CHAPTER 21: COMMUNICATOR

KEY TERMS:
assertive behaviors – ability to stand up for oneself and others using open,
honest, and direct
communication

body language – nonverbal communication; helps nurses to understand

subtle and hidden meanings

channel – medium or form of transmission the sender has selected to send

the message

communication – process of exchanging information and the process of

generating and transmitting
meanings between two or more individuals
- requires participation

empathy – identifying with the way another person feels

feedback – evidence that the message is correctly understood by the

receiver; the intended meaning is
translated and interpreted

group dynamics – how individual group members relate to one another

during the process of working
toward group goals

helping relationship – exists among people who provide and receive

assistance in meeting human needs

interpersonal communication – occurs between two or more people with a

goal to exchange messages

interviewing techniques – communication skills specifically designed to

gather and validate information

intrapersonal communication – self-talk; communication that happens

within the individual

language – prescribed way of using words so that people can share

information effectively

message – actual physiologic product of the source

noise – factors that distort the quality of a message

nonverbal communication – transmission of information without the use of

words
 organizational communication – occurs when individuals and groups within
an organization communicate
to achieve established goals
ex. nurses on a practice council meeting to review unit policies or
nurses working with
interdisciplinary groups on strategic planning

professionalism – a way of being / commitment to secure the interests and

welfare of those entrusted to
one’s care

rapport – a feeling of mutual trust experienced by people in a satisfactory

relationship

receiver (decoder) – person or group that must translate and interpret the
message sent

semantics – study of the meaning of words

small-group communication – occurs when nurses interact with two or

more individuals
ex. staff meetings, patient care conferences, teaching sessions, or
support groups

source or sender (encoder) – sender of the message; person or group who

initiates or begins the
communication process
- code with language and gestures

stimulus – agent, act or other influence capable of initiating a response

therapeutic touch – involves “unruffling” or unblocking, congested areas of

energy in the body and
redirecting this energy
- used to promote comfort, relaxation, healing, and a sense of well-being

verbal communication – an exchange of information using words, including

both the spoken and written
word

DESCRIBE THE COMMUNICATION PROCESS

The communication process is initiated based on a stimulus or patient need
that must be addressed.
The sender or source (encoder) of the message is a person or group who
initiates or begins the
communication process. The message is sent through a channel chosen by
the sender to the receiver.
 The channels available may be auditory (spoken words and cues), visual
(sight, observations, and
perception), or kinesthetic (touch). Once received, the receiver (decoder) has
to make a decision about
an accurate response. To be effective, the nurse will need to select a
message the appeals to the
client’s interests and that requires minimal effort and time to decode.
Confirmation of the message
provides feedback that the receiver has understood the intended message.

RELATE THE USE OF COMMUNICATION TO GROUPS

Intrapersonal communication – communication that happens within the
individual
- talking to one’s self

Interpersonal communication – communication between two or more people

with a goal to exchange
messages
- influences the nurse’s interpersonal sharing, problem solving, goal
attainment, team building, and
effectiveness in critical nursing roles (caregiver, teacher,
counselor, leader, manager, and
patient advocate)

Small-group communication – when nurses interact with two or more

individuals
- staff meetings, patient care conferences, teaching sessions, or support
groups

Large-group communication – communication with many people

Organizational communication – individuals 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 will use
organizational communication to
achieve their aims

DIFFERENTIATE BETWEEN VERBAL AND NONVERBAL COMMUNICATION

Verbal communication is an exchange of information using words, including
both the spoken and written
word – referred to as language which includes a common definition of
words and a method
of arranging the words in a certain order
- reveals aspects of the person’s intellectual development, educational
level, and geographic and
ethnic origin
 - helps nurses assess what the patient knows and feels

Nonverbal communication is the transmission of information without the use

of words – referred to as
body language
- helps nurses to understand subtle and hidden meanings in what is
being said verbally
- nonverbal communication can “scream” at others - - beware, patients
can read these loud and clear

GIVE SEVERAL EXAMPLES OF NONVERBAL COMMUNICATION

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

Eye Contact is often an attention-getting method to open conversation.

