Chapter 6: Communication in the Nurse-Patient Relationship

how to communicate to gain valuable info about clients health status and educational and counseling needs

"Earlier you said your father had a few toes amputated; are you worried the same will happen to you?" Explanation: It might become necessary at times to obtain more information about a topic brought up earlier in the interview or to introduce a new aspect of the current topic. In this way the nurse can gain additional valuable information to consider in assessing the client's health status and educational or counseling needs. Asking if lunch was ordered or if symptoms are being experienced are "yes or no" questions that do not contribute to educational or counseling need identification. A client would not be expected to differentiate the difference between complex endocrine disorders

how to communicate when a client is not talking and depressed

"Is that a new shirt you're wearing?" Explanation: When the client is not talking, the nurse should use the observation technique of therapeutic communication. The nurse should compliment the client to get his attention. Wearing a new shirt is an observation about the client that would draw communication from him. The nurse should avoid direct questions to a client who is in depression.

what are the 5 elements of nurse client contract

*know each others names *role and relationship clarified *parameters of professional relationship are clear *mutual expectation are agreed upon *circle of confidentiality is respected.

what is congruent and incongruent relationship

if the relationship between the 4 types of communication are related it is congruent, if not it is incongruent. Incongruent would be "yes nurse, I understand how to take my insulin" but has an angry face the patient is incongruent.

what is a helping relationship

A helping relationship exists among people who provide and receive assistance in meeting human needs. When a nurse and a client are involved in a helping relationship, the nurse assists the client to identify and achieve goals that allow the client's human needs to be met. • A helping relationship is purposeful and time limited. • A helping relationship is dynamic. • The helping relationship is built on the patient's needs, not on those of the helping person.

discuss key ingredients of therapeutic communication

EMPATHY, walk in their shoes, use reflective and active listening. "I can only imagine how hard this is on you. How can I help you?" An empathic nurse is sensitive to the client's feelings and problems, but remains objective enough to help the client work to attain positive outcomes. POSITIVE REGARD, caring, respect, non judgemental. It is not dependent on the patients behavior. COMFORTABLE SENSE OF SELF, how I experience me influences how I see others, be aware. Differences are interesting rather than bad or threatening.

when there is an interpreter

Take time to meet with the interpreter before meeting with the patient. Allow sufficient time—working with an interpreter may take twice as long as a meeting in which a common language is spoken. Speak directly to the patient. Speak in short sentences, and allow the interpreter to interpret. Develop alternatives to direct questions. Avoid ambiguous language, abstractions, and technical jargon. Speak slowly and clearly; use repetition as needed. Be aware of nonverbal messages that may require interpretation just as verbal messages do. Avoid using family members as interpreters.

what is the intimate zone and other zones

The INTIMATE ZONE refers to interactions between parents and children or people who desire close personal contact, eg talking while changing a wound. The PERSONAL ZONE refers to the distance when interacting with close friends. The SOCIAL ZONE refers to the space when interacting with acquaintances, such as in a work or social setting. The PUBLIC ZONE refers to communication when speaking to an audience or small groups

identify 3 key nontherapeutic responses and explain who each interferes with therapeutic communication

INCONGRUENT RELATIONSHIPS nurse not equal on all communication levels RESCUE FEELINGS I must be essential to the patients well being. some rescue feelings are ok but strong rescue feelings can lead to nurse thinking only she can serve and this could isolate other team members, also you might give too high hopes to patient and then they will be disappointed. FALSE ASSURANCE "everything will be fine", "There is nothing to the surgery", telling them not to worry, or we do this all the time. real reassurance is to be based on facts, "there will be postoperative pain and we have meds" this is ok GIVING ADVICE ie "The same thing happened to me and I quit.", "why dont you....." CHANGING THE SUBJECT "lets go for a walk and talk about something else" BEING MORALISTIC stay away from words like should and the right thing to do is. "patient should not get an abortion, its wrong" another way of being moralistic is to approve or dissaprove the patients judgement. Patient may feel good or bad NONPROFESSIONAL INVOLVEMENT

distinguish between a professional and a social relationship

KEY FOCUS is on patient not me and patient GOALS are meeting patients needs, solve problems, cope, and adapt to healthcare situation. Not mutual companionship, enjoyment, or interaction. PARAMETER limited to healthcare, relationship ends once goals are met. NOT sharing life experiences, activities. SELF ASSESSMENT nurse assess own role, values etc to see how they affect the professional relationship. Not each person assessing feelings

