ch 24 communication
What are the 3 main characteristics of a Therapeutic Relationship
rapport, empathy, and purpose
A student says to another student, "I'm sorry that you did poorly on the exam. I'm so worried that you won't pass this class." This is an example of __________.
sympathy
Evaluation
• Acquisition of verbal and nonverbal feedback. • Comparison of actual and expected outcomes. • Identification of factors affecting outcomes. • Modification and update of care plan. • Verbal and/or written explanation of care plan revisions to patient.
Analysis and Nursing Diagnosis
• Analysis and interpretation of assessment findings. • Identification and validation of health care needs and priorities via verbal discussion with patient. • Documentation of nursing diagnosis.
Implementation
• Delegation, discussion, and collaboration with interprofessional health care team • Verbal, visual, auditory, and tactile health teaching activities • Provision of support via therapeutic communication techniques • Written documentation of patient's response to nursing interventions in medical record
Other non-therapeutic responses:
Changing the subject False reassurance Sympathy Offering Approval or Disapproval
"I'm not sure I understand where you are experiencing the pain. Can you explain further?" What is the communication technique demonstrated by the nurse?
Clarifying
"You've told me when your pain started and what you've done to manage it; now, please rate your pain on a scale of 1 to 10." What is the communication technique demonstrated by the nurse?
Focus
After receiving the report, Stacy begins to assess the client, who states that pain is 9/10. The client requests additional pain medication, but there are no medications available at this time. Who should Stacy contact for assistance?
Healthcare provider
The client states, "I've smoked tobacco my entire life. I don't think I need to quit at this point." The nurse states, "You're not sure you need to quit smoking because you've not experienced any damaging health effects." What is the communication technique demonstrated by the nurse?
Paraphrasing
Other therapeutic communication strategies use by nurses are:
clarifying focusing paraphrasing validation asking relevant questions summarizing confrontation
What are elements of professional appearance?
clean, neat, well-groomed, and odor-free
Small group communication:
communication occurring within groups of three or more people. Outcome oriented and requires an understanding of group dynamics
Communication
is a lifelong learning process. Is essential to establish nurse-patient relationship and deliver high-quality patient-centered care.
Motivational interviewing (MI)
is a technique that encourages patients to share their thoughts, goals, beliefs, fears, and concerns with the aim of changing their behavior. It provides a way of working with patients who may not seem ready to make behavioral changes that are considered necessary by their health practitioners.
What is most important characteristic of small group communication?
organized and concise
State the main reason for the communication.
Situation
"You've told me a lot of things about your relationship with your daughter. We've developed some strategies for improving this relationship, and you've agreed to try some of them. You will let me know how things are going next week." What is the communication technique demonstrated by the nurse?
Summarizing
While Stacy is receiving the hand-off report, the physical therapist enters the room. What role does the physical therapist play in the client's recovery?
Teaching the client how to use a mobility device
Termination phase
During the ending of the relationship: -Marks the end of the relationship as it exists for the predefined purpose.
Stacy phones the healthcare provider. Which statement represents the recommendation?
"Can I have a prescription for a stronger pain medication?"
Asking for explanations/ "Why" questions
"Why" questions can also imply right or wrong and may be perceived as threatening or intimidating to the client. If the client doesn't know the answer they may become defensive. However, this is non-therapeutic.
A nurse is caring for a client who reports difficulty sleeping. Which response by the nurse is most appropriate? "Really? Every time I came to check on you, you were asleep." "You do not seem tired." "You are having difficulty sleeping?" "I always have trouble sleeping."
"You are having difficulty sleeping?"
Preintereaction phase
*Before meeting the client -Begins when the nurse starts preparation for the initial interaction with a client.
(Nurse makes eye contact with the client.) Nurse: Your hair looks very pretty today. Client: Thank you! I just got it cut last week. (A few minutes of silence passes while the client looks at herself in the mirror.) Client: I would love to do your hair for you one day. Nurse: If my hair gets any grayer, I may take you up on that offer. What therapeutic communication technique is Iryna using with this client? Select all that apply. -Summarizing -Active listening -Using silence -Paraphrasing -Sharing humor -Sharing observations
-Active listening -Using silence -Sharing humor -Sharing observations
Orientation phase
-Begins when the nurse and client meet for the first time.
