fundamentals of nursing chapter 20

goals of three phases in nursing relationshiop

-Orientation Phase The patient will call the nurse by name. The patient will accurately describe the roles of the participants in the relationship. The patient and nurse will establish an agreement about: Goals of the relationship Location, frequency, and length of the contacts Duration of the relationship -Working Phase The patient will actively participate in the relationship. The patient will cooperate in activities that work toward achieving mutually acceptable goals. The patient will express feelings and concerns to the nurse. -Termination The patient will participate in identifying the goals accomplished or the progress made toward goals. The patient will verbalize feelings about the termination of the relationship.

gait nonverbal communication

A bouncy, purposeful walk usually carries a message of well-being. A less purposeful, shuffling gait often means the person is sad or discouraged. Certain gaits are associated with illness. For example, patients recovering from recent abdominal surgery usually walk slightly bent over and slowly and might need the assistance of handrails or a helping person.

using cliches (block in communication)

A cliché is a stereotyped, trite, or pat answer. Most health care clichés suggest that there is no cause for anxiety or concern, or they offer false assurance. Patients tend to interpret them as a lack of real interest in what they have said. For example, even though the common question "How are you?" could start a conversation, it can cause a problem if patients hearing this suspect that the nurse is not sincerely interested in how they feel. Avoid the following common clichés because they tend to impede effective communication: "Everything will be all right." "Don't worry. You will be just fine in another day or two." "Your doctor knows best." "Cheer up. Tomorrow is another day." Another type of cliché makes a sweeping generalization that does not necessarily apply to a specific patient. It also tends to cut off communications and makes people feel as though they are insignificant. Consider the following examples: "Men tolerate pain poorly. That must be why you are complaining of severe pain." "Everybody is afraid of surgery. Why should you be any different?" "You teenagers are all alike. You aren't cooperative because you deny authority." Such comments rarely promote communication with the patient to whom they are addressed

mode of dress and grooming nonverbal communication

A person's clothing and grooming practices carry significant nonverbal messages. For example, healthy people tend to pay attention to details of dress and grooming, whereas people feeling ill often demonstrate little interest in personal appearance. It is often a sign of returning health when interest in their physical appearance and mode of dress returns.

roles and responsibilities

A person's occupation might give the nurse a general supposition of that individual's abilities, talents, interests, and economic status. Stereotyping a person according to occupation, however, can be misleading and should be avoided. This can be particularly dangerous when nurses assume that patients who are health care professionals know everything about their condition and need little nursing assistance, teaching, and counseling. The challenge in the provision of care is to respect the patient's roles and responsibilities, especially because these influence their preferred manner of communicating, without denying the patient needed care. For example, a successful attorney might have a "take-charge" demeanor and seem utterly self-sufficient; a skilled nurse will note this but still provide an opening for the patient to verbalize his or her needs. "You seem well prepared for this procedure and in control, but I know that patients often have questions that never get answered or fears that remain unvoiced. Is there anything I can help you with while I'm here?" Similarly, be careful not to ignore an uncomplaining patient who never asks for anything, because the power differences in the health care professional-patient relationship may make communication intimidating.

organizational responses to disruptive behavior

Addressing disruptive behaviors requires the determination that bullying will no longer be tolerated in order to promote a healthy work environment. The Joint Commission standard regarding preventing disruptive behaviors in health care facilities includes the following key recommendations: Education must be provided for all staff regarding respectful, professional behavior. All staff members must be held accountable for their behavior. Zero-tolerance policies must be implemented regarding disruptive behaviors and protection must be provided for those who report these behaviors. Those in leadership positions must attend training regarding professional standards of behavior and function as a positive role model. Surveillance and reporting systems must be available to identify unprofessional behaviors. Emphasis must be placed on the importance of documenting bullying behaviors (TJC, 2008). An organizational response coupled with individual nurses' efforts to address disruptive behaviors at all levels can create a healthy work environment, positively impact job satisfaction, improve the retention of nurses, and result in more positive patient outcomes.

characteristics of an interview

All interviews should begin with an explanation of the purpose of the interview. During the interview, you'll use interviewing techniques to obtain needed information while remaining flexible in approach. The interview itself is a therapeutic interaction and might be an essential part of the orientation phase of the helping relationship. At the end of the interview, plans for further interactions can be made. The following interviewing techniques are useful in nearly all nurse-patient interactions, especially the interview

channels of communication

Auditory—spoken words and cues Visual—sight, observations, and perception Kinesthetic—touch

bullying

Anger and aggressive behavior between nurses, or nurse-to-nurse hostility, has been labeled horizontal violence. This negative behavior is also referred to as bullying, lateral violence, and professional incivility. Bullying often occurs repetitively, whereas horizontal or lateral violence can occur as a single event (Stokowski, 2010). All are forms of psychological and social harassment and involve covert or overt behaviors (Flateau-Lux & Gravel, 2013). Covert bullying includes withholding information from a colleague, gossiping and spreading rumors, nonverbal communication such as eye rolling and other body language, and social isolation. Overt bullying behaviors include accusing a nurse of errors made by someone else (scapegoating) or humiliating a person in the presence of others. NURSE BULLYING Bullying behaviors occur in all health care environments and affect nurses at all levels of practice, including new graduates and nursing students (see the accompanying Research in Nursing box). According to recent surveys, the occurrence in the United States of nurses reporting being bullied ranges from 18% to 31% (ANA, 2012). The potential source of the disruptive behavior, the bully, may be a co-worker, supervisor, or physician. Medical-surgical units have the highest frequency, but incidents of bullying are also more common in critical care units, emergency departments, perioperative areas, and obstetric departments (Stokowski, 2010). According to a recent survey of new RNs in the United States, 60% quit a job after 6 months of employment as a result of being bullied (Flateau-Lux & Gravel, 2013; Townsend, 2012). Bullying also affects patient safety because teamwork is negatively influenced, resulting in deterioration in the quality of care and a greater potential for error. The physical and emotional toll on those employed in a toxic work environment can be significant. Commonly reported physical consequences include frequent headaches, sleep disturbances, gastrointestinal symptoms, and decreased energy. Psychological manifestations such an increased level of stress, anxiety, fear, frustration, and loss of self-esteem can result in burnout and emotional exhaustion (ANA, 2012). Nurses who refuse to be a victim can help break this cycle of violence. Once bullying is recognized as a problem, the need for a culture change is evident. Education is crucial; nurses need to learn effective communication strategies to combat bullying. Proactive behavior includes learning how to react professionally and protectively "in the moment," documenting and reporting the incident, welcoming new nurses, using conflict-management strategies when responding to a bully, and insisting that this abuse is addressed. Nurses who have always cared for others need to also care for themselves and their peers.

relating to people of different cultures

Assess your personal beliefs surrounding people from different cultures. Review your personal beliefs and past experiences. Set aside any values, biases, ideas, and attitudes that are judgmental and may negatively affect care. Assess communication variables from a cultural perspective. Determine the ethnic identity of the patient, including generation in America. Use the patient as a source of information when possible. Assess cultural factors that may affect your relationship with the patient and respond appropriately. Plan care based on the communicated needs and cultural background. Learn as much as possible about the patient's cultural customs and beliefs. Encourage the patient to reveal cultural interpretation of health, illness, and health care. Be sensitive to the uniqueness of the patient. Identify sources of discrepancy between the patient's and your own concepts of health and illness. Communicate at the patient's personal level of functioning. Evaluate effectiveness of nursing actions and modify nursing care plan when necessary. Modify communication approaches to meet cultural needs. Be attentive to signs of fear, anxiety, and confusion in the patient. Respond in a reassuring manner in keeping with the patient's cultural orientation. Be aware that in some cultural groups, discussion concerning the patient with others may be offensive and may impede the nursing process. Understand that respect for the patient and communicated needs is central to the therapeutic relationship. Communicate respect by using a kind and attentive approach. Learn how listening is communicated in the patient's culture. Use appropriate active listening techniques. Adopt an attitude of flexibility, respect, and interest to help bridge barriers imposed by culture. Communicate in a nonthreatening manner. Conduct the interview in an unhurried manner. Follow acceptable social and cultural amenities. Ask general questions during the information-gathering stage. Be patient with a respondent who gives information that may seem unrelated to the patient's health problem. Develop a trusting relationship by listening carefully, allowing time, and giving the patient your full attention. Use validating techniques in communication. Be alert for feedback that the patient is not understanding. Do not assume meaning is interpreted without distortion. Be considerate of reluctance to talk when the subject involves sexual matters. Be aware that in some cultures, sexual matters are not discussed freely with members of the opposite sex. Adopt special approaches when the patient speaks a different language. Use a caring tone of voice and facial expression to help alleviate the patient's fears. Speak slowly and distinctly, but not loudly. Use gestures, pictures, and play acting to help the patient understand. Repeat the message in different ways if necessary. Be alert to words the patient seems to understand and use them frequently. Keep messages simple and repeat them frequently. Avoid using medical terms and abbreviations that the patient may not understand. Use an appropriate language dictionary. Use interpreters to improve communication. Ask the interpreter to translate the message, not just the individual words. Obtain feedback to confirm understanding. Use an interpreter who is culturally sensitive.

