CRITICAL THINKING

The next time you are talking to one of your friends who is experiencing some difficulty in their life and telling you about it, try to simply rephrase what they are expressing. This is not an easy way to respond, so you will have to concentrate. Notice what effect paraphrasing has on the conversation. How is this conversation different to ones you normally have?

CHALLENGES AND PITFALLS IN PARAPHRASING

Paraphrasing is not the same as parroting—repeating what the other person has said word for word. Parroting is easily overused and is not as effective as paraphrasing. A simple ‘Oh?’ can give the nurse time to think if the other person says something that takes the nurse by surprise.

Nurses are sometimes reluctant to paraphrase what clients say out of fear of appearing incompetent; that is, they think that they should just know what the client means without having to say what they think. Another reason for a reluctance to use a paraphrase is the fear of ‘reinforcing’ distressing negative emotions when that is what the client is conveying. The paraphrase is comforting to clients when they are distressed because it demonstrates that the nurse is listening and trying to understand (Stein-Parbury, 2009).

CLARIFYING

To check whether understanding is accurate, the nurse can re-state an unclear or ambiguous message to clarify the meaning. Instead of paraphrasing the message, the nurse can also ask the other person to rephrase it, explain further or give an example of what the person means. Without clarification, the nurse may make invalid assumptions and miss valuable information. Despite efforts at paraphrasing, the nurse may not understand the client’s message and should let the client know if this is the case: ‘I’m not sure I understand what you mean by “sicker than usual”. What is different now?’

Authoritative communication interventions

Authoritative communication operates from the philosophy that the nurse needs to take charge and lead the client, instead of following the client as is the case with facilitative techniques. While authoritative techniques can be used to promote client autonomy, for example through health teaching, often they are not as patient-centred as facilitative techniques. More importantly, they are often over-used in healthcare situations.

PROVIDING INFORMATION

Providing relevant information tells other people what they need or want to know so that they can make decisions, experience less anxiety and feel safe and secure. It is also an integral aspect of health teaching. It is usually not helpful to hide information from clients, particularly when they seek it. Clients have a right to know about their health status and what is happening in their environment.

Research has shown that the provision of information is highly individual in the sense that some clients require more information than others (Jahraus and others, 2002). Identification of the amount and type of information needed by an individual client is essential in the use of this intervention.

• CRITICAL THINKING

Some clients want to know every detail about their health status and care, while others want only minimal information. How might you assess how much information a client desires?

INSTRUCTING

This technique is similar to providing information but is communicated in a more direct fashion. For example, a nurse might need to provide instructions to a postoperative client about how to splint the incision when attempting to cough.

SUGGESTING

Nurses often help clients by offering suggestions of what might be of benefit. For example, a nurse might suggest distraction as a useful way to cope with worry about pending diagnostic results. Suggestions should be posed tentatively and operate from an understanding of the client situation and knowledge of health. They are not based on the nurse’s personal opinions or values.

ADVISING

Nurses are often in a position to offer sound advice about health matters. Like suggestions, advice is not based on personal opinions of the nurse, but rather on an understanding of the health event.

CHALLENGES AND PITFALLS IN ADVISING

Giving personal opinions, e.g. ‘If I were you, I’d put your mother in a nursing home’, must be avoided. When the nurse gives a personal opinion, it takes decision making away from the client. It inhibits spontaneity, stalls problem solving and creates doubt. Personal opinions differ from professional advice. At times, clients need suggestions and help to make choices. Suggestions are presented to clients as options because the final decision rests with the client. Remember, the problem and its solution belongs to the other person and not the nurse. A much better response would be: ‘Let’s talk about what options are available for your mother’s care.’

PERSUADING

When advising and suggesting do not seem to be helpful to the client, a nurse often has to become persuasive in pursuing a therapeutic aim. For example, emergency-room nurses may need to persuade family members of a client who has died suddenly not to drive themselves home from the hospital while still in a state of shock at the death.

FOCUSING

Focusing is used to centre on key elements or concepts of a message. If conversation is vague or rambling or clients begin to repeat themselves, focusing is a useful technique. The nurse does not use focusing if it interrupts clients while discussing an important issue. Rather, the nurse uses focusing to guide the direction of conversation to important areas: ‘We’ve talked a lot about your medications, but let’s look more closely at the trouble you’re having in taking your tablets on time.’

SUMMARISING

Summarising is a concise review of key aspects of an interaction. Summarising brings a sense of satisfaction and closure to an individual conversation and is especially helpful during the termination phase of a nurse–client relationship. By reviewing a conversation, participants focus on key issues and can add relevant information as needed. Beginning a new interaction by summarising a previous one helps the client recall topics discussed and shows the client that the nurse has analysed communication. Summarising also clarifies expectations, as in this example of a nurse manager who had been working with a dissatisfied employee: ‘You’ve told me a lot of things about why you don’t like this job and how unhappy you’ve been. We’ve also come up with some possible ways to make things better, and you’ve agreed to try some and let me know if any of them help.’

