Unit 2
P&V Section 2Rita Carey, MSN,
RNTherapeuticCommunicationCommunication ProcessOne-way
communication Sender controls the messageNo opportunity for
feedbackTwo-way communicationEach person contributes equally
Involves feedback or discussion
Elsevier items and derived items 2009, 2005 by Saunders, an
imprint of Elsevier, Inc. All Rights Reserved.33Which type
communication is the usual form of communication?Example of one-way
communication: The surgeon tells the scrub nurse Hand me the number
5 dilator.How is feedback impossible? (The surgeon gave a specific
order with no expectation of feedback.)Example of two-way
communication: The instructor asks the class a question about the
topic being covered. (This purposefully prompts feedback or
discussion from students.)Is an open-ended question an example of
one-way communication? (No, an open-ended question asks for a
response.)
Factors that Affect CommunicationPersonal characteristics of
sender and receiverAge, gender, income, marital status, attitude,
etc.Cultural characteristicsSpace, language, touch, manners,
gestures, etc.Situational influencesPhysical and emotional state,
background noise, interruptions,
etc.ContextAppropriateness/inappropriateness of the messageElsevier
items and derived items 2009, 2005 by Saunders, an imprint of
Elsevier, Inc. All Rights Reserved.44What else in the environment
could affect communication? (different odors, room temperature,
colors, dcor)Discuss how hospitals and other health facilities make
the environment more comfortable.
Types of CommunicationVerbal NonverbalAffectiveElsevier items
and derived items 2009, 2005 by Saunders, an imprint of Elsevier,
Inc. All Rights Reserved.55How will the receiver interpret the word
trip in this sentence? I heard you had some trip.Ask the class for
examples of nonverbal communication. (tone of voice, facial
expressions, body posture, eye contact, hand gestures, fidgeting,
yawning, sighs, shoulder shrugging)What is ones attitude? (manner
or disposition toward a person or thing; a settled mode of
thinking)What is mood? (prolonged emotion that colors ones psychic
life) What is ones personal space? (an imaginary comfort zone
around a person)
Types of CommunicationVerbal communication: spoken messagesSpeak
clearlySpeak professionallySpeak only about what you knowNo slangNo
medical jargonColloquial expressions may be appropriateElsevier
items and derived items 2009, 2005 by Saunders, an imprint of
Elsevier, Inc. All Rights Reserved.66Think before you speak.If you
do not know something, let the patient know that you will find out
the answer or find someone who knows the answer.What are examples
of medical jargon that we assume patients understand? (examples:
NPO, OB, subq, analgesic, arrhythmia, bearing down, purulent)What
words could we substitute for these so that the patient understands
us?What are some acceptable colloquial (common) expressions we
could use?What illnesses may affect a patients verbalization?
Types of CommunicationNonverbal communication: body
languageExpressions, posture, movements, gestures, physical
appearance Clues to the truth of the spoken messageIndicators of
patient discomfortPhysical appearance is a part of nonverbal
communication Elsevier items and derived items 2009, 2005 by
Saunders, an imprint of Elsevier, Inc. All Rights
Reserved.77Nonverbal communication pertains to behaviors displayed
by an individual rather than his/her actual content of speech.What
are some examples of body language? (gait, coordination, observable
autonomic physiologic responses such as blushing, paleness, pupil
dilation, and diaphoresis)What information can the patients
personal appearance give the nurse?How can a patients body language
tell you he or she is in pain? (facial grimacing; holding an
affected body part; crying; slumped when sitting; face in hands;
prayingrosary or reading Bible; pacing or leg jiggling)
Types of CommunicationAffective communication: feeling toneTone
of communicationEmission of energyElsevier items and derived items
2009, 2005 by Saunders, an imprint of Elsevier, Inc. All Rights
Reserved.88What could determine a nurses mood when she arrives at
work? (traffic conditions, availability of parking, amount of
sleep, family situations, mood of co-workers, hunger, work load)How
does affective communication differ from verbal and nonverbal
communication?Truly honest communication integrates verbal,
nonverbal, and affective communications so that they all express
the same message.
