Communication and Customer Service in the Healthcare Office: Module 1: Introduction to Therapeutic Communication

Feedback

A method by which participants in a communication encounter can check their understanding of the messages exchanged.

The Receiver

A receiver is the recipient of the sender's message. The receiver must decode the message by evaluating the communication. The primary sensory skill used in verbal communication is listening. The spoken words, as well as the tone and pitch of voice, carry meaning. Even written communications carry a "tone" that is perceived by the receiver. It may be entirely neutral, only factual, but it may also indicate care and concern by the words used and the expressions identified. Any emphasis made by the sender must be fully understood by the receiver for the message to have meaning. The receiver, however, must also remember that his or her experiences, emotions, ideas, and beliefs will enter into the sense of the message.

Jen, a medical assistant, and Maria, a teenage patient. To successfully communicate with a patient, you should

encourage the patient with affirmative remarks or gestures.

The 6 Steps of the Communication Process

1 Set communication goals: Determine what is to be accomplished. This requires considering the receiver's needs, current circumstances, and the duties assigned to the health care professional. 2 Create the message: Select and organize appropriate content based on the communication goals and characteristics of the receiver. 3 Deliver the message: Choose the delivery method best suited for ensuring that the receiver will understand the intent of the message. 4 Listen to the response: Employ listening and observational techniques to determine whether the message was received as intended. 5 Offer feedback and seek clarification: Rephrase what you hear and/or ask questions or use teach back (asking receivers to explain what you have said in their own words) to check the receiver's understanding. 6 Evaluate the encounter and revise the message, if necessary: Determine whether the goal was met. If not, why not? What other options are available? What should be the next step?

blog

A Web site that is run by an individual or a group, is regularly updated, and generally is informal or conversational in style.

Reflecting

A communication technique that involves prompting the sender to either complete or add more detail to the original message.

Requesting examples

A communication technique to get additional, clarifying information.

Asking questions

A communication technique used to request clarification and additional information.

What is the meaning of health literacy?

Ability to obtain and understand basic health information.

Professional Application

As mentioned earlier, you are entering into a "helping profession." Caring must be an essential emotion for you. Are you the type of person most suited for a career in the health care profession? Some members of helping professions give so much of themselves to their clients and their work that they quickly become disillusioned and suffer burnout. Others remain so aloof and detached from their work and their clients' needs that they can become rude and disinterested. Neither situation is appropriate, successful, nor therapeutic. Health care professionals will want to ask themselves the following simple questions: 1.Do you genuinely enjoy helping people in a therapeutic manner? This implies that you have the technical skills and knowledge to help people solve their problems, and that you do so without the need to create more power for yourself. 2.Can you feel comfortable assuming a "servant" role for those in need? "Servant" does not imply "slave," but you must genuinely enjoy serving the needs of others. 3.Will you be able to treat any person as a "guest" no matter what their special circumstances may be? Remember, your employment is dependent upon a satisfied customer. 4.Can you be open to people and accept their differences? Even though your personal lifestyle might be quite the opposite, can you be accepting and unflappable? Are you tolerant? Can you keep your opinions to yourself and be aware of your body language? 5.Can you be firm, yet gentle? Procedures you perform may cause discomfort and/or pain, but your verbal and nonverbal communication must convey both firmness and gentleness. 6.Can you keep yourself out of a codependent relationship with those you help? People in helping professions may adopt a hostile attitude toward their clients after so many years of rescuing and giving so much. Many health care professionals are harried and overcommitted, and so locked into a caretaker role that they feel dismayed and rejected when they cannot "save" someone.

Cameron's supervisor told him during a performance evaluation that his work was not meeting the standards set by the clinic. What should Cameron do?

Ask the supervisor to explain what he means by "not meeting the standards."

teach back

Asking receivers (listeners) to explain what you have said in their own words.

Fascinating Facts

Between 70% and 80% of our waking hours are spent in some form of communication: approximately 30% speaking and 45% listening. The average person speaks at 125 to 175 words per minute and can understand 400 words per minute. After listening to a 10-minute presentation, the average person retains 50% of what was said. After 48 hours, retention drops to 25%.

The Communication Cycle

Communication is the sending and receiving of messages. Sometimes we are aware or conscious of the messages being sent or received and sometimes we are not. We are, however, always sending and receiving them. Communication is a complex action in which two or more people participate. Five basic elements involved in the communication cycle: 1.the sender, 2.the message, 3.the transmission or mode of communication, 4.the receiver, and 5.feedback.

Body Language

Body posture and movements convey messages. Some body language can have a negative impact on the receiver. Examples include crossing the arms, shrugging the shoulders, tapping the fingers or feet, clenching the fists, and rolling the eyes. These can communicate disagreement, lack of interest, disbelief, and impatience. Positive body language conveys interest, caring, and the willingness to listen to the sender's message, even if there is disagreement. It encourages sharing information and promotes exchanging honest messages. Positive body language includes the following: Looking at the other person Directing the body toward the other person Leaning slightly toward the person being addressed Holding the body in a relaxed position Nodding or verbalizing ("uh huh," "yes," "tell me more") occasionally to indicate acknowledgment Having open and warm facial expressions Approaching the patient, if standing at a distance Stopping the performance of tasks to give your full attention Positive body posture communicates "I am focused on, and paying attention to, you and what you are saying." Actions must match words. For example, if a patient wants to discuss a sensitive matter and the health care professional listens while facing toward the door, the message to the patient may be "I'm really in a hurry to leave." In another example, a health care professional wants to reassure a patient, but looks away nervously while speaking. The message will seem false and the patient will sense that important information, possibly negative, is being left unsaid. Establishing trust, an essential ingredient in effective communication, requires that spoken and nonverbal communications match. The use of pantomime, body movements that convey ideas or actions, can communicate when speaking is not possible or when the patient does not understand English. For example, acting out the movements a patient must make when performing an exercise can demonstrate exactly what needs to be done. Gestures are helpful when patients cannot be attended to immediately. Acknowledging their presence conveys respect and creates good will. For example, if the medical receptionist is speaking on the telephone when a patient arrives for an appointment, the patient should be greeted with a smile, nod of the head, and quick hand gesture to indicate that he or she will be attended to shortly.

Summary of Good Listening Skills

Clear your mind of distractions Face the sender Focus your full attention on the sender Maintain eye contact as appropriate for the culture Turn off "self-talk" Do not make value judgments about what you hear Mentally note anything that needs clarification Do not interrupt

Common Types of Questions

Closed-ended What is your date of birth? Are you taking any medications? Open-ended How did you fall? Why do you think you are feeling sad? Probing You said that you've been experiencing pain in your chest. Where, exactly, in your chest do you feel the pain? When is it the most severe? Can you tell me more about when you get these headaches? Leading Would you describe the pain as sharp, dull, throbbing, or aching? Do you feel more nauseated in the morning, afternoon, evening, or during the night?