give an example of each type of therapeutic technique

OFFER SELF Making self available to listen to the patient OPEN ENDED questionsAsking neutral questions that encourage the patient to express concerns OPENING REMARKS Using general statements based on observations and assessments about the patient, eg, "I notice you are going through some changes", "You seem to be feeling better". RESTATEMENT Repeating to the patient the main content of his or her communication, eg patient says, "I cant sleep its too hot in here and too noisy" my restatement is "you cant sleep because it is uncomfortable in here?" REFLECTION Identifying the main emotional themes contained in a communication and directing these back to the patient, eg patient says "Thats alright, all I can think about is the operation in the am" my reflection is "the thought of surgery is keeping you up" FOCUSING asking goal-directed questions to help the patient focus on key concerns. It is still open ended but its directed at key concern, eg, "We were talking about how people might respond to your mastectomy, can you say more about that?" ENCOURAGING ELABORATION helping the patient to describe more fully the concerns or problems under discussion, eg, "go on", "I see" SEEK CLARIFICATION helping the patient put into words unclear thoughts or ideas, "I am not sure I understand what you mean" or "what happened then" GIVING INFORMATION Sharing with the patient relevant information for his or her healthcare and well-being. The patient says, "I should have been more careful. I was wearing a short skirt. Maybe that caused the rape." Based on what the nurse knows about rape victims' perceptions, a timely intervention might be for the nurse to say, "When people are raped, it is normal for them to look for the cause within themselves. But the rape is not your fault. You are the victim in this situation." This information is based on research showing that rape victims commonly assume that they provoked the rape. In addition to giving this information, the nurse might also refer the patient to a rape counseling center in the community. LOOKING AT ALTERNATIVES helping the patient see options and participate in the decision-making process related to his or her healthcare and well-being. •What are some of your ideas about how to handle this? •Have you thought about [alternative courses of action]? •What else could you do? •If you met someone in the same situation as you, what would you advise him or her to do? •What are some advantages (or disadvantages) of the alternatives we have just discussed? SILENCE Allowing for a pause in communication that permits the nurse and patient time to think about what has taken place SUMMARIZING highlighting the important points of a conversation by condensing what was said "Today, it seems that you've thought about ..." and "Let's review what we've talked about today."

what are the 4 ELEMENTS of the communication process and their relevance to nursing

SENDER, RECEIVER, MESSAGE, FEEDBACK. also, all communication must have a SENDER, The sender is the person or group having a purpose to communicate, the communication must be translated into a code. Code can be done with language or non verbal, eg, gestures, facial expression. ENCODE, the process of getting the purpose/code actually translated is encoding. Encoding results in a message. when I am using words and making hand gestures. MESSAGE/COMMUNICATION CHANNEL, is the medium or carrier of the message, eg tv, voice, written, touch, translater. If the process stops here there is no actual communication as there must be a receiver. If a nurses patient doesn't speak English she will have to find an interpreter. The enterpreter will be the communication chanel. Pictures could be the chanel. RECEIVER, the target of the communication and must be able to understand/decode the message. decode FEEDBACK, once message is decoded sender and receiver uses one anothers reactions to communicate.

where to sit with a patient

Take note of the client's cues when choosing a position and act on these cues.

maintenance phase/working phase

The nurse and patient work toward achieving the specific task or goal agreed on in the introductory phase. In the working phase of a nurse-client relationship, the nurse tries not to retard the client's independence, because doing too much for the client is as harmful as doing too little. The nursing roles of educator and counselor are primarily performed during the working phase of the helping relationship. This is where the nurse's interpersonal skills are used to the fullest. • The client genuinely expresses concerns to the nurse in this phase • The client participates actively in the relationship in this phase •Keep focused on the tasks or goals to ensure that needed data are obtained and goals are achieved. •Encourage the patient to express his or her feelings, concerns, and questions. •Use techniques that facilitate communication between the nurse and patient (e.g., silence, general leads, validation). •Observe the nonverbal behavior that accompanies verbal responses (e.g., a patient may say she is not nervous, worried, or anxious while biting her fingernails, moving constantly, and smoking throughout the interview). •Assess the patient's ability to continue the interview (e.g., grimace of pain, shortness of breath, fatigue).•Facilitate goal attainment by moving to the next topic of discussion after needed data are collected.

identify important assessment areas to address when communicating with patients

assessment, use all skills above and assess external, internal environment. implementation is once communication is assessed how is the nurse going to communicate, use therapeutic skills helping getting the patient started by encouraging patient to express concerns, ask if they prefer to be called by first name etc. Use open ended questions

preperatory phase

The nurse's attention is directed toward preparing for the first nurse-patient interaction. •Review as much information as possible about the patient. •Decide what data are needed and what type of data collection form will be used. •Review the literature pertinent to the patient's developmental age, psychosocial aspects, and pathophysiologic considerations, if needed. •Assess your own feelings or reactions to previous patients that might interfere with the nurse-patient relationship. •Seek assistance from more experienced nurses, mentors, or supervisors if concerned about how to carry out the interview. •Plan for a private, quiet setting for the interview; schedule a mutually convenient time of day; and determine the length of time needed for data collection. •Modify the environment to facilitate the interview.

