sending and receiving messages between two or more people followed by feedback indicating that the infor- mation was understood or requires further clarification (Fig. 7-2). Communication takes place simultaneously on a verbal and nonverbal level. Because no relationship can exist without verbal and nonverbal communication, nurses develop skills that enhance their therapeutic inter- actions with clients.
COMMUNICATION
BOX 7-3 ● Barriers to a Nurse—Client Relationship
❙ Appearing unkempt: long hair that dangles on or over the client during care, offensive body or breath odor, wrinkled or soiled uniform, dirty shoes
❙ Failing to identify oneself verbally and with a name tag
❙ Mispronouncing or avoiding the client’s name
❙ Using the client’s first name without permission
❙ Showing disinterest in the client’s personal history and life experiences
❙ Sharing personal or work-related problems with the client or with staff in the client’s presence
❙ Using crude or distasteful language
❙ Revealing confidential information or gossip about other clients, staff, or people commonly known
❙ Focusing on nursing tasks rather than the client’s responses
❙ Being inattentive to the client’s requests (e.g., food, pain relief, assistance with toileting, bathing)
❙ Abandoning the client at stressful or emotional times
❙ Failing to keep promises such as consulting with the physician about a current need or request
❙ Going on a break or to lunch without keeping the client informed and identi- fying who has been delegated for the client’s care during the temporary absence
FIGURE 7-2
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Communication is a two-way process between a sender and a receiver.Verbal Communication
Verbal communication(communication that uses words) includes speaking, reading, and writing. Both nurse and client use verbal communication to gather facts. They also use it to instruct, clarify, and exchange ideas.
Many factors affect the ability to communicate by speech or in writing. Examples include (1) attention and concentration; (2) language compatibility; (3) ver- bal skills; (4) hearing and visual acuity; (5) motor func- tions involving the throat, tongue, and teeth; (6) sensory distractions; (7) interpersonal attitudes; (8) literacy; and (9) cultural similarities. The nurse promotes the factors
96 U N I T 3 ● Fostering Communication
that enhance the communication of verbal content and controls or eliminates those that interfere with the accu- rate perception of expressed ideas.
Therapeutic Verbal Communication
Communication can take place on a social or therapeutic level. Social communication is superficial; it includes common courtesies and exchanges about general topics.
Therapeutic verbal communication(using words and gestures to accomplish a particular objective) is extremely impor- tant, especially when the nurse is exploring problems with the client or encouraging expression of feelings.
Techniques that the nurse may find helpful are described in Table 7-1.
The nurse must never assume that a quiet, uncommu- nicative client has no problems or understands every- thing. It is never appropriate to probe and pry; rather, it may be advantageous to wait and be patient. It is not unusual for reticent clients to share their feelings and concerns after they conclude that the nurse is sincere and trustworthy.
Nurses must approach vocal, emotional clients deli- cately. For instance, when clients are angry or crying, the best nursing response is to allow them to express their emotions. Allowing clients to display their feelings with-
out fear of retaliation or censure contributes to a thera- peutic relationship.
Although nurses often have the best intentions of inter- acting therapeutically with clients, some fall into traps that block or hinder verbal communication. Table 7-2 lists common examples of nontherapeutic communication.
Listening
Listening is as important during communication as speak- ing.Giving attention to what clients say provides a stim- ulus for meaningful interaction. It is important to avoid giving signals that indicate boredom, impatience, or the pretense of listening. For example, looking out a window or interrupting is a sign of disinterest. When communi- cating with most people in the United States, it is best to position oneself at the person’s level and make fre- quent eye contact (Fig. 7-3). Refer to Chapter 6 for cul- tural exceptions. Nodding and making comments such as, “Yes, I see,” encourages clients to continue and shows full involvement in what is being said.
Silence
Silence(intentionally withholding verbal commentary) plays an important role in communication. It may seem contradictory to include silence as a form of verbal com-
THERAPEUTIC VERBAL COMMUNICATION TECHNIQUES
TABLE 7-1
TECHNIQUE USE EXAMPLE
Broad opening Giving information Direct questioning Open-ended questioning Reflecting
Paraphrasing
Verbalizing what has been implied Structuring
Giving general leads Sharing perceptions Clarifying
Confronting Summarizing Silence
Relieves tension before getting to the real purpose of the interaction
Provides facts
Acquires specific information Encourages the client to elaborate
Confirms that the nurse is following the conversation Restates what the client has said to demonstrate
listening
Shares how the nurse has interpreted a statement
Defines a purpose and sets limits Encourages the client to continue Shows empathy for the client’s feelings Avoids misinterpretation
Calls attention to manipulation, inconsistencies, or lack of responsibility
Reviews information that has been discussed Allows time for considering how to proceed or
arouses the client’s anxiety to the point that it stimulates more verbalization
“Wonderful weather we’re having.”
