Foundation lecture 10

You are invited to attend the weekly unit patient care conference. The staff discusses patient care issues. This type of communication is: a) public. b) intrapersonal. c) nonverbal. d) small group.

D Small group

Communication process

For communication to be effective, the process must be interactive and ongoing. Realizing that a variety of factors may initiate the communication process helps the nurse to critically analyze the purpose and meaning of interactions.

Hearing-Impaired Patients (Cont.)

For deaf patients Adequate lighting Avoid over-enunciation Speak slowly Provide an interpreter, if patient uses sign language Use gestures and pictures if interpreter unavailable Written communication Helpful for literate hearing-impaired or deaf patients and family members Use of a whiteboard Many of the strategies used when communicating with hearing-impaired patients are important when interacting with individuals who are deaf. Adequate lighting, avoiding over-enunciation, and speaking slowly while in direct proximity to deaf patients can help their ability to read lips and perceive the meaning of gestures and facial expressions. If deaf patients use sign language as their primary means of conversing, an interpreter should be contacted to help with communication of critical information. Gestures and the use of pictures can facilitate informal communication when an interpreter is unavailable. Written communication is especially helpful when the nurse is providing detailed information to literate hearing-impaired or deaf patients and family members. A whiteboard and erasable marker or computer tablet kept at the bedside of a deaf patient may facilitate more effective communication. Institutional policies detailing the accommodations necessary to provide safe care to deaf patients should be followed.

While admitting a patient, during the initial interview, a family member tells you, "My mom really means that she does not understand her medical diagnosis." The communication form used by the family member is: Focusing. Clarifying. Summarizing. Paraphrasing.

b Clarifying

Nonverbal

body language, such as gestures and eye contact

Interpersonal

One-to-one interaction between two people

Nontherapeutic Communication

*Nontherapeutic communication* can be hurtful and potentially damaging to interaction. Many aspects of social conversation should be avoided when interacting with patients. Most are considered nontherapeutic and tend to shift the conversational focus away from the patient's concerns. Nurses engaging in nontherapeutic social conversation tend to be labeled by patients as uncaring and self-absorbed. Changing the subject (e.g., in response to a patient who expresses a desire to talk about a concern that makes the nurse uncomfortable) or sharing personal opinions limits conversation between the nurse and the patient and discourages open conversation on sensitive topics. *[Review Table 3-4, which provides examples of nontherapeutic communication that should be avoided.]* Avoiding nontherapeutic communication requires practice and experience. Intentionally incorporating as many therapeutic communication strategies as possible into conversations helps a nurse better meet patients' needs.

Factors Affecting the Timing of Patient Communication

*Pain or Anxiety* Short questions, short sentences, and specific instructions are best Patient education or preoperative teaching should be conducted earlier or at a different time *Location and Distractions* Privacy and confidentiality Minimize technology and distractions Safe Practice Alert: Make sure the patient is alert and oriented before conducting a health history or asking the patient to make significant health care decisions. Pain or Anxiety Patients experiencing a moderate to high level of pain comprehend direct, empathetic communication most effectively. Short questions or specific instructions are the best methods for exchanging information with patients when they are suffering from acute or severe chronic pain or are experiencing intense anxiety. If the nurse must provide an anxious patient with instructions for a diagnostic test or surgical procedure, short sentences that include only essential information should be used. Extensive patient education or preoperative teaching should be provided at an earlier or different time, when the patient is more relaxed or when the pain level is more tolerable. Location and Distractions Privacy and confidentiality are critical during the interviewing and assessment process. Patients should not be asked to share their health histories while visitors or non-health care providers are present. Simply pulling a cubicle curtain around a patient's bed does not prevent the transmission of sound beyond the curtain. *If it is impossible to provide a private area in which to gather vital information, ask for the patient's permission to conduct the interview in the current setting before initiating the health history interview.* Make every effort to talk with patients in an environment with as few interruptions and distractions as possible. Effective communication can be challenging if the patient and nurse are distracted by technology and other people. Although technology, such as MP3 players, televisions, and cardiac monitors, may provide entertainment or valuable patient information, communication is enhanced when the people involved are totally attentive to the interaction. Ask the patient to turn off competing technology and to focus on the nurse-patient interaction as needed. Turn down the volume of audible monitor alerts during an extensive patient interaction. Remember to return the monitor alerts to their original levels before leaving the patient's bedside. *It is appropriate for the nurse to ask visitors to leave a patient's room for a few minutes to obtain critical, private information directly from the patient.* The best source of information for an alert, oriented adult patient is the patient, not a spouse, another relative, or a visitor who happens to be present when the health history is taken. By focusing directly on the patient, the nurse communicates concern and is more attuned to subtle information communicated verbally and nonverbally. With the patient's permission, relatives and friends may be considered secondary sources of subjective information. Data gathered from these persons may be helpful in validating or clarifying the information provided first by the patient. Relatives or friends of the patient may become sources of information after required permission has been secured, especially if the patient is disoriented, comatose, or absent, or is a minor.