Characteristics of Health Care Professionals

Communication (verbal and nonverbal) Written communication is clear and concise and reflects clinic image Nonverbal communication reflects acceptance, values client, and expresses willingness to help Needs are met, trust is fostered, and client is open to express health concerns Presentation Appears dressed and groomed appropriately Demeanor or outward behavior and conduct is respectful Expresses kindness, caring, and respect Confident in health care choice Comfortable in setting Feels valued and respected Empathy Identifies with client, feels what client is feeling Dispels fear and anxiety Comfortable Attitude Cultivates a positive outlook, supportive Compliant Cooperative Competency Knowledgeable, skilled, competent in performing skills, dependable, demonstrates initiative, desires to continue to learn Safe, confident, assured of confidentiality Integrity Honest, follows moral and ethical principles, is accountable Builds trust, confidence, assured of confidentiality Attention to detail Completes correct documentation, follows all protocols of the clinic, completes all tasks Improved health care Insurance benefits assured

Importance of Communication in Health Care

Communication is the process in which messages are exchanged between a sender and a receiver. The sender, also referred to as the speaker, is the person who creates and delivers a message. The receiver, also called the listener, is the person to whom the sender directs the message. Communication is successful when the receiver interprets and understands the sender's message as it was intended. Good communication is essential for the delivery of safe, effective health care. Modern health care systems rely on the efficient and accurate delivery of large amounts of information. Diagnoses and treatments are usually based on a variety of data that must be shared among many health care providers. There are vast networks of primary care providers, specialists, therapists, testing centers, medical facilities, and insurance companies that work together to provide and coordinate patient care. Chances of miscommunication increase as systems become larger and more complex. Good face-to-face communication is also essential. It is reported that the root cause of nearly 66% of medical errors is the result of poor team communication (https://healthcarecomm.org/about-us/impact-of-communication-in-healthcare). Health care professional dissatisfaction and turnover also increase when there is poor communication among staff.

therapeutic communication

Communication that employs certain techniques specifically aimed at meeting the needs of patients.

Step Two: Create the Message

Creating an appropriate message requires the selection of content and use of language that is based on the answers to the questions listed earlier. (Creating a message is also called encoding.) Health care communication usually takes place at a deeper level than everyday conversation and must be clear and accurate. It may involve sharing very personal information, such as a patient's fears. Information must be presented in a manner that the receiver understands. For example, although the use of medical terminology helps ensure accuracy in communications with other health care professionals, it can confuse and intimidate patients. Even everyday language may have to be simplified into common terms for some patients, depending on their age and language skills. For example, "number two" might be substituted for "bowel movement." At the same time, take care not to talk down to patients. Organize long messages to make them easier to follow. Here are some examples of organizational strategies: Explain what you plan to do and what the patient should expect to hear, feel, and so on. Rank information in order of importance. List a sequence of steps for the patient to follow. State facts, following each with an explanation. Present an overview of a procedure before detailing the individual steps. Give instructions along with a description of possible consequences if they are not followed. Break information into sections, if possible, so the patient can grasp each part or set of facts before moving on to the next. Use teach back: Have patients demonstrate understanding by explaining the information in their own words or by performing the task or exercise being taught.

Patient's level of understanding

Does the patient appear to be confused?

Emotional state

Does the patient's behavior demonstrate anxiety?

Team Communication

Effective communication is essential to effective team interactions in the workplace. It is helpful if health care professionals receive specialized training in the facility's protocol for the use and dissemination of all forms of communications. Not only is there emphasis upon communication with clients and customers, the same attention is to be paid to communication among employees and providers. A sensitive employee can easily determine if another employee or one of the providers is having a "not so good" day. A warm greeting, the offer of a cup of coffee, a friendly gesture—all these go a long way in turning that day into something better for everyone in terms of productivity and accomplishments. All the guidelines and recommendations in this chapter are to be employed in team communication to help make the facility run more smoothly. Remember, your clients are smart. They will immediately pick up the vibes of discontent from employees when it exists. Effective communicators in the health care team will strive to do the following: Listen carefully to others. Explain their ideas clearly. Clarify others' ideas as necessary. Express feelings in a nonthreatening manner. Check for feelings based on nonverbal cues. Initiate conversations with others if there appears to be tension. Encourage others to be effective communicators. There also must be guidelines or policies on what can be communicated via email and any social media used within the facility and among coworkers. Some simple rules to consider follow: Do not use email if a walk into an adjacent office for a face-to-face communication is possible. Reserve two to four times daily to check email; notify others of your decision. Otherwise, you can become a "slave" to the technology. Answer email within a 24-hour time period. Create a response message when you are out of the facility for any period of time. Remember that email is not private. Be careful what you forward and seek permission when you do so. Do not use the facility's computer for personal email or any form of social media. Use "flags" and "Important" sparingly. Never send libelous, defamatory, offensive, racist, or obscene remarks. In order to communicate effectively as a team member, take time to develop skills that will ensure trust, and to build into the team a sense of worth and importance. Successful team communication requires collaboration. That means that health care professionals assume complementary roles and work together in a cooperative manner. Responsibilities are shared because there is an awareness of each other's knowledge, skills, education, and training. There is also a shared goal of carrying out plans for clients' care and working together for a common goal or common aim. Such an interdisciplinary approach pools the specialized services of each team member into an individualized care program for each client. Clients will find it more comfortable to communicate with a cohesive team rather than with individuals who do not know what others are doing in the client's care.

Facial Expression

Eye contact is another form of facial expression, and is often viewed as a sign of interest in the individual. It provides cues to indicate that what others say is important. A long stare may be interpreted as an invasion of privacy, which creates an uncomfortable, uneasy feeling. A lack of eye contact in Western culture is usually interpreted to mean a lack of involvement, or avoidance. Perhaps the most important nonverbal communicator is facial expression. It has been said that the eyes mirror the soul. Certain movements of the eyebrow seem to indicate questioning, while others may disclose feelings of amusement, surprise, puzzlement, or worry. The manner in which the forehead is wrinkled also sends similar messages. The eyes can communicate several kinds of messages. Have you ever seen laughter and joy, grief, or pain reflected in another's eyes?

Facial Expressions

Facial expressions are an important form of nonverbal communication. The health care professional's expressions can be a source of reassurance or anxiety for patients, so it is important to learn to be aware of, and control, them. This can be difficult when dealing with situations that are challenging, unpleasant, or offensive. For example, you may feel very frustrated with the behavior of an angry patient. Efforts at calming the patient will be less effective if your face reflects signs of impatience and annoyance. The health care professional's face should reflect warmth, confidence, and interest in the welfare of the patient.