Communication StrategiesActive ListeningMost important part of
any therapeutic communication Key factors include purpose,
disciplined attention, and focus A common mistake is to listen to
the words, but not really hear the words Elsevier items and derived
items 2009, 2005 by Saunders, an imprint of Elsevier, Inc. All
Rights Reserved.99Purpose refers to the health-related reason for
gathering data or giving information. Disciplined attention means
that you do not assume accuracy of information without checking it
out.Focus means that all your senses are alert to clues that the
patient may be communicating. How can you clarify what a patient is
saying to you?Communication StrategiesTypes of QuestionsOpen-ended
questions Permit variety of responsesOften begin with what, where,
when, how, or whyWhat happened to your leg?Closed-ended questions
Require a specific answerWhen did you first notice the pain?Focused
questions Provide more definitive informationOn a scale of 1 to 10,
with 10 as the worst possible pain, how would you rate your pain
right now?
Communication StrategiesActive Listening
BehaviorsRestatingClarificationReflectionParaphrasingMinimal
encouragingSilenceSummarizingValidation
Elsevier items and derived items 2009, 2005 by Saunders, an
imprint of Elsevier, Inc. All Rights Reserved.1111Ask the class to
identify each of the following statements:Nurse: In this hour you
and I discussed. (summarizing)Nurse: I am not sure I follow that.
(clarification)Patient: Its a waste of time to talk to anyone.
Nurse: You dont think anyone understands? (paraphrasing)Nurse: Tell
me whether my understanding is the same as yours.
(validation)Nurse: Go onI see. (minimal encouraging)Patient: Should
I have the surgery? Nurse: Do you think you should?
(reflection)What may happen if you try to fill silence with
chatter?Avoid making interruptions and doing busy work while the
patient is speaking.
Patient: My knee hurts even while Im sitting in my chair.Nurse:
So you are telling me you have pain in your left knee even at
rest?RestatingRepeating in a slightly different way what the
patient has said.12Nurse: I am not sure I follow that.
Clarification
Asking closed ended question in response to a patients statement
to be sure you understand13Nurse: In this hour you and I discussed.
SummarizingBriefly stating the main data you have
gathered14Patient: Its a waste of time to talk to anyone. Nurse:
You dont think anyone understands?Paraphrasing
Expressed in your own words what you think the patient
means.15Nurse: Tell me whether my understanding is the same as
yours. ValidationProvides the patient with the opportunity to
correct information if necessary at time of summary16Nurse: Go onI
see. Minimal encouragingUses sounds words or short phrases to
encourage the patient to continue17Patient: Should I have the
surgery? Nurse: Do you think you should? Reflection
Putting into words the information you are receiving from the
patient at an affective communication level.tone energy
18Communication StrategiesNurse/Patient CommunicationEvaluation
Communication is far more complex than just talkingEvaluate the
characteristics that are working for you and those you need to work
onElsevier items and derived items 2009, 2005 by Saunders, an
imprint of Elsevier, Inc. All Rights Reserved.1919Blocks to
CommunicationFalse reassurance guarantees positive outcomeProbing
pushes for information beyond medical necessity Chiding or scolding
for behavior such as smokingBelittling, mimicking, or making fun of
the patient, downplaying symptomsGiving adviceProviding pat answers
negates individuality of the situationElsevier items and derived
items 2009, 2005 by Saunders, an imprint of Elsevier, Inc. All
Rights Reserved.2020What reasons may cause the nurse to slip into
communication styles that block communication? Ask the class to
identify the following statements:What else do you dislike about
your doctor? (probing)Just keep your chin up. (providing pat
answers)Its bad to (chiding)I wouldnt worry about . (false
reassuring)You wont die that soon. (belittling)What are some
additional blocks to communication? (giving approval, rejection,
agreeing/disagreeing, challenging, testing, defending, requesting
an explanation, using denial, interpreting, and introducing an
unrelated topic)
Male/Female DifferencesMost males and females follow certain
patterns with regard to:ConversationHead
movementsSmilingPostureDifferences in patient communication have
important nursing implications
Elsevier items and derived items 2009, 2005 by Saunders, an
imprint of Elsevier, Inc. All Rights Reserved.2121Are men more or
less likely to express feelings honestly or openly? Ask the class
to demonstrate how a man and woman might answer the same question
in a different manner.Why are male opinions often valued more
highly without validation?Would it be easier or more difficult for
a nurse to communicate with a patient of the same sex?Patterns of
communication may differ between people of the same sex, so it is
important for nurses to ask probing questions.How can you be sure
that you understand what a patient is communicating?