Ethical, Legal, and Professional Practice

*SBAR* (situation, background, assessment, and recommendation) is a widely accepted method of handoff communication that involves interpersonal communication designed to enhance patient safety and outcomes: Situation: What is happening right now? Background: What led up to the current situation? Assessment: What is the identified problem, concern, or need? Recommendation: What actions or interventions should be initiated to alleviate the problem? Using SBAR format when documenting patient progress notes increases the clarity of shared information for legal purposes.

As Suzanne works with Roberto, she develops a helping relationship. Suzanne knows that posing questions for the patient's reflection helps her assess his needs and support his self-care strategies.

A helping relationship between you and your patient does not just happen. You create it with care and skill, and build it on the patient's trust in you as a nurse. You help patients to clarify needs and goals, solve problems, and cope with situational or maturational crises. Creating this therapeutic environment depends on your ability to communicate, provide comfort, and help the patient meet his or her needs.

Helping relationships serve as the foundation of clinical nursing practice. Contracts for a therapeutic helping relationship are formed during the: Orientation stage. Working stage. Termination stage. Preinteraction stage.

A) orientation stage

Collaboration and Delegation

Collaboration with the institutional department responsible for obtaining interpreters for deaf or limited English proficiency (LEP) patients should be initiated by the nurse as soon as the need is identified. Interpretation may be provided by a professional interpreter face-to-face with patients and families or by phone or video medical interpretation. Family members should not be used as interpreters. Family members should not be used as interpreters of specific medical information to maintain the patient's right to privacy and to avoid possible misinterpretation of medical terminology. Access to interpretation or translation for deaf and LEP patients is required by Title VI of the Civil Rights Act of 1964, which mandates equal rights for people regardless of race, color, or national origin.

Message

Content of the message

Communication

Effective communication is an essential skill for the professional nurse. Critical nursing roles such as assessment and patient education require excellent and comprehensive communication to meet patients' needs. Patient advocacy, collaboration among health care team members, and safe patient care require the nurse to communicate in a way that clarifies a given situation. In one review, in more than 62% of sentinel health care events (i.e., unexpected death, injury, or serious risk of injury), communication breakdown was identified as one of the top three causes. To be viewed as competent, the nurse's communication skills must be professional and credible. Understanding the process of communication, the various modes in which individuals communicate, and the skills of therapeutic communication can greatly enhance the ability of a nurse to effectively care for patients and their families.

Nonverbal Communication (Cont.)

Gently touching a blind patient's arm before providing care helps to alert the patient to the nurse's presence. Therapeutic touch, such as holding the patient's hand or touching the patient's shoulder, can provide comfort and may alleviate pain. *Touch, Gestures, and Symbolic Expressions* Making physical contact in patient care situations can communicate caring or can be perceived as restrictive, depending on the type of touch used. This is especially true when a patient is undergoing a painful or stressful procedure. In most cases, it is important for the nurse to be aware of or verify a patient's openness to touch before implementing it as a nursing intervention. The use of gestures may be challenging to nurses practicing in a multicultural environment. Although they may enhance verbal communication, gestures may be viewed as inappropriate by patients of various cultures. Gestures may be most effective when used with people who have limited hearing. Establishing specific meanings for gestures before placing a patient on a ventilator or before a patient loses the ability to speak because of an advancing neurologic disease can facilitate communication when the patient is unable to speak. Symbolic expression through the use of make-up, jewelry, or clothing may communicate self-esteem, economic resources, or mental health. Observing the appearance of a patient may provide the nurse with an indication of the patient's wellness or need for attention. Make-up and clothing may be used by a patient to hide inner feelings, or these symbols can indicate that the patient's condition is improving. Nurses should be aware of their own use of symbolic expressions. Professionalism is best expressed without dramatic make-up and with minimal jewelry while performing patient care. Nurses who take pride in their professional appearance are more likely to be perceived by patients as competent and caring.