- suggests respect and a willingness to listen and to keep
communication open
- absence often indicates anxiety or defenselessness, or avoidance of
communication
- some cultures, however, are taught to avoid eye contact out of respect
for superiors and privacy
- can be indicative of fear, anxiety, daydreaming or inattentiveness

Facial Expressions are the most expressive

- convey anger, joy, suspicion, sadness, fear, and contempt

Posture for those in good health and positive attitude usually have good
alignment
- depressed or tired people are likely to slouch
- provides clues concerning pain and physical limitations

Gait can carry a message of well-being, sadness, discouragement, and pain

Gestures (thumbs up for victory, kicking an object expressing anger, wringing

the hands or tapping a
foot indicating anxiety or anger, and waving a hand serves to beckon
someone, or if waved in
another way, signifies that someone should leave ) are ways of
communication

DISCUSS SEVERAL FACTORS THAT CAN INFLUENCE COMMUNICATION

Gender – men and women possess differing communication styles and might
give different
interpretations to the same conversation
- girls generally 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
 Sociocultural Differences
- cultural refers to the common lifestyles, languages, behavior patterns,
traditions, and beliefs that
are learned and passed from one generation to the next
- provides specific rules for dealing with the universal events of life –
birth, mating, childbearing,
illness, pain, and death
- economic condition or status

Roles & Responsibilities – a person’s occupation might give the nurse a

general supposition of his/her
abilities, talents, interests, and economic status
- stereotyping is misleading and should be avoided (ex. nurses caring for
nurses – they don’t know
every area of the medical profession)

Space & Territoriality – people are most comfortable in areas they consider
their own
- the urge to maintain an exclusive right to certain space is being
territorial
- people have a sense of how much personal or private space is needed
and what distance between
individuals is optimum

Physical, Mental and Emotional State – degree to which people are physically
comfortable and mentally and
emotionally free to engage in interactions
- a full bladder, dull headache, crushing chest pain, anxiety about a
pending diagnosis or concern
about what is happening at home or work, and fear can all
negatively influence
communication
- cognitively impaired persons present special challenges

Values – the way people values themselves, one another, and the purpose of
any human interaction

Environment – best situation when the environment facilitates an easy

exchange of needed information
- most conducive when one is calm and non-threatening
- minimize distractions and ensure privacy
- use of music, art, and interior design decorations might assist in
placing the patient at ease

RELATE THE COMMUNICATION PROCESS TO THE NURSING PROCESS

Assessing – gathering information in both verbal and nonverbal
communication forms
- written word to obtain data, read records and/or charts before meeting
patients, written and spoken
 word to give / receive reports and during admissions /
discharges, spoken word with one-to-
one communication with patient

Diagnosing – written and spoken word (slow and simple)

- diagrams, drawings, gestures

Planning – written and spoken word

Implementing – verbal and nonverbal forms are used to enhance basic

caregiving measures and to teach,
counsel, and support patients and their families

Evaluating – verbal and nonverbal cues are used to verify whether patient
objectives or goals have been
achieved

Documentation – written communication becomes a permanent record

**Always talk to unconscious / incontinent patients - - tell them everything

and be careful of what is said
because they can hear it all!! **

DISTINGUISH THE DIFFERENCE BETWEEN A HELPING VS. A SOCIAL RELATIONSHIP

Helping Relationship exists among people who provide and receive assistance
in meeting human needs.
- care, concern, trust and growth components
- occurs for a specific purpose with a specific person
- characterized by an unequal sharing of information: patient shares
information related to personal
health problems, whereas the nurse shares information in terms of
a professional role
- built on the patient’s needs, and not on those of the helping person

Social Relationship – care, concern, trust and growth components

- spontaneous
- information sharing is more likely to be similar in quantity and type
- might grow out of helping relationship, but is separate from the
purposeful, time-limited interaction
described as a helping relationship

