Ch.24- Communication

Communicaton

A lifelong learning process. It is essential when establishing nurse- patient relationships and delivering patient-centered care. Nurse communicates with patients and families- develops relationships. In those relationships, collects relevant data, provides education and counseling, and interacts during therapeutic interventions. The intimate connection makes the difference in the QOC. Patient safety also requires communication among members of the HC team as patients move caregivers and settings. Good communication helps reduce risk of errors, promotes improved patient outcomes, and increased patient satisfaction. Effective team communication and collaborations is essential to ensure patient safety and optimum care. Competent communication maintains effective relationships within sphere of professional practice and meets legal, ethical, and clinical standards of care.

Non-therapeutic communication techniques

AKA "blocking" These hinder or damage professional relationships and often cause others to be defensive. Discourage further expression of feelings or ideas and engender neg responses. Asking personal questions "Why didn't you and John get married" Asking personal questions that are not relevant to satisfy curiosity is inappropriate professional comm. NOsy, invasive, and unnecessry To lean more about a patents interpersonal roles and relationships instead ask: "How would you describe your relationship with John" Giving personal opinions "If I were you, I'd do it this way" When a nurse gives a personal opinion, it takes away decision making. It inhibits spontaneity, stalls problem solving, and creates doubt. Opinions are different than prof advice or suggestions. At times ppl need suggestions to help them make choices. Suggestions present options- the person makes the final decision. Better response "Lets talk about what options are best" Nurse should also not make promises that require collaboration ex"I can't recommend quitting meds, but I can inform your primary doc and ask for a change" Changing the subject "Lets not talk about that; its time for your walk" Changing the subject when a pat is communicating is rude and shows lack of empathy. Blocks further communication; sender will withhold imp info and fail to openly express feelings. Better: "After your walk, lets talk about that" Automatic Responses "Older adults are always confused" Making stereotyped comments about others reflects poor judgement and threatens Nurse-team relationship. A cliche is a sterotyed comment "You can't win them all" and belittles/minimizes the person's comment. Parroting- easily overused and is not as effective as paraphrasing Being too task oriented makes the task the focus of interaction and you miss opturnities to communicate and meet needs.- Often perceived as cold and uncaring, unapproachable. In time, you learn to integrate communication with tasks to accomplish several goals simultaneously. False Reassurance When a pt is seriously ill, you may be tempted to offer hope with statements like "everything will be ok". When a pt is reaching for understanding, false reassurance discourages communicaton Although you are trying to be kind, it has the secondary effect of helping you avoid the other person's distress and blocks conversation. Better: "It must be difficult not to know what the surgeon willl find" Sympathy "Im so sorry, you probably feel devastated" Sympathy is concern, sorrow, pity felt for another person. A nurse often takes on problems as their own.I It is subjective and can prevent a clear perspective. If a nurse overidenties with pt., objectivity is lost, and nurse is unable to help the patient. Although sympathy is a compassionate response, it is not as therapeutic as empathy A nurse's own emotions can prevent effective problem solving and impair good judgement. More empathetic: "This loss is a major change. Do you feel comfortable talking about it" Asking for explanations "Why are you so anxious" Some nurses are tempted to ask why pts feel, act, or believe in a certain way. Patients often interpret "why" as an accusation or simply a test. These cause resentment, insecurity, and mistrust. It is best to phrase a question and avoid "why" "You seem upset. What's on your mind" is more likely to help Approval or Disapproval "you shouldn't even think about that; its not right" Do not impose your beliefs, morals, values, attitudes on others while in professional helping role. Judgemental responses often contain "should, ought, good, bad, wrong, right" Agreeing or disagreeing send a message that you have the right to make value judgements about pat decisions. Often a pt shares a decision, to discuss feelings. Disapproval implies the pat needs to meet your expectations. Instead, help them explore their own beliefs :"I'm surprised you are considering that; tell me more about it" Defensive Responses "No one here would do that" Becoming defensive in the face of criticism imply that the other person has no right to an opinion. Sender's concerns are ignored while the nurse focuses on defending herself, HC team, or others. When pat expresses criticism, listen; does not imply agreement. Listen nonjudgementally do discover reason for anger or dissatisfaction. By avoiding defensiveness, you are able to defuse and uncover deeper concerns. Better: You believe people are dishonest. It must be hard to trust" Passive or Agressive Responses "things are bad and there's nothing I can do about it" "Things are bad and its all your fault" Passive responses avoid conflict. They reflect feelings of sadness, depression, anxiety, powerlessness, and hopelessness. Agressive responses provoke confrontation at other person's expense. Reglect anger, frustration, resentment, and stress. Nurses who lack assertive skills will often use triangulation- complaining to a third party This lowers team morale and draws others into conflict. Assertive comm is far more professional. Arguing " how can you say you didn't sleep when I heard you snoring" Challenges or arguing against perceptions denies that they are real and valid. A skilfull nurse provides reality in a way that avoids argument Ex: "You feel as though you didn't sleep, even though I thought you sleep well because I heard you snore"

