THE COMMUNICATION PROCESS

Communication is the exchange of thoughts, feeling, and other

information
►Is the interchange of information between two or more people; in
other words the exchange of ideas or thoughts.
►Thoughts are conveyed to others not only by spoken or written
words but also by gestures or body actions.
►It can be transmission of feelings or a more personal and social
interaction between people.
►It is a basic component of human relationships.
►the intent of any communication is to elicit a response. It includes
all the techniques by which an individual affects another.

*Two main purpose:

a. to influence others
b. to obtain information

The communication Process

Face-to-face communication involves a sender a message a

receiver and a response or feedback. In its simplest form,
communication is a two away process involving the sending and the
receiving of a message.

Sender
The sender a person or groups who wish to convey a message to
another can be considered the source-encoder. This term suggest
that the person or group sending a message must have an idea or
reason communicating (source) and must put the idea or feeling into
a form that can be transmitted.
Encoding involves the selection or specific signs or symbol (codes)
to transmit the message such as which language and words to use
how to arrange the words to use how to arrange the words and what
tone of voice and gestures to use.

Message
The second component of the communication process is the
message itself-what is actually said or written the body language that
accompanies the words and how the message is transmitted. The
medium used to convey the message is the channel and it can target
any of the receiver’s senses. It is important for the to be appropriate
for the message and it should help make the intent of the message
more clear.

Receiver
The receivers the third component of the communication process is
the listener who must listen observe and attend. This person is the
decoder who must perceive what the intended (interpretation).
Perception uses all of the senses receive verbal and nonverbal
messages.

Response
The fourth component of the communication process the response is
the message that the receiver returns to the sender is also called
feedback. Feedback can be either verbal or non verbal or both.
Nonverbal examples are a nod of the head or a yawn. Either way
feedback allows the sender to correct or record message.

Modes of Communication

Verbal Communication
Verbal Communication is largely conscious because people choose
the words they use. The words used vary among individuals
according to culture socioeconomic background, age, and education.
As a result countless possibilities exist for the way ideas are
exchange. An abundance of word can be used to form messages. In
addition, a wide variety of feelings can be conveyed when people
talk. When choosing words to say or write, nurses need to consider.

A. PAGE AND INTONATION. The manner of speech as in the

pace rhythm and intonation will modify the feeling and the
impact of a message. The intonation can express enthusiasm,
sadness, anger, or amusement. The pace of speech may
indicate interest, anxiety, boredom, or fear. For example
speaking slowly and softly to an excitement may help calm the
client.
B. SIMLPICITY. Simplicity includes the use of commonly under
stead words brevity and completeness. Many complex technical
 terms become natural to nurses. However laypersons
misunderstand these terms.
C. CLARITY AND BREAVITY. A message that is direct and single
will be more effective. Clarity is saying precisely what is meant
and brevity is using the fewest words necessary. The result is a
message that is simple and clear. An aspect of this is
congruence or consistency where the nurse’s behavior or
nonverbal communication matches the words spoken.
D. TIMING AND RELEVANCE. Nurses need to be aware of both
relevance and timing when communicating with clients. No
matter how clearly or simply words are stated or written the
timing needs to be appropriate to ensure that words are heard
Moreover the messages need to relate to the person or to the
person’s interests and concerns. This involves sensitivity to the
client’s needs and concerns.
E. ADAPTABILITY. Spoken messages need to be altered in
accordance with behavioral cues fro the client. This adjustment
is referred to as adaptability. What the nurse says and how it is
said must be individualized and careful considered. This
requires astute assessment and sensitivity to the client’s needs
and concerns.
F. CREDIBILITY. Credibility means worthiness of belief
trustworthiness and reliability. Credibility may be the most
important criterion of effective communication. Nurses foster
credibility by being consistent, dependable, and honest. The
nurse needs to be knowledgeable about what is being
discussed and to have accurate information. Nurses should
convey confidence and certainty in what they are saying while
being able to acknowledge their limitation (e.g.,” I don’t know
the answer to that but I will find someone who does”)
G. HUMOR. The use of humor can be positive and powerful tool in
the nurse client relationship but is must be used with care.
Humor can be used to help clients adjust to difficult and painful
situation. The physical act of laughter can be both emotional
and physical release reducing tension by providing a different
perspective and promoting a sense of well being.

Nonverbal Communication
Nonverbal communication is sometimes called body language. It
includes gestures body movements use of touch and physical
appearance including adornment. Nonverbal communication often
tells other more about what a person is felling than what is actually
said because nonverbal behavior is controlled less consciously
than verbal behavior. Nonverbal communication either reinforces
or contradicts what is said verbally.

