Fundamentals Chpt 20
Touch
-Touch is the most highly developed sense at birth. Tactile experiences of infants and young children appear to be essential for the normal development of self and awareness of others. It has also been found that many older people long for touch, especially when isolated from loved ones because of hospitalization or being in a long-term care facility. -dexterity and sureness in the use of the hands help to assure the patient of your expertise when measuring blood pressure or giving an injection.
Patients Who Do Not Speak English
-Use an interpreter whenever possible. -Use a dictionary that translates words from one language to another so that you can speak at least some words in the patient's language. -Speak in simple sentences and in a normal tone of voice. -Demonstrate or pantomime ideas you wish to convey, as appropriate. -Be aware of nonverbal communication. Remember that many nonverbal communication cues are universal.
Open ended question
-When obtaining a nursing history, use the open-ended question technique to allow the patient a wide range of possible responses. - It encourages free verbalization. The greatest advantage of this technique is that it prevents the patient from giving a simple yes or no answer that has the effect of limiting the patient's response
Empathy
-is identifying with the way another person feels. An empathic nurse is sensitive to the patient's feelings and problems, but remains objective enough to help the patient work to attain positive outcomes -"This must be a hard time for you . . . how are you coping?" "Is there any way I can be of help?"
Assertive behavior
-is the ability to stand up for oneself and others using open, honest, and direct communication. -focus is on the issue and not the person. -expressing feelings and beliefs in a nondefensive manner.
message
-is the actual communication product from the source. -It might be a speech, interview, conversation, chart, gesture, memorandum, or nursing note.
The channel of communication
-is the medium the sender has selected to send the message. -might target any of the receiver's senses
Communication
-is the process of exchanging information and generating and transmitting meanings between two or more people. It is the foundation of society and the most primary aspect of a nurse-patient interaction. -assists in meeting our psychosocial needs of love, belonging, and self-esteem. -basic to human functioning and well-being.
Proxemics
-is the study of distance zones between people during communication
receiver (decoder)
-must translate and interpret the message sent and received. -the receiver must then make a decision about an accurate response
Termination
The patient will participate in identifying the goals accomplished or the progress made toward goals. The patient will verbalize feelings about the termination of the relationship.
Clarifying question/comment
The use of the clarifying question or comment allows the nurse to gain an understanding of a patient's comment. Ex:Patient: I have never needed to take medicine before in my life. Nurse: Is this the first health problem you have had? Patient: Yes, I've always been healthy.
Do not use why or how questions
are intimidating to many patients. Consider the following questions: Nurse: Why were you not tired enough to sleep? Nurse: How did you ever decide to go on a crash diet? These two questions would be better stated as follows: Nurse: What were you doing while you were unable to sleep? Nurse: What things prompted you to decide to go on a crash diet?
communicating with older patients,
assess for any problems with hearing or sight (discussed later in this chapter), confusion, or depression, any of which could affect nurse-patient interaction.
Tannen (1990)
believes that this is because girls and boys grow up communicating differently. Whereas girls generally play with "best friends" and use language to seek confirmation, minimize differences, and establish or reinforce intimacy, boys use language to establish their independence and to negotiate status activities in large groups.
Phases of helping relationship
three phases: (1) the orientation phase, (2) the working phase, and (3) the termination phase.
therapeutic touch
to promote comfort, relaxation, healing, and a sense of well-being
Gestures
using various parts of the body can carry numerous messages—for example, thumbs up means victory, kicking an object often expresses anger, wringing the hands or tapping a foot usually indicates anxiety or anger, and a waving hand serves to beckon someone to come on,
Don't use cliches
"Everything will be all right." "Don't worry. You will be just fine in another day or two." "Your doctor knows best." "Cheer up. Tomorrow is another day." "Men tolerate pain poorly. That must be why you are complaining of severe pain." "Everybody is afraid of surgery. Why should you be any different?" "You teenagers are all alike. You aren't cooperative because you deny authority."