Assessment

Assess each patient and critically analyze findings to make patient centered decisions. ASSESSMENT: Through the Patient's Eyes: Requires careful assessment of patient's: values preferences cutlural, ethnic, and social backgrounds Nurse also explores personal biases that would interfere with ability to form a therapeutic relationship. Internal and External Factors ALSO affect patient's ability to communicate: Box 24-6 -(Below) Physical and Emotional Factors: Esp important to assess psychophysiological factors that influence communication: Altered health states limit communication (hearing/visual imp, facial trauma, extremely breathless, mental illness, high anxiety) Patient's medical record contains relevant info about their ability to communicate: physical barriers to speech, neurological deficits, and pathophysiology affecting hearing or vision. Medication history- certain drugs affect slurred speech. Nursing progress notes can reveal other info, such as absence of family to provide more info on confused pat. Assessment includes communicating directly with patients to determine their ability to attend to, respond, and interpret stimuli. Important to assess the effect of the problem and possibly involve family and find alternate comm methods. Developmental Factors: Aspects of development affect nurse-pat interactions. (infants limited to crying, body movement, facial expressions) Adapt comm techniques to each unique need. (Give toys to children to speak with parents; Children esp responsive to loud noise, sudden mvmts and prefer to make first move in interactions) (Child with little environmental interaction will be behind in language devt) Age alone does not determine adult's capacity for communication. Hearing loss/Visual imp contribute to communication barriers. Comm with older adults on an adult level- do not patronize or condescend. -(Box 24-7- below) Sociocultural Factors: Culture influences thinking, feeling, behaving, and communicating. Be aware of patterns in various ethnic groups. Know patient individually- (feel comfortable with eye contact or sharing info with family) Non or little English spoken- difficulty with expressing themselves or understanding. People of diff backgrounds use different degrees of eye contact, personal space, gestures, loud voice, pace, touch, etc. - Don't interpret messages through your own cultural perspective. Avoid stereotyping or making fun of other cultures. Language and cultural barriers can be dangerous due to delay in care (Box 24-8- below) Gender: Influences how we think, act, feel, communicate Men tend to be less verbal but more likely to initiate communication and address issues directly. Women tend to disclose person info and use more active listening, answering with responses that encourage other person to keep convo going Recognize a patient's gender communicaiton pattern. Assess communication patterns of each individual and do not make assumptions simply on basis of gender, race, sexuality, or cultural differences.

Elements of the Communication Process

Communication Process is ongoing and continuously changing: you change, other people change, environment changes. Circular transactional communication process model- Includes several elements: referent sender and receiver message channels context or environment feedback interpersonal variables In this model- each person is both a speaker and a listener and can be simultaneously sending and receiving messages. Both parties view the perceptions, attitudes,, and potential reactions to a sent message. Comm becomes a continuous and interactive activity. Feedback form receiver or environment enables communicators to correct or validate communication. This model describes the role relations of communicator as complementary and symmetrical. Occurs when nurse provides education Complementary- one person holding elevated position. Group of patients discussing plans after discharge Symmetrical- more equal

Nurse-Health Care Team Relationships

Communication with other members of the health care team affects patient safety and the work environment. Patient outcomes are optimized when HC team members communicate well. Acronym SACCIA is one way to assist nurses in communicating effectively. S-Sufficiency A- Accuracy C- Clarity C- Contextualization I- Interpersonal A- Adaptation When patients move providers or units, there is risk for miscommunication. To address this risk, HC providers provide detailed hand-off reports to ensure smooth transition and to reduce risk or errors. Use of a common language, such as SBAR improves communication of critical information between HC providers. S- Situation B- Background A- Assessment R- Recommendation Sometimes- I- Identify - when HC providers do not know one another; they start with an introduction, description of location, and role for caring for patient. Techniques like this help to relay relevant info in a structured and timely manner. Failure to completely and accurately communicate during nurse-to-nurse handovers is a course of miscommunication and can lead to errors. Bedside nurse-to-nurse shift reporting is a tool that may enhance patient-centered care, patient and nurse satisfaction, and patient understanding.

Box 24-6

Factors influencing Communication: Psychophysiological Context (Internal Factors :) Physiological Status (pain, hunger, nausea, dyspnea) Emotional Status (anxiety, anger, hopeless, euphoria) Growth and Development (age, developmental task) Unmet needs (safety/security, love/belonging) Attitudes, values, and beliefs (meaning of illness experience) Perceptions and Personality (optimist/pessimist, introvert/extrovert) Self-concept. and self-esteem (positive or negative) Relational Context (Nature of Relationship Among Participants: Social, helping, or working rel Level of trust among participants Level of caring expressed Level of self-disclosure among participants. Shared history of participants Balance of power and control Situational Context (Reason for Communication): Information Exchange Goal Achievement Problem Resolution Expression of Feelings Environmental Context (Surrounding where comm occurs): Privacy level Noise level Comfort/Safety Level Distraction Level Cultural Context (Socioculturla Elements affecting interaction:) Education Level of participants Language and self - expression patterns Customs and expectations