PERSONAL APPEARANCE. Clothing and adornments can be

sources of information about a person. Although choice of apparel
is highly personal it may convey social and financial status,
culture, religion, group association, and self concept. Charms and
amulets maybe worn for decorative or for health protection
purpose. When the symbolic meaning of an object is unfamiliar the
nurse can be inquire about its significance which may foster
rapport with the client.

POSTURE AND GAIT. The ways people walk and carry

themselves are often reliable indicators of self concept current
mood and health. Erect posture and an active purposeful stride
suggest a feeling of well being. Slouched posture and slow
shuffling gait suggest depression or physical discomfort. Tense
posture and a rapid determined gait suggest anxiety or anger.

FACIAL EXPRESSION. No part of the body is as expressive as

his face suggests happiness and sadness can be conveyed by
facial expression. Nurses need to be aware of their own
expression and what they are communicating to others. Clients are
quick to notice the nurse’s facial expression particularly when the
clients feel unsure or uncomfortable. Eye contact is another
essential element of facial communication. In many cultures,
manual eye contact acknowledges recognition of the other person
and the willingness to maintain communication.

GESTURES. Hand body gestures may emphasize and clarify

spoken word or they may occur without words to indicate a
particular felling or to give a sign. A wave good-bye and the
motioning of a visitor toward a chair are gestures that have
relatively universal meaning.
 Communication in different level of deployment.

Infants
*Infants communicate through their senses. Teach parents
about the importance of touch.
*They respond best to high-pitched soft or gentle tone of voice
and eye contact.

Toddlers and Preschoolers

*Allow time for them to complete verbalizing their thoughts
without interruption.
*Provide a simple response to question because they have
short attention spans.
*Drawing a picture can provide another way for the child
communicates.

School-Age Children
*Talk to the children at his or her eye level to help decrease in
*Include the children in the conservation when communicating
with the parents.

Adolescent
*Take time to build rapport with the adolescent
* Use active listening skills.
*Project z nonjudgmental attitude and non reactive behavior
even when the adolescent says disturbing remarks.

Factors influencing the Communication Process

A. Development
Language psychosocial and intellectual development
moves through the stages across the life span. Knowledge of a
client’s development stage will allow the nurse to modify the
message accordingly. The use of dolls and games with simple
language may help explain a procedure to an 8-years-old. With
adolescent who have developed more abstract thinking skill a
more detailed explanation can be given wherereas a well
educated middle-age business executive may wish to have
detailed technical information provided. Older clients are apt to
have a wider range of experiences with the health care system
which may influence their response and understanding. With
aging also come changes in vision and hearing acuity that can
affect nurse-client interactions.

B. Gender
From an early age females and males communicated
differently. Girls tend to use language to seek conformation,
minimize differences and establish intimacy. Boys use language
to establish independence and negotiate status within a group.
These differences can continue into adulthood so that the same
communication may be interpreted different a man and a
woman

C. Values and Perceptions

Values are standards that influence behavior and
perceptions are the personal view of an event. Because each
person has unique personality traits, values, and life expression
each will perceive and interpret messages and experiences
differently. For example if the nurse draws the curtain around a
crying woman and leaves her alone the woman may interpret
this as “The nurse thinks that will upset others and that I should
cry” or” The nurse respects my need to be alone”. It is important
for the nurse to be aware of client’s values and to respect or to
correct perception to avoid creating bartries in nurse client
relationship.

D. Personal Space
Personal space is the distance people prefer in interact with
others. Proxemics is the study of distance between person in
their interaction. Middle class North Americans use definite
distances in various interpersonal relationships along with
specific voice tones and body language. Communication alters
in accordance with four distances each with a close to a far
phase. Tamparo and Lindh (2000,p.91) list the following
examples:
1. Intimate:Touching to 1 1/2 feet
2. Personal: 11/2 to 4 ft
3. Social: 4 to 12 ft
4. Public: 12-15 ft
Intimates distance communications characterized by body
contact heightened sensations of body heat and smell and
vocalization that are low. Vision is intense restricted to a
specific body part and may be distorted.

Personal distance is less overwhelming than intimate distance.

Voice tones are moderate and body heat and smell are notice
less. Physical contact such as handshake or touching a
shoulder is possible.

Social distance is characterized a clear visual perception of the

whole person. Body heat and other odor are imperceptible eye
contact is increased and vocalizations are loud enough to be
hear by others. Communication is therefore more formal and is
limited to seeing and hearing.