true

Both the American Nurses Association (ANA) and the NCSBN have issued guidelines for RNs regarding use of social media. They agree that professional boundaries must be followed in the social media environment. In a 2010 NCSBN survey of Boards of Nursing (BON), a majority stated that they had received complaints regarding nurses who violated patient privacy by providing information or photos of patients on social media websites (NCSBN, 2011). The response from the BON varied from a letter of concern to suspension of the nurse's license. See Box 20-2 for the six principles for social networking endorsed by the ANA.

environment influencing communciation

Communication happens best when the environment facilitates an easy exchange of needed information. The environment most conducive to communication is one that is calm and nonthreatening. The goal is to minimize distractions and ensure privacy. The use of music, art, and interior decorations might help put the patient at ease. A patient with newly diagnosed human immunodeficiency virus (HIV) infection will find it difficult to discuss sexual history or genital warts in an area that lacks privacy. A toddler might find it easier to communicate if a parent, favorite stuffed animal, or blanket is nearby.

other rapport builders

COMFORTABLE ENVIRONMENT A comfortable environment, in which both the patient and the nurse are at ease, helps to promote interactions. Suitable furniture, proper lighting, and a moderate temperature are important. Also, effective relationships are enhanced when the atmosphere is relaxed and unhurried. If you seem preoccupied and on the run, or if the patient is ill at ease for fear of missing visitors or because of another commitment, communication is impaired. PRIVACY It might not always be possible to carry on conversations alone with the patient in a room, but every effort should be made to provide privacy and to prevent conversations from being overheard by others. Sometimes merely drawing the curtains around the bed in a hospital or long-term care facility or sitting in a corner of the waiting room or lounge can provide the sense of privacy that is so important in most interactions. Home visits might need to be timed to ensure the privacy the patient desires and needs. CONFIDENTIALITY The confidentiality with which patient information is to be treated should be established with the patient. Indicate with whom the information that the patient gives will be shared. The patient should know about the right to specify who might have access to the information. Failure to consider this factor can be considered a breach of the patient's right to privacy. See Chapter 16 for guidelines concerning patient confidentiality. PATIENT VERSUS TASK FOCUS Communication in the nurse-patient relationship should focus on the patient and patient needs, not on the nurse or an activity in which the nurse is engaged (see the accompanying box: Through the Eyes of a Patient). Consider the following example, in which the nurse's comment focuses on the patient and the patient needs: Patient: I don't know why these injections scare me, but they do. Nurse: You are afraid of these injections? In contrast, consider this example, in which the nurse's comment focuses instead on the nursing activity: Patient: I don't know why these injections scare me, but they do. Nurse: I give hundreds of injections. Don't be so immature. USING NURSING OBSERVATIONS Observations, which involve both seeing and interpreting, are especially useful for validating information. For example, a nurse suspects that a patient is afraid to hear the results of certain blood tests, but the patient insists that the results are unimportant. The nurse then observes the patient pacing in the corridor, apparently deep in thought. Observing the patient's behavior helps validate the nurse's suspicion that the patient is fearful and the patient's assertion of being unconcerned appears to be a cover-up for truer feelings. Observation serves several important purposes: It helps increase awareness of a patient's nonverbal messages. It is the primary source of information when a patient is unwilling or unable to communicate verbally. It demonstrates caring and interest in the patient. (Patients often recognize when a nurse is unobservant and, rightly or wrongly, usually conclude that the nurse does not care about them.) OPTIMAL PACING Consider the pace of any conversation or encounter with a patient. For instance, it would be ineffective to rush through a list of questions when obtaining a nursing history; it is more effective to let the patient set the pace. Let the patient know at the beginning of the interaction if time is limited so that the patient does not feel that you are rushing because of a lack of concern or personal interest.

eye contact

Communication often begins with

competence

Competent nurses are skilled in all aspects of basic nursing and can meet their patients' health care needs through their technical, cognitive, interpersonal, and ethical/legal skills. Take responsibility for evaluating your own strengths and weaknesses so that your patients will receive optimal care. Consequently, your patients will develop trust in and respect for you as their nurse, facilitating helping relationships and good communication.

gestures nonverbal communication

Gestures using various parts of the body can carry numerous messages—for example, thumbs up means victory, kicking an object often expresses anger, wringing the hands or tapping a foot usually indicates anxiety or anger, and a waving hand serves to beckon someone to come on, or if waved in another way, signifies that someone should leave. Gestures are often used extensively when two people speaking in different languages attempt to communicate with each other.

gender factor influencing communication

Men and women have differing communication styles and might give different interpretations to the same conversation. Tannen (1990) believes that this is because girls and boys grow up communicating differently. Whereas girls generally play with "best friends" and use language to seek confirmation, minimize differences, and establish or reinforce intimacy, boys use language to establish their independence and to negotiate status activities in large groups. In contrast, Townsend (2009) states that gender roles are changing in American society because sexual roles are becoming less distinct. Factors contributing to this change are the growing use of the term "unisex" and the fact that women and men enter professions previously dominated by the other sex. It is necessary to be sensitive to the fact that men and women might communicate differently. As such, when working with patients of the opposite gender, you'll need to validate that both you and your patient are accurately receiving the message the other is trying to communicate

general physical appearance

Most illnesses cause at least some alterations in general physical appearance. Observing for changes in appearance is an important nursing responsibility for detecting illness or evaluating the effectiveness of care and therapy. For example, a person with an insufficient intake of fluids has dry skin that wrinkles easily, eyes that might be sunken and dull in appearance, and poor muscle tone. On the other hand, the person in good health tends to radiate a healthy status through general appearance.

silence nonverbal communication

Periods of silence during a conversation often carry important nonverbal messages. A silence between two people might indicate complete understanding of each other, that both of the two people are thinking, or that they are angry with each other. Silence and its possible uses and meanings are discussed later in this chapter.

facial expression

The face is the most expressive part of the body. Examples of the various messages facial expressions convey are anger, joy, suspicion, sadness, fear, and contempt. Some people have extremely expressive faces, whereas others mask their feelings, making it more difficult to determine what the person is really thinking. Nurses need to learn to control their own facial expressions.

using questions that require a yes or no answer (block to communication)

Questions that can be answered by simply saying yes or no tend to cut off discussion, even when the person might wish to continue. Consider the following question: Nurse: Did you have a good day? The question begs for a noncommittal answer, which tells the nurse little. This is a better question: Nurse: Tell me about your sessions in therapy. How did you feel they went today? Another pitfall is to pose a question to which the patient can say no when that answer could present a problem. Consider the following question that a nurse asks a postoperative patient: Nurse: Are you ready to get out of bed? By offering the patient the chance to say no, the nurse might have created difficulties if the patient should be getting out of bed. At times, of course, questions that can be answered with yes or no are appropriate, such as in these examples: Nurse: Did you take your insulin before breakfast this morning? Nurse: Do you have pain when I move your arm this way? The problem with yes or no questions arises when seeking more detailed information or when the question might create difficulty.

sequencing questions in an interview

Sequencing is used to place events in a chronologic order or to investigate a possible cause-and-effect relationship between events. Nursing assessment is facilitated when events leading to a problem are placed in sequence. This technique is evident in the following example: Patient: I don't feel like myself anymore since I've been taking my blood pressure medicine. I'm tired and don't have any energy. Nurse: Your tiredness began after you started taking your medicine?

impaired verbal communication

Specific communication strategies may be necessary for older adults who have speech, language, and hearing disorders. Nurses and other caregivers should avoid "elderspeak" when communicating with older adults. Elderspeak involves using speaking patterns and words mimicking "baby talk" that imply that the older person is not competent. It is actually a form of ageism and used more commonly with frail older adults in long-term care facilities. Communication adjustments may be necessary but must be respectful, positive, and individualized. Chapter 19 also addresses communication with older adults. Box 20-6 offers guidelines for communicating with patients with special needs. The causes of hearing loss include chronic ear infections, heredity, birth defects, health problems at home, certain drugs, head injury, viral or bacterial infection, exposure to loud noise, aging, and tumors. Causes of speech and language disorders are related to hearing loss, cerebral palsy, and other nerve and muscle disorders; severe head injury; stroke (brain attack); viral diseases; mental retardation; certain drugs; physical impairments, such as cleft lip or palate; vocal abuse or misuse; and inadequate speech and language.