Which clients may benefit from motivational interviewing? Select all that apply. 1. Client who has asthma and does not want to rehome their cat to prevent an attack 2. Client who recently had a heart attack and does not want to reduce fat intake 3. Client who is pregnant and excited to learn more about natural childbirth 4. Client who wants to quit smoking and is seeking help 5. Client who is obese and does not think they have time to exercise
1. Client who has asthma and does not want to rehome their cat to prevent an attack 2. Client who recently had a heart attack and does not want to reduce fat intake 5. Client who is obese and does not think they have time to exercise
Rearrange the stages of the therapeutic relationship into the correct order. 1. Mutual problem solving to accomplish therapeutic goals 2. Planning and starting the process before the purposeful interaction with the client begins 3. Separating from the formal therapeutic relationship 4. Meeting, creating rapport, and establishing trust through honesty and empathy
2. Planning and starting the process before the purposeful interaction with the client begins 4. Meeting, creating rapport, and establishing trust through honesty and empathy 1. Mutual problem solving to accomplish therapeutic goals 3. Separating from the formal therapeutic relationship
When Stacy returns to the nurses' station, she overhears the night shift nurse mention that Stacy is a new graduate and probably not capable of caring for such a complicated client. When the nurse sees that Stacy has overheard the comment, the nurse groans and walks away. What action should Stacy take first?
Approach the nurse privately and ask to speak about the comment.
Client: Yes, I've actually had to turn away customers. My schedule is so overbooked. Nurse: Thank you for making time to see us today. Tell me how it makes you feel to turn away customers. What therapeutic communication technique is Iryna using with this client?
Asking relevant questions
The nurse is educating a client and at the end of each sentence asks, "Okay?" The nurse's speech is rapid and explanations are lengthy. Which aspect of verbal communication is the nurse breaching?
Clarity
What are elements of professional demeanor?
Clear voice Good listening skills Warm and friendly Confident and Competent Good grammar help and support colleagues Communicate effectively Prepare Time Organized
Rachel finishes the teaching session and asks Ms. Simpson to repeat back how to care for her surgical site. Which part of the nursing process is Rachel performing?
Evaluation
Introduce yourself and identify your location and role in the care of the client.
Identify
Zones of Personal Space
Intimate distance (0-18 inches) Personal distance (18-40 inches) Social distance (4-12 feet) Public distance (12 feet and more)
Levels of Communication
Intrapersonal (self-talk). Interpersonal (one-on-one). Small group. Public. Electronic.
Nurse-Patient caring Relationship
Nurse assume the role of a professional who cares about each patient and his or her unique health needs, human responses, and patterns of living.
Autonomy
Nurses are self-directed and independent in accomplishing goals and advocating for others.
Trustworthy
Nurses display consistency, reliability, honesty, competence, and respect.
Courtesy
Nurses say hello and goodbye to clients and knock on doors before entering.
interpersonal relationships
One-on-one communication. All behavior communicates, and all communication influences behavior.
client: Good morning nurse: Good morning! What would you like to talk about today? Open-ended question or Close-ended question?
Open-ended question
Which are aspects of nonverbal communication?
Personal appearance, Territory and personal space, Posture and gait, sound, Gestures, Eye contact, Facial expression, Metacommunication
Recommend next action steps to assist the client.
Recommendation
Ms. Simpson's daughter arrives and Rachel prepares to begin teaching. How should Rachel prepare for the education session?
Secure an authorized translator who can also perform sign language.
"You're concerned that you will not be able to ride your bike after your knee replacement." What is the communication technique demonstrated by the nurse?
Validation
Barriers to communication with facial expressions are:
hearing impaired/confused lonely frightened/anxious sad/withdrawn flirtatious
Touch conveys ?
affection, emotional support, encouragement, tenderness, and personal attention.
Self-disclosure in therapeutic communication
occurs when the nurse shares personal experiences with a client.
Julian returns to the client's room 30 minutes later to find that the client is tearful and states, "I am worried about having this surgery. What if something bad happens? Who will take care of my children?" Which response by Julian is therapeutic? "This must be a difficult time for you. Would you like to talk more about this?" "Why are you worried? You have the best surgeon I have ever met." "This is a very common surgery. You will be fine." "Let me contact the surgeon and get some medication to calm your nerves."