Using touch is a natural part of health care that patients expect and tolerate.

False

You should only evaluate a communication encounter with a patient after completing the conversation.

False

Step Five: Ask for Feedback

Feedback is a method used to check understanding of what is said. Did the message come across as the sender intended? All of us have had the experience of believing we understood a message perfectly, only to discover later that we had misinterpreted it. Obtaining feedback helps avoid misunderstandings. Here are four ways to obtain feedback: Paraphrasing: The receiver rewords the sender's message in the receiver's own words and then asks the sender for confirmation. Example "I understood you to say that you have experienced these headaches every day for the past two weeks. Is that correct?" Reflecting: This is similar to paraphrasing, but prompts the receiver to either complete or add more detail to the original message. Example "You say that it's difficult for you to do the exercises the therapist has recommended because ." (Pause and allow time for response.) Asking questions: Request clarification and additional information. Many words, such as "difficult," "painful," and "a lot," have different meanings for people. In health care, the use of questions can help patients describe their conditions more clearly. Accurate diagnoses and appropriate treatments depend, in part, on the clarity and completeness of information supplied by the patient. Example "What symptoms are you experiencing when you say you are feeling terrible?" Questions can be used to check the receiver's understanding of important information. Instead of asking if the receiver understands, ask a question whose answer will demonstrate understanding. Example "Can you list for me the three steps you'll take when giving your son his medication?" This is an example of teach back. Open-ended questions, discussed earlier, can be used to encourage patients to talk about their values and beliefs. Although it is not the role of the health care professional to make value judgments about patients, what is learned can help you better understand the behavior and motivations of patients and find ways to meet their needs. Example "Why do you say that you deserved to have the accident?" This question may help in understanding why a patient is making no effort to perform the exercises that will assist in recovering from injuries. Requesting examples: Examples can help to more clearly explain and fill in meaning. Example "Tell me about the kind of situations in which you feel lightheaded." Feedback can be an important tool for fostering professional growth. For example, Rosie's supervisor informs her that a report she has prepared is "unacceptable." Rosie can request more specific feedback by asking questions such as "What did I do or not do that made my performance on this task unacceptable?" and "Can you tell me exactly what it is that makes the report unacceptable?" These questions will encourage the supervisor to be specific and provide details from which Rosie can learn.

Feedback

Feedback occurs when the receiver and sender both verify their perception of the message. Feedback may be either verbal or nonverbal. It reveals to the sender whether the message was interpreted accurately, and enhances understanding by verifying and/or clarifying any misunderstanding. Feedback should be succinct, timely, and relevant to the situation.

social media

Forms of electronic communication such as Web sites or blogs that enable users to share content or to participate in social networking, sharing ideas, and personal messages.

clustering

Grouping of gestures, facial expressions, and postures into nonverbal statements.

Why would it be recommended that you avoid using too many leading questions when asking a patient if he is following the diet the physician gave him?

He may simply agree because he knows what you want to hear.

Nonverbal Communication

How a message is delivered can either reinforce or change the intended meaning. For example, an otherwise friendly remark, stated in a sarcastic voice, distorts the intended message. The words "that's a nice thing to say" can be delivered in a way that indicates the sender's pleasure. The same words, delivered in a mocking tone with stress on the word "that's," convey the opposite meaning. It sends the message that what was said was hurtful. Nonverbal communication includes tone of voice, body language, gestures, facial expressions, touch, and physical appearance. Up to 70% of the meaning of messages are expressed nonverbally. Nonverbal communication is usually the most accurate expression of what the sender truly feels and believes. This is because it comes from within and is conveyed without the awareness of the sender. It takes place subconsciously. Health care professionals must be aware of the nonverbal communication of both themselves and others. The nonverbal communication of patients should always be observed. For example, if a patient reports feeling "fine" but appears very tense and nervous, the verbal and nonverbal messages do not match. In such cases, the health care professional needs to observe carefully, ask questions, and provide opportunities for the patient to share what he or she is really experiencing. The appearance of the health professional is a form of nonverbal communication. It can influence the patient's confidence in the worker's competence, which in turn can affect how messages are perceived

Which of the following is an example of an open-ended question?

How did you break your arm?

The Transmission

How the message is actually sent is known as the transmission. This can be done through face-to-face encounters, telephone, email, texting, letters, facsimile (fax), reports, videoconferencing, and social media routes. Whatever the route, it is important to transmit the message clearly, at an appropriate time, and with the appropriate mode of transmission if the message is to be perceived correctly by the receiver. How we send and how we perceive messages, to a large extent, are based on the influences discussed earlier. Regardless of these influences, the message sent must be adapted to fit the situation and the receiver. Each of these channels of communication has its appropriateness. In some instances, a written message may be the most effective means of communication; in other cases, spoken communication may be best. Email and videoconferencing is growing in popularity in the health care environment, and videoconferencing can be most helpful in communications involving a number of individuals or medical specialists in different areas of the country. Cell phone texting is also increasingly used in today's environment.

Life Factors that Influence Communications

How you feel about yourself can and will directly affect how therapeutic you will be in both social and professional communications. There are a number of factors that influence your personal communication skills. They are neither good nor bad; they simply are a part of your heritage, culture, and lifestyle. These factors greatly impact our lives and dominate how we feel about ourselves and how we feel others perceive us.

Martha calls Fairdale Hospital and identifies herself as the sister of Edna, one of the patients. Under what conditions can the nurse give Martha information about Edna's condition?

If Edna has signed a release form on which Martha is listed.

receiver

In communication, the person to whom the sender directs a message; also called the listener.

sender

In communication, the person who creates and delivers a message; also called the speaker.

Social Media in Health Care

In today's society, many individuals communicate via social media. Social media can be used for education, obtaining information, networking, goal setting, receiving support (i.e., losing weight or lowering blood sugar levels), and tracking personal progress. Health care providers increasingly turn toward online social media to connect with clients and share information about particular issues in health care or share the latest news of the clinic. Facebook, Twitter, and YouTube are most commonly used. For example, a PCP might send a message to remind everyone to get a flu shot. A pediatrician might use a blog to share information with clients who have diabetes and who then can connect with others with similar needs. A quick Internet search reveals many different social media sites for almost any health condition and group of people. For instance, breastcancer.org provides an online community for those diagnosed with breast cancer, including informational pages and newsletters, blogs, discussion boards, and podcasts. Client-centered care is one of the primary goals of social media used within the health care environment. Increasingly, clients prefer social media for setting appointments and receiving reminders, getting test results, refilling prescriptions, and getting answers to general questions. Twitter is often used to connect with other professionals about specific topics of interest to providers. The National Institutes of Health reports that PCPs use social media to read news articles, explore the latest drug research, and communicate with other providers regarding health care issues.