DISCUSS THE THREE PHASES OF COMMUNICATION IN A HELPING RELATIONSHIP, INCLUDING THE GOALS OF
EACH PHASE
Orientation Phase – tone and guidelines for the relationship are established
- patient and nurse meet and learn to identify each other by name
- roles of both people in the relationship are clarified, with the nurse,
generally, assuming leadership
(does not mean control in a restrictive or manipulative sense, but
involves taking the
initiative to enlist the patient’s point of view)
 - a simple verbal agreement or, occasionally, a written contract about
the relationship is established
- elements include the goals of the relationship; location,
frequency, and length of contract;
and duration of the relationship
- might also include the way in which personal information will be
handled
- orientation to the healthcare facility, its services, admission routines,
and any pertinent information
the patient requires to decrease anxiety
- one of the goals in the nurse-patient helping relationship
- a nurse’s openness and interest in the concerns of the patients pave
the way for development of
trust and communicate care and respect

Working Phase – actions that meet the goals; usually the longest phase
- nurse and patient work together to meet the patient’s physical and
psychosocial needs
- interactions are designed to ensure achievement of health goals or
objectives that were mutually
agreed upon
- the nurse provides whatever assistance might be needed to achieve
each goal
- the nurse also provides the patient assistance to perform
activities of daily living
- a goal is to build satisfactory sentiments and feelings between the
people that will be working
together
- satisfactory interaction preserves people’s integrity while
promoting an atmosphere
characterized by minimal fear, anxiety, distrust and tension
- nursing roles of teacher and counselor are performed primarily during
this phase
- 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

Termination Phase – occurs when the conclusion of the initial agreement is

acknowledged, such as at
change-of-shift time, when the patient is discharged, or when a nurse
leaves on vacation or for
employment elsewhere
- nurse and patient examine the goals of the helping relationship for
indications of their attainment or
evidence of progress toward them

DISCUSS FACTORS THAT CAN FACILITATE OR BLOCK COMMUNICATION

 Failure to Perceive the Patient as a Human Being – focus on the whole patient,
not just the patient’s
diagnosis

Failure to Listen – nurse defensiveness is a huge barrier to open and trusting

communication

Inappropriate Comments and Questions – clichés, questions requiring only a

yes or no answer, questions
containing the words “why” and “how”, questions that probe for
information, leading questions,
comments that give advice, judgmental comments

DISCUSS FACTORS THAT ARE USED TO FACILITATE EFFECTIVE COMMUNICATION INCLUDING TECHNIQUES,
INTERPERSONAL COMPETENCIES AND ASSERTIVE SKILLS
Conversation Skills – the exchange of verbal communication as a social
interaction
- control the tone of your voice so that you are conveying exactly what
you mean to say and not a
hidden message

- indicate interest rather than boredom, patience rather than

anger, acceptance rather than
hostility, etc.
- be knowledgeable about the topic of conversation and have accurate
information
- convey confidence and honesty to the patient
- be flexible
- follow the patient’s lead whenever possible
- be clear and concise and make statements as simple as possible
- stay on one subject at a time
- avoid words that might have different interpretations
- be truthful
- if you are unsure of something, admit it and seek an answer
rather than make a comment
that is likely to be an error
- keep an open mind
- take advantage of available opportunities

Listening Skills – involves both hearing and interpreting what another says
(requires attention and
concentration to sort out evaluate, and validate data)
- when possible, sit when communicating with a patient
- do not cross your arms or legs
- be alert and relaxed and take sufficient time
- keep the conversation as natural as possible and avoid sounding overly
eager
- if culturally possible, maintain eye contact with the patient, without
staring, in a face-to-face pose
 - indicate that you are paying attention to what the patient is saying by
using appropriate facial
expressions and body gestures
- think before responding to the patient
- do not pretend to listen
- listen for themes in the patient’s comments (repeated themes and
behaviors, topics avoided,
inconsistencies and gaps)