"This must be a difficult time for you. Would you like to talk more about this?"
Effective interpersonal communication consists of:
-Sense of mutuality (nurse-patient both are equal participants). -Client response are not always what you think. -clients have special communication needs. -More is communicated than meets the eye (and the ear). -Provide client with privacy.
Through a professional therapeutic relationship with a nurse, the client:
-achieves optimal personal growth -forms positive relationships with others -satisfies health needs -achieves personal goals
What does AIDET stand for?
ACKNOWLEDGE. Greet the client by name. Make eye contact, smile, and acknowledge family or friends in the room. INTRODUCE. Introduce yourself with your name, skill set, professional certification, and experience. DURATION. Give an accurate time expectation for procedures, medications, and discharge. When this is not possible, give a time in which you will update the client on progress. EXPLANATION. Explain step-by-step what to expect next, answer questions, and let the client know how to contact you, such as a nurse call button. THANK YOU. Thank the client for choosing your hospital or for their communication and cooperation.
When caring for a client who is hearing-impaired, which techniques may improve communication?
Assess the need for adaptive equipment, such as a hearing device. Allow the client time to process the information and respond. Keep communication short, simple, and direct.
Give relevant assessment data that presents a clear picture of the client's current status.
Assessment
Communication through the nursing process steps:
Assessment. Analysis and nursing diagnosis. Planning and outcomes identification. Implementation. Evaluation.
Non-therapeutic communication NEGATIVE responses:
Automatic responses Defensive responses Passive or Aggressive responses Arguing
Which strategies implemented by the nurse would facilitate safe client transfer from the medical-surgical unit to the intensive care unit (ICU)? Select all that apply. A. The transfer should occur during daytime hours only during the weekday. B. The nurse should use a standardized communication tool to provide information to the ICU nurse. C. The nurse should allow time to answer any questions the ICU nurse has before transitioning the client. D. The nurses from both departments should meet face-to-face to discuss the client's transition. E. The nurse should ask the client's family members to relay information to the ICU nurse.
B. The nurse should use a standardized communication tool to provide information to the ICU nurse. C. The nurse should allow time to answer any questions the ICU nurse has before transitioning the client. D. The nurses from both departments should meet face-to-face to discuss the client's transition.
The night shift nurse uses a standardized communication tool to provide hand-off information to Stacy. Identify the correct letter of the ISBAR to match the statements. >The client's pain has been increasing over the past 4 hours. >Continue to monitor the client's pain. You may need to contact the healthcare provider. >The client had surgery two days ago and has a history of diabetes mellitus. >The client's temperature, pulse, and blood pressure are elevated. The blood sugar level is normal. >My name is Anna, RN. I have been caring for the client for the past 12 hours.
I= My name is Anna, RN. I have been caring for the client for the past 12 hours. S= The client's pain has been increasing over the past 4 hours. B= The client had surgery two days ago and has a history of diabetes mellitus. R= Continue to monitor the client's pain. You may need to contact the healthcare provider. A= The client's temperature, pulse, and blood pressure are elevated. The blood sugar level is normal.
A standardized communication tool used in healthcare to enhance quality care and client safety uses the acronym ISBAR. What does ISBAR stand for?
Identify Situation Background Assessment Recommendation
Stacy Calhoun (preferred pronouns she, her) is a registered nurse in a medical-surgical unit. Today, she is assigned to care for an older adult client who had a below-the-knee amputation of the right leg two days ago. The client is planning to discharge today and her daughter is at the bedside. Stacy prepares to receive a report from the night shift nurse. Where is the best location for the hand-off report to occur?
Inside the client's room
How does interprofessional collaboration improve health and wellness?
Leverages knowledge from multiple disciplines to improve the care of an individual
Asking Relevant Questions is...
Nurses need to ask relevant questions to seek information needed for decision making. Only ask one question at a time and explore one concept at a time. Ask questions in a logical manner, moving from general questions to more specific. -Open-ended questions allow the client to lead the conversation. For example, "Can you describe your pain?" -Focused (closed-ended) questions are used when more specific information is needed. For example, "When did your pain start?"