Genetic Factors

Inherited traits, such as height, body structure, and skin color, are defined and established by the genes passed on during fertilization. Even our gender influences perception. Nurses in hospital nurseries will tell you that every infant born has a unique personality. This is because even our personalities have a genetic component. Personality traits are polygenic, meaning multiple genes are involved in determining a trait that is then manipulated by life experiences.

Leading questions

Inquiries in which all or part of the answer is included in the wording of the question.

Closed-ended questions

Inquiries that can be answered with a single word or a response of "yes" or "no."

Probing questions

Inquiries that request additional information or clarification.

Open-ended questions

Inquiries that require more than a one-word response; used to encourage patients to provide more detailed information or explanations.

Physical factors

Is the patient in pain?

Which of the following statements best describes the effect of nonverbal communication during oral communication exchanges?

It can express up to 70% of the sender's meaning.

Step Three: Deliver the Message

It is important to first determine to whom the message should be delivered. This is not always obvious. For example, if the patient is a child, elderly person, or disabled, should communication be directed to the patient or to a family member? Patients who are able to understand any or all of the message should be addressed directly. Detailed information or instructions can also be given to a family member later. For example, a medical assistant who greets 87-year-old Mrs. Hernandez by asking her daughter, "How is your mother doing today?" is failing to show respect for the patient. Older patients often face the biases of a youth-oriented society. Using titles, such as Mrs., Ms., and Mr., demonstrates respect for patients. It is inappropriate to address older persons as "dearie" or "hon." Although this may be considered a sign of affection, it is offensive to some patients. A common guideline for health care professionals is to address patients older than themselves more formally than those who are the same age or younger. If in doubt, it is best to ask patients how they wish to be addressed. Some cultural groups designate a family member, often the oldest or a male, to make decisions on behalf of the patient. Although it is important for the health care professional to understand the dynamics of the patient's family, this does not suggest that the laws governing confidentiality can be broken in order to accommodate cultural preferences. Well-meaning family members, friends, and others who appear to have a valid right to know cannot be given information unless the patient has signed a release. It is essential to recognize which messages have a restricted audience and exactly who that audience is. Advance directives and a health care power of attorney, discussed in Chapter 3, serve as the links between health care professionals and patients who have lost their ability to communicate. It is essential to know what medical treatments patients desire to be performed and who may receive information and speak on their behalf. It is believed that many patients who cannot speak or respond can hear and experience touch. Under these circumstances, health care professionals can provide comfort by maintaining communication. They should speak reassuringly and consider making appropriate physical contact, such as touching the patient's hand or shoulder when speaking.

Word of Caution

It must be remembered, however, that nonverbal communication can easily be misinterpreted. The folded arms may mean the person is cold, not closed to communication. The wrinkled brow may indicate the person has a headache, not a questioning or doubting attitude. Look for congruency between verbal and nonverbal communication for a clear message. Do not make assumptions. In the earlier scenario, when the delivery room nurse asked Elaine if she would like to hold the baby, the verbal and nonverbal messages were congruent. When Elaine said no, the nurse held her hand, smiled, and told her that was fine. Together, the cluster of mannerisms used by the delivery room nurse said, "I understand, I care, and your response is appropriate."

Which of the following is NOT an example of positive body language?

Leaning back in your chair

Posture

Like distance, posture is important to the health care professional. Individuals in threatening situations usually tense, but tend to relax in a nonthreatening environment. Posture can be used as a barometer for feelings. For example, sitting with the limbs crossed over one's chest can send a message of closure and avoidance; leaning back in a chair with the arms up and hands clasped behind the head can indicate openness to suggestions. Slumped shoulders may signal depression, discouragement, or in some cases even pain. It is important to validate the messages before continuing a procedure. For example, you may ask the client, "Are you comfortable?" or "Is this position too painful?" Technicians must be careful to be in tune with the client's physical comfort.

Step four, five and six

Listen to the response Offer feedback and seek clarification Evaluate and revise message if necessary

Which of the following would be best to help hospitalized patients who are lonely or depressed?

Listen to them.

Active listening

Listening characterized by focusing fully on what a speaker is saying.

Step Four: Listen to the Response

Listening is not passive, but an active process that requires the following: Concentration Attention Observation Hearing and taking in words take place at a rate that is several times faster than the rate of speech. This is helpful when taking notes, but it also allows time for the mind to wander. Effective listening can be hindered by receivers' reactions to what the sender is saying. For example, if the receiver strongly disagrees with the message, his or her mind may become occupied formulating mental arguments instead of listening carefully. Another common interference to listening is thinking about how one is going to respond when the speaker stops talking. The mind becomes engaged in self-talk and stops listening. Good listening also requires that receivers do not interrupt senders or complete messages for them. Allow enough time for senders to complete their messages. Encouraging remarks and gestures may be used as prompts: "I see," "Go on," or a nod of the head. Interrupting, however, can convey a lack of respect and impatience. It can also distort the sender's intended message, preventing important information from being conveyed. Effective listening skills can be developed. This is worth the effort because patients report that being listened to is a major determinant in their opinions of health care providers (Anderson, Barbara, & Feldman, 2007). Start by becoming aware of lapses in your attention. When you realize you are losing focus, bring your mind back to the speaker. With practice, you can decrease internal interference and poor attention. Periods of silence can be a meaningful component of communication. Some cultures have a high respect for the value of silence. Allowing periods of silence may feel awkward at first, but they can be a valuable tool in promoting good communication.