Public distance requires loud clear vocalization with carefree

reification although the faces and forms of people are at public
distance individuality is lost instead the person is of the group of
people or the community.

E. Territoriality
Territoriality is a concept of the space and things that an
individual considers are belonging to the self. Territoriality
marked off by people may be visible to others. For example
clients in a hospital often considered their territory as bounced
by the curtains around the bed unit or by the walls of the private
room. This human tendency to claim territory must be
recognized by all health care workers. Clients often feel the
need to defend their territory when it is invaded by others for ex.
When a visitors or nurse removes a chair to use at the other
bed the visitor has inadvertently violated the territoriality of the
client whose chair was removed. Nurses need to obtain
permission from clients to remove rearrange or borrow object in
their hospital area.

F. Roles and Relationship

The roles and the relationship between sender and
receiver affect communication process. Roles such as nursing
student and instructor client and physician or parent and child
affect the content and responses in the communication process.
Choice of words sentence structure and tone of voice vary
considerably from the role to the role In addition the specific
relationship between the communicators is significant. The
nurse who meets with a client for the first time communicates
differently from the nurse, who has previously developed a
relationship with that client,

G Environment
People usually communicate most effectively in a
comfortable environment. Temperature extremes excessive
noise and a poorly ventilated environment can all interfere with
communication Also lack of privacy may interfere with a clients
communication about matter that clients considers private. For
Ex. A client who is worried about the ability of his wife to care
for him after discharge from hospital may not wish discuss
concern with a nurse hearing of others clients in the room.
Environmental distraction can impair and distort
communication.

H. Congruence
In Congruence communication the verbal and non verbal
aspects of the message match. Clients more readily trust the
nurse when they perceive the nurse’s communication as
congruent. This will also help to prevent miscommunication.
Congruence between verbal expression and non verbal
expression is easily seen by the nurse and the client. Nurses
are taught to asses clients but clients often just adept at reading
a nurses expression or body language If there are
incongruence the body language or nonverbal communication
is usually the one with the true meaning For ex, when teaching
a client how to care for a colostomy the nurse might say “You
won’t have any problem with this.” However if the nurse looked
worried or disgusted while saying this the clients are less likely
to trust the nurse’s words.

Therapeutic Communication
Therapeutic communication promotes understanding and
can help establish a constructive relationship between the
nurse and the client. Unlike the social relationship where there
 way not be a specific purpose of direction the therapeutic helping
relationship is client and goal directed. Nurses needed to
respond not only the content of client’s verbal message but also
the felling expressed. It is important to understand how the
clients view the situation and feels about it before responding.

Attentive Listening
Attentive Listening is listening actively using all these senses as
opposed to listening passively with just the ear It is probably the
most important technique in nursing and is based all other
techniques attentive listening is an active process that requires
energy and concentration. It involves paying attention to the total
message both verbal and nonverbal.

Barriers to communication

THE HELPING RELATIONSHIP

Nurse client relationship are referred to by some as
interpersonal relationship by other as therapeutic relationships and
by still others as helping relationship Helping is a growth facilitating
process that strives to achieve two basic goals (Egan 1998)

1. Helps client manage their problems more effectively and

develop unused or underused opportunities more fully.
2. Helps client become better at helping themselves in their
everyday lives.

A helping relationship may be develop over weeks of working with

a client, or within minutes. The keys o the helping relationship is {the
development of trust and acceptance between he nurse and {b} an
underlying belief that the nurse cares about and wants to help the
client.

The helping relationship is influenced by the personal and

professional characteristics of the nurse and the client. Age, sex,
appearance, diagnosis, education, values, ethnic, and cultural
background, personality, expectations, and setting can all affect the
development of the nurse- client relationship.
 Phases of the Helping Relationship
The helping relationship process can be described in terms of four
sequential phases, each characterized by identifiable tasks and skills.
The relationship must progress through the stages in succession
because each builds on the one before. Nurses can identify the
progress of a relationship by understanding these phases.

Preinteraction Phase
The preinteraction phase is similar to the planning stage before an
interview. In most situations, the nurse has information about the
client before the first face-to-face meeting. Such information may
include the client’s name, address, age, medical history and or social
history. Planning for the initial visit may generate some anxious and
feeling specific information to be read positive outcomes can evolve.

Introductory Phase
Introductory phase, also referred to as the orientation phase, is
important because it sets the tone for the rest of the relationship.
During this initial encounter, the client and the nurse closely observe
each other and form judgments about the others’ behavior. The tree
stages of this introductory phase are opening the relationship,
clarifying the problem, and structuring and formulating the contact.
Other important tasks of the introductory phase include getting to
know each other and developing a degree of trust.
After introductions, the nurse may initially engage in some social
interaction to put the client at ease. For example nurse and client may
talk about what a nice day it is and what they would like to do if at
home.