Touch (form of nonverbal communication)

Tactile sense has been studied seriously as a form of nonverbal communication only since the 1960s. Touch is a personal behavior and means different things to different people. Familial, regional, class, and cultural influences largely shape tactile experiences. Factors such as age and sex also play a key role in meanings associated with touch. Despite its individuality, touch is viewed as one of the most effective nonverbal ways to express feelings of comfort, love, affection, security, anger, frustration, aggression, excitement, and many others.

warmth and friendliness

The helping relationship depends on the nurse's ability to begin the orientation phase successfully. A pleasant greeting and friendly smile can facilitate this phase and place the patient at ease. By maintaining qualities of warmth and friendliness throughout the helping relationship, you will convey continuous acceptance of the patient and interest in discussing the patient's feelings and concern.

differences between helpful and social relationships

The helping relationship does not occur spontaneously, as do most social relationships. It occurs for a specific purpose with a specific person. The helping relationship is characterized by an unequal sharing of information. The patient shares information related to personal health problems, whereas the nurse shares information in terms of a professional role. In a friendship, information sharing is more likely to be similar in quantity and type. The helping relationship is built on the patient's needs, not on those of the helping person. In a friendship, needs of both participants are generally considered. A friendship might grow out of a helping relationship, but this is separate from the purposeful, time-limited interaction described as a helping relationship.

working phase

The nursing roles of teacher and counselor (see Chapter 21) are performed primarily during this phase.

what silence may mean in a therapeutic communication

The patient might be comfortable and content in the nurse-patient relationship. Continuous talking is unnecessary. The patient might be trying to demonstrate stoicism and the ability to cope without help. The patient might be exploring inner thoughts or feelings, and conversation would disrupt this. In effect, the patient is really saying, "I need some time to think." The patient might be fearful and use silence as an escape from a threat. The patient might be angry and use silence to display this emotion. The patient's culture may require longer pauses between verbal communication.

reflective question in an interview

The reflective question technique involves repeating what the person has said or describing the person's feelings. It encourages patients to elaborate on their thoughts and feelings. An example of this technique follows: Patient: I've been really upset about my blood pressure and have to take these pills. Nurse: You've been upset . . . Patient: I guess I'm worried about what could happen if my blood pressure gets too bad.

honesty authenticity and trust

Patients should be able to trust that nurses are who they say they are (professional helpers), and that they can be trusted to do everything within their level of expertise to secure the resources and to help meet the patient needs.

adolescents

detailed and accurate explanations may be given to

factors influencing communication

gender; sociocultural differences; roles and responsibilities; space and territoriality; physical, mental, and emotional state; and environment.

group communication

includes small-group and organizational group communication.

4 levels of communication

intrapersonal communication, interpersonal communication, small-group communication, and organizational communication.

process of communication part 2

Auditory—spoken words and cues Visual—sight, observations, and perception Kinesthetic—touch Nurses use all three of these channels to communicate with patients. The receiver (decoder) must translate and interpret the message sent and received. Through the translation of the message, the receiver must then make a decision about an accurate response. To be an effective communicator, the nurse needs to be considerate of the receiver, and select a message that appeals to the patient's interests and that requires minimal effort and time to decode. Recall Randolph Gordon, the middle-aged man who was comatose. When planning Mr. Gordon's care, the nurse would need to incorporate knowledge about changes in mental status and their effect on communication. The patient's current mental status mandates that the messages sent by the nurse and other health care providers be simple, clear, and easy to understand. Confirmation of the message provides feedback (i.e., evidence) that the receiver has understood the intended message. Noise—factors that distort the quality of a message—can interfere with communication at any point in the process. These distractors might be from the television, or from pain or discomfort experienced by the patient. Communication is a reciprocal process in which both the sender and the receiver of messages participate simultaneously. The communication process is illustrated in Figure 20-1. Messages might be influenced on either end by the person's previous knowledge, past experiences, feelings, or sociocultural level. Test your knowledge of communication by reading the situation in Box 20-1 .

other blocks to communication

Changing the Subject A quick way to stop conversation is to change the subject. The patient might be at a point of readiness to discuss something and will likely feel frustrated if put off by a change in the topic of conversation, as in this following example: Patient: When can I expect to be told about my insulin? Nurse: Let's discuss your diet now so that you will know what to eat when you get home. We can discuss your insulin some other time. A nurse might also change the subject when feeling uncomfortable about the topic of conversation. For example, the patient's needs are being met when the nurse allows the patient to speak of impending death, thoughts of suicide, or contemplated abortion. The nurse is ignoring the patient, however, if the nurse changes the subject because of feeling uncomfortable talking about it. Giving False Assurance Because it is easier and more pleasant to deal with positive outcomes than negative outcomes, nurses might try to convince the patient that things are going to turn out well even when knowing the chances are not good. False assurance might give patients the impression that the nurse is not interested in their problems. The use of clichés gives a patient false assurance. Communication might be impeded when providing the patient and family with false assurance. If you inadvertently do use false assurance, then you should explain with an apology and implement effective communication techniques.

values influencing communication

Communication is influenced by the way people value themselves, one another, and the purpose of any human interaction. Nurses who believe that teaching is an important aspect of nursing and who value empowering patients will communicate this to patients. Conversely, a nurse who believes teaching is an unimportant chore is unlikely to be an effective teacher. Similarly, the patient's motivation (or lack of motivation) to develop new self-care behaviors cannot help but influence nurse-patient communication.

process of communication part 1

Communication is the process of exchanging information and generating and transmitting meanings between two or more people. It is the foundation of society and the most primary aspect of a nurse-patient interaction. Without communication, it would be impossible to share family experiences, gain knowledge, establish and maintain practice protocols, and enhance caregiving. By nature, humans are social beings, and human needs are met in collaboration with other humans. Human relationships enable us to meet our physical and safety needs. Communication also assists in meeting our psychosocial needs of love, belonging, and self-esteem. The ability to communicate is basic to human functioning and well-being. David K. Berlo (1960) is credited with the classic description of the communication process, which involves a source (encoder), message, channel, and receiver (decoder). This communication process is initiated based on a stimulus, in this case a patient need that must be addressed. The need might be due to a patient's discomfort or desire for information or to address any uncertainty the patient might be experiencing. The sender or source (encoder) of the message is a person or group who initiates or begins the communication process. The message is the actual communication product from the source. It might be a speech, interview, conversation, chart, gesture, memorandum, or nursing note. The channel of communication is the medium the sender has selected to send the message. The channel might target any of the receiver's senses. The message can be sent to the receiver through the following channels:

eye contact form of nonverbal communication

Communication often begins with eye contact. A glance, for example, is often an attention-getting method to open conversation. In many cultures, eye contact suggests respect and a willingness to listen and to keep communication open. Its absence often indicates anxiety or defenselessness, or avoidance of communication. Some view eye contact as the nonverbal communication that reveals a person's true nature. However, some Asian and Native American cultures view eye contact as an invasion of a person's privacy. In other cultures, people are taught to avoid eye contact or, out of respect, not to make eye contact with a superior. In addition to the messages sent by eye contact, the eyes carry other nonverbal messages. For example, the eyes fix in a stare during anger, tend to narrow in disgust, and ordinarily open wide in fear. Some people who experience fear might be unable to speak and only their eyes will send the message of anxiety. A blank stare can indicate daydreaming or inattentiveness.