A helping relationship exists
- among people who provide and receive assistance in meeting human needs. It sets the climate for the participants to move towards common goals. -nurse is the helper and the patient is the person being helped. - The quality of the relationship between these individuals is the most significant element in determining helping effectiveness. -professional relationships
Patients Who Are Visually Impaired
-Acknowledge your presence in the patient's room. -Identify yourself by name. -Remember that the visually impaired patient will be unable to pick up most nonverbal cues during communication. -----Speak in a normal tone of voice. -Explain the reason for touching the patient before doing so. -Indicate to the patient when the conversation has ended and when you are leaving the room. -Keep a call light or bell within easy reach of the patient. -Orient the patient to the sounds in the environment and to the arrangement of the room and its furnishings. -Be sure the patient's eyeglasses are clean and intact or that contacts are in place.
Channel types
-Auditory—spoken words and cues -Visual—sight, observations, and perception -Kinesthetic—touch
Patients Who Are Unconscious
-Be careful of what is said in the patient's presence. Hearing is believed to be the last sense lost; therefore, the unconscious patient is often likely to hear even though there is no apparent response. -Assume that the patient can hear you. Talk in a normal tone of voice about things you would ordinarily discuss. -Speak with the patient before touching. Remember that touch can be an effective means of communication with the unconscious patient. -Keep environment noises at as low a level as possible. This helps the patient focus on the communication.
The Joint Commission standard regarding preventing disruptive behaviors in health care facilities includes the following key recommendations:
-Education must be provided for all staff regarding respectful, professional behavior. -All staff members must be held accountable for their behavior. -Zero-tolerance policies must be implemented regarding disruptive behaviors and protection must be provided for those who report these behaviors. -Those in leadership positions must attend training regarding professional standards of behavior and function as a positive role model. -Surveillance and reporting systems must be available to identify unprofessional behaviors. -Emphasis must be placed on the importance of documenting bullying behaviors (TJC, 2008)
Patients Who Are Cognitively Impaired
-Establish and maintain eye contact with the patient to hold attention. -Communicate important information in a quiet environment where there is little to distract the patient's attention. -Keep communication simple and concrete. Break down instructions into simple tasks and avoid lengthy explanations. Do not use pronouns or abstract terms. Use pictures or drawings when appropriate. -Whenever possible, avoid open-ended questions. Ask "Would you like to wear the brown pants or the gray pants?" instead of "What would you like to wear?" -Be patient and give the patient time to respond. If the patient does not respond after 2 minutes, repeat what you said. If there is still no response, take a break before continuing the conversation so that neither you nor the patient becomes frustrated.
Types of Proxemics
-Intimate zone: interaction between parents and children or people who desire close personal contact -Personal zone: distance when interacting with close friends -Social zone: space when interacting with acquaintances such as in a work or social setting -Public zone: communication when speaking to an audience or small groups
Observation serves several important purposes:
-It helps increase awareness of a patient's nonverbal messages. -It is the primary source of information when a patient is unwilling or unable to communicate verbally. -It demonstrates caring and interest in the patient. (Patients often recognize when a nurse is unobservant and, rightly or wrongly, usually conclude that the nurse does not care about them.)
dynamics of a helpful relationship
-It is dynamic. Both the person providing the assistance and the person being helped are active participants to the extent each is able. -It is purposeful and time limited. This means there are specific goals that are intended to be met within a certain period. -Although both parties in the helping relationship have responsibilities, the person providing the assistance is professionally accountable for the outcomes of the relationship and the means used to attain them. Helping persons should present their helping abilities as honestly as possible and not promise to provide more assistance than they can offer.
American Nurses Association's Principles for Social Networking
-Nurses must not transmit or place online individually identifiable patient information. -Nurses must observe ethically prescribed professional patient-nurse boundaries. -Nurses should understand that patients, colleagues, institutions, and employers may view postings. -Nurses should take advantage of privacy settings and seek to separate personal and professional information online. -Nurses should bring content that could harm a patient's privacy, rights, or welfare to the attention of appropriate authorities. -Nurses should participate in developing institutional policies governing online conduct.
