Communication Chapter 24

Key Terms

Active Listening (p352) being attentive to what the client is saying both verbally and nonverbally

Assertiveness (p348) conveys a sense of self-assurance while also communicating respect for others. Advantages of assertive behavior include: it is more likely you will get what you want when you ask for it, people respect clear, open, honest communication, you stand up for you own right and experience self-respect, you avoid the invitation of aggression, you are more independent, you become a decision maker, you feel more peaceful and comfortable w/yourself.

Nurses teach assertiveness skills to others as a means for promoting personal health. Assertive people express feelings and emotions confidently, spontaneously and honestly. They control their lives more effectively and deal w/criticism and manipulation by others, learn to say no, set limits, and resist intentionally imposed guilt.

Autonomy (p348) ability to be self-directed and independent in accomplishing goals and advocating for others. Nurses make choices and accept responsibility for the outcomes of their actions. Initiative in problems solving and communicates in a manner that reflects the important and purpose of the therapeutic conversation.

Nurse also recognizes the client’s autonomy because people who seek health care are often concerned about losing control of decisions that influence how they live.

Channels (p343) Means of conveying and receiving messages through visual, auditory, and tactile senses. When teaching clients nurses should use all channels of communication so the client will understand more clearly.

Ex)when teaching about insulin self0injection, the nurse talks about and demonstrates the technique, gives the client printed information, and encourages hands on practice with the vial and syringe.

Communications (p340) a lifelong learning process for the nurse. Therapeutic relationship, unequal because nurses do not need to share everything about themselves or as much as the patient needs to share

Empathy (p353) The ability to understand and accept another person’s reality, to accurately perceive feelings, and to communicate this understanding to the other. Nurse reflects understanding of the importance of what the other person communicated on a feeling level. Nurses must be both sensitive and imaginative, especially if the nurse has not had similar experiences. Statements reflecting empathy are highly effective because they tell the person that the nurse heard the feeling

content, as well as factual content, of the communication. Empathy statements are neutral and nonjudgmental and help establish trust in difficult situations.

Environment (p344) The setting for sender-receiver interaction. Environment needs to meet participant needs for physical and emotional comfort and safety. Noise, temperature extremes, distractions, and lack of privacy or space create confusion.

Feedback (p343) The message the receiver returns. Indicates whether the receiver understood the meaning of the sender’s message. Sender needs to seek verbal and nonverbal feedback.

Interpersonal communication (p342) one-to-one interaction between the nurse and another person that often occurs face to face. It is the level most frequently used in nursing situations and lies at the heart of the nursing practice. Ex) when teaching a client about a health concern, you use interaction to assess understanding and clarify misinterpretations.

Intrapersonal variables (p343) A powerful form of communication that occurs w/in an individual. Self-talk, self-verbalization, and inner thought. Develops self – awareness and a positive self concept by replacing negative thoughts with positive assertions. Also self0instruction provides a mental rehearsal for difficult tasks or situations so individuals are able to deal with them more effectively.

Message (p343) the content of the communication. Verbal, nonverbal, and symbolic language. Two nurses can provide the same information yet convey very different messages according to their personal communication styles. Two persons understand the same message differently. Effective messages are sent by expressing clearly, directly, and in a matter familiar to the receiver. Determine need for clarification by watching the listener for nonverbal cues.

Metacommunication (p346) A broad term that refers to all factors that influence communication. The underlying messages in what we say and do. Metacommunication is all the nonverbal cues (tone of voice, body language, gestures, facial expression, etc.) that carry meaning that either enhance or disallow what we say in words. There’s a whole conversation going on beneath the surface.

Nonverbal communication (p344) includes all of the 5 on is important, senses and everything that does not involve the spoken or written word. Appox 7% of meaning is transmitted by words, 38% is transmitted by vocal cues, and 55% is transmitted by body cues. All kinds of nonverbal communication is important, but interpreting them is often problematic. Different cultures identify differently to different nonverbal cues.

Perceptions (p341) everyone bases their perceptions on the 5 senses of sight, hearing, taste, touch, and small. Culture and education also influence perception.