Listening Skills

Listening is often identified as the passive aspect of communication. However, if done well, listening is very active. Good listeners have their eyes upon the speaker, are attentive, and are aware of the nonverbal messages as well as the verbal information coming from the sender. Effective listening requires concentration. Therapeutic listening includes listening with a "third ear": that is, being aware of what the client is not saying or picking up on hints as to the real message. The health care professional should have three listening goals: to improve listening skills sufficiently so that clients are heard accurately; to listen for what is not being said or for information transmitted only by hints; and to determine how accurately the message has been received. A technique used by many and suggested by professionals is the ability to paraphrase the client's message or statement. This technique allows the receiver of the message to return the message to the sender, perhaps worded differently, allowing the sender to acknowledge the accuracy of the message. Example: Sender: "Will I be able to use my medical coupons for prenatal care in your clinic?" Receiver: "You're concerned about whether our doctor accepts medical coupons for payment." Sender: "That's correct. I have no money. My baby will be adopted, but I know we both need proper medical care." Receiver: "Our clinic does take medical coupons, and we make no distinction in our care whether you pay privately or use your coupon. Would you like to make an appointment?" This example shows both active listening and therapeutic communication skills. The clinic assistant heard both concerns—the monetary concern and the concern for quality and proper care. Health care professionals must be prudent in how they use active listening techniques, however. It is not appropriate to paraphrase everything the client says; otherwise, the client begins to feel stupid, or believes the professional has a hearing problem. One of the greatest barriers to listening occurs when receivers find themselves thinking about something else while trying to listen. It is difficult to try to concentrate on what is being said when the mind is wandering. When this happens, pull concentration back to the sender, apologize if necessary, and continue with the communication. There is a time in communication, in listening, when silence is appropriate. So many times health care professionals try to "fix" everything with a recommendation, a prescription, or even advice. Sometimes none of those things are necessary. The client simply needs someone to listen, to acknowledge the difficulty, and to remember that the client is not helpless in finding a solution to the problem. Skill in communication takes years of practice and frequent review. It will never become perfect; the goal is to become better at it with each passing day. Communication is and always will be the very basis for any therapeutic relationship.

Nonverbal communication

Meaning conveyed by tone of voice, body language, gestures, facial expressions, touch, and physical appearance.

The Communication Process

Messages can be exchanged in at least four ways: Orally (this chapter) Nonverbally (this chapter) In written form (Chapter 17) Electronically (Chapter 18) It is commonly believed that oral communication consists of simply talking and listening, activities that most people have been doing all their lives. We carry on dozens of conversations daily with family members, friends, classmates, and coworkers. Effective communication in health care, often referred to as therapeutic communication, is specifically aimed at meeting the needs of patients. It involves the application of a set of skills that can be acquired through practice. In this text, communication is organized into a six-step process. This process provides a structured approach for studying and learning the skills that make up effective communication. Like other health care skills, communication cannot be taken for granted or performed in a routine manner. Each communication encounter presents its own set of circumstances and requires the health care professional's full attention. Good communication involves applying the thinking skills

Using Humor

Messages need not always be serious. The careful use of humor can offer relief from the difficult situations faced by patients and their families. It can help relieve tension and promote the open discussion of sensitive issues. Humor, however, should never be at the expense of anyone, even in the person's absence. Patients will sometimes joke about their condition as a cover-up for fear or embarrassment, but the health care professional should never initiate this type of humor. Listen carefully in these situations, because these jokes may indicate the patient's need for help in dealing with a difficult condition. It is appropriate to let patients know that if they wish, they can discuss fears they have or request information they need.

Gestures/Mannerisms

Most everyone uses gestures or "talks" with their hands to some degree. Gestures are useful in emphasizing ideas, in creating and holding others' attention, and in relieving stress. Some common gestures and their perceived meanings might be: Finger-tapping—impatience, nervousness, rudeness Shrugged shoulders—indifference, discouragement Rubbing the nose—puzzlement Whitened knuckles and clenched fists—anger Fidgeting—nervousness, anxiety The nonverbal message is more quickly believed than the verbal message.

Step One: Set Communication Goals

Much of our everyday communication is spontaneous and superficial and requires little or no planning. This includes everyday greetings ("Hi, how are you?"), which are said automatically and from which little real information is usually expected. Interactions in health care settings are more purposeful. Suppose a nurse has a goal of learning about the current health status of a patient. Instead of asking the patient "How are you?" which may result in a programmed response of "Fine," she needs to ask more specific questions. These will be based on communication goals. Examples of specific questions include the following: On a scale of 1 to 10, what is your pain level? Do you have any questions about your care? Are you feeling nervous about the procedure? Here are some examples of health care goals: Gather objective and subjective information about a patient's condition. Instruct individuals on postsurgical home care procedures so family members can understand and follow them correctly. Inform a patient about the benefits of the recommended treatment. Report patient care information to a coworker who is taking over the care of the patient. In addition to goals that are specific to the situation, there are three more that should be included in every interaction with a patient: 1. Demonstrate sincere concern for the patient's welfare. Have a warm smile. Use a gentle manner. Do not act hurried. Listen carefully. 2. Establish trust. Establish eye contact as culturally appropriate. Explain why a procedure, treatment, or test is necessary. Explain in advance everything you are going to do. Follow through with anything you say you will do (return in five minutes, call patient at home to check on progress, and so on). 3. Enhance the patient's self-esteem. Involve the patient in decision-making whenever possible. Clarify the patient's communication if you're unsure of meaning. Address the patient properly and respectfully. Provide for privacy. Ask the patient for input on how he or she wants things done, when appropriate.

Mrs. Anderson is 89 and her daughter, Katherine, usually accompanies her to her doctor's appointments. Which is the correct way for the medical assistant to greet them?

Nice to see you, Mrs. Anderson.

Nonverbal Communication

Nonverbal communication is information shared without spoken words. Communicating nonverbally uses gestures and mannerisms. It is the language we learn first. It is learned seemingly automatically, as infants learn to smile in response to a smile or loving touch on the cheek long before they respond verbally. Taber's Cyclopedic Dictionary defines body language as the unconscious use of postures, gestures, or other forms of nonverbal expression in communication. Kinesics is the term often used to define the systematic study of the body and the use of its static and dynamic position as a means of communication. Much of our body language is a learned behavior and is greatly influenced by the culture in which we are raised. For example, eye contact may send different nonverbal messages depending on the culture of the client. These variations make it important to assess clients' cultural identity to ensure proper nonverbal communication. Feelings are communicated quite well nonverbally. Since nonverbal communication is much less subject to conscious control, emotional dimensions are often expressed nonverbally. The body naturally expresses our true, repressed feelings. Most of the negative messages we express nonverbally are unintended. But whether they are intentional or not, the message is relayed. Experts tell us that 70% of communication is nonverbal. The tone of voice communicates 23% of the message, and only 7% of the message is actually communicated in what is said.

Personal Space

Personal space is the distance at which individuals are comfortable with others. It may be determined by social and cultural influences. Personal space can be thought of as the invisible fence no one can see. However, the way in which we define boundaries is evident to others. We feel threatened when others invade our personal space without our consent. Many individuals have well-defined personal space boundaries. Intimate—touching to 1½ feet Personal—1½-4 feet Social—4-12 feet (most often observed) Public—12-15 feet Many cultures uphold these four categories of spatial relationships; however, the distances may vary from one culture to another. Many medically related tasks involve invading another's personal space. It is beneficial to explain procedures that intrude on another's space before beginning the procedure. This gives the client some control and a sense of dignity and worth.