Developing Communication Skills

Gaining expertise in a communication requires both an understanding of the communication process and reflection about one's communication experiences as a nurse Nurses who develop CT skills make the best communicators: They form therapeutic relationships, gather relevant and coprhensive info, draw on theoretical knowledge about comm and integrate it with previous clinical experience. They interpret messages from others to obtain new info, correct misinformation, promote pat understanding, and plan pt-centered care. CT attitudes and ethical standards promote effective communication. When you consider a patient's problem, it is important to apply CT and critical reasoning to improve comm in assessment and care of patients. CT helps nurses overcome perceptual biases or stereotypes that interfere with perceiving and interpreting messages from others. People often incorrectly assume they understand pa person's culture- tend to ignore or distort info that goes against expectations and preconceptions. By thinking critically, you learn to control these tendencies and become more effective in personal relationships. You become more competent in the nursing process as comm skills develop. Each step of the nursing process depends on effective communication. Integrate comm skills in nursing process: Assessment: verbal interviewing observation of nonverbal behavior visual, tactile, auditory data gathering during physical exam written medical records, diagnostic test, literature rev Diagnosis: Interpersonal analysis of assessment findings Validation of HC needs and priorities via verbal discussion with pt. Documentation of diagnosis Planning Interpersonal HC team planning Iterpesonal collaboration with pat and family to determine implementation methods written documentation of expected outcomes written / verbal referral to HC team members Implementation Delegation / Verbal discussion with HC team verbal, visual, auditory, tactile health teaching provision of support via therapeutic comm techniques contact with other health resources written documentation of progress in recod Evaluation Acquisition of verbal / nonverbal feedback Comparison of expected and actual outcomes Identification of factors affecting outcomes Modification of care plan Verbal/ written explanations of revisions Nature of comm process requires you to constantly decide what, when, where, why and how to convey a message. Decision is contextual (specific to situation) . - ex: diet panning vs death planning Challenging communication situations: People who are: silent/ withdrawn/ difficulty expressing needs sad or depressed Require assistance with visual or speech disabilities angry or confrontaional and unwilling to listen Uncooperative and resent being asked to help others Talkative and lonely, need someone constantly Demanding Frightened, anxious, difficult coping Confused and disoriented Speak little to no English Flirtations / Sexually inappropriate

Nurse-community relationships

Many nurses form relationships with community groups by participating in local organizations, volunteering for community service, or becoming politically active. Establish relationships in community to become a change agent. Providing clear and accurate info to public is best way to prevent errors, reduce resistance, and promote change. Communicaiton within comm occurs through channels such as newsletter, health fairs, public bulletin boards, radio, tv.

Nurse-family relationships

Nursing situations , esp those in community and home care, require you to form caring relationships with entire families. Same principles as the nurse-client relationship Requires understanding family dynamics, needs, and relationships.

Implementation for Communication- Therapeutic Techniques:

Therapeutic Communication Techniques Specific responses that encourage the expression of feelings and ideas and convey acceptance and respect. Active Listening- Being attentive both verbally and nonverbally Enhances trust by communicating acceptance and respect. A model of Active Listening: Surety Model S- Sit at an angle facing the patient. (non confrontational - you are there to listen) U- Uncross legs and arms. (crossed arms can convey defensive attitude) R- Relax (communicates comfort and interest) E- Eye Contact (conveys involvement and willingness to listen) T- Touch (Acceptable touch communicates empathy) Y- Your intuition (trust your intuition as you grow and individualize techniques) Sharing Observations Make observations by commenting on how the patient look, sound, or acts to help them communicate without the need for extensive questioning, focusing, or clarification. Do not use statements that will embarrass: "You look like a mess" Do not make assumptions: fatigue is because they are depressed It is a gentle technique: "You seem different today" Sharing Empathy The ability to understand and accept another person's reality, accurately perceive feelings, and communicate this understanding to them. Key to showing concern and support.E Emphathetic statement show that you heard both factual and emotional content and are nonjudgmental and establish trust. Ex: "it must be frustrating to now be able to do what you want" Sharing Hope Nurses recognize that hope is essential for healing and comm "Sense of possibility" to others. Appropriate encouragement and positive feedback foster hope and self confidence. Reassure patients that meaning and growth can come from illness experience. Ex. "I believe you'll find a way to face this because I've seen your courage and creativity" Sharing Humor Important and underused resource- a coping strategy that can reduce anxiety and promote positive feelings. A perception and attitude that a person can experience joy even in difficult situations. Provides emotional support to patients and colleagues and humanizes the illness experience. Enhances teamwork and releases tension. Use with caution when caring for others from a different cultural background- can be misinterpreted. NEVER appt to joke about sexual orientation, race, economic status, liability, or any cultural attribute. Using dark humor after traumatic situations can be hurtful to other patients and loved ones. Sharing Feelings Emotions are subjective from one's perspective; they are not right or wrong but can be pleasant or unpleasant. Not expressing feelings can worsen illness- help pts express emotion by making observations, acknowledging feelings, encouraging communicaiton, allowing for sharing of "neg" feelings. Sharing your emotions with patients is appt if you are in control and do not burden the pt or break confidentiality. It is inappt to express anger or sadness with patient. Using Touch One of most potent and personal forms of communication. Expresses concern or caring and established connection and promotes healing. Comforting touch, such as hand holding, is esp imp for vulnerable pts experiencing severe illness with physical and emotional losses. Be aware of patient's nonverbal cues and ask permission before touching to ensure it is acceptable. If pat is uncomfortable with touch, let other nurses caring for the know- a nod, eye contact, body position can also convey interest and acceptance. Using Silence Allow silence for the patient to sort out feelings and think. Let them break silence if they initiated it. Esp useful when confronted with decisions that require thought. Also allows time for nurse to pay attention to nonverbal messages (worried expressions and loss of eye contact) Demonstrates patience. Esp therapeutic during sadness and grief. Providing Information Providing relevant information tells others what they need and what to know so they are able to make informed decisions, experience less anxiety, and feel safe and secure. Usually not helpful to hide info, but if you have to- clarify why. Patients have a right to know about their health status and what is happening in their envt. Information that is distressing should be communicated with sensitively and at a pace appt for patient's ability to absorb it, and in simple terms. Clarifying To check your understanding of a message, restate what you understand to patient. Ask for further explanation if you do not understand. Without clarification, invalid assumptions can be made. Focusing Involves centering a conversation on key elements or concepts of a message. If patients are vague, rambling, or repeat themselves, focusing is a good technique. Do not interrupt when pt is discussing imp issues; use it as a guide to direct the conversation to important areas. Ex; "We've talked a lot about your meds, now let's look more closely at the trouble you are having taking them on time." Paraphrasing Restating another's message briefly using your own words. Sends feedback to pt that they are actively involved in search for understanding. Do not change the message. Validation Used to recognize and acknowledge a pt's feelings, thoughts, needs. They will know they are being heard and taken seriously when caregiver addresses their issues. Ex: Tell me if I understand your concerns: you worry that you won't be able to..." Asking Relevant Questions Ask relevant questions to seek information for decision making. Ask one at a time. During assessment, usually proceed from general to more specific. Open ended questions all ow patients to take conversational lead and introduce pertinent info. Focused questions are used when more specific info is needed. Close ended is a yes or no answer. Too many questions can be dehumanizing- try using general leads "Tell me about..." Combining general leads, making observations, paraphrasing, focusing, and providing relevant info can help you discover imp info that would have remain hidden with questioning alone. Summarizing A concise review of the key aspects of the interaction; Brings a sense of satisfaction and closure to an individual conversation and is esp useful in termination phase of nurse-pat relationship. Beginning a new conversation with summarizing a previous convo, helps pts recall topics discussed and shows that you analyze the communication. Summarizing also clarifies expectations: "We've discussed this problem... We've come up with some ways to make things better.... You've agreed to try...." Self-Disclosure Subjectively true personal experiences about self that are intentionally revealed to another person. NOt therapy for nurse- used to show that they understand his experiences. Offered as an expression of sincerity and honesty. An aspect of emp athy Needs to be relevant and appropriate and benefits patient. Confrontation When confronting in a therapeutic way, help the other person become more aware of inconsistencies in his or her feelings, attitudes, beliefs, and behaviors. Improves pat self awareness and recognize growth and deal with issues. ONLY use after you have established trust. Use it gently and sesitively EX: You say you've already decided what to do; yet your still talking about your options."