Perceptual biases (p341)A nurse must learn to overcome perceptual biases. These are our human tendencies that interfere with accurately perceiving and interpreting messages from others. Assuming that others feel, act, react, and behave the same as

you would…..ignoring or distorting information that goes against expectations, preconceptions, or stereotypes. Critical thinking about personal communication habits will help you control these tendencies.

Public communication (p342) Interaction with an audience. Requires special adaptations in eye contact, gestures, voice inflection, and use of media materials to communicate message effectively.

Receiver (p343) Person who receives and decodes the message. Attending to, translating, and responding to sender’s message. Occurs simultaneously with sender. The more the sender and receiver have in common the closer the relationship will be and the more accurately the message will be perceived.

Referent (p343) In healthcare setting…sights, sounds, odors, time schedules, messages, object, emotions, sensations, perceptions, ideas and other cues initiate communication. Motivates one person to communicate with another. Stimulus initiated communication is able to develop and organize messages for efficiently and better perceive meanings in another’s message. Ex) a client request for help prompted by difficulty breathing brings a different nursing response than a request prompted by boredom.

Sender (p343) Person who encodes and delivers the message. Puts ideas or feelings into a form that is transmitted and is responsible for the accuracy of its content and emotional tone. The sender’s message acts as a referent (stimulus initiated) for the receiver.

Small-group communication (p342) Interaction that occurs when a small number of persons meet together. Goal oriented and requires an understanding of group dynamics.

Symbolic communication (p346) Verbal and non verbal symbolism used by others to convey meaning. Art and music are forms that the nurse can use to enhance understanding and promote healing. Studies have found creative expressions like this have healing effects on clients and clients report decreased pain and greater sense of joy and hope.

Sympathy (p356) “I’m so sorry about your mastectomy; it must be terrible to lose a breast.” Concern, sorrow, or pity felt for the client generated by the nurse’s personal identification with the client’s needs. A subjective look at another person’s world that prevents a clear perspective of the issues confronting that person. Sympathy is not as therapeutic as empathy.

Therapeutic communication techniques (p352) Specific responses that encourage the expression of feelings and ideas and convey acceptance and respect.

Transpersonal communication (p342) interaction that occurs within a person’s spiritual domain. Prayer, meditation, guided reflection, religious rituals and other means to communicate with their “higher power”. Nurses have a responsibility to assess client’s spiritual needs and intervene to meet those needs.

Verbal communication (p344) spoken or written words, a code that conveys specific meaning through combination of words.

Professional Nursing Relationships:Zones of Personal Space and Touch (Box 24-3)

Intimate Zone (0-18 inches) Personal Zone (18 inches – 4 ft) Social Zone (4 -12 ft)_ Public Zone (12 ft and greater)

Review Zones of Touch….pg 345

Phases of the Helping Relationship (Box 24-4)1. Preinteraction Phase: Before Meeting the Client Review available data, including medical and nursing history.

Talk to other caregivers who have information about the clientAnticipate health concerns or issues that ariseIdentify a location and setting that will foster comfortable, private interaction.Plan enough time for the initial interaction

2. Orientation Phase: When nurse and client meet and get to know one another.

Set the tone for the relationship by adopting a warm, empathetic, caring mannerRecognize that the initial relationship is often superficial, uncertain, and tentativeExpect the client to test the nurse’s competence and commitmentClosely observe the client, and expect to be closely observed by the clientBegin to make inferences and form judgments about client’s messages and

behaviorAssess the client’s health statusPrioritize the client’s problems, and identify the client’s goalsClarify the client’s problems, and identify the client’s goalsClarify the client’s and nurse’s rolesForm contracts with the client that specify who will do whatLet the client know when to expect the relationship to be terminated

3. Working Phase:When nurse and client work together to solve problems and accomplish goals. Encourage and help the client to express feelings about his/her health.Encourage and help the client to set goalsTake action to meet the goals set with the clientUse therapeutic communication skills to facilitate successful interactionsUse appropriate self-disclosure and confrontation