Cultural DifferencesUnderstanding cultural differences will help
nurses respond respectfully and therapeuticallyDifferences apply
generally to groups as a wholeIndividual patient differences should
still be identified
Elsevier items and derived items 2009, 2005 by Saunders, an
imprint of Elsevier, Inc. All Rights Reserved.2222What is the
difference between a culture and an ethnicity? (Culture: total way
of life of a people; social legacy of norms and values the
individual acquires from his/her group. Ethnicity: affiliation due
to shared linguistic, racial, or cultural background)Differences
exist within each cultural group, ranging from extremely
conservative or orthodox to very liberal and reformed. Be aware of
where your patient falls in his or her cultural group.
Role Changes for the PatientDependent positionSet tone by
providing respect and information; do not use first name unless
specifically requested by patientAvoid medical jargonAsk if patient
has questionsBe sensitive to personal or environmental factors that
may cause anxiety
Elsevier items and derived items 2009, 2005 by Saunders, an
imprint of Elsevier, Inc. All Rights Reserved.2323How might a
patient, who normally leads a very independent life, react to being
in the hospital? (increased anxiety and disturbance in
self-esteem)Baby boomers (born post-WWII through the 1960s) and
younger usually prefer to be called by first name, but always ask.
How would you introduce yourself to a patient?What may a patient be
fearful of?How can environmental factors be adjusted to better met
a patients needs?
Communication CharacteristicsImportant in All
CommunicationsRespectTrustHonestyEmpathySensitivityHumorKnowledge
PatienceCommitmentSelf-esteemElsevier items and derived items 2009,
2005 by Saunders, an imprint of Elsevier, Inc. All Rights
Reserved.2424Respect gives patient sense of worth.What may signal a
patient that you either respect or disrespect them?Honesty: Never
make up an answer if you are not sure of it. Let the patient know
you do not know, but will return with the correct answer.When you
are sympathetic, as you would be with a family member or dear
friend, you actually experience the emotion.When is humor not
appropriate? Lack of patience with a patient can lead to increased
anxiety.Commitment: Why are you really in nursing?
Communication CharacteristicsSelf-esteemEarned, not learned
Gives you permission to recognize that you have something very
special to offer in nursing communication ThoughtsRandom thoughts
usually pass through, unless you pick a thought and change it into
an active thought Straightforward communicationBe direct in your
conversation, remembering that language is never innocent Elsevier
items and derived items 2009, 2005 by Saunders, an imprint of
Elsevier, Inc. All Rights Reserved.2525 If your thoughts are not
serving you, change them.Thoughts also set the feeling tone for how
you communicate with patients and other staff.Life Span
Communication Each age group has differentcommunication
needsInfantsCries have different meaningsInfluenced by the sound of
the voiceRespond to calm, low tonesPreschoolCannot verbally express
frustration, leading to tantrumsCommunicate by pointingCan help if
coached
Elsevier items and derived items 2009, 2005 by Saunders, an
imprint of Elsevier, Inc. All Rights Reserved.2626If your thoughts
are not serving you, change them.Thoughts also set the feeling tone
for how you communicate with patients and other staff.
Life Span CommunicationSchool-ageCan be part of many
discussionsCan use drawings or pictures to explain an
illnessTeenageExtend same courtesy as to adultsEncourage expression
of feelings
Elsevier items and derived items 2009, 2005 by Saunders, an
imprint of Elsevier, Inc. All Rights Reserved.2727Validation of
school-age childrens perceptions is especially importantWhat would
you say to a nine-year-old to elicit feedback on a procedure you
just explained to her? (Now you tell me what is going to happen to
you. Then, clear up any misperceptions.) Remember that younger
children think well in the afternoon. Use of teen slang generally
does not work out. Without real knowledge of the meaning, you may
end up appearing foolish instead of cool.