Patients Who Are Hearing Impaired
-Orient the patient to your presence before initiating conversation. This may be done by gently touching the patient or moving so that you can be seen. -Talk directly to the patient while facing him or her. If the patient is able to lip read, use simple sentences and speak in a quiet, natural manner and pace. Be aware of nonverbal communication. -Do not chew gum or cover your mouth when talking with the patient. -Demonstrate or pantomime ideas you wish to express, as appropriate. -Use sign language or finger spelling, as appropriate. -Write any ideas that you cannot convey to the patient in another manner. -Be sure that hearing aids are clean, functioning, and inserted properly.
Failure of nurses
-Patients should be addressed by a formal name such as Mr., Mrs., Ms., or Dr. rather than slang terminology such as "honey" or "sweetie."
Rapport depends on what variables
-SPECIFIC OBJECTIVES -COMFORTABLE ENVIRONMENT -PRIVACY -CONFIDENTIALITY -PATIENT VERSUS TASK FOCUS -USING NURSING OBSERVATIONS -OPTIMAL PACING
Patients With a Physical Barrier (Laryngectomy or Endotracheal Tube)
-Select one or more simple means of communication that the patient is physically able to use. Options include eye blinks or hand squeezes to communicate yes or no; writing pads or magic slates; communication boards with words, letters, or pictures; flash cards; sign language. -Be sure that everyone communicating with the patient—family, friends, and caregivers—understands and is able to use the communication devices selected. -Demonstrate patience with the time needed to communicate effectively, and reinforce the patient's efforts. -Ensure that the patient has an effective means of signaling need for assistance, such as a call bell or alarm.
Visual Modes of Transmission
-Sight-Receiving a visual stimulus -Observation-Interpreting a visual stimulation by making note of nonverbal enhancement -Perception-Assigning meaning to a visual event
Environment
-The goal is to minimize distractions and ensure privacy. - A patient with newly diagnosed human immunodeficiency virus (HIV) infection will find it difficult to discuss sexual history or genital warts in an area that lacks privacy. -A toddler might find it easier to communicate if a parent, favorite stuffed animal, or blanket is nearby.
Helping relationships differences to social relationship
-The helping relationship does not occur spontaneously, as do most social relationships. It occurs for a specific purpose with a specific person. -The helping relationship is characterized by an unequal sharing of information. The patient shares information related to personal health problems, whereas the nurse shares information in terms of a professional role. In a friendship, information sharing is more likely to be similar in quantity and type. -The helping relationship is built on the patient's needs, not on those of the helping person. In a friendship, needs of both participants are generally considered. A friendship might grow out of a helping relationship, but this is separate from the purposeful, time-limited interaction described as a helping relationship.
Silence
-The patient might be comfortable and content in the nurse-patient relationship. Continuous talking is unnecessary. -The patient might be trying to demonstrate stoicism and the ability to cope without help. -The patient might be exploring inner thoughts or feelings, and conversation would disrupt this. In effect, the patient is really saying, "I need some time to think." -The patient might be fearful and use silence as an escape from a threat. -The patient might be angry and use silence to display this emotion. -The patient's culture may require longer pauses between verbal communication.
Working Phase
-The patient will actively participate in the relationship. -The patient will cooperate in activities that work toward achieving mutually acceptable goals. -The patient will express feelings and concerns to the nurse.
Orientation Phase
-The patient will call the nurse by name. -The patient will accurately describe the roles of the participants in the relationship. -The patient and nurse will establish an agreement about: Goals of the relationship Location, frequency, and length of the contacts Duration of the relationship
nonverbal communication
-The transmission of information without the use of words -body language -helps nurses to understand subtle and hidden meanings in what the patient is saying verbally
territoriality.
-This urge to maintain an exclusive right to certain space -People are most comfortable in areas they consider their own.