4. Termination Phase: During the ending of the relationshipRemind the client that termination is nearEvaluate goal achievement with the client

Reminisce about the relationship with the clientSeparate from the client by relinquishing responsibility for his/her careAchieve a smooth transition for the client to other caregivers as needed

Assessment of a client’s ability to communicate includes gathering data about the many contextual factors that influence communication.

o Physical and emotional factors – assess psychophysiological factors that influence communication. Persons w/hearing or visual impairments have fewer channels through which to receive messages. Persons with facial trauma, laryngeal cancer, or endoscopes cannot articulate words. Breathless persons need to use oxygen to breathe rather than speak. Client who cannot communicate effectively will often have difficulty expressing needs and responding appropriately to the environment.

o Developmental Factors Infants self-expression is limited to crying, body movement, and facial expression, older children express their needs more directly. Nurse adapts communication techniques for different factors. Include parents, child, or both sources of information about the child’s health, depending on the child’s age. Children are especially responsive to nonverbal messages, and sudden movements, loud noises or threatening gestures are frightening. Children often prefer to make the first move in interpersonal contacts and do not like adults to star or look down at them. Older adults (box 24-7) Tips for improved communication w/older adults who have communication needs/barriers. Get clients attention before speaking, check for hearing aids and glasses, introduce yourself, be sure you face is visible and use facial expressions and gestures, choose a quiet, well-lit environment with minimal distractions, DO NOT SHOUT - it distorts sounds, speak clearly at a moderate rate, allow time for response – do not assume uncooperative if response is absent or delayed, give chance to ask questions, do not talk to client like a child (use words appropriate to the clients developmental level)

o Sociocultural factors Cultural influences thinking, feeling, behaving, and communicating. There are patterns of interaction that characterize various cultures. (European Americans more open and willing to discuss private family matters, Hispanics, African American, and Asian Americans are sometimes reluctant to reveal personal or family information to strangers.) Hispanics and Asian American value a quiet demeanor and self restraint. Native Americans

value silence and are comfortable with it. If English is second language difficulty with self-expression or language comprehension can exist. Practice cultural sensitivity in communication – understand different cultures use different degrees of eye contact, personal pace, gestures, loudness of voice, pace of speech, touch, silence, and meaning of language. Language and cultural barriers are not only frustrating, but also dangerous, causing delay in care.(Box 24-8) State laws and federal laws require consumers of health care have access to interpreter services, these services can be costly, so use is often limited to crucial interactions. Sometimes there is a delay in interpreter services, yet some clients require urgent care. Use of family members, children, or auxiliary personnel poses legal liabilities. It is important to use a translator with patients who do not speak language – trained medical personnel who speak the language and can give accurate forms of information. Written instructions should also be in the language of the patient. Know that nodding “okay” does not necessarily mean the client understands.

o Gender another factor of how we think, act, feel, and communicate. Males tend to be less verbal but more likely to initiate communication and address isues more directly and more likely to talk about issues. Females tend to disclose more personal information and use more active listening. Because of gender differences communication is sometimes more effective when the nurse and the client are of the same gender.

Nursing Diagnosis primary nursing diagnostic label used to describe the client with limited or no ability to communicate verbally is impaired verbal communication. This is the state where individual experiences a decreased, delayed, or absent ability to receive, process, transmit, and use symbols. Primary problems of impaired verbal communication – the associated difficulty in self-expression or altered communication patters may also contribute to other nursing diagnoses: anxiety, social isolation, ineffective coping, compromised family coping, powerlessness, impaired social interaction. R/T factors focus on the causes of the communication disorder – physiological, mechanical, anatomical, psychological, cultural, or developmental- to select interventions you must be accurate in identifying R/T factors.Ex) manage the diagnosis of impaired verbal communication R/T cultural difference very differently than impaired communication R/T deafness.