Communication

Process in which messages are exchanged and meanings interpreted between a sender and a receiver.

Professional Skills

Professional skills in the health care setting include communication, presentation, empathy, attitude, competency, integrity, and attention to detail. Professional interaction will require you to: 1.Focus your observation. 2.Fully engage in listening. 3.Become skilled in asking open-ended questions. 4.Be intentional about affirming clients' feelings. 5.Avoid placing blame. 6.Help clients ask questions and/or express their concerns. Becoming skilled in the six steps identified above requires another component on your part, called the "caring" component. Health care is a caring and helping profession that requires health care professionals to value and support clients. Verbally or nonverbally, professional skills are employed every day—from the date of birth to the time of death. This communication may be a mother's soothing and loving words to a child or a simple "well done" to a colleague. Therapeutic communication focuses on enhancing the well-being of another person, and for the purposes of this text, your clients.

Paraphrasing

Rewording the sender's message in the listener's own words and asking the sender for confirmation.

Step one, two and three (in order):

Set communication goals Create a message Deliver the message

Technical Skills

Technical skills represent those specialized tasks that are required to deliver and support medical care. It includes skills used to explain difficult ideas and concepts, and skills to deal with difficult individuals. The opening scenario illustrates several technical skills demonstrated by the staff in the emergency room, the lab and x-ray staff support, and the assistant who bandaged the wounds. Those who assessed the injuries and followed appropriate medical-care guidelines exhibited technical skills. In comparing the responses from the two providers, one provider showed competency in technical communications but less competency in professional communication and the other was competent in both technical and professional communications.

Communication with Patients

The ability to communicate well can be as important to the professional success of the phlebotomist as her ability to safely draw blood. The well-being of patients depends on more than technical competence. For example, if a nurse is instructing a patient about how to change the dressing on a wound, the patient's understanding of these instructions is critical for successfully carrying out self-care practices at home. Studies have shown that health and treatment outcomes are significantly influenced by the quality of communication between patients and health care providers. Several factors have increased the need for competent communication: Increasingly complex coverage of health care costs: Costs covered by private insurance, Medicare, Medicaid, and other insurance plans can be difficult to identify and understand. Patients need clear communication to determine which treatments and drugs they qualify for. Significant decrease in the length of time patients spend in hospitals and other health care facilities: Patients are now more responsible for their own follow-up care and need clear instructions to correctly carry out necessary self-care procedures. Shift in major causes of death from infectious diseases to cancer, heart disease, chronic obstructive pulmonary disease (COPD), and stroke: There has been an increase in chronic illness because people are living longer. An important part of the health care professional's responsibilities is providing patient education about factors that promote wellness. New medications: Many patients take a large number of medications and this makes it more difficult for them to organize and take them properly. The attitudes of health care professionals influence their ability to communicate effectively with patients. Therefore, the first step in achieving excellent communication skills is to develop respect for, and an understanding of, individual patients and their needs, as discussed in Chapter 15. Effective communication involves more than applying a set of techniques. It must be based on sincere compassion and concern for patients and their welfare. The health care world can be intimidating for patients. They may be anxious about receiving negative test results and learning that they have serious medical conditions. Or they may fear experiencing pain and discomfort during treatments. Still others are worried about losing control over portions of their lives as a result of their physical conditions. These concerns, combined with the physical stress caused by illness or injury, can negatively affect patient recovery. Health care professionals can help relieve patient stress by showing compassion, providing appropriate information, and answering questions. Good communication has been shown to increase the speed of patient recovery. Loneliness and depression are commonly experienced by patients during their stay in health care facilities. This is especially common among older patients in facilities such as nursing homes. Health care professionals may be their principal contact with the outside world. Being willing to talk and, even more important, to listen to patients can lift their spirits. Situations do not have to involve a direct threat to health to be stressful experiences for patients. As discussed in Chapter 15, any health care encounter can represent a loss for the patient and be a source of anxiety. Well-chosen words and a willingness to listen can help relieve anxiety. Patients' satisfaction is determined, to a great extent, by the quality of their communication with health care staff. As stated in Chapter 3, poor communication between patients and their providers is a major cause of medical malpractice lawsuits. Another factor that affects communication with patients is health literacy. This is defined as "the ability to obtain, process, and understand basic health information and services needed to make appropriate health decisions" (https://www.cdc.gov/healthliteracy/training/page572.html). A significant percentage of Americans read at a grade-school level and do not understand instructions on prescription bottles, appointment reminders, and other written materials. They also report not understanding what their health providers tell them orally, but are too embarrassed to admit they miss what is said. The American Medical Association Foundation has produced an excellent video featuring real patients who explain their difficulties in understanding what health care professionals tell them. It is available at www.youtube.com/watch?v=cGtTZ_vxjyA. There are other reasons, related to communication, that patients do not follow medical advice: 39% disagreed with the recommended treatment 27% were concerned about cost 25% found the instructions for self-care too difficult to follow 20% felt it was against their personal beliefs 7% stated they didn't understand what they were supposed to do Source: https://healthcarecomm.org/about-us/impact-of-communication-in-healthcare When patients are not comfortable expressing these concerns to their health care providers, there is no opportunity to address them. Good communication skills, discussed in this chapter, can assist health care professionals to better help their patients discuss their concerns.

health literacy

The ability to obtain, process, and understand basic health information and services needed to make appropriate health decisions.

Asking Questions

Some messages are phrased as questions. There are several types of questions: Closed-ended questions can be answered with a single word or a response of "yes" or "no." This type of question is used to gather factual information. For example, the health care professional may ask closed-ended questions when obtaining background information about a patient. Closed-ended questions are not recommended when checking for understanding. Many patients will answer "Yes" to the question "Do you understand?" even if they do not. They are afraid of appearing dumb or do not want to "bother you" by having the information repeated. Open-ended questions cannot be answered with a simple "yes" or "no." They require a more complete response and are used to encourage patients to provide more detailed information or explanations. These questions can be used to learn about the patient's symptoms, to encourage them to share feelings and opinions, or to check understanding of the message. Probing questions are requests for additional information or clarification. For example, they can be used to lead patients to more fully discuss their symptoms. If a patient states, "My stomach hurts," appropriate probing questions would inquire about the exact location and type of pain, when it first occurred, and when it is experienced. It is important not to confuse the purposeful use of probing questions with digging for unnecessary personal details, which patients may find offensive. Leading questions are those in which all or part of the answer is included in the wording of the question. Leading questions should be avoided when they encourage the receiver to give the answer believed to be correct or what the health care professional wants to hear. However, leading questions can be useful when used with patients who have difficulty speaking or who do not understand English well enough to phrase a complete answer. In these situations, take extra care to check for understanding to ensure that the patient is not simply agreeing with you. After asking a question, it is important to pause and give the receiver sufficient time to respond. Some people need more time than others to formulate answers. Do not interrupt or finish sentences for patients. If it is obvious that they do not understand the question or are unable to reply, reword the question and provide another opportunity for a response. Consider the state of each patient and his or her ability to answer questions. For example, Mrs. Feinstein is an elderly patient who has difficulty remembering. Hospitalized for severe back pain, she cannot accurately respond to questions about how she is feeling today compared to yesterday. A more effective way to get the needed information is to ask her to rate her pain level on a scale of 0 to 10, with 0 being no pain and 10 being the highest level she can imagine.