Listening Skills
-When possible, sit when communicating with a patient. Do not cross your arms or legs because that body language conveys a message of being closed to the patient's comments. -Be alert and relaxed and take sufficient time so that the patient feels at ease during the conversation. -Keep the conversation as natural as possible, and avoid sounding overly eager. -If culturally appropriate, maintain eye contact with the patient, without staring, in a face-to-face pose. This technique conveys interest in the conversation and willingness to listen. -Indicate that you are paying attention to what the patient is saying by using appropriate facial expressions and body gestures. Be attentive to both your own and the patient's verbal and nonverbal communication. -Think before responding to the patient. Responding impulsively tends to disrupt communication and listening. -Do not pretend to listen. Most patients are sensitive to an attitude of feigned attention or to boredom and apathy. -Listen for themes in the patient's comments. What are the repeated themes in the person's speech and behavior? ------What topics does the patient tend to avoid? What subjects tend to make the patient shift the conversation to other subjects? What inconsistencies and gaps appear in the patient's conversations?
Rapport,
-a feeling of mutual trust experienced by people in a satisfactory relationship, facilitates open communication
When speaking to elders
-avoid "elderspeak" when communicating with older adults. -Elderspeak involves using speaking patterns and words mimicking "baby talk" that imply that the older person is not compete
Using leading questions
-can lead to patient not being honest -Nurse: You aren't going to smoke that cigarette, are you? Nurse: You have been well cared for by your nurses, haven't you?
Characteristics of an assertive nurse
-confident, open body posture; eye contact; use of clear, concise "I" statements; and the ability to share effectively one's thoughts, feelings, and emotions. -attitude toward work is characterized by working to capacity with or without supervision, the ability to remain calm under supervision, the freedom to ask for help when necessary, the ability to give and accept compliments, and honesty in admitting mistakes and taking responsibility for them.
Sympathy
-differs from empathy because it shifts the emphasis from the patient to the nurse as the nurse shares feelings and personal concerns and projects them onto the patient, limiting ability to focus objectively on the patient's needs
Verbal communication
-exchange of information using words, including both the spoken and written word. -depends on language, or a prescribed way of using words so that people can share information effectively. EX:writing for publication, and composing signs and posters
Most common failure of nurses
-failure to establish rapport and a helping-trust relationship with the other person" (Watson, 1985, p. 24). -Communication is the means used to establish rapport and helping-trust relationships.
four levels of communication
-intrapersonal communication, interpersonal communication, small-group communication, and organizational communication.
Group dynamics
-involve how individual group members relate to one another during the process of working toward group goals.
communication process
-involves a source (encoder), message, channel, and receiver (decoder). -initiated based on a stimulus,
Aggressive behavior,
-involves asserting one's rights in a negative manner that violates the rights of others. -Aggression can be verbal or physical. -It is communication that is marked by tension and anger, and inhibits the formation of good relationships and collaboration. -Characteristics of aggressive verbal behavior include using an angry tone of voice, making accusations, and demonstrating belligerence and intolerance -"do it my way" or "that's just enough out of you" -enhnace self-esteem and prove their superiority through destructive
Reflective Question or Comment
-involves repeating what the person has said or describing the person's feelings. It encourages patients to elaborate on their thoughts and feelings. Ex: Patient: I've been really upset about my blood pressure and have to take these pills. Nurse: You've been upset . . . Patient: I guess I'm worried about what could happen if my blood pressure gets too bad.
Touch
-is a personal behavior and means different things to different people. - Factors such as age and sex also play a key role - most effective nonverbal ways to express feelings of comfort, love, affection, security, anger, frustration, aggression, excitement, and many others
Directing Question or Comment
-obtain more info about a topic brought up earlier in the interview or to introduce a new aspect of the current topic. In this way, the nurse can gain additional valuable information to consider in assessing the patient's health status and educational or counseling needs. Ex:Nurse: You mentioned your dad earlier. Did he develop complications related to high blood pressure? Patient: Yes. Nurse: What sort of complications? Patient: Kidney failure. He was on dialysis for years before getting a transplant. Nurse: Are you afraid this might happen to you?