Planning once communication dysfunction has been identified you must consider factors when designing the care plan. Motivation is a factor in improving communication and clients often require encouragement to try different approaches that involve change.Make sure to meet basic comfort and safety needs BEFORE introducing new communication methods and techniques. Allow adequate time for practice.

o Goals and Outcomes: effective nursing interventions will have the goal of the client experiencing a sense of trust in the nurse and healthcare team. Expected outcomes (SMART) for impaired communication are also important to identify.

Ex) Client initiates conversation about diagnosis or health care problem Client is able to attend to appropriate stimuli

Client conveys clear and understandable messages with family members and healthcare team

Client will express increased satisfaction with the communicationprocessClients who are well can have difficulty in communicating that interferes with healthy interpersonal relationships, in these cases impaired communication will possibly be a contributing factor to other diagnoses such as impaired social interaction or ineffective coping. Interventions to help client improve communication – model effective communication techniques and provide feedback regarding client’s communication. Role play can help. Expected outcomes could be demonstrate the ability to appropriately express needs, feelings and concerns; communicate thought and feelings more clearly; engaging in appropriate social conversation w/peer and staff; increasing feelings of autonomy and assertiveness

o Setting of Priorities maintain open line of communication so client can express emergency needs or problems ex) intervention as simple as keeping call light in reach for a client restricted to bed or providing communication augmentative devices (message boards/Braille computer). For lengthy interactions address physical care priorities so that the discussion is not interrupted. Client comfortable by ensuring any symptoms are under control and any elimination needs have been met.

o Continuity of Care Collaborate with other health care team members who have expertise in communication strategies. Speech therapists help clients with aphasia, interpreters are often necessary for other languages, psychiatric nurse specialists can help with angry or anxious clients and help them communicate more effectively.

Implementationo Therapeutic Communication Techniques are specific responses that encourage

the expression of feelings and ideas and convey acceptance and respect. Learning and implementing therapeutic communication techniques helps develop awareness of the variety of nursing responses available for use in different situations.

Active Listening involves metacommunication and facilitates client communication - being attentive to what client is saying both verbally and no verbally. Use the 2:1 ration ears:mouth!

S.O.L.E.R. acronym to help use nonverbal skills to facilitate attentive listening.

S-Sit in front of client – this posture sends message that nurse is there to listen and interested in what client has to say.

O-Observe an open posture (keep arms and legs uncrossed) this Suggests nurse is “open” to what client says. “closed” conveys defensive attitude, can provoke similar response from client.L-Lean toward client – conveys nurse is involved and interested in the interactionE-Establish and maintain intermittent eye contact – conveys nurse’s involvement in and willingness to listen to what client is saying. Absence of eye contact or shifting of eyes gives message of non-interest.

R-Relax this is important to communicate sense of being relaxed and comfortable w/client. Restlessness communicates lack of interest and feelings of discomfort.

Sharing Observations - commenting on how other person looks, sounds, acts. Stating observations can help the client communicate w/o extensive questioning, focusing, clarification. This technique helps start a conversation with quiet or withdrawn persons. DO NOT state observations that will embarrass or anger – even if made w/humor – can create resentment.

Sharing observations is DIFFERENT than making assumptions. Making assumptions puts client in position of having to contradict the nurse. Ex)interpreting fatigue as depression, assuming that untouched food indicates lack of interest in meeting nutritional goals.

Observations are gentler and safer ex) You look tired, you seems different today, I see you haven’t eating anything. – then the client will be able to express reasons.

Sharing Empathy – understanding. Nurse reflects understanding of the importance of what person communicated on a feeling level. Nurse must be sensitive and imaginative, especially if nurse has not had similar experiences. Sharing empathy is the key to unlocking concern and communicating support for others. Es tell the person that the nurse head the feeling content as well as factual content of the communication. Empathy statements are neutral and nonjudgmental and help establish trust in difficult situations. Ex) nurse says to an angry client who has low mobility after a stroke: “It must be very frustrating to know what you want and not be able to do it”.

