The nurse’s ability to establish effective communication in nursing is imperative to providing the best care and patient outcomes possible; to develop a helping relationship. Communication may be helpful or unhelpful. It is helpful when it encourages the transfer of information, thoughts, or feelings between communicators, and unhelpful if otherwise. Helpful communication allows for better assessment, intervention, and evaluation. Therapeutic communication allows for:
- Assess the patient’s perception of the problem
- Facilitate the client’s expression of emotions
- Recognize the client’s needs
- Implement interventions
- Guide the client towards identifying a plan of action to a satisfying and socially acceptable resolution of needs.
- Facilitating personal growth and behavioral change
- Teach the client and family necessary self-care skills
Modes of Communication
- Verbal Communication
- Non-Verbal Communication
- Kinesics (body, facial, and eye movements)
- Paralanguage: voice-related behaviors e.g. pitch, tone, rate, volume
- Proxemics
- Autonomic physiologic response e.g. rate of breathing, pallor, sweating; general and physical appearance and characteristics
- Written Communication
Communication Process
- Sender: the source and encoder who initiates communication to another. This involves choosing a mode of communication and the type of encoding used such as language, vocabulary, and gestures.
- Message: the actual result of encoding.
- Receiver: the one who perceives the message from the sender. All senses may be used to receive various modes of communication, even involuntarily such as subtle first impressions of a person’s appearance.
- Feedback: response; the returning message in response to the sender’s first correspondence.
flowchart LR
1(Sender)
1--Message-->2
2(Receiver)
2--Feedback-->1
In-Person Communication
- Pace and Intonation: rate, rhythm, and tone of speech.
- Simplicity: use of common words, brevity, and completeness.
- Clarity: saying precisely what is meant.
- Timing and Relevance: sensitivity to the client’s needs and concerns
- Adaptability: altering spoken messages in accordance with behavioral cues from the client.
- Credibility: means worthiness of belief, trustworthiness, and reliability. It is fostered by being consistent, dependable, and honest.
- Humor: may be powerful, but should be used with care. It may be able to allow clients to adjust to difficult and painful situations.
Factors Affecting Communication
- Proxemics: “personal space” used in communication, with varying levels of “closeness” depending on patient status.
| Space | Distance | Use Case |
|---|---|---|
| Intimate | 0 to 1.5 ft. | Body contact; assisting in ambulation, positioning, etc. |
| Personal | 1.5 to 4 ft. | Often used in nursing care e.g. administering medication, teaching, and various forms of therapeutic use of self |
| Social | 4 to 12 ft. | Formal communication limited to seeing and hearing, group communication |
| Public | 12 ft.+ | Communication requires a loud and clear voice |
- Boundaries: the defining limits of an individual. The nurse must maintain a clear professional boundary with the patient. Keep the focus on the patient and avoid sharing personal information. Gift exchanges, excessive time with the patient, and believing only the nurse understands the patient are all over-extensions beyond this boundary.
- Gender: men and women communicate differently, and may decode identical messages differently.
- Values: standards that influence behavior, and may result in differences in message decoding.
- Interpersonal Attitudes: these convey beliefs, thoughts, and feelings about people and events.
- Attentive listening: active listening; mindfulness and full use of the senses to what the client does, says, and feels. Behaviors for this use the mnemonic SOLER: sit straight and squarely with the patient; use an open posture (no crossed arms, etc.), lean forward, use eye contact appropriately, and use a relaxed attending attitude.
- Congruence: the harmonization of the verbal and non-verbal aspects of communication.
- Touch: may be comforting and supportive, but may violate the intimate or personal space.
Therapeutic Communication Techniques
Open Ended
Allows the client to share their personal experiences.
- Giving Broad Openings: these may stimulate hesitant patients to start talking.
- “Is there something you’d like to talk about today?”
- Gentle Encouraging Descriptions of Perception
- “Tell me/Share with me/Describe for me something about your home life.”
- “What happened?”
- “What does the voice seem to be saying?”
Focused
Often used with resistant clients who often change topics. These questions are used to identify and stay on one topic of interest.
