Lecture Notes of Communication

and Nursing Process

Spring 2009

By

Daniel Nanguang, R.N., M.Ed.

COMMUNICATION• Learn the key terms or the terminologies of

communication in chapter 26 of Kozier & Erb (2008).

• Communication – its meaning depends on the setting and the context of its use. Basically, however, it is a necessary component in human relationships, and, therefore, means or is used for thought/information exchange between or among two or more people as well as intra-personally (self-talk).

A. Modes of Communication. • The three main ways it is used in communication

are: verbal, non-verbal and electronic methods.• Verbal communication = both spoken (type

words and tone of voice, speed),written (words and the meaning they convey), timing and clarity of the message.

• Non-verbal communication = body language, facial expressions, appearance, posture, gait (manner of walk) gestures, nods, etc.

• Electronic communication = computer messages, i.e. e-mail, etc.

B. Process of Communication.

• Effective communication involves either a personal (face to face) communication or some means of an encounter that requires the following four necessary components: a sender, a message, a receiver and a response.

• Sender = may one, two or a group of people with a message to send/convey and a system of sign(s) or symbol(s) (code, i.e. – language, etc.) to use in transmission/sending (encoding) it.

• Message (from sender) and (from receiver) = contents or meaning, language (words arrangement and use) and the tone which the message is meant to convey.

• Receiver = the recipient/listener of the message decodes (i.e. – relates to or understands message) and returns communication. Refer to Figure 26-2 picture representation in Kozier & Erb, (2008), page 461.

• Response = the message or feedback (non-verbal cues, i.e. winks nods, etc.) that the receiver sends back to the sender.

C. Factors That Influence Communication. • A variety of factors influence the process of

communication: perception, attitudes, relationships, values, roles, development, gender, and space.

• The level of development – helps in modifying both the message and the response. Example: a message to an astronaut requires modification if sent to either a lay person or a ten years old child.

• Gender – males and females develop differently and so have some difference communicate, even in adulthood.

• Values = the standards (personal, communal and societal) that influence behavior – therefore, personal value traits and experiences do influence the perception of communication and behaviors of others as well as the response to them.

• Perception = is a personal view of any situation, which in effect, influences the perception and response to events.

• Attitude = of caring, concern, interest, etc., are portrayed or betrayed by either good or bad mood.

• Example: Elderspeak = To speak knowingly or unknowingly, and believing that are conveying caring, but the patient sees it as demeaning or patronizing.– Caring – indication of deep emotional warmth.– Warmth – an indication of emotional closeness.– Respect – an attitude that conveys individual

worth and respect for his/her wishes, regardless what the wishes are.

– Acceptance – places emphasis on neither approval nor disapproval.

• Personal space (proxemics – study of the distance between people in interaction). Example of distances in communication: – Intimate = 1&1/2 ft – is characterized by body

contact, etc.– Personal = 1&1/2 – 4ft – characterized by more

space, less overwhelming, with a moderate tone of voice.

– Social distance = 4-12 ft and characterized by a clear view of the whole individual with clear and louder tone of voice.

– Public = 12-15 ft, requires careful enunciation, a louder tone of voice and a clearer vocality.

• Territoriality = is also about space a domain that one considers as personal i.e. a client’s room or space around the bed with a demarcating curtain.

• Roles = student/teacher, father-mother/son-daughter, roles etc.

• Relationships = this is a similar role as the teacher/student relationship above.

• The environment = a comfortable surrounding with controlled temperature, and noise-free, etc.

• Congruence = this refers to compatibility of verbal and non-verbal messages – that they both match and not seen as giving two or more different messages.

D. Use of Communication.Communication is used to: get a response, influence or obtain information. • Therapeutic Communication. Therapeutic

communication helps in promoting understanding and constructive relationship – understanding of both the content and feelings expressed by responding in kind. Refer to Therapeutic Techniques in Table 26-2 of Kozier & Erb, (2008), pp.469-471.

• Attentive Listening. This is an active listening without giving the impression of either selective listening or not listening, that the message is not all that important to you or that you are in a hurry and would rather be somewhere else.

• Physical Attending. This portrays a physical presence with full attention span and interested. Refer to Box 26-1 Ibid., p. 469 for more on the topic.

E. Barriers to Communication.

Barriers to communications occur principally as a result of non-therapeutic communication. Good examples to this failure include: •Wrong or improper decoding of the message.•Poor choice of words.•Wrong tone – raised voice, etc.

• Failure to listen – not listening by looking away or doing other things as a sign of disinterest.

• Wrong environment or poor environmental control – noisy surrounding or environment.

• Wrong timing – while or when client is eating or doing something or in pain.

• Inconsideration by the nurse or health professional- client eating or sleeping, with nurse not willing or ready to wait.