E-mail and text messages
-should be concise and avoid text abbreviations -The patient may have to sign an authorization permitting e-mail communication from the health care agency. Any e-mails sent to a patient must be duplicated and become part of the medical record for that patient.
Eye contact
-some Asian and Native American cultures view eye contact as an invasion of a person's privacy. -In other cultures, people are taught to avoid eye contact or, out of respect, not to make eye contact with a superior. -eyes fix in a stare during anger, tend to narrow in disgust, and ordinarily open wide in fear. Some people who experience fear might be unable to speak and only their eyes will send the message of anxiety. A blank stare can indicate daydreaming or inattentiveness.
Sequencing Question or Comment
-used to place events in a chronologic order or to investigate a possible cause-and-effect relationship between events. -Nursing assessment is facilitated when events leading to a problem are placed in sequence -Ex:Patient: I don't feel like myself anymore since I've been taking my blood pressure medicine. I'm tired and don't have any energy. Nurse: Your tiredness began after you started taking your medicine?
Private zones
Although most people consider their hands, arms, shoulders, and back within a social zone, increasing levels of privacy are according to (1) mouth and feet; (2) face, neck, and front of body; and (3) genitalia.
I-SBAR-R
BAR form to include an initial identification of yourself and the patient (I) and the opportunity to ask and respond to questions or readback (R) at the close of the communication (QSEN Institute, 2008). This reformulated I-SBAR-R allows a nurse to clearly introduce oneself and the patient when communicating with a caregiver during patient hand-offs or conversations with physicians. Many health care institutions are using this revised I-SBAR-R format.
How to speak to clients
Control the tone of your voice so that you are conveying exactly what you mean to say and not a hidden message. Your tone should indicate interest rather than boredom, patience rather than anger, acceptance rather than hostility, and so forth. Be knowledgeable about the topic of conversation and have accurate information. When possible, be familiar with the subject of conversation before discussing it with the patient. If the topic is unfamiliar to you (e.g., the availability of community resources for family caregivers of patients with special needs), admit that to the patient and family and direct them to other resources. Convey confidence and honesty to the patient. Be flexible. You might want to discuss a certain subject but learn that the patient wishes to discuss something else. It is better to follow the patient's lead whenever possible; in due time, you can return to the subject. For example, you arrive at the patient's bedside to administer a medication, but the patient begins to talk about diet issues. It is better to take a little time to talk about the patient's interest than to insist on talking about only the procedure at hand, as long as there is enough time for the conversation. Be clear and concise, and make statements as simple as possible. Patients are often anxious and fail to understand the message unless the patient understands the language used. Stay on one subject at a time. This helps prevent confusion. Avoid words that might have different interpretations. The study of the meaning of words is called semantics. Even when two people speak the same language, some words—such as love, hate, freedom, and health—might have different meanings to different people. Be truthful. A patient who is given false information will soon distrust the nurse. If you're not sure about something, admit you don't know and seek an answer rather than make a comment that may be an error. Keep an open mind. An attitude of "I know better than the patient" is quickly discerned by the patient. Patients can make valuable contributions to their own health care. Take advantage of available opportunities. During most caregiving situations, you can facilitate conversation that makes even the most routine task meaningful. For instance, when giving a bed bath to a patient, ask about the patient's employment. This would allow the patient to verbalize any positive or negative feelings about the job and being temporarily absent from it, reducing the anxiety that often occurs with the loss of work. It is often comforting to know that someone understands and cares.
Nurses and patients private space
Develop the habit of seeking the patient's permission before touching areas within a patient's private zones.