What is therapeutic touch

Therapeutic touch involves "unruffling," or clearing, congested areas of energy in the body and redirecting this energy. After assessing a patient's "energy field," the nurse uses therapeutic touch to promote comfort, relaxation, healing, and a sense of well-being

if a person is unconscious how should I speak to them

• The nurse is careful what is said in the patient's presence since hearing is the last sense to go. Assume they can hear. • The nurse assumes the patient can hear and discusses things that would ordinarily be discussed. • The nurse speaks with the patient before touching him or her. minimize environmental noise and use touch to communicate.

if a patient is anxious

acknowledge the anxiety, explain the purpose and the procedure to calm the patient. if a patient is anxious about a severe procedure like thoracentesis Thoracentesis is a painful procedure and it is important to sit still to avoid injuring the pleura. The nurse should reassure the client that she will be present during the procedure and help throughout. The nurse should provide correct knowledge as well as reassurance. Likewise, the nurse should avoid giving false reassurance about the procedure being painless. Additionally, the nurse should abstain from stating reasons that could scare the client. The nurse should not use an authoritarian approach. Describing the process as "a little bit uncomfortable" understates the discomfort and provides false expectations. say "The needle causes pain when it goes in, but I will be by your side throughout and will help you hold your position." for someone with anxiety of an iv getting started remember PROCEDURE and PURPOSE. "I will start an IV that will add fluids directly to the blood stream."

The interview

an essential skill for obtaining information for the nursing history, consists of asking questions designed to elicit subjective data from the patient or family members. The nursing history focuses on the patient's account of the actual or potential health problems and their impact on his or her health status. The nursing history helps the nurse do the following: •Clarify and verify the patient's perception of his or her health status •Compare the patient's present and past health status, lifestyle behaviors, and coping abilities •Identify actual and potential nursing diagnoses •Develop the patient plan of care •Implement nursing interventions to support the patient's adaptive responses it has 4 phases, preparatory, introductory, maintenance, and concluding.

question A 36-year-old patient who underwent a hysterectomy 4 days ago says to the nurse, "I wonder if I'll still feel like a woman." Which response would most likely encourage the patient to expand on this and express her concerns in more specific terms?

answer "Feel like a woman . . ." The best response of the options listed is the statement "Feel like a woman..." This response is a reflective comment, which allows the client to reflect and elaborate on their feelings. Remaining silent is a skill that is appropriate many times, but not the most appropriate in the situation at hand. Asking a yes/no question such as "Do you want more children?" does not encourage the client to reflect and elaborate on their feelings. The question "When did you begin to wonder about this?" does not direct the client in a direction for more reflection on their feelings

question about anxiety A nurse finds that a client has infiltration around the IV line that needs to be removed. What explanation should the nurse give to reduce the client's anxiety?

answer "I know that you are anxious, but removal will be painless and the IV location needs to be changed." The nurse uses therapeutic communication by both acknowledging the client's anxiety and giving honest information that another IV line needs to be started. Telling the client that infiltration is causing pain but will be relieved upon removal of the IV line does not address the client's anxiety and does not inform the client about restarting another IV line. Also, the nurse telling the client to take deep breaths, or stating that the procedure is minimal and will be over soon, does not consider the client's anxiety. Finally, telling the client that many clients experience this is generalizing the client and is not appropriate.

congruent relationships

as the nurse does rounds she explains her role, confers with them about their needs, schedules tasks, dressed well, professional. The nurse is congruent among nonverbal, verbal, and metacommunications.

describe 2 special situations that affect communication

children and adolescents adults and older adults cross cultural communication the patient in the icu. not all communication is effective with everyone

How to speak to an ICU patient

communication is more important than ever, even with distractions. talk the same as if with any other patient. Give cues about day and time, calendars. For people who cannot speak give notepads or magic slates. Once they are stable help them understand why they are in ICU

if a person is dehydrated

dry skin, wrinkles easily, eyes sunken and dull, poor muscle tone. Capillary refill can also be but heart rate will not slow down. Diaphoresis would not be present as you are too dehydrated to sweat.

how to communicate with patient who is hullucinating

if they are affraid of spiders. When a client is hallucinating, the nurse should constantly orient him to reality, addressing his feelings simultaneously. The nurse should avoid statements that disregard the client's feelings. Also, the nurse should not use statements that are not reality-based. The nurse telling the client that she can see the spiders, and asking if he wants the nurse to kill the spiders, are not reality-based statements. say "I know that you are frightened, but there are no spiders on the wall."