Metacommunication

broad term that refers to all factors that influence communication. Awareness of influencing factors helps people better understand what is communicated. For ex: young pat holding body rigidly but saying surgery is no big deal with sharp voice. Nurse realizes the tone and nonverbal behavior don't match- further exploration needed.

Nursing Process- (Communication)

(Nursing process provides a clinical decision-making approach for you to develop and implement an individualized plan of care.) It guides care for patients who need special assistance with communication. Use therapeutic techniques as an intervention in an interpersonal nursing situation.

Adapting Communication Techniques for Patients With Special Needs

As population ages, more pats have communication difficulty. Hearing loss increases with age. Vision loss affects communication and presents a challenge, esp over age 65.- Among top 10 disabilities. VL impacts daily living and leads to depression and isolation. Interacting with ppl who have conditions that impart comm requires special thought. Must adapt to specific circumstances of pt, developmental level, or cognitive and sensory deficits. ex: Caring for a pt with "Impaired Verbal Comm related to cognitive impairment" can use several techniques such as pictures or demonstration to enable pat to understand caregiver. Nurse directs actions toward meeting goals and outcomes identified in plan, addressing both the comm impairment and its contributing factors. Box 24.9- Methods to encourage, enhance, restorative, or substitute for verbal comm. Be sure pat is physical able and it does not cause frustration to use method: Communicating with patients with special needs Pat who cannot speak clearly (Aphasia, Dysarthria, Mute) Listen, be patient, do not interrupt Ask yes or no quesitons Allow time to respond Use visual cues (words, pictures, objeects) Only one person speak at a time Encourage patients to converse Let pt know if you have not understood Collaborate with speech therapist Use communicaiton aids- letter boards, flashcards, computer-generated speech program Patients with Cognitive Impairment Use simple sentences and avoid long explanations Ask one question at a time Allow time to respond Be attentive listener Include family in conversations, esp in familiar subjects Use pics or gestures that mimic actions Patients with Hearing Impairment Check for healing aid and glasses Reduce envt noises Get patients attention before speaking Face pat with mouth visible Do not chew gum Speak at normal volume Rephrase rather than repeat if misunderstood Provide sign language interpreter if necessary Patients who are visually impaired Chek for glasses or contacts Identify yourself when you walk in room, notify when leaving Speak in normal tone of voice Do not rely on gestures or nonverbal comm Use indirect lighting, avoiding glare. Use at least 14 point print Patients who are Unresponsive Call patient by name Comm both verbally and touch Speak as though they can hear Explain all procedures and sensatiosn Provide orientation to person, place, or time Avoid talking about pt with others in his or her presence Patients who do not speak english Use normal tone of voice Establish method for pt to ask for assistance (call light) Provide professional interpreter as needed Avoid using family members, esp children as interpreters Use comm board, pictures, or cards Translate words fro native language into English for pat to make basic requests. Hve dictionary (Spanish/Engish) available if pt can read Because nursing care of older adult is delivered through inteprofessional model, the primary goal is to establish a reliable comm system that all HC team can understand. Encourage them to share life stories- therapeutic Avoid sudden shifts in convo Helpful to include pat's family and friends and to become familiar with pts fav topics

Box 24.8

Cultural Aspects of Care Cultural Diversity Communication Differences in language impede understanding and negatively impact quality and safety of care Variablility in word usage, vocabulary, and literacy may skew understanding. Differences in nonverbal comm can create misunderstanding or discomfort (personal space) Among different cultures, decision making authority for patient care vary Variability in religious beliefs affect how individuals perceive HC experience. Implications: Understand your own cultural values and biases Assess patient's primary language and level of English Speak directly to patient, even with interpreter Nodding or "OK" do not necessarily mean the same to patient Provide written info in English and primary language Learn about other cultures, esp those commonly encountered. Incorporate pat's comm methods into plan of care Communication with Non-English Speakers: Federal and State laws require hospitals receiving federal funding (Medicare, Chip, etc) are required to provide language access svcs. Hospitals unable to provide on site svcs, must provide telephone interpretation. Use of family, friends, hospital staff is discouraged.(legal liabilities) In emergency, use family/friends cautiously