“Your surgery is scheduled at noon.”
“Do you have any allergies?”
“How are you feeling?”
Client:“I haven’t been sleeping well.”
Nurse:“You haven’t been sleeping well.”
Client:“After every meal, I feel like I will throw up.”
Nurse:“Eating makes you nauseous, but you don’t actually vomit.”
Client:“All the nurses are so busy.”
Nurse:“You’re feeling that you shouldn’t ask for help.”
“I have 15 minutes. If your pain is relieved, we could discuss how your test will be done.”
“Uh, huh,” or “Go on.”
“You seem depressed.”
“I don’t quite understand what you’re asking.”
“You’re concerned about your weight loss, but you didn’t eat any breakfast.”
“You’ve asked me to check on increasing your pain medication and getting your diet changed.”
C H A P T E R 7 ● The Nurse–Client Relationship 97
munication. Nevertheless, one of its uses is to encourage the client to participate in verbal discussions. Other ther- apeutic uses for silence include relieving a client’s anxiety just by providing a personal presence and offering a brief period during which clients can process information or respond to questions.
Clients may use silence to camouflage fears or to express contentment. They also use silence for introspection when they need to explore feelings or pray. Interrupting some- one deep in concentration disturbs his or her thought process. A common obstacle to effective communication is ignoring the importance of silence and talking excessively.
NONTHERAPEUTIC VERBAL COMMUNICATION TECHNIQUES
TABLE 7-2
TECHNIQUE AND CONSEQUENCE EXAMPLE IMPROVEMENT
Giving False Reassurance
Trivializes the client’s unique feelings and discourages further discussion Using Clichés
Provides worthless advice and curtails exploring alternatives
Giving Approval or Disapproval Holds the client to a rigid standard;
implies that future deviation may lead to subsequent rejection or disfavor
Agreeing
Does not allow the client flexibility to change his or her mind
Disagreeing
Intimidates the client; makes him or her feel foolish or inadequate
Demanding an Explanation
Puts the client on the defensive; he or she may be tempted to make up an excuse rather than risk disapproval for an honest answer
Giving Advice
Discourages independent problem solv- ing and decision making; provides a biased view that may prejudice the client’s choice
Defending
Indicates such a strong allegiance that any disagreement is unacceptable Belittling
Disregards how the client is responding as an individual
Patronizing
Treats the client condescendingly (less than capable of making an indepen- dent decision)
Changing the Subject
Alters the direction of the discussion to a safer or more comfortable topic
“You’ve got nothing to worry about.
Everything will work out just fine.”
“Keep a stiff upper lip.”
“I’m glad you’re exercising so regularly.”
“You should be testing your blood glucose each morning.”
“You’re right about needing surgery immediately.”
“That’s not true! Where did you get that idea?”
“Why didn’t you keep your appointment last week?”
“If I were you, I’d try drug therapy before having surgery.”
“Ms. Johnson is my best nursing assis- tant. She wouldn’t have let your light go unanswered that long.”
“Lots of people learn to give themselves insulin.”
“Areweready for ourbath yet?”
Client:“I’m so scared that a mammogram will show I have cancer.”
Nurse:“Tell me more about your family.”
“Tell me your specific concerns.”
“It must be difficult for you right now.”
“Are you having any difficulty fitting regular exercise into your schedule?”
“Let’s explore some ways that will help you remember to test your blood glu- cose each morning.”
“Having surgery immediately is one possibility. What others have you considered?”
“Maybe I can help clarify that for you.”
“I see you couldn’t keep your appoint- ment last week.”
“Share with me the advantages and dis- advantages of your options as you see them.”
“I’m sorry you had to wait so long.”
“You’re finding it especially difficult to stick yourself with a needle.”
“Would you like your bath now or should I check with you later?”
Client:“I’m so scared that a mammogram will show I have cancer.”
Nurse:“It is a serious disease. What con- cerns you the most?”
98 U N I T 3 ● Fostering Communication
movements. Some add that clothing style and accessories such as jewelry also affect the context of communication.
Box 7-4 describes various examples of nonverbal behavior and their meaning.
Knowledge of kinesics is important for the nurse being evaluated by his or her clients and vice versa. To create a positive impression during a client interaction, the nurse should:
• Stand tall.
• Relax arms, legs, and feet; do not cross any body part.
• Maintain eye contact approximately 60% to 70% of the time or whatever is appropriate for the culture (see Chap. 6); in a group, focus on the last person who spoke.
• Keep the head level, both horizontally and vertically.
• Lean forward to demonstrate interest and attention.
• Keep the arms where they can be seen.