Life Span CommunicationAdultCollect data at all three
communication levelsLimit questions to medical areasElderlyCheck
which side is best for hearingRead directions aloud
Elsevier items and derived items 2009, 2005 by Saunders, an
imprint of Elsevier, Inc. All Rights Reserved.2828Written
information seems to be more neutral and does not evoke the
emotional reaction that words would have. Which eye has more visual
acuity in the male?When communicating with the elderly:Be aware of
a possible diminishment of senses.Use a matter-of-fact, yet gentle,
approach.Do not patronize or talk to them as if they are children.
Include the elderly patient in communication even if family members
are there.
Conflict ResolutionAccept conflict as a natural part of
lifeShift your own attitude and behaviorTake time to think
critically before reactingTreat conflict as an opportunity to voice
your own opinion and listen to the other side of the storyChoose
your approachListen and learnDiscover what is importantRespect each
otherFind common ground, generally the patients highest good
Elsevier items and derived items 2009, 2005 by Saunders, an imprint
of Elsevier, Inc. All Rights Reserved.2929Conflict can be related
to diversity, English as a second language, differences in gender,
generation, and personality. How do physicians and nurses
communication techniques differ? Electronic CommunicationFax
machinesComputer patient chartingE-mailKeep sentences and
paragraphs short; check spelling, punctuationSkip a line to
separate topicsSend message to the right personWrite subject line
carefullyBe specificBe cautious with humorAvoid all CAPSElsevier
items and derived items 2009, 2005 by Saunders, an imprint of
Elsevier, Inc. All Rights Reserved.3030Why are we including
electronic communication in this chapter?Additional e-mail
tips:Answer swiftly.Answer all questions and preempt further
questions.Do not attach unnecessary files.Do not overuse the high
priority option.Do not copy or attach a message without
permission.Do not use e-mail to discuss confidential
information.Keep your language gender neutral.Avoid using Urgent
and Important.
Electronic CommunicationCell Phones and Text Messaging Shut off
cell and text messaging phones during class and clinicalAvoid
behaving in ways disruptive to the instructor and other
studentsElsevier items and derived items 2009, 2005 by Saunders, an
imprint of Elsevier, Inc. All Rights Reserved.3131Assertiveness in
NursingElsevier items and derived items 2009, 2005 Saunders, an
imprint of Elsevier, Inc. All rights reserved.33Assertiveness:
Expected in NursingHelps nurse advocate for the patientPromotes
honest, open communication and behavior Considers others feelings
and needsBenefits nurse, patient, and staff33What do you think of
when you hear the term assertive behavior?What are some
misconceptions about assertive behavior? (Might be perceived as
pushy, refusing to give ground, unwilling to compromise, stubborn
on some issues, inflexible)Assertiveness is a style of interaction
that is direct, honest, and respectful of self and others.
Elsevier items and derived items 2009, 2005 Saunders, an imprint
of Elsevier, Inc. All rights reserved.34Communication
StylesTranslate into behavior patternsNonassertive
(passive)AggressiveAssertive34Most people demonstrate each of these
communication styles.What do you think of when you think of (a)
nonassertive, or passive, and (b) aggressive behaviors?How can
nonassertive and aggressive behaviors cause problems in work,
personal, and family situations?Most people have to make a
conscious effort to develop consistent assertive behaviors.The
nurse who communicates assertively can help minimize conflict and
reduce stress, which can lead to more positive outcomes.Elsevier
items and derived items 2009, 2005 Saunders, an imprint of
Elsevier, Inc. All rights reserved.35Nonassertive (Passive)
BehaviorAutomatic response not based on choiceEmotional response
based on fearDishonest, self-defeatingOverall message: I do not
count. You count.Consequence: nurse unable to recognize and meet
patient needs35This behavior is indirect and passive and
communicates a self-perception of inferiority.Allowing the wants,
needs, and rights of others to be more important creates a lose-win
situation. What is an example of a lose-win interaction in a
nursing environment? Who loses? Who wins? Is it a real win? What is
the impact on the patient? Elsevier items and derived items 2009,
2005 Saunders, an imprint of Elsevier, Inc. All rights
reserved.36Aggressive BehaviorAutomatic response not based on
choiceEmotional behavior based in angerViolates the rights of
othersAttacks person instead of behaviorOverall message: You do not
count. I count.Consequence: distances aggressor from staff and
patients36Aggressive behavior can be active or passive, direct or