Sharing Hope Nurse recognizes hope is essential for healing and learn to communicate a “sense of possibility” to others. Appropriate encouragement and positive feedback are important in fostering hope and self-confidence and for helping ppl achieve their potential and reach goals. Ex) Nurse says to a patient who is discouraged about a poor prognosis, “I believe you will find a way to face your situation, because I have seen your courage and creativity in the past.”

Sharing Humor Important and underused in nursing interactions. The goal in using humor is to bring hope and joy to the situation and enhance the client’s well being and therapeutic relationship. It has been found to improve client’s self-esteem and make nurses seem more approachable. Laughter signifies positive events to people and contributes to feelings of togetherness, closeness, and friendliness. Use of humor is one indicator of mental well-being. It minimizes the effects of negative factors and protects from difficulties. It is reported that humor in healthcare: shows you care, reduces tension and helps you get on with work, shows your clients personalities with their defenses down, makes us equals-because we all laugh at the same things, makes us more likely to be accepted.

Humor works to promote positive communication in 3 ways:

Prevention – using humor when crisis occurs in a work environment makes staff more willing to work together when tensions can be high.

Perception – injecting humor into a situation changes the perception that the situation is so terrible that it cannot be handled.

Perspective – assists us in keeping the big picture in view and not taking ourselves too seriously.

Humor reduces stress and tension, provides social control, permits cognitive reframing, reflects social change, and expresses emotion.Cultural Sensitivity with humor: when clients do not have a full grasp of the language, it is important to note that clients may misunderstand or misinterpret humor. Coping Humor: dark, negative humor after difficult or traumatic situations as a way to deal w/unbearable tension and stress has a high potential for misinterpretation as uncaring by persons not involved in the situation. (student nurses are sometimes offended and wonder how staff is able to laugh and joke after unsuccessful resuscitation efforts) Coping humor should NEVER be used within earshot of clients or loved ones because this can cause great emotional distress.

Sharing Feelings emotions are subjective feelings that result from one’s thoughts and perceptions. Feelings ARE NOT right, wrong, good, or bad. They are pleasant or unpleasant. If ppl do not express feelings, stress and illness will worsen. Help clients express emotions by: making observations, acknowledging feelings, encouraging communication, giving permission to express “negative” feelings, and modeling healthy emotional self-expression.NOTE: Clients can direct anger or frustration prompted by their illness toward the nurse. DO NOT take such expressions personally. Acknowledging client’s feelings communicates that you are listened to and understood the emotional aspects of their illness situation. (that is directly from the book pg 353 but seems to be a confusing sentence)BE AWARE OF YOUR OWN EMOTIONS: feelings are difficult to hide. Sharing emotions makes ppl seem more human and brings them closer. It is appropriate to share feelings of caring or even cry with others, as long as the nurse is in control of the expression of those feelings and does NOT burden the client or break confidentiality.It is usually inappropriate to discuss negative personal emotions such as anger or sadness with clients. A social support system of colleagues is helpful, and employee assistance programs, peer group meetings, and use of interdisciplinary teams such as social work and pastoral care provide other means for nurses to safely express feelings away from clients.

Using Touch touch is one of the most potent forms of communication. Touch conveys many messages: affection, emotional support, encouragement, tenderness, and personal attention,

Comfort touch such as holding a hand, is especially important for vulnerable clients who are experiencing severe illness with its accompanying physical and emotional losses. In older persons touch increases a sense of safety, increases self-confidence, and decreases anxiety. Research has found that nurse’s soothing nonessential touch has decreased anxiety and lowered distress in children having a lumbar puncture. Touch should be as gentle or as firm as needed and delivered in a comforting nonthreatening manner.Withhold touch when highly suspicious or angry persons respond negatively or even violently to nurse’s touch.

Using Silence empty spaces that allow time for nurse and client to observe one another, sort out feelings, think how to say things, and consider what has been communicated. In general, allow the client to break the silence particularly when the client has initiated it.Silence is particularly useful when ppl are confronted w/decisions that require much thought. Ex) helps client gain confidence needed to share the decision to refuse medical tx. Allows nurse to pay particular attention to nonverbal messages such as worried expressions or loss of eye contact. Remaining silent demonstrates the nurses patience and willingness to wait for a response when the other person is unable to reply quickly. Silence is especially therapeutic during times of profound sadness or grief.