true

Concerns about social media occur when nurses inadvertently reveal information about patients that compromise the patients' privacy. Nurses must adhere to Health Insurance Portability and Accountability Act (HIPAA) regulations that protect patient confidentiality and privacy and be aware of their employer's policies about using social media. Health care facilities may specifically address personal use of computers in the facility and types of websites that may be accessed during working hours from employer computers. Health care facility policies often do not address employee use of social media when not at work, but disclosing information that violates the privacy and confidentiality of patients or professional standards, and posting defamatory remarks about an employer, supervisor, co-worker or patient has serious consequences for nurses

ways to improve conversational skills in therapeutic relationship

Control the tone of your voice so that you are conveying exactly what you mean to say and not a hidden message. Your tone should indicate interest rather than boredom, patience rather than anger, acceptance rather than hostility, and so forth. Be knowledgeable about the topic of conversation and have accurate information. When possible, be familiar with the subject of conversation before discussing it with the patient. If the topic is unfamiliar to you (e.g., the availability of community resources for family caregivers of patients with special needs), admit that to the patient and family and direct them to other resources. Convey confidence and honesty to the patient. Be flexible. You might want to discuss a certain subject but learn that the patient wishes to discuss something else. It is better to follow the patient's lead whenever possible; in due time, you can return to the subject. For example, you arrive at the patient's bedside to administer a medication, but the patient begins to talk about diet issues. It is better to take a little time to talk about the patient's interest than to insist on talking about only the procedure at hand, as long as there is enough time for the conversation. Be clear and concise, and make statements as simple as possible. Patients are often anxious and fail to understand the message unless the patient understands the language used. Stay on one subject at a time. This helps prevent confusion. Avoid words that might have different interpretations. The study of the meaning of words is called semantics. Even when two people speak the same language, some words—such as love, hate, freedom, and health—might have different meanings to different people. Be truthful. A patient who is given false information will soon distrust the nurse. If you're not sure about something, admit you don't know and seek an answer rather than make a comment that may be an error. Keep an open mind. An attitude of "I know better than the patient" is quickly discerned by the patient. Patients can make valuable contributions to their own health care. Take advantage of available opportunities. During most caregiving situations, you can facilitate conversation that makes even the most routine task meaningful. For instance, when giving a bed bath to a patient, ask about the patient's employment. This would allow the patient to verbalize any positive or negative feelings about the job and being temporarily absent from it, reducing the anxiety that often occurs with the loss of work. It is often comforting to know that someone understands and cares.

conversation skills therapeutic relationship

Conversation, or the exchange of verbal communication, is a social interaction. As social beings, humans learn as children how to converse with others; nursing students, therefore, have already had years of experience communicating verbally. However, you can improve your communications with patients and achieve a more effective helping relationship in the following ways:

Sounds Nonverbal Communication

Crying, moaning, gasping, and sighing are oral but nonverbal forms of communication. Such sounds can be interpreted in numerous ways. For example, a person might cry because of sadness or joy. Gasping often indicates fear, pain, or surprise. A sigh might be a sign of reluctant agreement to do something or of relief.

true

Describing a patient by using a room number or diagnosis rather than a name is still considered a breach of confidentiality and a violation of patient privacy. When your relationship with a health care institution is apparent, use a disclaimer to verify that any views expressed are yours alone and not your employer's (Pagana, 2011a). Employers also may use social media to screen potential employees as long as they do not violate discrimination laws. Any information you have provided about yourself on a social media website may influence a hiring decision. The ease with which information can be posted on a social media site allows minimal time to consider the implications and the effect a posting can have on a nurse's personal and professional life (NCSBN, 2011).

Disruptive Interpersonal Behavior

Disruptive behavior has a negative effect on clinical outcomes and interpersonal relationships. Adverse events occur when communication between health care professionals is ineffective, abusive, or negative. The Joint Commission (TJC), in an effort to eliminate disruptive behavior in hospitals, issued a leadership standard that requires hospitals to establish a code of conduct defining acceptable and unacceptable behavior. Hospitals are also required to have policies in place to address these incidents when they occur. Additionally, TJC advises hospitals to educate all staff about the code of conduct, develop reporting systems, use mediators when necessary, and document all efforts to address unacceptable behavior (TJC, 2008). Disruptive interpersonal behavior compromises patient safety, influences satisfaction with care, and contributes to medical errors. Incivility is rude, intimidating, and undesirable behavior directed at another person. This behavior is recognized as a major concern among health care workers (Stokowski, 2011). Incivility is considered by some as a precursor to bullying behavior or lateral violence and by others as a form of bullying (Lower, 2012).

working phase

During this phase, the nurse works together with the patient to meet the patient's physical and psychosocial needs. Interaction is the essence of the working phase.

email and text messages

E-mail and text messages are efficient means to communicate with staff members and, in some cases, patients. The risk for violating patient privacy and confidentiality exists any time a message is sent electronically. Health care agencies usually have security measures in place to safeguard e-mail and text communications. E-mail and text messages should be concise and avoid text abbreviations (Pagana, 2012). Nurses should be aware of agency policies and guidelines regarding the use of electronic communication with patients. The patient may have to sign an authorization permitting e-mail communication from the health care agency. Any e-mails sent to a patient must be duplicated and become part of the medical record for that patient. While e-mail and text messages are additional communication tools, it is always necessary to follow agency policies and adhere to your professional code of conduct. Individualizing patient care requires nurses to determine which form of communication is most beneficial for each patient.

empathy

Empathy is identifying with the way another person feels. An empathic nurse is sensitive to the patient's feelings and problems, but remains objective enough to help the patient work to attain positive outcomes. By retaining this quality, you can establish successful helping relationships without appearing cold or stern. Sympathy differs from empathy because it shifts the emphasis from the patient to the nurse as the nurse shares feelings and personal concerns and projects them onto the patient, limiting ability to focus objectively on the patient's needs (Videbeck, 2011). For example, although it is understandable for team members to become impatient with family members who never seem satisfied with the care their loved one is receiving, it helps to empathize with the family who might be feeling frightened and helpless. "This must be a hard time for you . . . how are you coping?" "Is there any way I can be of help?" When the patient and family sense that you have some idea of what they are experiencing and that you are committed to helping, the basis is set for a trusting therapeutic relationship.

gossip and rumor

Gossip and rumor are common forms of communication, particularly in health care settings, sometimes referred to as "the grapevine." Gossip and rumor can produce detrimental effects on relationships and group building. Gossiping might be used to inform, influence others, entertain, or ventilate. It can be harmless but could also damage the reputation of others. Rumors serve similar functions but become more widespread. Both rumors and gossip might cause blocks to team building and damage the reputations of the people who are the subject of the information.

specific objectives ( rapport builders)

Having a purpose for an interaction provides guidance toward achieving a meaningful encounter with the patient. One objective might be to perform a head-to-toe physical assessment when greeting the patient and at the beginning of each shift. Another objective might be the discussion of a patient's feelings about being newly diagnosed with diabetes. The shortest encounter with a patient can have an objective, even if it is as simple as conveying a feeling of friendliness. Be flexible at all times, and follow the patient's cues to work toward meeting all needs.