indirect, honest or dishonest.What does it always communicate? An
aggressive communicator aims to get his or her own way and not
allow others a choice. People behaving aggressively try to set up a
win-lose situation. How do you feel if you are the recipient of
aggressive behavior? What examples have you encountered at work,
school, on the road, shopping? Who is the real loser? The real
winner?Elsevier items and derived items 2009, 2005 Saunders, an
imprint of Elsevier, Inc. All rights reserved.37Assertive
BehaviorAssertiveness: current name for honestyPro-active, not
emotional responsePositive, confident, open standOverall message: I
count. You count.Consequence: Nurse feels in control of emotions
and responses, and can be more effective patient
advocate.37Assertive behavior is active, direct, and honest.It
communicates self-respect and respect for others. An assertive
communicator views his or her wants, needs, and rights as equal to
those of other people. What are some examples of assertiveness in a
nursing environment? Who are the beneficiaries? Goal is to have a
win-win interaction. How is this accomplished? Encourages honest,
open interactions and relationships.How can assertive behavior
contribute to better patient care and help reduce caregiver
burnout?Elsevier items and derived items 2009, 2005 Saunders, an
imprint of Elsevier, Inc. All rights reserved.38Assertive
BehaviorNonassertive (passive) and aggressive behaviors are based
on emotional hooks. These styles are ultimately damaging to all
parties. Be alert to unresolved feelings that can lead to a cycle
of:worry > fear > anger > rage
38Effective communication helps the nurse develop the trust and
respect of colleagues and patients.The nurse must be aware of
verbal and nonverbal messagesthe nurses own and others.Be alert to
unspoken messagesthe thoughts behind the words.When interacting
with fearful, angry, or frustrated people, avoid getting involved
with their emotions. If someone speaks or behaves aggressively, how
can the nurse avoid becoming part of a negative cycle? Elsevier
items and derived items 2009, 2005 Saunders, an imprint of
Elsevier, Inc. All rights reserved.39Assertive BehaviorOwn your own
feelings.Dont blame others.Be direct.Use I statements to make your
feelings known.Make sure verbal and non-verbal messages are
consistent.39What are the benefits of using I feel statements? How
can I statements be useful in more complex situations? What to
avoid:(a) expressing a belief or judgment (b) you statements (c)
expressing only negative feelings (d) using nonverbal body language
that contradicts your wordsWhat are some examples of contradictory
voice-body messages?Work-Related Aggressiveness Workplace assaults
take place more often against health care workers, especially
nurses, than people in any other occupation.Contributing
factorsPersonal FactorsWorkplace PracticesEnvironmental FactorsRisk
DiagnosisNurses can and shouldprotect themselves.advocate for a
safer workplace.
The prevention of workplace violence is an important safety
issue in hospitals and other health care facilities. The workplace
is any location where an employee performs a work-related activity.
What steps can nurses take to protect themselves and advocate for a
safer workplace?
40Sexual HarassmentUnwanted Sexual Advances Verbal or Physical
Conduct of a Sexual NatureA condition of employment or advancementA
hostile environment, where the advances intimidate, offend, or
interfere with the nurses ability to do their workNot about sex or
passion; about abuse of power
Claims of harassment should be taken seriously and investigated.
Some behavior might not specifically violate company policy, even
if it upsets the complaining party. Example: one employee shows
more than average interest in anothers personal life. Might this be
perceived as harassment?While some situations might not require
investigation, they need resolution that both parties can
understand. Addressing complaints prevents misunderstandings from
turning into larger conflicts, and indicates that the organization
is committed to protecting its workforce from harassment.41Sexual
Harassment:What the Nurse Can DoRespond assertively.Make sure
verbal, nonverbal, and affective messages are consistent.Document
what happened.Report to management.Consider counseling.Consider
seeking legal redress.
The recipient of unwanted behavior should inform the harasser
directly that the conduct is unwelcome and must stop. The recipient
should use any workplace complaint mechanism or grievance system
available. Prevention is the best tool to eliminate sexual
harassment in the workplace.What ways can the nurse advocate for
prevention of sexual harassment in the workplace?
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