Active listening using SURETY stands for:
S: Sit at an angle facing the client. U: Uncross your arms and legs to suggest that you are "open" to what the client has to say. R: Relaxed. Make your voice and posture communicate to the client that you are relaxed and comfortable. E: Eye contact. Establish and maintain intermittent eye contact with the client to convey your willingness to listen. Absence of eye contact may indicate that you are not interested. T: Touch. Use respectful and appropriate touch to convey empathy and compassion. Y: Your. Trust your intuition! As you grow more confident in your communication abilities, learn to individualize, adapt, and apply communication techniques.
Xavier Jones is talking with a family whose grandfather has just passed away. While answering questions and providing information, Xavier shares a story about his experience of losing his grandmother last year. What communication technique is Xavier using?
Self-disclosure
In applying Therapeutic Communication, as nurses we share.... Name them.
Share observations, Share humor, Share hope, Share empathy, Share/provide information, and Share feelings
How do the phases of the nurse-client relationship compare to the nursing process?
The nurse is performing assessment during the orientation phase.
After providing education about medication compliance, Prisha thanks Mr. Lang and makes an appointment for him to return to the clinic in one month. What has Prisha accomplished?
The therapeutic relationship has terminated and a plan for the future was established.
What is the purpose of active listening? a. To fill the gap in time while a client thinks about their actions b. To allow a family member to jump into the conversation c. To give the nurse time to think of something to say d. To convey trust and respect to the client
To convey trust and respect to the client
In which phase of the therapeutic relationship, does the nurse encourage the client through self-exploration and use therapeutic communication to facilitate successful interactions?
Working phase
Which statement represents the "recommendation" in ISBAR? Good evening, Dr. Jones. [This is Anna Patrick, RN, calling from St. Mary's Hospital medical-surgical unit about your client, Mr. Smith, in room 611.] I'm doing well. Thank you for asking. [Mr. Smith has reported severe pain in his left knee that is not relieved by the oral pain medication ordered.] [He had a knee replacement two days ago and has been working with a physical therapist to use crutches.] [He reports his pain as 9/10 one hour after receiving the ordered pain medication. His temperature is normal, but his blood pressure, pulse rate, and respiratory rate are elevated. There are no signs of infection at his surgical incision.] [Can I get a prescription for another pain medication that may help to better relieve Mr. Smith's pain?]
[Can I get a prescription for another pain medication that may help to better relieve Mr. Smith's pain?]
Which statement represents the "background" in ISBAR? Good evening, Dr. Jones. [This is Anna Patrick, RN, calling from St. Mary's Hospital medical-surgical unit about your client, Mr. Smith, in room 611.] I'm doing well. Thank you for asking. [Mr. Smith has reported severe pain in his left knee that is not relieved by the oral pain medication ordered.] [He had a knee replacement two days ago and has been working with a physical therapist to use crutches.] [He reports his pain as 9/10 one hour after receiving the ordered pain medication. His temperature is normal, but his blood pressure, pulse rate, and respiratory rate are elevated. There are no signs of infection at his surgical incision.] [Can I get a prescription for another pain medication that may help to better relieve Mr. Smith's pain?]
[He had a knee replacement two days ago and has been working with a physical therapist to use crutches.]
Which statement represents "assessment" in ISBAR? Good evening, Dr. Jones. [This is Anna Patrick, RN, calling from St. Mary's Hospital medical-surgical unit about your client, Mr. Smith, in room 611.] I'm doing well. Thank you for asking. [Mr. Smith has reported severe pain in his left knee that is not relieved by the oral pain medication ordered.] [He had a knee replacement two days ago and has been working with a physical therapist to use crutches.] [He reports his pain as 9/10 one hour after receiving the ordered pain medication. His temperature is normal, but his blood pressure, pulse rate, and respiratory rate are elevated. There are no signs of infection at his surgical incision.] [Can I get a prescription for another pain medication that may help to better relieve Mr. Smith's pain?]
[He reports his pain as 9/10 one hour after receiving the ordered pain medication. His temperature is normal, but his blood pressure, pulse rate, and respiratory rate are elevated. There are no signs of infection at his surgical incision.]