- Focusing
- “Of all of the concerns you’ve mentioned, which is the most troublesome?”
- Exploring: examination of a topic by asking further questions
- “Can you tell me what the voices are saying?”
- Qualitative Questions: try to gain understanding of the patient’s experience of a certain situation.
- “How’s your appetite?”
- Quantitative Questions: attempt to discover cause and effect relationships, often through comparison.
- “How many times were you visited this week?”
Statement of Inquiry
- Reflecting/Paraphrasing: directing client actions, thoughts, and feelings back to the client.
- P: “My family always dotes on my mistakes.”
- N: “*Are you saying you are viewed as the bad guy in the family?”
- Reflecting on Expressed Feelings
- P: “No one wants to be around me”
- N: “Do you feel rejected?”
- Clarifying Statements
- P: “I’m crazy.”
- N: “What do you mean by that?”
- Validate Statements
- P: “I can’t sleep. I stay awake all night.”
- N: “I understand you’re having difficulty sleeping”
- Restate or Give Feedback
- P: “Nurse, am I crazy?”
- N: “Do you think you’re crazy?”
Empathetic Statements
- Sharing Perceptions, responding in a way that the client feels like they are worthy and important.
- “It sounds like a troubling time for you.”
Faciliatory Statements
- Accepting: indicates that the nurse has heard the patient, and that they are interested. Utilizes “accepting” application of facial expressions, paralanguage, etc.
- “Yes.”
- Head nodding
- Offering General Lead: indicates that the nurse is following along with the client, without taking away the initiative from the patient.
- “Go on?”
Close Ended
Help obtain important facts or specific details and give information or explanations. These may also help focus a wandering client.
- Close Ended Questions/Seeking Information
- “How long have you been hearing these voices?”
Other Useful Techniques
- Presenting Reality: indicating what is real to the patient.
- “I see no one else in the room.”
- P: “Someone’s trying to shoot me!” N: “That was a car backfiring.”
- Encourage Expression of Feelings
- P: “I want to kill myself.”
- N: “What makes you feel that way?”
- Offering Self: making the self as an available resource for the patient.
- “I’ll sit with you for a while.”
- Consensual Validation: words and phrases may contain differing meanings and may cause misunderstandings. These allow the patient and nurse to unite their understandings.
- “Tell me whether my understanding of it is the same as yours”
- Encouraging Comparison: comparing and contrasting differences of situations of circumstances.
- “Was it better when you were with your mother, or with your father?”
- “Have you had similar experiences?”
- Giving Information: informing the client about a topic (allows them to know what to expect), which also aids in building trust.
- “I’m here to…”
- “Visiting hours are…”
- Giving Recognition: greeting the client by their preferred name, indicating awareness of changes in their appearance or demeanor, or noting their efforts allow the patient to feel recognized as an individual.
- “I see you’ve finished your tasks for today.”
- “Your hair looks nice today. Did you style it?”
- Formulating a Plan of Action: creating definite plans to allow the client to cope effective in a similar situation in the future.
- “How can we handle this better next time it occurs?”
- Making Observations: verbalizing the nurse’s perceptions. The patient may feel encouraged to talk or express themselves.
- “I noticed you’re biting your nails. Are you uncomfortable?”
- Silence: may provide the patient with the time they need to formulate answers, regain composure, or when to talk. The nurse should be aware of their nonverbal behaviors. Eye contact and conveyance of interest should be maintained.
- Summarization: reviewing main points and conclusions during the interaction. It provides a sense of closure and completion, and re-establishes the agreements the nurse and patient have created.
- “Let’s see… so far, we have talked about…”
- Translating Into Feelings: verbalizing the patient’s indirectly expressed behaviors or feelings. Meaningless or unrealistic statements may have underlying meanings or motivations.
- P: “I’m way out in the ocean.”
- N: “Do you feel lonely or isolated?”
- Voicing Doubt: expressing uncertainty about the reality of the client’s perceptions. It allows the patient to recognize that other people’s perceptions may differ from theirs, then to reevaluate their perceptions.
- “Isn’t that unusual?”