Hall's Zones of Interaction

Hall's zones of interaction significantly affect communication in cross-cultural settings. Anthropologist Edward Hall developed the theory of *proxemics*, the study of the spatial requirements of humans and animals. He identified four specific distances in which people interact: intimate space (0 to 1.5 ft) personal space (1.5 to 4 ft) social space (4 to 12 ft) public space (12 ft or more). Nurses interact with patients within each of these distances. Nurses must become increasingly comfortable with and sensitive to interacting within the intimate-distance area while providing direct care.

Hearing-Impaired Patients

Hearing Aids Encourage morning insertion Check and replace batteries Nurse: Ensure good lighting Minimize background noise Raise voice slightly Speak clearly and stay within 3-6 feet Ensure patient can see your face Extra patience may be required by the nurse to demonstrate caring while communicating with hearing-impaired patients. Various approaches may be effective in providing patient care for those with impaired hearing. Patients who normally wear hearing aids should be encouraged to place them in their ears during morning care. Checking or replacing hearing aid batteries regularly helps to avoid most associated mechanical difficulties. When communicating with a hearing-impaired patient, the nurse should make sure that the area is well lit with as little background noise as possible. Hearing aids amplify all sounds, making noisy environments confusing and frustrating. Raising the voice level slightly, speaking clearly, and making sure that the patient can see the nurse's face helps to facilitate communication. Adequate lighting enhances the patient's ability to see the speaker's mouth and face and interpret nonverbal communication. Stay within 3 to 6 feet of patients with hearing problems when conversing and avoid turning or walking away while talking. Consistent affirmative answers to the nurse's questions may be an indication that the patient is not hearing the information being shared. Care should be taken to verify that patients truly understand the content of verbal interaction.

Public

Interaction with an audience

Small Group

Interactions with a small number of people

Types of Communication (Cont.)

Interpersonal Communication Between two or more people Research indicates that 70% to 80% of medical errors involve issues of interpersonal communication. *Interprofessional communication* Open communication among interdisciplinary teams of health care professionals creates a culture of safety, which is necessary to protect patients from harm and meet patient safety standards. Ethical implications *Role boundaries* *Interpersonal communication* takes place between two or more people. It may be formal or informal and conversational, and it may or may not have a stated goal or purpose. In the context of an interview, it may vary from the strictly formal to very casual. Health history interviews and patient- nurse interactions have a specific focus and intention and require confidentiality and setting of role boundaries. Effective interpersonal communication among health care professionals is essential to ensure patient safety. Interprofessional Communication Effective collaborative communication among various members of the interdisciplinary health care team is essential for patient safety. This is especially true when patient care is being transferred to new care providers. Almost 70% of sentinel events were caused by communication breakdown, and 50% of those cases occurred during patient handoff. One method of interpersonal communication that has been adopted to increase interprofessional and handoff communication is the SBAR model, shown on a later slide. *Ethical Implications* Information shared during informal and formal nurse-patient interaction is considered confidential. The nurse must maintain the patient's right to privacy to ensure that the Health Insurance Portability and Accountability Act (HIPAA) regulations are met. The American Nurses Association's Principles for Social Networking and the Nurse provides guidance to nurses on how to use social networking ethically while providing for the privacy and confidentiality required for professional nursing practice. Professional &role boundaries& define the limits and responsibilities of individuals in a given setting. When undertaken by nurses, actions such as sharing personal phone numbers with patients, agreeing to meet patients outside the health care setting, and inappropriate touching violate these boundaries. Ethical or legal action may be taken against nurses who ignore professional role boundaries.

Hall's Zones of Interaction part 2

Interpersonal distance. Hall described the interpersonal distances of man (the relative distances between people) in four zones: intimate space, personal space, social space, and public space.

Types of Communication

Intrapersonal Communication: "Self-Talk" Positive self-talk Negative self-talk Meditation Prayer Nurses engage in four basic types of professional communication: intrapersonal, interpersonal, small-group, and public communication. Each has a different focus and potential outcome. *Intrapersonal communication* (i.e., occurring internally) focuses on personal needs and can influence a person's well-being. *Positive self-talk* is internal conversation that provides motivation and encouragement; it may be used to build self-esteem and self-confidence. By encouraging positive self-talk, nurses empower patients to fight their diseases and persevere through difficult situations. Nurses and student nurses may use positive self-talk to overcome anxiety or discomfort while taking examinations or performing new or painful procedures, such as starting an intravenous infusion. Negative self-talk (i.e., harmful or destructive internal conversation) may damage the ability of an individual to achieve his/her greatest potential or to overcome adversity. *Negative self-talk* may increase a patient's perception of pain, anxiety, or inability to meet the challenges of a poor prognosis. *Meditation* (i.e., mindful reflection or contemplation) is another form of intrapersonal communication. Some people use it regularly as a means of self-encouragement and reassurance. Different from *prayer* (i.e., form of meditation traditionally directed to a deity), meditation is a continuous thought process that centers on one idea with the goal of achieving inner peace and relaxation.