Proximity of different cultures
European Americans and African Americans require more personal space between two people who are speaking than other cultures (Mediterranean, Hispanic, Asian, Middle Eastern, East Indian) who are comfortable at a closer distance when speaking
SABR
Healthcare Improvement (IHI) have recommended using SBAR reports to improve hand-off communication(transfers). SBAR, which stands for Situation, Background, Assessment, and Recommendations, provides a consistent method for hand-off communication that is clear, structured, and easy to use
Auditory Modes of Transmission
Hearing-Receiving an auditory stimuli Listening-Gaining awareness of underlying messages and feelings accompanying auditory events
Kinesthetic Modes of Transsmission
Procedural touch-Performing nursing procedures and techniques Caring touch-Conveying emotional support
What to say to patients
I would like to help. Tell me, what is making you cry? Patient: I think I have a right to be afraid of this operation. Nurse: Tell me what makes you feel afraid.
Gender difference
Men and women have differing communication styles and might give different interpretations to the same conversation.
Nurses and Teaching
Nurses who believe that teaching is an important aspect of nursing and who value empowering patients will communicate this to patients.
Humor
Nurses with a sense of humor are able to laugh at themselves and accept their failures, confront the absurdities of everyday practice without falling apart, and challenge patients to situate their current dilemma within the context of their larger life experiences. Laughter releases excess physical and psychological energy and reduces stress, anxiety, worry, and frustration.
Validating question/comment
This type of question or comment serves to validate what the nurse believes he or she has heard or observed. Ex: Nurse: At home, you have been taking both a water pill and a blood pressure pill every day. Did you take them today? Patient: Yes, I took one of each with my breakfast. Clarifying Question or Comment
Helping relationships similarities to social relationship
care, concern, trust, and growth
. Human communication is
essential for learning, working, and social interaction.
Noise
factors that distort the quality of a message—can interfere with communication at any point in the process.
Patient vs task force
focus on patient and the patient needs: Ex: Patient: I don't know why these injections scare me, but they do. Nurse: You are afraid of these injections? In contrast, consider this example, in which the nurse's comment focuses instead on the nursing activity: Patient: I don't know why these injections scare me, but they do. Nurse: I give hundreds of injections. Don't be so immature.
Small-group communication
interact with two or more people. To be functional, members of the small group must communicate to achieve their goal. Examples of small-group communication include staff meetings, patient care conferences, teaching sessions, and support groups
A dispositional trait
is a characteristic or customary way of behaving. Nurses who consistently demonstrate warmth and friendliness; openness and rapport; empathy, honesty, authenticity and trust; caring; and competence are well disposed to communicate effectively.
sender or source (encoder)
is a person or group who initiates or begins the communication process
Factors influencing communication include
level of development; gender; sociocultural differences; roles and responsibilities; space and territoriality; physical, mental, and emotional state; and environment.
Interpersonal communication
occurs between two or more people with a goal to exchange messages
Organizational communication
occurs when people and groups within an organization communicate to achieve established goals. Nurses on a practice council meeting to review unit policies
Intrapersonal communicationx
or self-talk, is communication within a person
A nurse who suspects a speech, language, or hearing problem should
refer the patient to a speech-language pathologist or audiologist.
Culture
refers to the common lifestyles, languages, behavior patterns, traditions, and beliefs that are learned and passed from one generation to the next.
Nurses must adhere to Health Insurance Portability and Accountability Act (HIPAA)
regulations that protect patient confidentiality and privacy and be aware of their employer's policies about using social media.
The first step toward cultural competence
requires becoming aware of your own personal cultural beliefs and identifying "prejudices or attitudes that could be a barrier to good communication" -women in some cultures might speak of personal things only to their spouses. For this reason, a maternal care nurse might talk with the patient's husband about the woman's postdelivery care.
Incivility
rude, intimidating, and undesirable behavior directed at another person. -recognized as a major concern among health care workers -precursor to bullying behavior or lateral violence and by others as a form of bullying
Townsend (2009)
states that gender roles are changing in American society because sexual roles are becoming less distinct.
feedback (i.e., evidence)
that the receiver has understood the intended message.