Characteristics of a Helping Relationship

A helping relationship
* Is an intellectual and emotional bond between he nurse and the
client and is focused on the client.
*Respect the client as an individual, including
*Maximizing the client’s abilities to participate in decision
making and treatments
* Considering ethnic and cultural aspects
* Considering family relationship and values
*Respects client confidentiality
*Respect on the client’s well- being
*Is based on mutual trust, respect, and acceptance.
By the end pf the introductory phase, clients should begin to
*Develop trust in the nurse.
*View the nurse as a competent professional capable of helping.
►View the nurse as honest, open, and concerned about their
welfare.
►Believe the nurse will try to understand and respect their cultural
values and beliefs.
►Believe the nurse will respect client confidentiality.
►Fell comfortable talking with the nurse about feeling and others
sensitive issues.
►Understand the purposes of the relationship and the roles.
►Feel that they are active participants in developing a mutually
agreeable plan of care.

Working Phase
During the working phase of a helping relationship, the nurse
and the client begin to each other as unique individuals. They begin
to appreciate this uniqueness and care about each other. Caring is
sharing deep and genuine concern about the welfare of another
person. Once caring develops the potential for empathy increases.
The working phase has two major stages: exploring and
understanding thought and feelings, and facilitating and talking
action. The nurse helps the client to explore thought, feelings, and
actions and helps the client plan a program of action to meet
preestablished goals.

EXPLORING AND UNDERSTANDING THOUGHT AND FEELINGS.

The nurse requires the following skills for this phase of the helping
relationship.

● Empathetic listening and responding nurses must listen

attentively and communicate (respond) in ways that indicate they
have listened to what was said and understand how the client feels
the nurses respond to content and feeling or both as appropriate. The
nurse’s nonverbal behaviors are also important. Nonverbal behaviors
indicating empathy include moderate gesturing and little activity or
body movement. According to Egan (1998) empathy “can be seen as
an intellectual process that involves understanding correctly another
person’s emotions state and point of view” and also as an emotional
response experienced by the helper. Empathetic listening focuses on
a kind of “being with” clients to develop an understanding of them and
their world. This understanding, however, must also be
communicated effectively to the client-emphasis response. The end
result of empathy is comforting and caring for the client and a helping,
healing relationship.

● Respect. The nurse must show respect for the client’s

willingness to be available, desire to work with the client, and a
manner that conveys the idea of taking the clients point of view
seriously.

● Genuineness. Personal statements can be helpful in

solidifying the rapport between the nurse and the client. The nurse
might offer such comments as “I recall when I was in (similar
situation), and I felt angry about being put down.” Egan outlines five
behaviors that are components of genuineness. Nurses need to
exercise caution when making references about themselves. These
statements must be used with discretion. The extreme of matching
case of the client’s problems with a better story of the nurse’s own is
of little value to the client.

● Concreteness. The nurse must assist the client to be

concrete and specific rather than to speak in generalities. When the
client says, “I’m stupid and clumsy.” The nurse narrows the topic to
the specific by pointing out, “You tripped on the rugs.”

● Confrontation. The nurse points out discrepancies between

thoughts, feelings, and actions that inhibit the clients self
understanding or exploration of specific areas. This is done
empathetically, not judgmentally.

During the first stage of the working phase, the intensity of

interaction increases, and feelings such as anger, shame, and self-
consciousness may be expressed. If the nurse is skilled in this stage
and if client is willing to pursue self-exploration the outcome is a
beginning understanding on the part of the client about behavior and
feelings.
Termination Phase
The termination phase of the relationship is often expected to be
difficult and filled with ambivalence. However, if the previous phases
have evolved effectively, the client generally has a positive outlook
and feels able to handle problems independently. On the other hand,
because caring attitudes have developed, it is natural to expect some
feeling loss, and each person needs to develop a way of saying
good-bye.
Many methods can be used to terminate relationships.
Summarizing or reviewing the process can be produced a sense of
accomplishment. This may include sharing reminiscences of how
things were are the beginning of the relationship and comparing them
to how they are now. It is also helpful for both the nurses and the
client to express their feelings about termination openly ad honestly.
Thus termination discussions need to start to advance of the
independence. In some situations referrals are necessary or it may
be appropriate to offer an occasional standby meeting to give support
as needed. Follow-up Phone calls or e-mails are other interventions
that ease the client’s transition to independence.