SELF-DISCLOSING

To use self-disclosure, the nurse reveals personal experiences, thoughts, ideas, values or feelings in the context of the relationship with the intent of helping the other person. This is not therapy for the nurse; rather, it shows clients that their experiences can be understood and are not unique. Self-disclosures should be relevant and appropriate and made to benefit the client rather than the nurse. They are used sparingly so that the client is the focus of the interaction: ‘That happened to me once, too. It was devastating, and I had to face some things about myself that I didn’t like. I went for counselling, and it really helped … What are your thoughts about seeing a counsellor?’

CONFRONTING

To confront someone in a therapeutic way, the nurse helps the client to become aware of inconsistencies in his or her feelings, attitudes, beliefs and behaviours (Stuart, 2009). This technique improves client self-awareness and helps the client recognise growth and deal with important issues. Confrontation should be used only after trust has been established, and it should be done gently, with sensitivity: ‘You say you’ve already decided what to do, yet you’re still talking a lot about your options.’

ENCOURAGING

Like offering hope, nurses are often in a position to encourage clients, especially when discouragement is evident. Encouragement is best offered in concrete terms, such as ‘I can see that you are able to walk much better today. It only took you a few minutes to get to the toilet today. A few days ago it took nearly 20 minutes.’

OFFERING DIRECT ASSISTANCE

It may seem obvious that nurses assist clients. However, a direct offer of assistance can help when clients are overwhelmed with unpleasant feelings. ‘Here, let me help you with putting on your shoes’ is an example of direct assistance. In doing so, it is important that the nurse does not take over for clients and make them feel useless and more vulnerable.

Adapting communication techniques for the client with special needs

Interacting with those who have conditions that impair communication requires special thought and sensitivity. Such clients benefit greatly when the nurse adapts communication techniques to their unique circumstances or developmental level. For example, the nurse caring for a client with impaired verbal communication related to cultural differences may provide a table of simple words in the client’s language. The nurse and client use the table to help communicate about basic needs such as food, water, toileting, pain relief and sleep.

The nurse’s actions are directed at meeting the goals and expected outcomes identified in the plan of care, tackling both the communication impairment and its contributing factors. Box 12-8 lists many methods available to encourage, enhance, restore or substitute for verbal communication. The nurse must be sure that the client is physically able to use the chosen method and that it does not cause frustration by being too complicated or difficult.

BOX 12-8 COMMUNICATING WITH CLIENTS WHO HAVE SPECIAL NEEDS

CLIENTS WHO CANNOT SPEAK CLEARLY (APHASIA, DYSARTHRIA, MUTENESS)

• Listen attentively, be patient and do not interrupt

• Ask simple questions that require ‘yes’ or ‘no’ answers

• Allow time for understanding and response

• Use visual cues (e.g. words, pictures and objects) when possible

• Allow only one person to speak at a time

• Do not shout or speak too loudly

• Encourage the client to converse

• Let client know if you have not understood him/her

• Collaborate with speech therapist as needed

• Use communication aids:

– pad and felt-tipped pen or magic slate

– communication board with commonly used words, letters or pictures denoting basic needs

– call bells or alarms

– sign language

• use of eye blinks or movement of fingers for simple responses (‘yes’ or ‘no’)

CLIENTS WHO ARE COGNITIVELY IMPAIRED

• Reduce environmental distractions while conversing

• Get client’s attention prior to speaking

• Use simple sentences and avoid long explanations

• Avoid shifting from subject to subject

• Ask one question at a time

• Allow time for client to respond

• Be an attentive listener

• Include family and friends in conversations, especially in subjects known to client

CLIENTS WHO ARE UNRESPONSIVE

• Call client by name during interactions

• Communicate both verbally and by touch

• Speak to client as though he or she could hear

• Explain all procedures and sensations

• Provide orientation to person, place and time

• Avoid talking about client to others in his or her presence

• Avoid saying things client should not hear

CLIENTS WHO DO NOT SPEAK ENGLISH

• Speak to client in normal tone of voice (shouting may be interpreted as anger)

• Establish method for client to signal desire to communicate (call light or bell)

• Provide an interpreter (translator) as needed

• Avoid using family members, especially children, as interpreters

• Develop communication board, pictures or cards

• Translate words from native language into English list for client to make basic requests

• Have dictionary (English/Arabic and so forth) available if client can read

EVALUATION

It is important that nurses develop skills in evaluating how clients respond to the use of various skills. This enables nurses to ascertain whether their therapeutic intention has been fulfilled. For example, if using a pen and paper proves frustrating for a non-verbal client whose handwriting is shaky, the care plan can be revised to include use of a picture board instead. If expected outcomes are not met or progress is not satisfactory, the nurse needs to determine what factors influenced the outcomes, then modify the communication approach. A high degree of self-awareness, astute observation and the capacity to reflect on actions are necessary. Reflective practice (such as described by Taylor, 2000) forms the basis of evaluating communication effectiveness.