Providing Information providing relevant information tells patients what they want or need to know so they are able to make decisions, experience less anxiety, and feel safe and secure. It is also an integral aspect of health teaching. Clients have a right to know their health status and what is happening in their environment. Information of distressing nature needs to be communicated with sensitivity, pace appropriate to what client can absorb, and in general terms.It is not helpful to hide information from clients especially if they are seeking it. If a physician withholds information, the nurse needs to clarify the reasoning.

Clarifying check if you have an accurate understanding by having him restate or rephrase what are saying. Without clarification you may make invalid assumptions and miss valuable information.Ex) “I’m not sure I understand what you mean by ‘sicker than usual’, what is different now”

Focusing on key elements or concepts of a message if conversation is vague or rambling or if a client begins to repeat themselves focus is a useful technique. Nurse does not use focusing if it interrupts the client while discussing an important issue, rather they use focusing to guide the direction of the conversation to important areas.Ex) “we have talked a lot about your medications but let’s look more closely with the trouble you are having with taking them on time”

Paraphrasing restating another’s message more briefly and using one’s own words. By providing the client with feedback the nurse sends a message to the patient that they are actively involved in the search for understanding. If the meaning or message is distorted through paraphrasing communication becomes ineffective.Ex)” I have been overweight all my life and not had any problems and do not understand why I need to be on a diet.” Incorrect response: “you do not care if you are overweight or not” Correct response: “you are not convinced you need to diet because you have stayed healthy all your life”

Asking Relevant Questions by nurses to seek information needed for decision making. You need to fully ask one question at a time and fully explore one topic before moving to another area. During assessment questions follow a sequence starting with generalized and progresing to more specific. Use open ended questions to allow patient to provide pertinent information. Close ended questions are less useful during therapeutic exchanges.Asking too many questions can be dehumanizing, and can make the patient feel uncomfortable, it should be more in a conversation form.Making observations, paraphrasing, focusing, providing info…you will discover important info that would have remained hidden if the nurse limited the communication process to questions alone.

Summarizing concise review of key aspects of an interaction and clarifies expectation. It brings a sense of satisfaction and closure to the patient. It is especially useful during the termination phase of a nurse/client relationship. By reviewing the conversation participants focus on key issues and add relevant information as needed. Beginning a new interaction by summarizing a previous interaction helps patients recall topics discussed and shows the client the nurse has analyzed the information.

Self-Disclosure subjectively true personal experiences about the self that are intentionally revealed to another. This is NOT therapy for the nurse, rather it shows clients that the nurse understands their experiences and that they are not unique. It is indicactive of the closeness of the nurse/client relationship and involves a particular kind of respect for the patient.USE SELF DISCLOSURE SPARINGLY so that the client remains the focus of the interaction.Ex) “That happened to me once too, it was devastating and I had to face some things about myself that I didn’t like, I went for counseling and it really helped……what are your thoughts about seeing a counselor?”

Confrontion –confronting someone in a therapeutic way helps them see their inconstancies about feelings, attitudes, beliefs and behaviors. This technique improves client self-awareness, recognize growth, and deal with important issues. Confrontation is only to be used after you have established trust, and to be used gently and w/sensitivity.

o Nontherapeutic Comunication Techniques aka blocking: certain communication techniques hinder or damage professional relationships. They

cause recipients to activate defenses to avoid being hurt or negatively effected and discourage further expression of feelings, ideas. AVOID THESE NON THERAPEUTIC COMMUNICATION PITFALLS:

Asking Personal Questions Giving Personal Opinions Changing the Subject Automated Responses avoid stereotyped responses“older adults are

always confused” automated phrases communicate that the nurse is not taking concerns seriously or responding thoughtfully.

False Assurance Avoid saying “don’t worry, everything will be ok” Offering reassurance not supported by facts or based in reality will do more harm than good. It is appropriate to say “It must be difficult not to know what the surgeon will find. What can I do to help you?”