interpersonal and intrapersonal

inter is me and another person intra is me talking to myself

what is AIDET

it improves patient/staff communication Acknowledge, introduce, duration, explain, thank you.

explain the nature of the nurse patient relationship

key focus is the patient not me goals are to help patient identify feelings and concerns. 3 phases are ORIENTATION, intro and agree on roles/responsibility. build trust to pave the way to assessment. you are making a verbal contract. The nurse is performing teaching and counseling skills WORKING, explore and develop solutions to problems, nurse is coach, advocate, care for physical/emotional needs. TERMINATION, nurse patient relationship ends, ie, end of shift, discharge, if not it is unethical code of conduct

name 2 professional self care safety nets

not getting burnt out or too involved. Be self aware, journal what emotions are acceptable and not. clinical supervision program.

introductory phase

nurse and patient meet. establish raport and roles and exchange expectations: THIS IS IMPORTANT In the introductory phase, the client identifies one or more health problems, and the nurse is courteous and actively listens to the client's problems to ensure that the relationship begins positively •Introduce yourself by name and position, and explain the purpose and content of the interview. •Begin to establish rapport with the patient by conveying a caring, interested attitude; rapport is essential for a trusting, helpful nurse-patient relationship. •Observe the patient's behavior, and listen attentively to determine the patient's self-perceptions and how the patient views his or her health problems; validate the patient's perceptions as the interview progresses. •Let the patient know how long the interview is expected to last. •Inform the patient how the information collected will be used and that confidentiality will be maintained. •Start with nonthreatening, specific questions and proceed to open-ended questions. •Establish a verbal contract with the patient, incorporating the goals of the interview

incongruent realationships

patient says yes I understand but is frowning. The metacommunication is saying "I am tired of being told what to do and I am sick of this chronic condition" Recognizing this informs the nurse of the patients experience.

describe how language and experience affect the communication process

persons view of the world is via neurologic receptor systems, ie sight, smell, touch, hearing, vision. language helps us compare our world experience, therefore alterations in sensory perceptions can change a persons view. Limited language and words affect our experience and choices. our history affects our communication. stereotypes etc

The 4 phases of the interview are

preparatory, introductory, maintenance, and concluding.

difficult patients/challenging behavior can be

•Defensive, angry, frightened, or resistant behavior •Impulsive and manipulative behaviors •Somatizing behavior (vague or exaggerated symptoms) •Grief •Frequent visits to healthcare provider.

concluding phase/termination phase

review goals or tasks and expressing concerns related to this phase. In the terminating phase, the nurse ensures that the client manages independently and that the client's health condition has improved. examining goals of the relationship to determine their achievement. •Review goal or task attainment; such a review can foster a sense of achievement in the patient and nurse. •Summarize the highlights of the interview and its meaning to the nurse and the patient. •Encourage the patient to express and share his or her feelings regarding the termination of the interview. •Use language congruent with the patient's cultural background and local custom (e.g., "goodbye" may mean a final farewell in some cultures; promises to contact the patient in the future may be taken literally).

what happens during therapeutic communication

solve problems patient feels cared for and understood family and significant others included in education/teaching health promotion and prevention are delivered.

nonverbal communication

space, silence, face, gestures, affect, tone of voice, volume, pitch, quality.

sender and receiver impairments

structural deficits sense deficits, sight, hearing, smell, touch, taste loss of function disease drugs and others

name the elements of an informal nurse patient contract

the nurse patient relationship is informal contract. Contracts are verbal about how they are to work together. I will be your nurse while you are a patient here, im responsible for planning your care, etc. •Nurse and patient know each other's names. •Roles and responsibilities are clarified. •Parameters of the professional relationship are clear. •Mutual expectations are agreed on. •Circle of confidentiality is respected.

explain internal influence

this is the clients past experiences, cultural background, and or beliefs. Noise, privacy, and ambiance are external influences that affect communication between nurse and patient.

if someone speaks another language and no interpreter is available

use a caring voice and repeat messages frequently. Speak slowly and distinctly. Keep message simple Use hand motions and pictures when appropriate. Do not use family members especially children as interpreters.

how do we deal with these behaviors

use reflective statements, sincere apologies, listen and understand patients expectation, validate emotions, share. take time to reflect on my triggers and also remember the 6 elements that reduce difficult encounters: know your patient know families collaborate with staff have supplies and equipment care space change (meeting med needs to quickly for discharge)

cause and effect

use sequencing via chronological order. events leading up to the problem. the answer will be ask the patient about recent events not allergies etc.

what are the 4 major types of communication in

written verbal nonverbal metacommunication(all of the above)