Kinesics

Study of the body and its static and dynamic position as a means of communication.

Which of the following statements best describes the role of communication skills for health care professionals?

The communication skills of health care professionals influence the satisfaction of patients with their care.

Which is the best definition of successful communication?

The listener understands the speaker's message as intended.

The Message

The message is the content to be communicated. The sender chooses the words and medium to best match the message to be sent. The message is most likely either spoken or in written word, but can also be categorized into verbal and nonverbal communication. The message is affected by the communication styles displayed in the sender's tone, how the message is presented, the information the message contains, and even what has been omitted.

Physical Environment

The physical environment and how the health care professional is positioned in relation to the patient can affect the delivery of the message. Sitting behind a desk or standing over the other person projects a sign of authority or dominance. Other factors to consider include the following: Light sources: Can the patient see you clearly? Is there a glare on anything the patient is expected to see? Is light shining in the patient's eyes? Sounds: Can the patient hear you clearly? Are there unnecessary noises that are distracting? Should the television or radio be turned off? Privacy: Are there other people in the area who can hear the communication? If privacy is necessary, how can it be arranged? Are you speaking directly to the patient and only as loudly as necessary? Activity: Do you appear to be more focused on taking notes or entering data into a computer than on the patient? Comfort: Is the patient exposed or in an awkward position? Can communication wait?

Step Six: Evaluate the Encounter

The purpose of evaluation is to determine whether the communication goals have been met, demonstrated by the response or behavior of the receiver. If the goal is not met, the following questions can help identify the difficulty: Did I clearly state my messages? Did I present them at a level appropriate for the receiver? Did I listen actively? Which part of the message was misunderstood? The evaluation process actually continues throughout every communication encounter. A good communicator constantly checks for understanding by listening, observing, and asking for feedback as needed. That way, adjustments can be made as needed. Some communication goals are achieved over time, and the evaluation must be delayed. For example, if cardiac patient Heinrich Mueller is instructed about improving his eating habits, it may be weeks before the dietician finds out if he understood and was motivated to follow the low-fat eating plan. Another example of a long-term communication goal is making an effort over time to improve a relationship with a coworker.

The Sender

The sender begins the communication cycle by creating or encoding the message. The sender must formulate a clear thought to send. There is great value in choosing words carefully in order to send a clear message to the receiver. Knowledge of the audience or the receiver of the particular message is important, otherwise messages can be misunderstood.

Use of Touch

The use of touch has become a difficult issue in health care today. Although a friendly pat or squeeze of the hand has been a traditional way of communicating care and interest, any touching that a patient considers to be inappropriate can lead to legal problems. It is essential that health care professionals always practice good judgment and use common sense. It is also important that they be aware that patients may have cultural preferences regarding touch, as discussed in Chapter 15. Many health care activities require entering personal space that is normally reserved for only the closest and most trusted people in the patient's life. It is important that patients be told what is to take place and why. Explain what they should expect to see, hear, and feel. For example, when administering an injection, the health care professional should inform the patient of its purpose, where it will be given, and what sensations might be experienced. The health care professional should avoid touching areas that are considered sexual (buttocks, breasts, genital area) unless it is necessary when performing a procedure. Any unnecessary roughness, even done in a playful manner, can be interpreted as abusive and must be avoided. Gestures and body movements that are either positive or neutral to one person may be unacceptable to others. As discussed in Chapter 15, health care professionals should be sensitive to the possibility of such differences, willing to learn about various cultural practices, and observant of patient reactions. If a patient seems uncomfortable with any contact that was intended to be a sign of caring or reassurance, seek clarification by stating your intention and asking if the gesture was unacceptable.

Therapeutic Communication Defined

Therapeutic communication is defined as the interaction taking place between the provider and the client that is important to enhance both the physical and emotional needs of the client. It is one aspect of professionalism, which is defined as demonstrating competency and skill expected of a professional. Therapeutic communication requires clear communication of technical information in a manner that is empathetic to the client's emotional state. It requires adherence to accepted social behavior and political correctness. Therapeutic communication uses specific strategies to encourage clients to express their feelings and ideas. These expressions are then accepted by the health care professional with respect and understanding. It includes both verbal and nonverbal communications, the language used, and how you communicate and whether you are aware of the effect you have on others. Therapeutic communication involves both professional and technical skills.

Two Key Points to Successful Nonverbal Communication

There are two key points to remember in any successful communication. First, there must be congruency between the verbal and the nonverbal expressed message. This means the two messages must be in agreement or be consistent with each other. If I verbally tell you I am not angry, but speak in angry tones and have my fists clenched and my face contorted, I am sending a mixed message. Chances are you will believe my nonverbal message rather than the verbal. Second, remember that nonverbal cues appear in groups. The grouping of gestures, facial expressions, and postures into nonverbal statements is known as clustering. In the previous example, the tone of voice, the gesture of clenched fists, and the facial expression form a nonverbal statement or cluster of cues to true feelings and emotions.