Elements of Professional Communication

Courtesy- Say hello and goodbye to patients, knock on doors, state purpose, address people by name, say please and thank you, introduce yourself Use of Names- Always introduce yourself and give your status (RN) Make eye contact and smile. Addressing people by name conveys respect for human dignity. Nurses usually use person's last name in initial interaction. Children- first name Avoid terms of endearment such as "sweetheart" Respect and honor how people want to be addressed. Avoid referring to patients as room number or diagnosis. Trustworthiness- helping others without hesitation. To foster trust, communicate warmth, consistency, honesty, competency, and respect. Without trust, nurse-pat relationship rarely progresses beyond superficial care. Withholding key info, lying, or distorting truth violates ethical standards of practice. Sharing personal info/gossiping sends message you cannot be trusted. Autonomy and Responsibility being self-directed in accomplishing goals and advocating for others. Professional nurses make choices and accept responsibility for outcomes and their actions. Take initiative in problem solving and communicate in a way sth reflect the importance and purpose of therapeutic conversation . Recognize patient's autonomy Assertiveness express feeling and ideas without judging or harming others. Behavior includes: intermittent eye contact nonverbal communicaiton that reflects interest, honesty and active listening. spontaneous verbal responses with confident voice culturally sensitive use of touch and space. Assertive behaviors increase self esteem, increase ability to develop satisfying interpersonal relationships, and increase goal attainment. Assertive individuals make decisions and control own lives effectively. They deal with criticism and manipulation of others and learn to say no, set limits, and resist intentionally imposed guilt. Assertive responses: I want , I need, I think, I feel. Nurses may exprience ethical situations that make it difficult to use assertive skills for fear of retaliation(identifying error of another co worker- ethical dilemma) AIDET- is a technique developed by Studer Group to enable HC workers to provide accurate and timely communication to patients while focusing on excellent patient service. Commonly used in hospitals. A- Acknowledge I- Introduce D-Duration E-Explain T- Thank you When using AIDET- Acknowlege person in front of you with a positive attitude and make person feel comfortable. Introduce yourself and role in dept and their care. If possible, how long procedure will take, and results. Describe what patient will experience with procedure or test.Inform of any safety precautions. Thank patient for coming to organization and how much you enjoyed working with them.

Forms of Communication

Messages are conveyed verbally and nonverbally, concretely and symbolically. People express themselves through words, movements, voice inflections, facial expressions, use of space. These elements can work in harmony to enhance a message or conflict and confuse message.

circular transactional model

Referent- motivates one person to comm with the other. In HC setting- sights, sounds, sensations, perceptions, ideas - initiate comm process. Knowing a stimulus or referent allows you to develop and organize messages more efficiently. Ex. request for help prompted by diff breathing vs resulting from hunger. Sender and Reciever- Sender- person who encodes and delivers a message Receiver- receives and decodes message Sender puts the message into verbal and nonverbal symbols that receiver can understand. Sender's message acts as a referent to receiver. Transactional communication involves role of sender and receiver switching back and forth between nurse and patient. Decoding involves reciever interpreting meaning of word symbols. Active listening is required to decode. More the two have in common, closer the relationship, more likely to accurately perceive meaning and respond accordingly. Establish rapport with pat ensures more effective communication. Message- content of communication- verbal and nonverbal expressions of thoughts and feelings. Effective messages are clear, direct, and understandable. Individuals with barriers may need assistance vial clarification devices- hearing aids, interpreters, pictures. Personal perceptions may distort receiver's interpretation of message. Speak clearly, directly, in a manner familiar to pat; Determine need for clarification by assessing cues that suggest confusion or misunderstanding. Consider the difference in education and speak in plain language about medical issues Channels- Individuals are channels to send and receive messages through visual, auditory, and tactile senses. Facial expressions- visual message Spoken word- auditory Touch- tactile Individuals usually understand the message more clearly when sender uses more channels to send it. Feedback- message sender receives from receiver. Indicates if they understood meaning. Occurs continuously between receiver and sender. Sender seeks verbal and nonverbal feedback to evaluate receivers response and effectiveness of communicated message. Type of feedback a sender or reciever gives depends on factors such as: background experience attitudes cultural beliefs self-esteem Both need to be sensitive and open to each other's messages, to clarify messages, and to modify behavior accordingly for successful communication. Interpersonal Variables Factors within both sender and receiver that influence comm. Perception provides unique personal view of reality formed by culture, expectations, and experiences. Each person sense, interprets, an understands differently. Ex: "Is something wrong?" can be interpereted as caring or invading privacy. Cultural Interpersonal variables: education and developmental level sociocultural backgrounds values and beliefs emotions gender physical health roles and relationships Illness related Interpersonal variables: pain anxiety medication effects These variables affect nurse- pat communicaiton Environment setting for sender-receiver Effective setting provides participants with physical and emotional comfort and safety. Noise, temp extremes, distractions, lack of privacy create tension, confusion and discomfort. Control envy as much as possible to create favorable conditions for effective communication.