Diversity Considerations

Life Span Need for personal space increases Older adults may need same-gender family members Gender Eye contact Nurse of opposite sex not permitted Culture/Ethnicity Personal space *Life Span* • Children demonstrate a need for greater personal space as they age. • Older adults of some cultures require personal care from younger, same-gender members of their family. *Gender* • Making direct eye contact immediately before touching a patient of the opposite sex may help to communicate caring and alleviate anxiety in the patient. • In some cultures, nurses of the opposite sex may not be permitted to perform personal care or examine private areas of the patient's body. *Culture and Ethnicity* • People born in more densely populated areas typically require less personal space for comfort. • English-speaking people typically prefer at least 18 inches of distance between themselves and others when conversing. • In contrast, Middle Eastern people may be comfortable standing very close while communicating.

Special Communication Considerations

Many patients have sensory impairment, making nonverbal or verbal communication, or both, impossible. Communication with sensory-impaired patients requires patience, creativity, and adaptation to ensure that patient needs are met. The nurse's ability to modify the method of communication greatly impacts the quality of care delivered. Feelings of isolation, frustration, and depression by individuals with sensory impairment may be prevented if their caregivers use specific strategies to enhance communication. By assessing family dynamics and gathering community services information, nurses can better identify potential strengths and obstacles in patient support systems that affect effective communication.

Channel

Means of conveying and receiving messages

Feedback

Message the receiver returns

Modes of Communication

Most communication is nonverbal. Nonverbal communication is the more accurate mode of conveying information. Watching carefully for consistency or inconsistency between a patient's verbal and nonverbal communications allows the nurse to interpret and validate verbal statements. Although various methods can be used to convey information, there are only two basic forms of communication: verbal and nonverbal. Nurses are bombarded with verbal and nonverbal communication throughout each workday. Understanding the significance of the two primary modes of communication and the various methods through which they take place is essential.

Referent

Motivates one to communicate with another

Nonverbal Communication

Nonverbal communication = wordless transmission of information *THE MAJORITY OF COMMUNICATION IS NONVERBAL!* Realizing the frequency and value of nonverbal communication helps the nurse to observe and assess patients more accurately. Nurses who perceive the potential effect of their own nonverbal behavior will communicate more professionally and consistently when interacting with others. Body Language Posture, Stance, and Gait Facial Expressions and Eye Movements *Nonverbal communication* is wordless transmission of information; 93% of communication is nonverbal. *Body language* constitutes 55% of all nonverbal communication, and voice inflection accounts for 38%. Body language is conveyed in many ways: Posture, stance, gait, facial expressions, eye movements, touch, gestures, and symbolic expressions influencing personal appearance, such as jewelry and make-up, generally communicate a person's thoughts more accurately than simple verbal interactions. The nurse needs to observe the patient and family members for nonverbal cues while interviewing or completing assessments. Cultural and ethnic differences, mental health issues, and physical and emotional states affect the way people communicate. *Posture, Stance, and Gait* [Discuss the ways patients communicate nonverbally.] The way a person stands, sits, or ambulates can convey volumes to those observing. *Facial Expressions and Eye Movements* Grimacing or rolling the eyes communicates significant information. Some facial expressions may indicate fear or apprehension regarding impending diagnostic testing or surgery. The nurse must be especially perceptive when communicating with the patient and family members to observe the visual cues to their feelings. If there is incongruence between verbal communication and nonverbal facial expressions of patients or family members, the nurse must interview and assess the situation more carefully to identify and validate the most significant needs. The nurse must control his/her facial expressions to avoid communicating disdain or judgmental attitudes in challenging patient care situations. Maintaining a neutral facial expression establishes an environment of caring and openness in which the patient and family members can feel safe to share their innermost concerns.