communicating with patients with special needs

Patients Who Are Visually Impaired Acknowledge your presence in the patient's room. Identify yourself by name. Remember that the visually impaired patient will be unable to pick up most nonverbal cues during communication. Speak in a normal tone of voice. Explain the reason for touching the patient before doing so. Indicate to the patient when the conversation has ended and when you are leaving the room. Keep a call light or bell within easy reach of the patient. Orient the patient to the sounds in the environment and to the arrangement of the room and its furnishings. Be sure the patient's eyeglasses are clean and intact or that contacts are in place. Patients Who Are Hearing Impaired Orient the patient to your presence before initiating conversation. This may be done by gently touching the patient or moving so that you can be seen. Talk directly to the patient while facing him or her. If the patient is able to lip read, use simple sentences and speak in a quiet, natural manner and pace. Be aware of nonverbal communication. Do not chew gum or cover your mouth when talking with the patient. Demonstrate or pantomime ideas you wish to express, as appropriate. Use sign language or finger spelling, as appropriate. Write any ideas that you cannot convey to the patient in another manner. Be sure that hearing aids are clean, functioning, and inserted properly. Patients With a Physical Barrier (Laryngectomy or Endotracheal Tube) Select one or more simple means of communication that the patient is physically able to use. Options include eye blinks or hand squeezes to communicate yes or no; writing pads or magic slates; communication boards with words, letters, or pictures; flash cards; sign language. Be sure that everyone communicating with the patient—family, friends, and caregivers—understands and is able to use the communication devices selected. Demonstrate patience with the time needed to communicate effectively, and reinforce the patient's efforts. Ensure that the patient has an effective means of signaling need for assistance, such as a call bell or alarm. Patients Who Are Cognitively Impaired Establish and maintain eye contact with the patient to hold attention. Communicate important information in a quiet environment where there is little to distract the patient's attention. Keep communication simple and concrete. Break down instructions into simple tasks and avoid lengthy explanations. Do not use pronouns or abstract terms. Use pictures or drawings when appropriate. Whenever possible, avoid open-ended questions. Ask "Would you like to wear the brown pants or the gray pants?" instead of "What would you like to wear?" Be patient and give the patient time to respond. If the patient does not respond after 2 minutes, repeat what you said. If there is still no response, take a break before continuing the conversation so that neither you nor the patient becomes frustrated. Patients Who Are Unconscious Be careful of what is said in the patient's presence. Hearing is believed to be the last sense lost; therefore, the unconscious patient is often likely to hear even though there is no apparent response. Assume that the patient can hear you. Talk in a normal tone of voice about things you would ordinarily discuss. Speak with the patient before touching. Remember that touch can be an effective means of communication with the unconscious patient. Keep environment noises at as low a level as possible. This helps the patient focus on the communication. Patients Who Do Not Speak English Use an interpreter whenever possible. Use a dictionary that translates words from one language to another so that you can speak at least some words in the patient's language. Speak in simple sentences and in a normal tone of voice. Demonstrate or pantomime ideas you wish to convey, as appropriate. Be aware of nonverbal communication. Remember that many nonverbal communication cues are universal.

humor therapeutic relationship

Humor is increasingly valued as both an interpersonal skill for the nurse and a healing strategy for patients. Nurses can use humor effectively to maintain a balanced perspective in their work and to encourage patients to do the same. Nurses with a sense of humor are able to laugh at themselves and accept their failures, confront the absurdities of everyday practice without falling apart, and challenge patients to situate their current dilemma within the context of their larger life experiences. Laughter releases excess physical and psychological energy and reduces stress, anxiety, worry, and frustration. Humor, like other interpersonal competencies, is a learned skill. When used inappropriately, however, it can be destructive. You'll need an awareness of how various cultures perceive the use of humor in the presence of an illness. You might also find it helpful to identify nurses who use humor well and to "try on" observed behaviors. The use of humor is also discussed in

characteristics of a helping relationship

It is dynamic. Both the person providing the assistance and the person being helped are active participants to the extent each is able. It is purposeful and time limited. This means there are specific goals that are intended to be met within a certain period. Although both parties in the helping relationship have responsibilities, the person providing the assistance is professionally accountable for the outcomes of the relationship and the means used to attain them. Helping persons should present their helping abilities as honestly as possible and not promise to provide more assistance than they can offer.

professionalism

It is of great importance to remember that helping relations are professional relationships. It can be helpful to identify nurse models who, through their appearance, demeanor, and behavior, communicate a clear sense of professionalism or confidence and expertise in their practice. Patients and the public are more likely to trust and value nurses who appear competent and confident and who are focused on the patients entrusted to their care. Rudeness, sloppiness, inattention to person, sexually inappropriate behavior, and other breaches of professionalism undermine nursing's professional image and the effectiveness of individual nurses.

directing questions in an interview

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 patient's health status and educational or counseling needs. The following is an example of this technique: Nurse: You mentioned your dad earlier. Did he develop complications related to high blood pressure? Patient: Yes. Nurse: What sort of complications? Patient: Kidney failure. He was on dialysis for years before getting a transplant. Nurse: Are you afraid this might happen to you?

failure to listen

Patients might or might not feel able to speak freely to the nurse. Often, the signals indicating their readiness to talk are subtle. Don't miss valuable opportunities for important communication by approaching patients with a closed mind or focusing on your own needs rather than on the patient's needs. Nurses who lack confidence in their own ability to meet the challenges a patient presents might become defensive in response to a patient's comments. Nurse defensiveness is a huge barrier to open and trusting communication.

listening skills therapeutic relationships

Listening is a skill that involves both hearing and interpreting what the other says. It requires attention and concentration to sort out, evaluate, and validate clues to better understand the true meaning of what is being said (Fig. 20-7). The accompanying box, Through the Eyes of a Student, relates one student's experience with attentive listening. The following techniques are recommended to improve listening skills: When possible, sit when communicating with a patient. Do not cross your arms or legs because that body language conveys a message of being closed to the patient's comments. Be alert and relaxed and take sufficient time so that the patient feels at ease during the conversation. Keep the conversation as natural as possible, and avoid sounding overly eager. If culturally appropriate, maintain eye contact with the patient, without staring, in a face-to-face pose. This technique conveys interest in the conversation and willingness to listen. Indicate that you are paying attention to what the patient is saying by using appropriate facial expressions and body gestures. Be attentive to both your own and the patient's verbal and nonverbal communication. Think before responding to the patient. Responding impulsively tends to disrupt communication and listening. Do not pretend to listen. Most patients are sensitive to an attitude of feigned attention or to boredom and apathy. Listen for themes in the patient's comments. What are the repeated themes in the person's speech and behavior? What topics does the patient tend to avoid? What subjects tend to make the patient shift the conversation to other subjects? What inconsistencies and gaps appear in the patient's conversations?

Openess and respect

One key factor to effective communication is to be open, accepting, frank, respectful, and without prejudice. Patients who feel that a nurse is being judgmental might withhold significant information. You need to develop sensitivity to the unique challenges presented by each patient. Attention to patient variables that might influence the process of communicating (e.g., gender, developmental level, culture, life experience) can make the difference between effective and ineffective interactions. Box 20-4 highlights guidelines for relating to patients from different cultures (see also Chapter 5).

caring

Patients quickly sense whether they are merely a "task to be performed" (task-centered caring), or a person of worth who is both cared about and cared for (relation-centered caring). Expert nurses know how to communicate genuine caring the minute they step into a patient's space by how they look at and touch the patient and what they say and do. Patients who feel cared for will feel accepted.

therapeutic communication in helpful relationship

Nurses and other health care personnel enter health care in order to help people. Relationships between health care providers and patients do not develop but occur through purposeful communication. A helping relationship exists among people who provide and receive assistance in meeting human needs. It sets the climate for the participants to move towards common goals. Therefore, the patient's needs are met as the result of a successful helping relationship. In this book, the term helping relationship is used to refer to such relationships between nurses and patients (Fig. 20-5). When a nurse and patient are involved in a helping relationship, sometimes called the nurse-patient relationship, the nurse is the helper and the patient is the person being helped. The quality of the relationship between these individuals is the most significant element in determining helping effectiveness. "Of all the problems that can arise in nursing care, perhaps the most common is failure to establish rapport and a helping-trust relationship with the other person" (Watson, 1985, p. 24). Communication is the means used to establish rapport and helping-trust relationships.