Influence of Technology on Communication

There will always be face-to-face communication, telephone conversations between two individuals, and paper communication in the health care setting, but email, fax, text messaging, and video and teleconferencing are increasingly common in health care. In this environment, however, the content of the message is most likely to be examined for credibility without any of the nonverbal cues such as eye contact, facial expression, or posture. Communication interactions when using this technology require careful consideration. The use of email is popular in the health care setting, both in communication with clients and in communication with colleagues. It may be read at the convenience of the receiver. Clients are particularly interested in the use of email for such things as prescription refills, appointment scheduling, information updates, or simple requests that normally would not require a visit and are more convenient than placing a telephone call, leaving a message, and waiting for a response. Email communication is used only for clients who have been examined within the last 6 months. No information can be provided through email without the clients' release of information to do so. Only clients can determine what, if any, personal health information (PHI) can be shared. General guidelines for all email etiquette include the following: Be concise and to the point. Respond in a timely fashion and answer all questions. Use proper spelling and grammar. Do not attach unnecessary files. Do not write in CAPITALS. Add disclaimers to the email. Read any email carefully before pressing "Send." Any clinical email regarding a client should be copied and placed in the medical record. Fax messaging uses telephone lines to transmit data from one fax machine to another. It is often used for referrals, insurance approvals, and informal correspondence. The same standards of confidentiality for any client information identified in an email exist for fax communication. HIPAA requirements dictate that fax machines are not to be placed in a centralized area where unauthorized individuals may see documents being sent by fax. A cover sheet should be included that stipulates the information is for the intended recipient only. Fax messaging saves the time and effort of copying and mailing a document, allowing the sender to keep the original while providing the recipient with an exact duplicate. Satellite video and teleconferencing are used to share information, receive education and training in a particular field of health care, or conduct a meeting to make certain decisions. A video conference will allow participants to see one another and interact almost as if the individuals were together in one room. A teleconference consists of a group of individuals connected by only a telephone. Both video and teleconferences can become difficult to manage if more than 10 participants are included. A telephone conference should be limited to 30 minutes or less, since it is difficult for participants to concentrate while looking into space for any longer period of time. Effective video and teleconferencing, as well as telephone conference calls, include some basic rules of conduct: One person is the facilitator and is responsible for keeping the meeting on track. Come prepared with necessary documents or information that is to be shared. Before speaking, remember that everyone may not recognize your voice or know who you are; always begin with "This is __________." Silence is not bad. Facial expressions may not be evident, and someone may be formulating a question prior to speaking. Also, do not assume silence means consent. Stay focused on the meeting. The conscious mind cannot perform some other task and give full attention to the meeting at the same time.

Collect Information

To set appropriate goals, it is important to collect and review information that might affect communication. This includes the cultural and behavioral factors discussed in Chapter 15 as well as circumstances specific to the situation. The following factors should be considered: Patient's level of understanding Is the patient very young? Does the patient speak English? If so, is English the second language? Does the patient have a learning disability that affects his or her ability to understand? Does the patient appear to be confused or disoriented? What is the patient's ability to retain information? Is there short-term memory loss? What is the appropriate terminology to use? Emotional factors Does the patient's behavior indicate fear or anxiety? Are there signs that the patient is using a defense mechanism? (See Chapter 15.) Is the patient ready to accept the information that is to be offered? Physical factors Is the patient in pain? Is the patient on medication that causes drowsiness or affects the ability to concentrate? Does the patient have a hearing, visual, or speech impairment that affects the communication process? Urgency of the communication Must the communication take place now? Is this the appropriate setting for the communication? What are the consequences if it does not take place or if it is unsuccessful? Learning to make these determinations quickly is an important health care skill that is developed over time. One technique for new health care professionals is to use mental checklists to help them prepare for communication encounters.

Touch

Touch is one of the most sensitive means of communication. Touch is often used to express deep feelings that are impossible to express verbally, and can be a very powerful means of communication. For all health care professionals, many tasks involve touching the client. Most clients will understand and accept the touching behavior, as it is related to the medical setting. Some clients, however, are not comfortable being touched, so sensitivity is essential. It is helpful to tell clients when, where, and how they are to be touched during an examination. Explaining all assessments and treatments tends to put individuals at ease. This technique is essential when a client is autistic. An individual with autism has heightened sensory abilities and may attempt to escape sensory overload or a sudden invasion of their personal space. They tend to want to get away from strange people, voices, and equipment. If you find yourself in a helping situation or profession and feel uncomfortable touching, self-assessment or self-awareness may be necessary. Touch is often synonymous with reassurance, understanding, and caring. It is important to assess our level of comfort, and that of the client, in relation to the use of touch. When we are comfortable using touch and when we are sensitive to a client's level of acceptance to touch, touch can be used in a therapeutic manner.

The ability to communicate can be as important as having good technical skills.

True

pantomime

Using body movement and gestures to convey ideas or actions.

Verbal Communication

Verbal communication refers to the sharing of information via the spoken word. Mere words, however, carry no message unless they have meaning. If you overhear a conversation in a language foreign to you, you are a witness to verbal communication, but you may not understand the message. For communication to have any meaning, it must be understood by all parties to the communication. The book Legal Nurse Consulting Principles (Peterson & Kopishke, 2010) identifies the five Cs of communication. These five Cs apply equally well to therapeutic communications as well as spoken and written communication. They are: 1.complete, 2.clear, 3.concise, 4.cohesive, and 5.courteous. The message must be complete, with all the necessary information given. It appears that the adoption agency first told Elaine that she would be able to choose her baby's parents. What she discovered much later in the process was that she would not be able to do so until she had signed papers releasing the baby. The message was incomplete, even misleading, in its detail. The information given in the message must also be clear. It must be presented in terms understandable to both parties. It is best to enunciate carefully, with good diction, to keep objects out of and away from your mouth, and to keep background noises at a minimum. A concise message is one that does not include unnecessary information. Imagine how different the message would have been had the delivery room nurse said to Elaine, "Well, you really should hold this baby. She is yours. I'd certainly hold her if she were mine." A cohesive message is logical and in order. It does not jump abruptly from one subject to another. You would not say to a client, "Please remove all your clothes. No, we better weigh you first. Or do you want to give us a urine sample now?" You have confused the receiver and lost his or her attention. A message must always be courteous if it is to be therapeutic. Any time communication is not considerate, there is a risk that the message will be unclear, even not received, because of the defenses likely to be present in either the sender or the receiver.

If a patient does not respond quickly to your question, what should you do?

Wait patiently for a response.

Urgency of communication

What are the consequences if the communication does not take place now?

Position

When speaking with a client, it is helpful to maintain a close but comfortable position. Standing over a client denotes superiority, while too much distance may be interpreted as being exclusive or avoiding. Movement toward a client usually indicates warmth, liking, interest, acceptance, and trust. Moving away may suggest dislike, disinterest, boredom, indifference, suspicion, or impatience

Which of the following actions is NOT necessarily a good way to help maintain the self-esteem of patients?

Work efficiently.

The term used to describe the action of a health care professional who is fully focused on what a patient is saying is___________ listening.

active

When working with a patient who is upset by a recent diagnosis of cancer, nurse Karen should

ask the patient if she wants to talk about it.

The example, "Does your tooth hurt more when you eat something cold?" best illustrates the type of feedback called

asking questions

If you strongly disagree with what a patient is saying, you should:

continue to focus on what he is saying

The overall goal of therapeutic communication is to

meet the needs of the patient.

The example, "Am I hearing you say that the medicine doesn't seem to be helping?" best illustrates the type of feedback called

paraphrasing