Which statement represents the "situation" in ISBAR? Good evening, Dr. Jones. [This is Anna Patrick, RN, calling from St. Mary's Hospital medical-surgical unit about your client, Mr. Smith, in room 611.] I'm doing well. Thank you for asking. [Mr. Smith has reported severe pain in his left knee that is not relieved by the oral pain medication ordered.] [He had a knee replacement two days ago and has been working with a physical therapist to use crutches.] [He reports his pain as 9/10 one hour after receiving the ordered pain medication. His temperature is normal, but his blood pressure, pulse rate, and respiratory rate are elevated. There are no signs of infection at his surgical incision.] [Can I get a prescription for another pain medication that may help to better relieve Mr. Smith's pain?]
[Mr. Smith has reported severe pain in his left knee that is not relieved by the oral pain medication ordered.]
Client: Can you call someone to fix my TV? Nurse: Let's go and see what the cafeteria is serving for lunch. What non-therapeutic communication technique(s) is/are Jeffrey using with this client? -Aggressive response -Giving personal opinions -Sympathy -Changing the subject
-Changing the subject
What are the reasons for effective communication in healthcare?
-Improves client outcomes. -Meets legal, ethical and clinical standards of care. -Increases client satisfaction. -Reduces risk of errors.
Nonverbal Communication
-Personal space and Territoriality. -Posture and Gait. -Eye contact. -Personal appearance. -Facial expression. -Gestures. -Sounds. -Metacommunication.
What are the 4 phases of Therapeutic Relationships?
1. Preinteraction phase 2. Orientation phase 3. Working phase 4. Termination phase
Provide any relevant background information that is needed to make decisions.
Background
"You've already decided to stop smoking, but you are still debating whether you can or not." What is the communication technique demonstrated by the nurse?
Confrontation
In which phase of the therapeutic relationship does building rapport occur?
Orientation
John is talking to Tim and states, "Tim, you should quit your job if you are so unhappy." This is an example of giving _________.
sympathy
Silence is a valuable communication technique. It allows the client to ______, ______, and ________ .
think, gain insight, and share feelings
When communicating with clients, the use of _______ and _______ can be valuable.
touch, silence
Assessment:
• Verbal interviewing and history taking. • Visual and intuitive observation of nonverbal behavior. • Visual, tactile, and auditory data gathering during physical examination. • Written medical records, diagnostic tests, and literature review.
Prisha Patel is a nurse working in a medical clinic. Mr. Lang, age 78, presents to the clinic with his partner for laboratory testing to make sure his medication is working properly. After reviewing the results, Prisha determines that Mr. Lang may be taking his medication inconsistently. Prisha speaks to the healthcare provider and learns that Mr. Lang was recently diagnosed with a heart condition that requires daily medication. The provider explains that Mr. Lang was hesitant to take the drug and did not want to return to the clinic for monthly laboratory testing. Which phase of the therapeutic relationship does this represent?
Preinteraction
The nurse is caring for a client who only speaks and reads Spanish. What action should the nurse take when communicating with this client?
Use an authorized interpreter to provide translation for the education.
Verbal communication
Vocabulary Meaning Pacing Intonation (tone) Clarity and brevity Timing and Relevance
Working phase
When you and a patient work together to solve problems and accomplish outcomes. -Begins as the nurse and client collaborate as partners in promoting the client's health.
Which statement represents "identify" in ISBAR? Good evening, Dr. Jones. [This is Anna Patrick, RN, calling from St. Mary's Hospital medical-surgical unit about your client, Mr. Smith, in room 611.] I'm doing well. Thank you for asking. [Mr. Smith has reported severe pain in his left knee that is not relieved by the oral pain medication ordered.] [He had a knee replacement two days ago and has been working with a physical therapist to use crutches.] [He reports his pain as 9/10 one hour after receiving the ordered pain medication. His temperature is normal, but his blood pressure, pulse rate, and respiratory rate are elevated. There are no signs of infection at his surgical incision.] [Can I get a prescription for another pain medication that may help to better relieve Mr. Smith's pain?]
[This is Anna Patrick, RN, calling from St. Mary's Hospital medical-surgical unit about your client, Mr. Smith, in room 611.]