negative communication between nurses and physcians

Nurses continue to report the occurrence of negative communication with physicians. In a 2012 survey, 42% of nurse leaders reported that physician abuse or disrespect of nurses is still common (Gessler, Rosenstein, & Ferron, 2012). This factor is often cited as a contributor to poor job satisfaction and jeopardizes nurse retention. Nurses describe this disruptive behavior by physicians as rude, intimidating, and belittling, and state that it occurs more frequently with older physicians than among younger ones. In settings where teamwork is essential, such as operating rooms and intensive care areas, the relationship between nurse and physician is more positive. Nurses who remain current in their field of expertise, become involved in informal collaborative work groups, and participate in interdisciplinary hospital committees feel more empowered in their encounters with physicians. It is a mistake to permit negative behavior by a physician to discourage any future communication. When disruptive physician behavior occurs, it is best to respond assertively and confront the physician directly. If this is not possible, ask to speak to the physician in private and address any disrespectful remarks or behaviors. Nurses should factually document the occurrence of any bullying behaviors and speak to a nurse-manager if the behavior continues (Gessler, Rosenstein, & Ferron, 2012). Nurses who stay focused and professional and approach physicians in a collegial manner will be better prepared to avoid negative communication. If it occurs, the hospital administration policies and procedures should be implemented to deal with individual situations in a constructive manner.

failure to percieve patient as a human being

Nurses must focus on the whole patient and not merely the patient's diagnosis. Patients report that nothing is more discomforting than to be treated as merely an object of care rather than a patient. Patients should be addressed by a formal name such as Mr., Mrs., Ms., or Dr. rather than slang terminology such as "honey" or "sweetie." What distinguishes nursing from other health professions is its focus on the whole person, not simply the illness or dysfunction.

ana six principles of social media

Nurses must not transmit or place online individually identifiable patient information. Nurses must observe ethically prescribed professional patient-nurse boundaries. Nurses should understand that patients, colleagues, institutions, and employers may view postings. Nurses should take advantage of privacy settings and seek to separate personal and professional information online. Nurses should bring content that could harm a patient's privacy, rights, or welfare to the attention of appropriate authorities. Nurses should participate in developing institutional policies governing online conduct.

sociocultural differences influencing communication

Nurses need to recognize ways in which culture, economic condition, and overall lifestyle influence a patient's preferred mode of communicating. This helps one understand what the patient understands. Currently, approximately one in five U.S. residents speaks a language other than English (Ashton, 2012). Culture refers to the common lifestyles, languages, behavior patterns, traditions, and beliefs that are learned and passed from one generation to the next. The first step toward cultural competence requires becoming aware of your own personal cultural beliefs and identifying "prejudices or attitudes that could be a barrier to good communication" (Gerace & Salimbene, 2010). Likewise, understanding a patient's culture helps you understand nonverbal communication and deliver accurate nursing care to the patient and family. For example, women in some cultures might speak of personal things only to their spouses. For this reason, a maternal care nurse might talk with the patient's husband about the woman's postdelivery care. The health care system is a culture with its own customs, values, and language. Patients with limited proficiency in English have difficulty understanding medical instructions and understanding test results and diagnoses. Try to remain aware of these cultural variations and be careful to use lay terminology when speaking with patients, unless you know that the patient is a health care professional. Use of medical terminology (e.g., myocardial infarction for heart attack, cerebrovascular accident for stroke [brain attack], or cholecystectomy for gallbladder operation) usually alienates patients and can inhibit further communication. A patient's language proficiency should be evaluated upon admission to a health care facility, and medical interpreters should be available to facilitate any communication and improve the quality of care (Ashton, 2012). The recent Joint Commission Standards for Patient-Centered Communication and criteria for accreditation are discussed in detail in Chapter 21.

space and territoriality factors influencing communication

People are most comfortable in areas they consider their own. We generally feel relief when we come home, take our shoes and professional clothes off, and relax. This urge to maintain an exclusive right to certain space is termed territoriality. You might have already noticed that patients behave differently when being interviewed in their homes, at a health fair in the mall, or in an institutional setting. Similarly, health care professionals might behave differently when they are "on their own turf" in a health care setting compared to when they enter a patient's home as a guest caregiver. It is important to understand how territoriality influences the nurse-patient relationship. The actual physical difference between the nurse and patient during interaction is also important. Proxemics is the study of distance zones between people during communication (Videbeck, 2011). Each person has a sense of how much personal or private space is needed and what distance between people is optimum. Figure 20-3 demonstrates the four communication zones. Activities that are likely to occur during each of these zones include: Intimate zone: interaction between parents and children or people who desire close personal contact Personal zone: distance when interacting with close friends Social zone: space when interacting with acquaintances such as in a work or social setting Public zone: communication when speaking to an audience or small groups Some aspects of communication zones are dictated through culture, and some are idiosyncratic. Anywhere from 18 inches to 4 feet might be optimal distance to sit from a patient during an intake interview. For example, European Americans and African Americans require more personal space between two people who are speaking than other cultures (Mediterranean, Hispanic, Asian, Middle Eastern, East Indian) who are comfortable at a closer distance when speaking (Videbeck, 2011). People in the United States usually are comfortable standing about 3 feet away from each other when speaking (Pagana, 2011b). It is best to take cues from patients, noting whether they are moving backward from you if you are too near or leaning forward to get closer to you. Because many nursing interventions place one in proximity to a patient and entail forced intimacy, be sensitive to how offensive this might be to certain patients who are accustomed to large areas of private space. Develop the habit of seeking the patient's permission before touching areas within a patient's private zones. Although most people consider their hands, arms, shoulders, and back within a social zone, increasing levels of privacy are according to (1) mouth and feet; (2) face, neck, and front of body; and (3) genitalia

closed questions in an interview

The closed question provides the receiver with limited choices of possible responses and might often be answered by one or two words, "yes" or "no." Closed questions are used to gather specific information from a patient and to allow the nurse and patient to focus on a particular area. Closed questions are often a barrier to effective communication. The following is an example of an appropriate use of a closed question: Nurse: What medicines have you been taking at home? Patient: Let me see, my doctor gave me a water pill and a blood pressure pill to take every day.

physical mental and emotional states influencing communication

The degree to which people are physically comfortable and mentally and emotionally free to engage in interactions also influences communication. A full bladder, a dull headache, crushing chest pain, anxiety about a pending diagnosis or concern about what is happening at home or at work, and fear can all negatively influence communication. For example, patients who think that a nurse wants to hurt them will be difficult to interview. Be sensitive to the patient's physical, mental, and emotional barriers to effective communication. Cognitively impaired patients present special communication challenges. For example, an older patient who has aphasia and is agitated due to pain from an abscessed tooth might be unable to communicate with the nurse. The accompanying box, Examples of Nursing Interventions and Nursing Outcomes Classifications (NIC/NOC), suggests helpful cognitive stimulation activities and expected outcomes when communicating with these patients.

goals of a helping relationship

The goals of a helping relationship between a nurse and a patient are determined cooperatively and are defined in terms of the patient's needs. Broadly speaking, common goals might include increased independence for the patient, greater feelings of worth, and improved health and well-being. Selected nursing interventions will help the person move toward the goal. As the patient's needs and goals change, so do the nursing care interventions implemented to attain the patient's goals. You might also have many needs to be met, but in the helping relationship between the nurse and the patient, those are temporarily set aside—the focus is on the patient's needs.

orientation of phase of helping relationship

The helping relationship ideally begins between the nurse and patient during the data-gathering part of the nursing process. It can also be initiated at other times during the nurse-patient relationship. In the orientation phase, the tone and guidelines for the relationship are established. You and the patient meet and learn to identify each other by name. It is especially important to introduce yourself to the patient; it might even be helpful to write your name for the patient. Failure to do so might result in the patient becoming confused and mistrustful because of the number of caregivers with whom most patients come in contact. The following activities generally occur during the orientation phase of the helping relationship: The roles of both people in the relationship are clarified. An agreement or contract about the relationship is established. The agreement is usually a simple verbal exchange related to goals and the means of achieving them or occasionally a written document, especially if the relationship extends over a long period of time. The patient is provided with an orientation to the health care facility, its services, admission routines, and any pertinent information the patient requires to decrease anxiety. This orientation should be identified as one of the goals in the nurse-patient helping relationship. The development of a trusting relationship is critical to the development of the nurse-patient relationship. Exhibiting openness and interest in the concerns of the patient paves the way for developing trust and communicating care and respect.