Evaluation of the communication process will help nurses gain confidence and competence in interpersonal skills. Becoming an effective communicator greatly increases the nurse’s professional satisfaction and success. There is no skill more basic; no tool more powerful.

KEY CONCEPTS

• Communication is the means by which nurses meet their professional obligation to form therapeutic relationships with clients.

• Communication is a powerful therapeutic tool and an essential nursing skill used to influence others and achieve positive health outcomes.

• The dynamics of communication include both process and content.

• Effective communication involves being both responsive and assertive.

• Nurses consider many contexts and factors influencing communication when making decisions about what, when, where, how, why and with whom to communicate.

• Communication is influenced by physical and developmental status, perceptions, values, emotions, knowledge, sociocultural background, roles and environment.

• Effective verbal communication requires appropriate intonation, clear and concise phrasing, proper pacing of statements and proper timing and relevance of a message.

• Effective non-verbal communication complements and strengthens the message conveyed by verbal communication so that the receiver is less likely to misinterpret the message.

• Nurses use intrapersonal, interpersonal and small-group interaction to achieve positive change and health goals.

• Helping relationships are strengthened when the nurse demonstrates caring by establishing trust, empathy, autonomy, confidentiality and professional competence.

• Effective therapeutic communication techniques are both facilitative, in which the nurse follows the client’s lead, and authoritative, in which the nurse takes the lead.

• Ineffective communication techniques are inhibiting and tend to block the other person’s willingness to openly express ideas, feelings or concerns.

• The nurse must blend social and informational interactions with therapeutic communication techniques so that others can explore feelings and manage health issues.

• Methods that facilitate communication with children include sitting at eye level; interacting with parents; using simple, direct language; and incorporating play activities.

• Older adult clients with sensory, motor or cognitive impairments require the adaptation of communication techniques to compensate for their loss of function and special needs.

• Clients with impaired verbal communication require special consideration and alterations in communication techniques to facilitate shared meaning.

ONLINE RESOURCES

Communicating with patients from culturally and linguistically diverse backgrounds; an interactive learning resource that provides insight and understanding when interacting with patients from diverse backgrounds, http://mhclna.org.au/e-learning/CALD

Communication for Health in Emergency Contexts (CHEC); an interactive learning resource that focuses on communication with patients in an emergency department, www.chec.meu.medicine.unimelb.edu.au

The difficult nurse–patient relationship; an interactive learning resource that explores how to relate to and communicate with a hospitalised patient who is considered to be ‘difficult’, http://mhclna.org.au/e-learning/Rosie

REFERENCES

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Communication and nursing practice

The context of nursing practice

Why nurses need to communicate

Research focus

Research abstract

Evidence-based practice

Research focus

Research abstract

Evidence-based practice

Healthcare environments and communication

Patient-centred communication

Research focus

Research abstract

Evidence-based practice

Focusing on solutions

Effective communication

Communication and interpersonal relationships

Dynamics of interpersonal communication

Professional nursing relationships

Nurse–client helping relationships

Therapeutic and social relationships

PRE-INTERACTION PHASE

ORIENTATION PHASE

WORKING PHASE

TERMINATION PHASE

Nurse–family relationships

Nurse–healthcare team relationships

Levels of communication

Intrapersonal communication

Interpersonal communication

Small-group communication

Forms of communication

Verbal communication

Vocabulary

Meanings of words and phrases

Intonation

Clarity and brevity

Timing and relevance

Non-verbal communication

Posture and gait

Facial expression

Eye contact

Gestures

Territoriality and personal space

ZONES OF PERSONAL SPACE

INTIMATE ZONE (0–45 CM)

PERSONAL ZONE (45 CM TO 1.2 M)

SOCIAL ZONE (1.2–3.6 M)

PUBLIC ZONE (3.6 M AND GREATER)

ZONES OF TOUCH

SOCIAL ZONE (PERMISSION NOT NEEDED)

CONSENT ZONE (PERMISSION NEEDED)

VULNERABLE ZONE (SPECIAL CARE NEEDED)

INTIMATE ZONE (GREAT SENSITIVITY NEEDED)

Developing communication skills

The need to ‘unlearn’ previous communication patterns

Approval and disapproval

Stereotypical responses

False reassurance

Elements of professional communication

Courtesy and use of names

Privacy and confidentiality

Trustworthiness

COMMUNICATION WITHIN THE NURSING PROCESS

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

IMPLEMENTATION

EVALUATION

ASSESSMENT

PSYCHOPHYSIOLOGICAL CONTEXT

RELATIONAL CONTEXT

SITUATIONAL CONTEXT

ENVIRONMENTAL CONTEXT

CULTURAL CONTEXT

Physical and emotional factors

Developmental factors

COMMUNICATING WITH INFANTS

COMMUNICATING WITH TODDLERS AND PRESCHOOLERS

COMMUNICATING WITH CHILDREN