II. THERAPEUTIC RELATIONSHIPThe therapeutic relationship or helping relationship is typified by the relationship between a health professional and a client, but especially between nurses and their patients. Of great importance are:• Trust – the development of trust facilitates

acceptance of the nurse by patient.• Belief – allows client to believe that the

nurse cares about him/her and his/her needs.

Phases of Therapeutic Relationship.This type of relationship goes/progresses though stages:

• Pre-interaction phase – similar to planning the interview stage when information about client is obtained and planning of visit with some level of anxiety.

• Introductory (or pro-helping) phase – during this time that the tone for relationship is set, and client may display some level of resistance. This initial resistance can be alleviated by a genuine caring attitude by the nurse.

• Working phase – when both nurse and client view each other as individuals with separate but important roles and start to explore feeling and act towards accomplishing a set goal with empathy and:

- Respect.- Genuine concern and rapport.- Giving of correct information.- Friendly confrontation as nurse points out areas of

discrepancies.• Termination phase – a summary, by reviewing the

process and accomplishment of the interview session.

B. Developing Therapeutic Relationship.This is commonly achieved by:

• Attentive listening – not only paying attention, engaged with body language.

• Identifying with the feelings of client, i.e. “You seem angry about the unfairness of…”

• Empathy - by putting yourself their shoes and showing that you understand.

• Honesty - by admitting that you do not know some of the answers to some of the questions that you are being asked.

• Genuineness and credibility - about being truly concerned.

• Maintain an understanding of Cultural differences – as this fosters client- nurse interaction.

• Ingenuity – by employing some other means/avenues in handling the situation.

• Confidentiality – maintain patient’s rights of privacy as confidential on all information.

• Remaining within the boundaries of professional role – seek help if you need it, and clarify the functions of your role.

GROUP COMMUNICATION.

• Group Dynamics. Communication with any given group is known as group dynamics as determined by a variety of factors as each member affects the dynamics, depending on goal, feelings and the level of participation of each member, motivation and maturity of the group.

• Types of Health Care Groups. These usually include: task, teaching, self-help, self-awareness, growth, therapy work related social support groups.– Task group = most common of work-related

groups that nurses belong, with chairperson: i.e. health planning committees, nurse team meetings, nursing care conference, etc.

– Teaching group = main purpose is to impart information: i.e. continuing education, client health care groups, etc.

– Self-help group = usually small and composed of volunteers with similar health problems and similar beliefs in self-help, etc.

– Self-awareness = purpose is to develop interpersonal strength for improving functioning.

– Therapy group = for self-satisfaction and stress relief.– Work-related = form to provide support and encourage

members in dealing with work related stress.

COMMUNICATION & NURSING PROCESS.

The principal and overriding concerns are: professional conduct, clarity, attentive listening and a caring attitude in: • Assessment. Be aware of barriers to

communication; cultural influence, level of development and anxiety; make sure to have a clear communication; and to seek clarification on statements that are ambiguous.

• Diagnosis. Follow the same line of approach as above.

• Plan of care. Provide clear and effective communication in the use of language; by using every available means to have no anxiety or decreased levels of it; and consult with appropriate resources.

• Implementation. Make every effort to facilitate clear communication; and effectively control the environment in a therapeutic setting of the interview.

• Evaluation. Share information about the progress being made by patient with him/her.

COMMUNICATION AMONG HEALTH PROFESSIONALS.

Communication is an important aspect within and between the various health professions and their practitioners, but especially between the nurse and the physician as well as between the nurse and patient.

Communication Between Nurses and Physicians.

There are no available guidelines for verbal communication between doctors and nurses. As a consequence, this has contributed or resulted in many medications’ errors. There’s virtually no difference, or very little it, between the communication styles of nurses and doctors. Nurses’ prefer to focusing their communication more on the “narrative and descriptive” aspect; while physicians focus mainly on the “need or problem” of patients by “ruling out alternatives”.

Assertive Communication.

An assertive communication’s hallmark is that it seeks to promote patient safety in reducing miscommunication by seeking clarification for medical orders from doctors as well as with colleagues through the “I” and “you’ statements. Example: “I’m worried /concerned about this medication order” ; or, “…you did this/that in that way”, etc.

Nonassertive Communication.

There are two types/kinds of non-assertive communication:• Submissive type (believed to be due to insecurity or

low self-esteem) = people who allow their rights to be violated by seeking to meet the demands made by others with no or little regard to their own needs and feelings.

• Aggressive type (assertive aggression) = assert and defend legitimate rights, but using such aggressive behavior (as sarcasm, jokes rude behavior or downright insults, etc.) in disregard for the feelings, rights and or opinion of others around them.

References.

• Kozier, B. et al, Fundamentals of Nursing, Concepts, Process and Practice. 8th Ed., Upper Saddle River, N.J.: Pearson Education, Inc., 2008.