developmental level

The rate of language development is directly correlated with the patient's neurologic competence and cognitive development. Thus, it is helpful to understand the process of language development and the stages of intellectual and psychosocial development. This helps you communicate effectively with patients and family of all age ranges. The stages of development are presented in Chapters 17, 18, and 19. Knowing how each age group commonly perceives health, illness, and body functions should guide your interactions with patients. For instance, a 10-year-old child has limited understanding of what an infection is; therefore, explain things in simple terms so that the child cooperates with the treatment without being frightened. Because adolescents are developing abstract thinking, more detailed and accurate explanations can be given to them. Being familiar with commonly used slang usually helps when communicating with adolescents. Communicating with adults can be affected by their past positive or negative health-related experiences and by inaccurate information. When communicating with older patients, assess for any problems with hearing or sight (discussed later in this chapter), confusion, or depression, any of which could affect nurse-patient interaction.

termination phase of helping relationship

The termination phase occurs when the conclusion of the initial agreement is acknowledged. This might happen at change-of-shift time, when the patient is discharged, or when a nurse leaves on vacation or for employment elsewhere. At this point, you'll examine with the patient the goals of the helping relationship for indications of their attainment or for evidence of progress toward them. If the goals/outcomes have been reached, this fact should be acknowledged. Such acknowledgment generally results in a feeling of satisfaction for the patient and nurse. If the goals/outcomes have not been reached, the progress can be acknowledged and either the patient or you might make suggestions for future efforts. Ordinarily, emotions are associated with the termination of a helping relationship. If the goals have been met, there is often regret about ending a satisfying relationship, even though a sense of accomplishment persists. If the goals have not been achieved, the patient might experience anxiety and fear about the future. Whatever the feelings, patients should be encouraged to express their emotions about the termination. You can prepare for the termination of the helping relationship in various ways. It is thoughtful to set the stage for the patient to establish a helping relationship with another nurse, if appropriate. You can also assist the patient transferring from one agency to another or from one unit in an agency to another by offering explanations concerning the transfer. In some instances, you might introduce the patient to personnel who will be giving care. Interpersonal relations are discussed in greater detail in the classic works of nursing theorists Orlando (1961), Paterson and Zderad (1976), Peplau (1952), Travelbee (1971), and Watson (1985).

Non-verbal communication

The transmission of information without the use of words is termed ___________________, also known as body language. It often helps nurses to understand subtle and hidden meanings in what the patient is saying verbally. For example, a nurse asks the patient, "How do you feel today?" The patient responds, "I feel all right." However, the nurse notes that the patient does not maintain eye contact and his facial expression is tense. This would indicate that the nurse should investigate further because of the incongruence of the patient's verbal and ___________________ (Fig. 20-2). Information is exchanged through ___________________ in various ways. It is generally accepted that ___________________ expresses more of the true meaning of a message than verbal communication. Therefore, nurses must be aware of both the nonverbal messages they send and the nonverbal messages they receive from patients. Nurses working with patients from diverse cultural backgrounds should attempt to understand cultural variations to avoid misunderstanding ___________________. The various forms of ___________________ follow.

clarifying questions in the interview

The use of the clarifying question or comment allows the nurse to gain an understanding of a patient's comment. When used properly, this technique can prevent possible misconceptions that could lead to an inappropriate nursing diagnosis. However, overuse of clarifying questions or comments can lead the patient to believe that the nurse is not listening or lacks appropriate knowledge. The following is an example of effective use of this technique: Patient: I have never needed to take medicine before in my life. Nurse: Is this the first health problem you have had? Patient: Yes, I've always been healthy.

posture non verbal communication

The way a person holds the body carries nonverbal messages. People in good health and with a positive attitude usually hold their bodies in good alignment. Depressed or tired people are more likely to slouch. Posture also often provides nonverbal clues concerning pain and physical limitations, for instance, a rigid, stiff appearance might be a good indicator of tension and pain.

working phase of the helping relationship

The working phase is usually the longest phase of the helping relationship. During this phase, the nurse works together with the patient to meet the patient's physical and psychosocial needs. Interaction is the essence of the working phase. Nurse-patient interactions that occur at this time are purposeful in that they are designed to ensure achievement of health goals or objectives that were mutually agreed upon. In addition, the nurse as caregiver provides the patient with whatever assistance might be needed to perform activities of daily living. For example, if a patient with impaired mobility is unable to get out of bed except to use a bedside commode, the nurse or caregiver needs to help with daily hygiene. The nursing roles of teacher and counselor (see Chapter 21) are performed primarily during this phase. These roles involve motivating the patient to learn and to implement health-promotion activities, to facilitate the patient's ability to execute the plan of care, and to express feelings about health problems, nursing care, any progress or setbacks, and any other areas of concern. This is where your interpersonal skills are used to their fullest (see the discussions of interpersonal skills and effective communication techniques later in this chapter). A breakdown of the helping relationship on one of these levels could result in serious consequences. Satisfactory interaction preserves people's integrity while promoting an atmosphere characterized by minimal fear, anxiety, distrust, and tension. People feel harmonious and contented with each other as they work cooperatively to reach common goals.

validating questions in an interview

This type of question or comment serves to validate what the nurse believes he or she has heard or observed. Overusing validating questions and comments might lead the patient to think the nurse is not listening, however. To continue the example used in the previous technique, the nurse could validate the patient's reply as follows: Nurse: At home, you have been taking both a water pill and a blood pressure pill every day. Did you take them today? Patient: Yes, I took one of each with my breakfast.

touch in therapeutic communication

Touch is a powerful means of communication with multiple meanings. It can connect people; provide affirmation, reassurance, and stimulation; decrease loneliness; increase self-esteem; and share warmth, intimacy, approval, and emotional support. It can also communicate frustration, anger, aggression, and punishment, and invade personal space and privacy (Videback, 2011). Because of the personal nature of touching, be sure to weigh the benefit of touch against the detrimental use of touch for each patient. Touch can be a powerful therapeutic tool when used at the right time. Anxiety or discomfort might result, however, when a patient does not understand the meaning of a tactile gesture or when the patient simply dislikes being touched. Touch is the most highly developed sense at birth. Tactile experiences of infants and young children appear to be essential for the normal development of self and awareness of others. It has also been found that many older people long for touch, especially when isolated from loved ones because of hospitalization or being in a long-term care facility. Many older people have no living family to provide them with the caring touch so necessary for the sense of well-being. In such an instance, you can provide some special care by holding the patient's hand (Fig. 20-8). Many situations require touching the patient while implementing nursing care. Physical closeness between the patient and the nurse is essential and inevitable. Therefore, every nurse needs to become comfortable with the judicious use of this nonverbal communication technique so that a sense of security, rather than anxiety, results. As well, dexterity and sureness in the use of the hands help to assure the patient of your expertise when measuring blood pressure or giving an injection. Interest has continued to grow in the phenomenon known as 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. Many nurses are studying therapeutic touch in nursing educational programs and through special courses or workshops. It is becoming a widely accepted form of therapy, as well as a subject for nursing research. Many patients testify to the benefits of therapeutic touch. Refer to Chapters 27 and 34 for additional discussion of therapeutic touch.

other non therapeutic communication in a relationship

Using Questions Containing the Words Why and How Questions using the words why and how are intimidating to many patients. Consider the following questions: Nurse: Why were you not tired enough to sleep? Nurse: How did you ever decide to go on a crash diet? These two questions would be better stated as follows: Nurse: What were you doing while you were unable to sleep? Nurse: What things prompted you to decide to go on a crash diet? Using Questions That Probe for Information Questions that too obviously probe for information might cut off communication. Patients who are made to feel as though they are receiving the "third degree" become resentful, usually stop talking, and try to avoid further conversation. Although more information might be needed, it is better to follow the patient's lead. Letting the patient take the initiative allows you to delve more deeply at a time when the patient is ready. A nurse who says, "Let's get to the bottom of this" is likely to destroy conversation, unless the patient is ready to face the real cause of the problem. Using Leading Questions A leading question suggests what response the speaker wishes to hear. Leading questions tend to produce answers that might please the nurse but are unlikely to encourage the patient to respond honestly without feeling intimidated. Consider the following examples: Nurse: You aren't going to smoke that cigarette, are you? Nurse: You have been well cared for by your nurses, haven't you? These questions direct patients to give an answer that pleases the nurse rather than to express their own thoughts. Using Comments That Give Advice Giving advice often implies that the nurse knows what is best for patients and denies them the right to make decisions and have feelings. It also tends to increase the patient's dependence on caregivers. However, advice does have a rightful place when it is requested and when the person giving the advice has expert knowledge that the patient does not. Using Judgmental Comments Judgmental comments tend to impose the nurse's standards on the patient. Consider the comment of a nurse who notes that a young woman is crying: Nurse: You aren't acting very grown up. How do you think your husband would feel if he saw you crying like this? The nurse judges the patient as being immature, and the nurse's apparent hostility could end effective communication. A better comment in this situation might be as follows: Nurse: I would like to help. Tell me, what is making you cry? Consider the following exchange between a nurse and a patient about to have surgery: Patient: I think I have a right to be afraid of this operation. Nurse: Tell me what makes you feel afraid. This patient is likely to feel safe when allowed to express feelings without being judged.