The Nurse-Patient Helping Relationship

Nurse-patient relationships focus on five areas: (1) building trust (2) demonstrating empathy (3) establishing boundaries (4) recognizing and respecting cultural influences (5) developing a comprehensive plan of care Phases of the nurse-patient helping relationship: Orientation or introductory Working Termination A helping relationship develops through ongoing, purposeful interaction between a nurse and a patient. Each helping relationship evolves as a result of systematic, intentional activities of the nurse. The focal point of the nurse-patient helping relationship is the patient and the patient's needs and concerns. The nurse-patient helping relationship consists of three phases: orientation or introductory phase, working phase, and termination [Review Table 3-1 with students.] Preinteraction activities, such as gathering assessment and diagnostic data, organizing the data, identifying areas of concern, and planning the interaction, prepare the nurse for the initial contact with the patient. The five steps of the nursing process are used in each phase of the helping relationship. During preinteraction and the orientation phase, the nurse gathers assessment data and formulates nursing diagnoses that are appropriate for the patient. Objective data are collected during *preinteraction* and the *orientation phase*, whereas subjective data are obtained almost exclusively while interacting with the patient during the orientation or introductory phase. Nursing diagnoses [reviewed on the next slide] for individual patients are identified during the orientation phase after assessment data are gathered and clustered. During the *working* phase of the helping relationship, goals or outcome statements and nursing interventions are developed in collaboration with patients and their families. It is important for the nurse to discuss assessment findings and concerns with the patient to establish realistic short- and long-term goals. Communication with patients before initiating nursing interventions helps to alleviate anxiety and promotes goal attainment. The evaluation step of the nursing process is completed during the *termination* phase of the helping relationship. During this phase, the nurse and patient determine the level of patient goal fulfillment and the possible need for further intervention. Outcomes of the nurse-patient helping relationship are greatly affected by the nurse's use of therapeutic communication and by the patient's receptivity.

Nursing Diagnoses: Communication

Nursing diagnoses commonly related to communication concerns include the following: Impaired Verbal Communication Readiness for Enhanced Communication Powerlessness Risk for Powerlessness Social Isolation Situational Low Self-Esteem Anxiety Fear

Intrapersonal

Occurs within an individual

Sender and receiver

One who encodes and one who decodes the message

Roberto Ruiz is a 44-year-old man of Puerto Rican descent, suffering from HIV/AIDS. He was near death and in hospice, but his condition has improved and he is now home. Suzanne is a 54-year-old nurse dedicated to hospice and committed to maximizing quality of life in end-of-life care.

Personal Space! 1.5 to 4 ft.

Therapeutic Communication (Cont.)

Phrasing requests in a positive manner is a very effective communication technique that helps to promote patient cooperation and affirmation. Instead of saying, "Don't forget to use your incentive spirometer," reword the request with a positive focus by saying, "Remember to use your incentive spirometer every hour to help prevent pneumonia." Positive language tends to motivate individuals to comply with important activities Practice on friends and family by rewording requests in a positive manner that supports cooperation.

Families and Communities

Providing support for the families of hospitalized patients involves ongoing communication. Use of therapeutic communication techniques Family dynamics Nurses should become familiar with community services to provide for the ongoing needs of discharged patients and their families. Because the discipline of nursing addresses the effects of illness on patients rather than simply the illness itself, establishing and maintaining viable lines of communication among patients and their family members or friends is critical. Particularly helpful are therapeutic communication techniques, which may provide insight into the existence and strength of available support systems. Family dynamics are often revealed by listening and observing, providing a clearer picture of the impact of illness and the associated circumstances on patients and their families. Assessment data about patients' families and the communities in which they live are a significant resource for formulating patient-centered plans of care. Nurses should engage community leaders in dialogue related to health care access and home care services. By taking seriously their role as public communicators, nurses can influence the wellness and quality of life in the communities in which they work and live.

Physically or Cognitively Impaired Patients (Cont.)

Quadriplegic patients Use of electronic devices Use of gestures or eye movements Become familiar with assistive electronic equipment and meaning of gestures Intellectual disabilities Special attention needed Consult with family members Avoid confrontation Quadriplegic patients who have a tracheostomy or who are on a ventilator may use electronic devices and a variety of gestures or eye movements to communicate. Assistive devices that use eye movement technology help paralyzed patients who are mentally alert and have neuromuscular control of the head and neck to communicate. These devices include electronic transducers that connect remotely to computers. In addition to becoming familiar with assistive electronic equipment, nurses must pay close attention to the meaning of specific nods or shoulder shrugs to fully communicate with quadriplegic patients. Patients diagnosed with intellectual disabilities or dementia require special attention by caregivers. Consulting with the family members of these patients often provides helpful hints and insights into what is most effective in gaining their cooperation with necessary nursing interventions. Avoiding confrontation is important. It is better to accept a demented patient's thought process than to argue or try to correct an erroneous line of thinking.