Verval Communication

Spoken or Written words. Code that conveys a specific message. Aspects of Verbal Comm: Vocabulary- Communication is only. successful if we can translate each others words. Different languages- use interpreter Subcultural variations- word means one thing to one person, another thing to another. Medical jargon- sounds like foreign language to patients. Children- have limited vocab Teens- often use words in unique way unfamiliar to adults. Denotative and Connotative Meaning- Some words have several meanings. Individuals who share a common language share the denotative meaning: baseball- same meaning for everyone. Connotative- "code" to HC providers can mean cardiac arrest. Connotative meaning- shade or interpretation of a word influenced by thoughts, feelings, ideas people have about that word. Select words carefully, avoiding easily misinterpreted words, especially when explaining a medical condition or procedure - (taking vital signs to a child- may cause fear) Pacing Conversation is more successful at appropriate speed. Speak moderately slow and enunciate clearly Talking rapidly, excessively slow, awkward pauses sends unintended messages. Long pauses and awkward shifts may convey hiding something. Think before speaking and develop awareness of rhythm of your speech to improve pacing. Intonation Tone of voice Dramatically affects the meaning of the message. Even a simple question or statement can express enthusiasm, anger, concern with the intonation. If a patient interprets your tone as patronizing this will inhibit communication A patient's tone can provide info about their emotional state or energy level. Clarity and Brevity Effective comm is simple, brief, and direct. For some pops, like elderly, fewer words result in less confusion. Speak slowly, enunciate, use brief examples to make explanations easy to understand. Repeat important parts Saying "OK?" or "Understand?" too much detracts from clarity. Use sentences or questions that are simple and direct: "Where is your pain? as opposed to "I would like for you to describe the location of your discomfort" Timing and Relevance Timing is critical Even if message is clear, poor timing prevents it from being effective. For ex. Do not teach a pat in pain. Best time for interaction is when pat has expressed interest. Only discuss issues that are relevant to situation. - do not discuss smoking before surgery- not relevant -explaining procedure- relevant Face-to-face time while performing assessments, administering meds, or performing procedures offers an excellent opty to talk with patients and provide support or education. Patients report satisfaction, understanding, and perception of safety when RNs provide a bedside hand-off and communicate info about plan of care.

motivational interviewing (MI)

A technique that encourages patients to share their thoughts, beliefs, fears, and concerns with the aim of changing behavior. Provides a way of working with patients to change behavior that is medically necessary but they are not ready. It can be used to evoke change talk. Ex: using personal goals and values to promote a medication or exercise plan. Delivered in a nonjudgemental, guided approach; tries to understand patient's motivations and values.

Professional nursing Relationships

Application of knowledge, understanding of human behavior and communication, and commitment to ethical behavior create professional relationships. Having a philosophy based on caring and respect for others helps you be successful in establishing these professional relationships.

Communication and Interpersonal Relationships

Caring relationships formed by the nurse and those affected by the nurse's practice are at the core of nursing. All behavior communicates and all comm influences behavior. Nurses demonstrate caring by being with, doing for, and enabling patient well-being. Nursing actions that reflect care: Becoming sensitive and supportive to self and others Being present and encouraging the expression of pos and neg feelings Developing healing relationships Instilling faith and hope Promoting interpersonal teaching and learning Providing for nursing care needs in a supportive way. Respecting and allowing for spiritual expression. Nurse's ability to relate to others is important for interpersonal comm. For the nurse to relate to others, they must have ability to: take initiative in establishing and maintaining communication be authentic (one's self) respond appropriately to other person. Effective interpersonal comm requires a sense of mutuality (both are equal participants). Nurses honor that people are complex and ambiguous; each is unique with specific comm needs. Nurses need to embrace a nonjudgemental, holistic, view of people and understand need for effective, supportive comm and human interaciton. Patient and family centered comm, such as involving pt in conversations about transitions in care, contributes to safety. Therapeutic communication occurs wihtin a healing relationship between nurse and patient. A nurse's communication can result in harm or good. Every nuance of posture, small expression, word, attitude- has potential to hurt or heal. This gives nurses the ethical responsibility to do no harm- respect the potential power of comm and do not misuse it to hurt, manipulate, or coerce others. Skilled comm empowers others to express what they believe and make their own choices.

Evaluation

Evaluate your effectiveness in comm by videotaping practice sessions- or process recordings (written records of you verbal and nonverbal interactions with pts.) Process recording analysis reveals how to improve personal communication techniques: It determines whether you encouraged openness and allowed pt to "tell his story", expressing thoughts and feelings. Identifies any missed verbal or nonverbal cues or conversational themes. Examines whether nursing responses facilitated or blocked pt's efforts to communicate. Determine whether nursing responses were positive and supportive or superficial and judgmental Examines type and number of quesitons Determine type and number of therapeutic techniques used Discovers any missed optys to use humor, silence, or touch. Through the Patient's Eyes You and the pt determine the success of the plan by evaluating pt outcomes together. You determine which strategies or interventions were effective and which pat changes (behaviors or perceptions) resulted due to interventions. Ask pt if expectations were met by HC prof? ex: "does pt believe nurses responded in timely manner to call light? Successful nursing care related to communication needs needs results in clear and effective comm between pts and HC team and can favorably empact pt satisfaction and safety.