Silence – can be used appropriately by taking the time to wait for the patient
to initiate or to continue
speaking
- silent times have many meanings, such as the patient is comfortable in
the nurse-patient
relationship, the patient might be trying to gather his/her inner
thoughts or feelings, the
patient may be fearful and uses silence as an escape, or the
patient might be angry and use
silence as a display of this emotion

Touch – a powerful means of communication with multiple meanings

- can connect people, provide affirmation, reassurance and stimulation,
decrease loneliness,
increase self-esteem, and share warmth, intimacy, approval, and
emotional support
- can communicate frustrations, anger, aggression and punishment,
invade personal space and
privacy, and convey a negative type of relationship
- anxiety or discomfort might result when a patient does not understand
the meaning of a tactile
gesture or when the patient simply dislikes being touched

Humor – valued as both an interpersonal skill for the nurse and a healing
strategy for patients
- provides the ability to laugh on oneself and accept 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
- a learned skill
Assertiveness – communication in a way that demonstrates respect for all
parties involved
- the key is to be open, honest and direct
- components include having empathy, describing one’s feelings or the
situation, clarifying one’s
expectations, and anticipating consequences
 - characteristics include confident, open body posture; eye contact; use
of clear, concise “I”
statements; the ability to share honestly one’s thoughts, feelings,
and emotions; 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

DISCUSS THE NANDA NURSING DIAGNOSIS IMPAIRED COMMUNICATION INCLUDING DEFINITION, MAJOR
AND MINOR CHARACTERISTICS, AND RELATED FACTORS
NANDA = North American Nursing Diagnosis Association

Impaired Verbal Communication = the state in which an individual

experiences a decreased or absent
ability to use or understand language in human interaction

Related factors: decrease in circulation to the brain, brain tumor, physical

barrier (tracheostomy, intubation),
anatomic defect, cleft palate, psychological barriers (psychosis,
lack of stimuli), cultural
differences development or age related

Characteristics: individual is able to speak dominant language, speaks or

verbalizes with difficulty, does not
or cannot speak, stutters, slurs, has difficulty forming words or
sentences, has difficulty
expressing thought verbally, uses inappropriate verbalization, has
dyspnea, is disoriented

EXPLAIN HOW TO FACILITATE NURSE-PATIENT INTERACTION IN SPECIAL CIRCUMSTANCES

Visually Impaired
- acknowledge your presence
- identify yourself by name
- speak in a normal tone of voice
- explain reason for touching before doing so
- keep call light or bell within easy reach of patient
- orient patient to the sounds of the environment, arrangement of the
room and its furnishings
- be sure eyeglasses are clean and intact or that contacts are in place

Hearing Impaired
- orient patient to your presence before initiating conversation
- talk directly to the patient while facing him / her
- be aware of nonverbal communication
- do not chew gum or cover your mouth
- demonstrate or pantomime ideas
- use sign language or finger spelling
- write any ideas that you cannot convey in another manner
 - be sure hearing aids are clean, functioning, and inserted properly

Physical Barrier (Laryngectomy or Endotracheal Tube)

- select one or more simple means of communication that the patient is
physically able to use
- eye blinks, hand squeezes, writing pads or magic slates,
communication boards with
words, letters, or pictures, flash cards, sign language
- be sure family, friends, and caregivers understand and are able to use
the selected communication
devices
- demonstrate patience with the time needed to communicate
effectively and reinforce efforts made
by the patient
- ensure that the patient has an effective means of signaling need for
assistance

Cognitively Impaired
- establish and maintain eye contact
- communicate important information in a quiet non-distracting
environment
- keep communication simple and concrete
- do not use pronouns or abstract terms
- use pictures or drawings when appropriate
- when possible, avoid open ended questions
- be patient and give the patient time to respond

Unconscious
- be careful what is said in the patient’s presence
- assume the patient can hear you
- speak with the patient before touching
- keep environment noises as low as possible

Do Not Speak English

- use an interpreter whenever possible
- use a translation dictionary
- speak in simple sentences and a normal tone of voice
- demonstrate or pantomime ideas
- be aware of nonverbal communication