Defense mech

Refer patients for professional counseling if they exhibit detrimental use of defense mechanisms while trying to cope with stressful situations.

Essential Components of Nursing Communication

Respect - must convey verbally and nonverbally. Assertiveness The ability to express ideas and concerns clearly while respecting the thoughts of others Collaboration Requesting input from other members of the interdisciplinary health care team enhances a nurse's ability to meet the patient's needs. Each professional brings a different perspective and unique expertise that should be valued. Delegation - requires effective communication Advocacy - The hallmark of professional nursing! These components of professional nursing communication facilitate positive patient outcomes. Respecting patients and advocating on their behalf builds trust and conveys caring. Collaborating and delegating assertively with health care team members creates a positive work environment focused on patient needs. *Respect* for patients and their families is conveyed by nurses verbally and nonverbally. Asking a patient's name preference during initial contact demonstrates respect and establishes the foundation for a trusting nurse-patient relationship. Ensuring privacy, providing necessary health care information, and fostering autonomy in decision making are nursing actions that further strengthen the relationship. Controlling facial expressions and body language during challenging interactions with patients and health care team members is essential to consistently demonstrate respect. *Assertiveness* Assertive nurses communicate with patients, families, and other members of the health care team regularly and without hesitation. Assertive communication by nurses demonstrates confidence and elicits respect from patients and colleagues. Overly assertive nurses may be perceived as aggressive if they do not respect the rights and opinions of others. Nurses who communicate aggressively tend to receive negative or defensive responses from patients, family members, and health care team members. *Collaboration* with other health care professionals is a key factor in communicating necessary health care information and providing comprehensive patient care. Most patients require the collaboration of many different health care professionals during hospitalization or outpatient treatment, and the nurse is often the coordinator of this team. The nurse must contact key health care professionals in an expedient manner and with respect and recognition of time and resource limitations. Ongoing communication with the patient about the status of the health care team collaboration is essential to allay unnecessary anxiety associated with not knowing what is happening. *Delegation* is a multifaceted responsibility of the registered nurse. When communicating during delegation, nurses must show collegiality and respect for all members of the health care team. It is important to call other health care team members by their preferred names. Accuracy while communicating ensures positive patient outcomes. Receiving feedback from the person to whom care is delegated is required by law and provides an opportunity for clarity, which ensures greater accuracy. Communicating therapeutically with colleagues during the delegation process shows respect and recognizes the many stressors with which all members of the health care team cope while providing patient care. Offers of support and encouragement help convey empathy and promote teamwork. Patient *advocacy* is a hallmark of professional nursing. Advocacy involves defending the rights of others, especially those who are vulnerable or unable to make decisions independently. To be an effective advocate for patients, the nurse must be knowledgeable, organized, and able to communicate in a caring manner.

Types of Communication (Cont.)/ cont

Safe Practice Alert: It is the nurse's responsibility to establish and maintain professional role boundaries when interacting with patients. Small-Group Communication Small-group dynamics Phases of group development: *forming, storming, norming, performing (and adjourning)* Public Communication Training in public speaking may be beneficial for nurses who anticipate extensive public communication in their professional roles. Communication in small groups focuses on meeting established goals or the needs of group participants. Focus groups, support groups, and task forces are examples of groups in which patients or nurses may be involved. Leaders of small groups may emerge from the group or be appointed before a first meeting. Nurses may be asked to lead small groups in their professional roles. When asked to lead small groups, nurses need to be aware of the phases of group development and group dynamics that may facilitate or hinder communication. Aspects of the phases of *small group dynamics* parallel those of the nurse-patient helping relationship. Although Tuckman's phases appear to be linear in nature, leaders should remember that group dynamics include individual personalities and that the arrival or departure of members may cause fluctuation among the various stages of group development. During the *forming* phase, group members rely heavily on the leader to identify the mission and goals of the group. Ground rules are identified, and trust is established through the development of interpersonal relationships. The *storming* phase of small-group development may involve some personality conflicts among the group participants. Group members with control issues may emerge. During the storming phase, the group leader needs to work with members to resolve conflicts and build cohesion. It is the group leader's responsibility to ensure that all members feel safe to share their thoughts and ideas freely without fear of ridicule. Increased trust and openness emerge during the norming phase, resulting in productivity and meaningful sharing of information. During this phase, it is essential that the group leader encourage participation of all group members. The leader must redirect interaction if one member of the group tends to dominate the discussion. It is also important for group leaders to avoid sharing too many of their own thoughts or feelings. Sharing affirmations of what the group has accomplished and identifying future work constitute a vital role of an effective small-group leader. Interdependence emerges during the performing phase of group development. During this phase, problem solving takes place within the group. Group members are typically highly committed during this time. Collaboration is effective in groups that perform at a high level. The *adjourning* phase takes place as the small group disperses, having achieved the group's goals. By recognizing the various phases of group development and using strategies to encourage communication among all group members, nurses can be very effective small-group facilitators. Nurses communicate in a public forum through patient and community education on health care issues, including wellness. Public communication requires education, preparation, openness to diverse opinions, and communication skills that encourage acceptance and dialogue. Nurses may be asked to serve as professional experts on health care issues for the media.