Motivational interviewing focuses on exploring and resolving _________ related to __________ motivation toward ___________ unhealthy behaviors.
ambivalence, decreased, changing
A nurse is counseling a client about weight loss and suggests eliminating certain foods from the diet. The client refuses this advice stating, "But those are some of my favorite foods. I will not cut out those foods!" The nurse responds with, "You must cut out those foods or your health will continue to decline." This is an example of _________.
arguing
Clara reviews the client's medical record. Clara specifically wants to review the client's ethnicity and family form to determine any cultural needs to be addressed as part of dietary teaching. Additionally, Clara consults with the facility dietician for strategies to encourage family diet change. Which phase of the therapeutic relationship do Clara's actions demonstrate? a. Orientation b. Working c. Termination d. Preinteraction
d. Preinteraction
Rachel enters the room to perform an assessment while waiting for Ms. Simpson's daughter to arrive. The client reports that she is in pain and feeling nauseous. The nurse decides to _______ with the teaching session. Rachel is aware that _________ is important in this situation.
delay, timing
Non-therapeutic communication techniques _(discourage OR encourage)_ conversation and expression of feelings and causes _(positive OR negative)_ responses or behaviors in others.
discourage, negative
What are the characteristics of a therapeutic nurse-client relationship?
goal-oriented, purposeful, positive client change, and boundaries
Special Communication Approaches
hearing impairment, vision impairment, doesn't speak English, cannot speak clearly (aphasia, dysphoria, muteness), cognitive impairment, unresponsive
Upon entering the exam room, Prisha states, "Hello, Mr. Lang. I saw that today is your birthday. Do you have any plans to celebrate?" This statement begins the orientation phase of the therapeutic relationship. This phase should include (formal OR informal) communication that is (friendly OR professional).
informal, friendly
Rachel Montgomery (preferred pronouns she, her), a nurse in an inpatient rehabilitation unit, is caring for Ms. Simpson, aged 69 years, who speaks Polish. Ms. Simpson understands some English but speaks very little. Ms. Simpson is recovering from a broken hip and has been deaf since childhood. Her vision has deteriorated some with age. Today, Rachel is preparing to discharge Ms. Simpson to home, whose daughter will be arriving soon. As Rachel prepares to provide discharge teaching, which level of communication is most appropriate?
interpersonal (one-on-one)
Parroting (an automatic response)
is another type of automatic response that involves repeating the client's exact statements word for word. *Paraphrasing should be used instead of parroting.
What is the goal of Therapeutic Communication?
is to meet the expressed and unexpressed needs of the client in a timely manner and with respect to age, culture, and socioeconomic status. -which involves both verbal and nonverbal communication.
Assertive is
means that you express your feelings and ideas without judging or hurting others. Being assertive does not mean being rude or unkind. An assertive nurse is respectful of others' feelings, ideas, and choices. You might say, "I want...." or "I think..." or "I feel...."
Which communication technique involves repeating the client's exact statements word for word?
parroting
Tom says to Sally, "I'm not angry with you." Then Tom ignores Sally for the rest of the night. This is an example of __________.
passive response
Julian communicates with the charge nurse today. Julian: "Hi! I'm ready to receive the report." Charge Nurse: "It would be nice if you could be on time." Julian: "I'm sorry to keep you here longer. It won't happen again." Charge Nurse: "It better not! I have a family too, you know." Julian: "I'm wrong. You are correct." In this interaction between Julian and the charge nurse, Julian is using (aggressive/assertive/passive) responses. The charge nurse is using (aggressive/assertive/passive) responses.
passive, aggressive
Passive responses are used to:
used to avoid conflict. They reflect depression, sadness, or anxiety.
Social distance (4-12ft) examples:
• Giving directions to visitors in the hallway • Asking whether families need assistance from the patient doorway • Giving verbal report to a group of nurses
Intimate distance (0-18 inches) examples:
• Holding a crying infant • Performing physical assessment • Bathing, grooming, dressing, feeding, and toileting a patient • Changing a patient's surgical dressing
Planning and outcomes identification
• Interpersonal or small-group health care team planning sessions. • Interpersonal collaboration with patient and family to determine expected outcomes and implementation methods. • Written documentation of expected outcomes. • Written or verbal referral to health care team members.
Personal distance (18-40in) examples:
• Sitting at a patient's bedside • Taking a patient's nursing history • Teaching an individual patient
Public distance (12ft and more) examples:
• Speaking at a community forum • Lecturing to a class of students • Testifying at a legislative hearing