Nurse-Patient Caring Relationships

Foundation of nursing practice. Nurse assumes role of caring professional- who cares for each patient and their unique health needs, human responses, and patterns of living. Nonjudgmental acceptance important- a willingness to hear message or feelings, not necessarily agree with decisions. Created with skill and trust. Characterized by four phases. Four goal-directed phases that characterize nurse-patient relationship: (Begins when you meet a pat and continues until caregiving relationship ends) 1. Preinteraction Phase: Before meeting the patient: Review available data, including med and nursing history Talk to other caregivers who have info about patient Anticipate health concerns issues Identify location and setting that fosters comfortable, private, interaction. Plan enough time for interaction. 2. Orientation Phase: When you and patient meet together Set the tone by adopting a warm and caring manner Recognize that the initial relationship is often superficial, uncertain, and tentative Closely observe patient and expect to be closely observed. Begin to make inferences and form judgements about the patient's messages and behaviors. Asses the pat's health status. Prioritize problems and prioritize their goals. Clarify their and your roles. Form contracts that specify who will do what Let the patient know when to expect the relationship to be terminated. 3. Working Phase You and patient work together to solve problems and accomplish goals: Encourage expression of feelings about health Encourage and help with self-exploration. Provide info needed to understand and change behavior. Encourage and help pt set goals Take action to meet the goals set with the patient. Use therapeutic communication skills to facilitate successful interaction. Use appropriate self - disclosure and confrontation. 4. Termination Phase During the end of the relationship Remind pat that termination is near. Evaluate goal achievement with patient Reminisce about relationship with pat Separate with pat by relinquishing responsibility for their care. Achieve a smooth transition for pat with other caregivers if needed. Socialization is an important initial component of interpersonal relationships. Helps people get to know one another and relax. It is easy - whereas therapeutic relationships are more intense, difficult, and uncomfortable. A nurse will use social conversations to lay a foundation and establish trust, and then move beyond casual conversation to talk about health concerns or issues. In therapeutic, encourage patients to share personal stories, helps to get a context of their lives and what is meaningful to them; can help better articulate their wishes/needs. This info is not usually revealed from a history form. As a nurse, telling stories can enhance communicaiton; frame important messages and make them memorable for patients.

Patient Outcomes

If outcomes are not met or progress unsatisfactory, you determine which factors infuenced the outcomes and modify the plan. Possible questions when pt does not meet outcomes: You seem to be having difficulty comminicating. What do you think is contributing? Your telling me you don't feel anxious, but your face appears tense. Help me better understand how you're feeling You seem frustrated with pencil and paper to communicate. Would you like to try a letter board or pic? Evaluation in comm process helps nurse gain confidence and competence in interpersonal skills. Becoming an effective communicator greatly increases your profeessional satisfaction and success.

Nursing Diagnosis for Communication

Many patients experience difficulty with communication: Lacking skills in attending, listening, responding, or self-expression as a result of illness, treatment effects, or cultural / language barriers Primary diagnostic label used to describe pt with limited or no ability to communicate is Impaired Verbal Communication.: a state in which an individual experiences a decreased, delayed, or absent ability to receive, process, transmit, and use symbols for varying reasons. Defining characteristics : unable to articulate words and difficulty comprehending The associated difficulty in self-expression or altered communication patterns may also contribute to other nursing diagnoses: Communicative Barrier Difficulty Coping Powerlessness Impaired Socialization Assessment findings in a patient with Impaired Verbal Comm focus on the causes of the disorder, which can include physiological, mechanical, anatomical, psychological, cultural, or developmental. Accuracy in identifying assessment findings ins necessary to select interventions that will effectively resolve problem: Ex. you manage IVC related to cultural differences very diff than IVC related to hearing loss.

Levels of Communicaiton

Nurses use different levels of communicaiton in their professional role. A competent nurse uses a variety of techniques in each leve. Intrapersonal communication- Also called "self talk". Your thoughts and inner communications strongly influences your perceptions, feelings, behaviors, and self-esteem. Be aware of the nature of content of your own thinking: Positive self-talk provides a rehearsal for difficult situations so you can deal with them effectively and with increased confidence. Transform statements from "I'm afraid" to "This is an opportunity to learn". Interpersonal communication- One-on-one interaction done face-to-face. Most frequently used in nursing situations. Because meaning resides in people and not in words, the messages received are not always what was intended. Nurses work with people with different opinions, experiences, values, beliefs; It is important to validate meaning between participants. Ex: use interaction to assess understanding and clarify misinterpretations when teaching a pt. Meaningful interpersonal comm results in: exchange of ideas problem solving expression of feelings decision making goal accomplishment team building personal growth. Small group communication- interaction that occurs in small number of people. Usually goal directed and requires understanding of group dynamics. Working on Committees, participate in patient care conferences Comm should be organized, concise, and complete All participants should contribute and provide feedback. Helps participants to meet patient's needs and promote safe environment. Public communicaiton- interaction with an audience Nurses often speak with groups of consumers about health topics, present scholarly work to colleagues, lead classroom discussions with peers or students. Requires special adaptations in eye contact, voice inflection, and use of media materials. Increases knowledge about health topics, health issues, etc. important to nursing profession. Electronic - use of tech to create ongoing relationships with patients and HC team. Secure messaging provides opty for frequent and timely communication with pat's physician or nurse via patient portal. Elec portal enables pt.s to stay engaged and informed

Box 24.7

Older Adults- Tips for Improved Communication with older adult with hearing loss Make sure patient knows you are talking Face the patient, mouth visible, do not chew gum or talk while chewing Speak clearly, but do not exaggerate mouth or shout Speak a little more slowly, but not excessive Check if patient uses adaptive equipment (glasses, hearing aid) Choose quiet, well lit environment; minimal distractiosn Allow time for pt to respond; Do not assume pt is uncooperative if they do not respond or take a long time Give pt chance to ask questions Keep comm short and to the pt.: One question at a time