Verbal Communication

Setting, Context, and Content The context and content of verbal communication must be closely monitored by the nurse to avoid misinterpretation or errors in patient care. Written Communication Lacks voice inflection May not communicate urgency Electronic Communication Need to maintain confidentiality Consider potential for miscommunication Only 7% of communication about feelings and attitudes is verbal. This research finding underscores the critical need to integrate spoken, written, and electronic information with nonverbal cues garnered through observation and physical assessment. *Setting, Context, and Content* Spoken words may be communicated face to face, in a group setting, or through devices such as phones or intercoms. The setting of communication greatly influences what is or what can be shared. Depending on the confidentiality or privacy of the interaction; conversations may be overheard or taken out of context. Although it is important to get feedback when sharing patient information verbally to verify that the information is accurate, verbalizing potentially harmful or confidential information in a public setting may have legal ramifications for health care professionals. *Written communication*, although effective in providing details and legal documentation, lacks the nuances that voice inflection and interactive conversation can provide. For example, it may be difficult to perceive urgency when reading progress notes. The meaning of written communication is often enhanced through discussion. Oral reports or grand rounds typically highlight the urgency of patient needs more than written documentation. Special care must be taken to maintain confidentiality while communicating electronically. *Electronic communication* in the form of information referencing, e-mail, social networking, and blogging can quickly contribute to a person's knowledge, providing patients and health care professionals with vital information. However, the potential for miscommunication exists, in part because nonverbal cues are not apparent. When communicating verbally by electronic media, patients and nurses must take time to validate and verify shared information because misunderstandings can occur if feedback is inadequate.

Social, Therapeutic, and Nontherapeutic Communication

Significant differences exist between social and *therapeutic communication*. Nurses who understand this difference are effective in gathering information from patients and identifying their needs. Therapeutic communication is beneficial for the patient and is a positive interaction. Social communication has a balanced focus on all parties engaged in the conversation. Patients perceive nurses who develop strong therapeutic communication skills as caring, professional, and compassionate. Nurses who understand the impact of effective communication on patient care are less likely to engage in social conversation with patients and co-workers when it is not appropriate. Social communication most often occurs among individuals who know each other or who are getting to know each other informally. It typically involves mutual sharing of ideas. Friends may compare experiences, give advice, verbalize opinions, or make judgments on the behavior of others; anger and humor—appropriate or inappropriate—may be expressed. Most social conversations are multifaceted and change focus as topics of conversation evolve.

Physically or Cognitively Impaired Patients

Special accommodations for patients with: Endotracheal intubation or tracheostomy Expressive aphasia (may need communication aids) Weakness Semi-comatose or postoperative patients Use of touch Observe nonverbal signs Nurse continues to talk before and during procedures Individuals can hear even when they are physically unable to move or speak. Communicating in ways that best meet the needs of physically or cognitively impaired individuals requires ongoing creativity and adaptation. Patients with severe respiratory difficulties requiring endotracheal intubation or a tracheostomy need special accommodations to communicate. Some of these patients may be able to use nonverbal cues such as head nodding or hand-squeezing to communicate their needs. A whiteboard with erasable markers or a computer tablet can be particularly helpful. Patients with expressive aphasia may also benefit from these communication aids if their cognitive capacity and physical ability to write are intact. If a patient is weak, the caregiver should hold the board and help the patient write. Communication with a semi-comatose or postoperative patient still partially anesthetized may be realized through physical touch and hand-squeezing and by observing for nonverbal signs. If the patient grimaces when touched or moved or responds when asked to squeeze the nurse's hand, communication is established. The nurse must talk to the patient before initiating care and throughout procedures, even if the patient is seemingly unaware of the surroundings. Remember that individuals can hear even if they are physically unable to move or speak, when caring for patients who are temporarily noncommunicative or comatose.