variables of effective and ineffective groups

VARIABLE EFFECTIVE GROUP INEFFECTIVE GROUP Group identity Members value and "own" the aims of the group; aims are clearly articulated. Group's aims are not of major importance to members. Cohesiveness Members generally trust and like one another and are loyal to the group; high commitment; high degree of cooperation. Members often feel alienated from the group and from one another; low commitment; members tend to work better alone than with the group. Patterns of interaction Honest, direct communication flows freely; members support, praise, and critique one another. Communication is sparing; little self-disclosure; self-serving roles (i.e., dominator, blocker, or aggressor) may be unchecked. Decision making Problems are identified, appropriate method of decision making is used (i.e., individual, minority, majority, consensus, or unanimous); decision is implemented and followed through; group commitment to decision is high. Problems are allowed to build without resolution; little responsibility is shown for problem solving; group commitment to decision is low. Responsibility Members feel strong sense of responsibility for group outcomes. Little responsibility for group felt by group members. Leadership Effective style of leadership to meet desired aims Ineffective leadership styles Power Sources of power are recognized and used appropriately; needs or interests of those with little power are considered. Power is used and abused to "fix" immediate problems; little attention to needs of powerless.

assertive vs aggressive behavior

When interacting with patients, family members, other nurses, physicians, and other members of the health care team, nurses should communicate in a way that demonstrates respect for all parties. Assertive behavior is the ability to stand up for oneself and others using open, honest, and direct communication. The focus is on the issue and not the person. Assertive behaviors, which are one hallmark of professional nursing relationships, are very different from aggressive (i.e., harsh, injurious, or destructive) behaviors. They also differ greatly from avoidance or acquiescent behaviors. The key to assertiveness is expressing feelings and beliefs in a nondefensive manner. "I" statements—"I feel . . ." and "I think . . ."—play an important role in assertive statements. They communicate personal feelings and preferences without expressing a judgment or blaming another person (Hodgetts, 2011). Table 20-2 gives examples of assertive, nonassertive, and aggressive speech. Characteristics of the assertive nurse's self-presentation include a confident, open body posture; eye contact; use of clear, concise "I" statements; and the ability to share effectively one's thoughts, feelings, and emotions. The assertive nurse's attitude toward work is characterized by working to capacity with or without supervision, the ability to remain calm under supervision, the freedom to ask for help when necessary, the ability to give and accept compliments, and honesty in admitting mistakes and taking responsibility for them. Aggressive behavior, on the other hand, involves asserting one's rights in a negative manner that violates the rights of others. Aggression can be verbal or physical. It is communication that is marked by tension and anger, and inhibits the formation of good relationships and collaboration. Characteristics of aggressive verbal behavior include using an angry tone of voice, making accusations, and demonstrating belligerence and intolerance (Zeiler, 2010). Aggressive behavior is rude and threatening. The focus is usually on "winning at all costs" and/or demonstrating personal excellence (Marquis & Huston, 2012). Comments such as "do it my way" or "that's just enough out of you" are examples of aggressive verbal statements. People speaking in an aggressive manner may invade another's personal space, speak loudly, and use gestures that are very emphatic or threatening. Aggressive people enhance their self-esteem and prove their superiority through destructive comments directed at others.

open ended questions in an interview

When obtaining a nursing history, use the open-ended question technique to allow the patient a wide range of possible responses. It allows patients to express what they understand to be true, yet is specific enough to prevent digressing from the issue at hand. It encourages free verbalization. The greatest advantage of this technique is that it prevents the patient from giving a simple yes or no answer that has the effect of limiting the patient's response. The following is an example of an open-ended question and the response: Nurse: What did your physician tell you about your need for this hospitalization? Patient: He told me that my blood pressure is dangerously high and that I need some special tests done while I am here.

verbal communication

___________________ is an exchange of information using words, including both the spoken and written word. ___________________ depends on language, or a prescribed way of using words so that people can share information effectively. Language includes a common definition of words and a method of arranging the words in a certain order. A person's use of written and spoken language forms reveals aspects of the person's intellectual development, educational level, and geographic and cultural origin. Nurses must also consider whether English is a second language for the patient. Language helps nurses assess what the patient knows and feels. In turn, nurses must develop their own language skills to assist in reciprocal responses in the communication process. Nurses use ___________________ extensively when providing patient care, including verbal interactions with patients and family, giving oral reports to other nurses, writing care plans, and recording progress in the patient's chart. Other examples of ___________________ include public speaking, writing for publication, and composing signs and posters. Words and language in the previous examples communicate messages to others.

rapport

a feeling of mutual trust experienced by people in a satisfactory relationship (Fig. 20-6), facilitates open communication.

true

always make the communication at the pace of the patient

social media

are web-based technologies that allow users to create, share, and participate in dialogue in virtual communities and networks

group dynamics

involve how individual group members relate to one another during the process of working toward group goals. Although effective leadership facilitates a group's achievement of its goals, success or failure largely results from members' behavior. Ideally, all group members use their talents and interpersonal strengths to help the group to accomplish its goals. The group's ability to function at a high level depends on each member's sensitivity to the needs of the group and its individual members. Effective groups have members who are mutually respectful. If a group member dominates or thwarts the group process, then the leader or other group members must confront that member to promote the needed collegial relationship. Effective and ineffective groups are contrasted in Table 20-1.

touch

is viewed as one of the most effective nonverbal ways to express feelings of comfort, love, affection, security, anger, frustration, aggression, excitement, and many others.

interpersonal communication

occurs between two or more people with a goal to exchange messages. Most of the nurse's day is spent communicating with patients, family members, and members of the health care team. The ability to communicate effectively at this level influences your sharing, problem solving, goal attainment, team building, and effectiveness in critical nursing roles (e.g., caregiver, teacher, counselor, leader, manager, patient advocate).

small group communication

occurs when nurses interact with two or more people. To be functional, members of the small group must communicate to achieve their goal. Examples of small-group communication include staff meetings, patient care conferences, teaching sessions, and support groups. The more people involved in the communication process, the more complex it becomes

organizational communication

occurs when people and groups within an organization communicate to achieve established goals. Nurses on a practice council meeting to review unit policies, or nurses working with interdisciplinary groups on strategic planning or quality assurance, use organizational communication to achieve their aims.

intrapersonal communication

or self-talk, is communication within a person. This communication is crucial because it affects the nurse's behavior and can enhance or detract from positive interactions with the patient and family. Imagine two different nursing students preparing for the first experience with a critically ill patient. Both are frightened. One tells herself, "Calm down, you've been in challenging situations before and always survived. You can handle this." The other repeatedly tells himself, "There's no way you can survive this experience. The instructor will be all over you, and you might as well admit defeat before you start." Obviously, the first student's positive self-talk is more helpful than that of the second student.

commonalities between helpful vs social relationships

the components of care, concern, trust, and growth

asian and native american

view eye contact as an invasion of a person's privacy. In other cultures, people are taught to avoid eye contact or, out of respect, not to make eye contact with a superior.

investigate the incongruence

what should the nurse do if there is an incongruence beteween a patients verbal and non verbal communication

during the data gathering phase

when does the orientation phase ideally begin