- “I find that hard to believe.”
Non-Therapeutic Communication Techniques
Denoted by the mnemonic COWARD:
- Changing Topics, Challenging, Testing, and Defending
- Giving Opinions, Advice, Value Judgement, False Reassurance
- “Why?” Questions
- Asking Yes or No Questions
- Refusing to Listen or Pay Attention
- Disapproving or Approving
Changing Topics
The nurse may change topics when they are unable to respond, has a topic in mind they want to discuss, or uncomfortable. They attempt to introduce an unrelated topic into the conversation.
- P: “I’d like to die. Can you kill me with an overdose?”
- N: “Did you have any visitors last evening?”
Challenging
For the nurse to demand proof from or present counterarguments to the patient. This may result in those with altered perception to defend their perceptions more strongly than before.
- “If you say you’re dead, then why is your heart still beating?”
Defending
Attempting to protect someone or something from verbal attacks by the patient. This makes the patient feel like they have no right to express impressions, opinions, or feelings, which results in communication blockage.
- P: “Is the doctor really trying to cure me?”
- N: “I’m sure the doctor has your best interests in mind.”
Testing
Appraisal of the client’s degree of insight; acknowledgement of the client’s lack of insight is not helpful.
- “Do you know what kind of hospital this is?”
Opinions and Value Judgement
These are opinionated or moral feedback from the nurse that limit the patient’s decision-making, thinking, analysis, and independence.
- “That’s unfair.”
Advising
Telling the client what or how to do things, which imply that only the nurse know the best for the client.
- “I think you should…”
- “Why don’t you…”
False Reassurance
Indication that there is no reason for anxiety or other forms of discomfort in an attempt to dispel the client’s feelings, stating there is no sufficient reason for concern.
- “Everything will be alright.”
- “You’re coming along just fine.”
Requesting an Explanation
The use of “Why?” questions that ask the client for reasons to their thoughts, feelings, behaviors, or events. This form of questioning is intimidating, and the client likely does not have an answer. They may become defensive trying to explain themselves. There is a marked difference between asking the patient to describe perceptions than to explain them.
Probing Questions
Persistent questioning, which causes feelings of being “used” or being invaded. Patients have the right to withhold concerns or feelings, and probing will only encourage the client to close up.
- “Now tell me about your recent suicide attempt. You know I have to find out.”
Yes-No Questions
Due to its limited nature, questions that are answered only with yes or no are unable to provide an accurate look into the patient’s ideas, thoughts, or feelings.
Interpreting
Asking to make conscious that which is unconscious, and telling the client about the meaning of their experiences. The nurse cannot decipher the patient’s feelings. Only the client can identify or confirm the presence of feelings.
- “So what you’re really saying is…”
Stereotyped Comments
The use of cliché phrases from social conversation with the patient provides little to no value. Any “automatic” responses lack the nurse’s consideration or thoughtfulness.
- “Keep your chin up.”
- “It’s for your own good.”
Approving or Disapproving
Sanctioning or denouncing the client’s behaviors, thoughts, or ideas. These imply that the nurse has the right to give judgment over the client’s thoughts and actions, also creating an expectation that the client should please the nurse.
- “I’d rather you wouldn’t…”
- “That’s good.”
Agreeing or Disagreeing
These create the idea that the client is “right” or “wrong”. If accepted, the client cannot change their mind without being “wrong”. Opinions and conclusions should only be from the client. If rejected, the client may then feel defensive about their points of view or ideas.
Rejecting or Denying
Refusing to consider or even showing contempt for the client’s ideas or behaviors, or even refusing to admit the existence of a concern or problem. These block exploration and deny the feelings and seriousness of the client due to dismissal.
- “Let’s not talk about this.”
- “I don’t want to hear about it.”
- “Don’t be silly.”
Devaluation of Expression
Belittling or minimizing the feelings of the patients, or giving literal responses to figurative comments reduce the importance of the patient’s concerns.
- P: “I wish I was dead.” N: “Even I’ve felt that way before.”
- P: “They’re looking in my head with a television camera.” N: “Oh yeah? What channel is it on?”