Verbal

Spoken, written, or electronic

Therapeutic Communication

Talking with patients at eye level enhances communication. The use of therapeutic communication techniques enhances nurse-patient relationships and helps to achieve positive outcomes. Consistent use of therapeutic communication demonstrates empathy and concern for patients. Various techniques greatly assist the nurse in gathering, verifying, and validating assessment data. *[Review Table 3-2, which provides examples and rationales for verbal therapeutic communication techniques that nurses should practice while providing care within all settings. ]*

Visually Impaired Patients

Typically, blind patients have heightened auditory and olfactory senses. (inform them upon arrival) Use anticipatory communication. Use analog clock reference for position of food on a plate and orienting to hospital room. Use large-print, Braille, audio, or e-books. Gentle physical contact, such as a light touch on the arm, alerts the blind patient that someone is present. An important factor to remember when caring for visually impaired or blind patients is that they are rarely hearing impaired. Communication with blind patients can be characterized as anticipatory in nature, meaning that the nurse should alert visually impaired patients of potential hazards or object locations to provide necessary information and safe care. The position of numbers on an analog clock is often used as a reference when communicating the location of food on the plate of a blind patient. For example, the nurse may inform the visually impaired patient that the meat entrée is in the 6-o'clock position and the coffee cup is at 2 o'clock on the tray. This system may be helpful in orienting blind patients to their hospital rooms. For example, from the vantage point of lying in bed, the bathroom may be at the 10-o'clock position and the phone at 5 o'clock on the bedside cabinet. Large-print, Braille, audio, or e-books may be helpful in communicating effectively with visually impaired or blind patients. Gentle physical contact is especially important if the patient has been sleeping, is in a noisy environment, or is hearing impaired.

Nonverbal Communication (Cont.)/cont

Voice Inflection The second-most significant form of nonverbal communication is voice inflection. Spoken words may be emphasized through tone, volume, and the rhythm or rate of speech. Nurses must actively listen to perceive the quality of speech used during interactions with others. Voice inflection provides insight into the significance of information being shared. [Have students practice in pairs giving the same instructions to a patient with different voice inflections.]

Defense Mechanisms

When individuals are under extreme stress or unable to comprehend and cope with the reality of a situation, they may use defense mechanisms to protect themselves and their psyches. *Defense mechanisms* are unconscious strategies that allow an individual to decrease or avoid unpleasant circumstances. Some defense mechanisms are protective when used for short or long periods; others are consistently harmful. When used indefinitely, some defense mechanisms, such as denial, prevent an individual from effectively addressing critical issues. Others, such as compensation, may positively influence the productivity of an individual's life. Patients faced with a situation perceived as hopeless may exhibit anger toward a nurse. When this happens, it is important for the nurse to recognize displacement and address the real concerns of the patient rather than taking the patient's expressions of anger personally. *[Review Table 3-5, shown on later slides, which defines common defense mechanisms that are important for the nurse to recognize when used by patients overwhelmed with the stress or realities of unpleasant situations in which they find themselves.]* Nurses should document the use of defense mechanisms by patients. Use of unhealthy defense mechanisms over an extended period may require referral to a professional counselor.

During her visit, Roberto tells Suzanne, "I really want to go visit my uncles in New York, but I'm not sure I'm up for the trip." Suzanne is understanding: "It sounds like you miss your family. Let's talk about your options for maintaining contact." As they talk, Suzanne helps Roberto to identify two methods of communicating with his family in New York.

[Suzanne identifies two outcomes from her conversation with Roberto. What are the outcomes that Suzanne identifies?] Outcomes for Roberto include the following: Patient identifies two methods to maintain communication with family in New York. Patient verbalizes his concerns regarding his declining health.

Suzanne learns that Roberto wants to travel to New York to see his extended family. Even though Roberto is in poor health and the trip will be difficult, Suzanne expresses her understanding of the importance of the trip. She understands how important extended family is in the Puerto Rican culture.

[What is Suzanne demonstrating?] Her understanding of the importance of the extended family in the Puerto Rican culture helps her appreciate the importance of the trip to New York. Expressing an understanding of the importance of the trip, even though he is in poor health and it will be a difficult trip, demonstrates cultural sensitivity. In the example above, Suzanne did not question why he felt it important to see more distant relatives.