• Strike a balance in arm movements—neither too demonstrative nor reserved.
• Keep the legs as still as possible.
Paralanguage
Paralanguage(vocal sounds that are not actually words) also communicates a message. Some examples include drawing in a deep breath to indicate surprise, clucking the tongue to indicate disappointment, and whistling to get someone’s attention. Vocal inflections, volume, pitch, and rate of speech add another dimension to communica- tion. Crying, laughing, and moaning are additional forms of paralanguage.
Proxemics
Proxemics(use and relationship of space to communica- tion) varies among people from different cultural back- grounds. Generally, four zones are observed in interactions between Americans (Hall, 1959, 1963, 1966): intimate space(within 6 inches), personal space(6 inches to 4 feet),
social space(4 to 12 feet), and public space(more than 12 feet;
Table 7-3).
BOX 7-4 ● Examples of Body Language
POSITIVE INTERPRETATION NEGATIVE INTERPRETATION
Tilt of head Interested Arms crossed Blocking; oppositional
Open hands Sincere Clenched jaw Angry; antagonistic
Brisk, erect walk Confident Downcast eyes Remorseful; bored
Hand to cheek Contemplative Rubbing nose Doubtful; deceitful
Rubbing hands Anticipatory Drumming fingers Impatient
Steepled fingers Authoritative Fondling hair Insecure
Nod Agreement Frown Disagreement
Stroking chin Stalling for time Shifting from foot to foot Desire to get away
Looking at watch Bored
Adapted from: Examples of body language in use. Available at: http://www.bodylanguagetraining.com/
examples.html; Body language, sending signals without words. Available at: http://www.uwm.edu/~ceil/career/
jobs/body.htm; and Examples of body language. Available at: http://www.deltabravo.net/custody/body.php.
FIGURE 7-3
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Appropriate positioning, space, eye contact, and atten- tion promote therapeutic communication. (Copyright B. Proud.)Nonverbal Communication
Nonverbal communication(exchange of information with- out using words) involves what is not said. The manner in which a person conveys verbal information affects its meaning. A person has less control over nonverbal than verbal communication. Words can be chosen with care, but a facial expression is harder to control. As a result, people often communicate messages more accurately through nonverbal communication.
People communicate nonverbally through the tech- niques described next: kinesics, paralanguage, proxemics, and touch.
Kinesics
Kinesics(body language) includes nonverbal techniques such as facial expressions, posture, gestures, and body
C H A P T E R 7 ● The Nurse–Client Relationship 99
Most people in the United States comfortably tolerate strangers in a 2- to 3-foot area. Venturing closer may cause some to feel anxious. Understanding the client’s comfort zone helps the nurse to know how spatial rela- tions affect nonverbal communication.
Closeness is common in nursing because of the many times nurses and clients are in direct physical contact.
Therefore, some clients can misinterpret physical near- ness and touching within intimate and personal spaces as having sexual connotations. Approaches that may pre- vent such misunderstanding include explaining before- hand how a nursing procedure will be performed, ensuring that a client is properly draped or covered, and asking that another staff person of the client’s gender be present during an examination or procedure.
Touch
Touch(tactile stimulus produced by making personal con- tact with another person or object) occurs frequently in nurse–client relationships. While caring for clients, touch can be task-oriented, affective, or both. Task-oriented touch
involves the personal contact required when performing nursing procedures (Fig. 7-4). Affective touch is used to demonstrate concern or affection (Fig. 7-5).
Affective touch has different meanings to different people depending on their upbringing and cultural back- ground. Because nursing care involves a high degree of touching, the nurse is sensitive as to how clients may per- ceive it. Most people respond positively to touch, but there are variations among individuals. Therefore, nurses use affective touching cautiously even though its inten- tion is to communicate caring and support. In general, affective touch is therapeutic when a client is
• Lonely
• Uncomfortable
COMMUNICATION ZONES
TABLE 7-3
ZONE DISTANCE PURPOSE
Intimate space
Personal space
Social space
Public space
Within 6 inches
6 inches to 4 feet
4 to 12 feet
12 or more feet
•Lovemaking
•Confiding secrets
•Sharing confidential information
•Interviewing
•Physical assessment
•Therapeutic interven- tions involving touch
•Private conversations
•Teaching one-on-one
•Group interactions
•Lecturing
•Conversations that are not intended to be private
•Giving speeches
•Gatherings of strangers
FIGURE 7-4
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Examining a client involves task-oriented touch. (Copy- right B. Proud.)FIGURE 7-5
•
This nurse uses affective touch as she talks with her client. (Copyright B. Proud.)• Near death
• Anxious, insecure, or frightened
• Disoriented
• Disfigured
• Semiconscious or comatose
• Visually impaired
• Sensory deprived