Planning for Communication

Once the nature of communication issue is identified, consider several factors when designing care plan. Motivation is a factor in improving communication, patients often require encouragement to try diff approaches that involve significant change. Involve family and patient in decisions Consider needs of basic comfort and safety before introducing communication methods/tech Allow adequate time for practice in a quiet, private place. Goals and Outcomes Once diagnosis is identified; select a goal that is relevant and achievable, such as being able to express needs or achieving understanding of physical condition. Next, select expected outcomes that are SPECIFIC and MEASURABLE. Outcomes identify ways to determine if broader goal is met. Examples: Patient initiates conversation about diagnoses problem Patient is able to attend to appropriate stimuli Patient conveys clear, understandable messages with HC team Setting Priorities Essential to maintain open line of communcation so pt can express emergent needs. This involves interventions such as keeping nurse call button in each or providing comm augmentative devices(Braille comp). When you need to have a lengthy convo, first tend to physical care priorities - symptoms under control and elimination needs Teamwork and Collaboration Sometime sneed to collaborate with other HC members who have expertise in comm strategies: Speech language pathologists interpreters mental health nurse

Non-verbal communication

includes the 5 senses and everything that does not include spoken or written word. Voice tone, eye contact, body positioning- as important as verbal. Nonverbal comm is unconsciously motivated and more accurately indicates person's intended meaning Than spoken words. When there is incongruity between verbal and non- receiver usually "hears" the nonverbal message as true. Sociocultural background is major influence on meaning of nonverbal behavior. messages between different cultures are easily misinterpreted. Assessing and responding to nonverbal messages is important aspect of nursing. Personal Appearance Includes physical characteristics, facial expressions, and manner of dress and grooming. Research shows patients prefer nurses wear same uniform with LPN or RN diplayed Many agencies restrict how much jewelry, tattoos For hygiene, wear hear back, short, clean fingernails Nurses learn to develop a general impression of patient's health and emotional status based on appearance, and patient's assess a general impression of nurse's professionalism and caring in same way. Posture and Gait manner or pattern of walking Way people sit, stand, move reflects attitudes, emotions, self- concept, and health status. Erect posture with quick, purposeful gait reflects well-being and confidence. Leaning forward communicates attention. Slumped posture, slow -shuffling gait indicate depression, illness, fatigue. Facial Expression- Most expressive part of the body. Convey emotions - fear, surprise, etc Some people have emotionless face which reveals little of how they feel. An inappropriate effect is a facial expression which does not match content- smile during sad story People are sometimes unaware of how facial expressions convey- nurse frowns in concentration and patient interpret anger. Consider how your facial expressions affect patients. Attempt to avoid shock, disgust, dismay, or distress - in reaction to patients. Eye contact People signal readiness to communicate through eye contact. Maintaining eye contact shows respect and willingness to listen. Lack of eye contact sometimes indicates anxiety, defensiveness, discomfort or lack of confidence. Although, some cultures consider it intrusive, harmful, threatening and minimize using it. Always consider culture when interpreting eye contact. Looking down at someone established authority, interacting at same eye level indicate equality. Rising to same level as angry person helps establish authority. Gestures Gesture emphasize, punctuate, and clarify spoken word. Alone can convey meaning or create messages with other cues. ex: finger pointing at someone has several meanings, paired with frown and stern voice communicates accusation. Pointing to area of pain is more accurate than describing it. Sounds Sighs, moans, groans, sobs communicate feelings. Combined with other nonverbal comm, sounds help send clear messages. Have several interpretations: crying can be happiness sadness, or anger. Validate nonverbal messages with patients to interpret them : "I notice you frowning; do you have pain?" Territoriality and Personal Space Territoriality is the need to gain, maintainer and defend one's right to space. Territory provides a sense of privacy, identity, security, control. Sometimes visual: fence or curtain Personal space is invisible and individual and travels with a person. During interpersonal interaction, people use varying amounts of personal space; depending on culture, nature of relationship, situation. When personal space is threatened people respond defensively and comm less effectively. Zones of Personal Space: Intimate Distance (0-18 in) Holding an infant Performing physical assessment Bathing, grooming, dressing, feeding, toileting Changing surgical dressing Personal Distance (18-40in) Sitting at bedside Taking history Teaching Social Distance (4-12 ft) Giving directions in hallway Asking if family needs assistance in hallway Giving verbal report to nurses Public Distance (12 ft or more) Speaking at community forum Lecturing students in class Testifying in court Special Zones of Touch Social Zone (Permission not needed) Hands, arms, shoulders, back Vulnerable Zone (Special Care Needed) Face, Neck, Front of body) Consent Zone (Permission needed) Mouth, wrists, feet Intimate Zone (Permission and Great Sensitivity Needed) Genitalia, rectum

Lateral Violence

workplace bullying between colleagues. Includes behaviors such as withholding info, backbiting, snide remarks, put downs, nonverbal expressions. Adversely affects the work environment, leading to job dissatisfaction, decreased sense of value, poor teamwork, poor retention of qualified nurses, and nurses leaving profession. New nurses are prone. Can be a precursor to compassion fatigue, as workers perceive a threat during interactions with colleagues and react emotionally rather than in a professional manner. Interferes with effective health care team communication and jeopardizes patient safety. Intimidation decreases likelihood that a nurse will report a near-miss event, question an order, or act to improve the quality of patient care. Must be a zero tolerance policy. Develop skills in conflict management and assertive communicaiton to stop spread of lateral violence. Requesting a mentor can help learn skills address perpetrators, as well as offer support and role model. Techniques when experimenting lateral violence: Address the behavior in a calm matter Describe how behavior affects your functioning. Ask for abuse to stop. Notify manager to get support. Pan for taking action in future. Document incidents in detail in personal notes, not patient records.