Sympathy Don’t act like you know how they are feeling, Don’t say “I am sorry about your mastectomy, it must be terrible to lose a breast” Use empathy instead of sympathy “The loss of a breast is a major change. How do you think it will affect your life?”

Asking for explanations asking “why” causes resentment, insecurity and mistrust. It can be interpreted as the nurse knows the reason and is simply testing the. When needing additional information avoid using the word “why” - instead say “you seam upset – what’s on your mind?”

Approval or Disapproval shows judgment – avoid should, ought, good, bad, right, or wrong. Agreeing or disagreeing sends the subtle message you have the right to make value judgment about client decisions. When a client shares a decision with a nurse, it should not be not be viewed as an effort to seek approval but to provide a means to discuss feelings.

Defensive Responses implies the other person has no right to an opinion. “No one here would intentionally lie to you” Rather say: “You believe people have been dishonest with you, it must be hard to trust anyone.”

Passive or Aggressive Responses Serves to avoid conflict or sidestep an issue. Avoid statements like “things are bad and there is nothing I can do about it” - passive. “things are bad and it’s all your fault” – aggressive. Assertive communication is a more professional approach.

Arguing “How can you say your didn’t sleep a wink, when I heard you snoring all night long?” this implies that the other person is lying, misinformed or uneducated. Rather state “You feel like you didn’t get any rest at all last night, even though I though you slept well since I heard you snoring”.

Adapting Communication Techniques for the client with special needs:Effective communication involves adapting to ANY special needs resulting from sensory, motor, or cognitive impairments present. Nurses should encourage, enhance, restore, or substitute for verbal communication. Make sure the client Is physically able to use the chosen method and that it does not cause frustration by being too complicated or difficult.

Deaf/or hard of hearing most things for the nurse to do was ask the client how to best communicate with him/her.

For older adults: nursing care is ideally delivered through interdisciplinary model, the primary goal is to establish a reliable communication system that all health

care team members can understand easily. Encourage older adults to share life stories and reminisce about the past, this is therapeutic and increases sense of well-being. Avoid sudden shifts from subject to subject. Include the client’s family/friends to become familiar with clients favorite topics for conversation.

(Box 24-10) Clients who cannot speak clearly (aphasia, dysarthria, muteness)

Listen attentively, be patient, do not interrupt.Ask simple questions that require yes/no answersAllow time for understanding/responseUse visual cues (words/pics/object) when possibleAllow only one person to speak at a timeDo not should or speak too loudlyEncourage client to converseLet client know if you have not understood themCollaborate w/speech therapist as needed

Use communication aids (pad and felt-tipped pen or magic slate, communication board w/commonly used words, letters or pictures denoting basic needs, call bells or alarms, sign language, use of eye blinds or movement of fingers for simple responses like yes/no)

Cognitively ImpairedReduce environmental distractions while conversingGet client’s attention before speakingUse simple sentences and void long explanationsAsk one questions at a timeBe an attentive listenerInclude family/friends in conversations, especially subjects known to client.

Hearing ImpairedCheck for hearing aids AND glassesReduce environmental noiseGet client’s attention before speakingFace client with mouth visibleDO NOT CHEW GUMSpeak at a normal volume-do not shoutRephrase rather than repeat if misunderstood Provide a sign language interpreter if indicated

Visually ImpairedCheck for glasses or contact lensesIdentify yourself when you enter room, notify client when you leave roomSpeak in a normal tone of voiceDo not rely on gestures or nonverbal communication to convey messagesUse indirect lighting, avoiding glare (why???)Use at least 14 point print

Unresponsive ClientsCall client by name during interactionsCommunicate both verbally and by touchSpeak to client as though he/she can hearExplain all procedures and sensations

Provide orientation to person, place, and timeAvoid talking about client to others in his/her presenceAvoid saying things client should not hear

Clients who do not speak EnglishUse normal tone of voice, shouting may be interpreted as angerEstablish method for client to signal desire to communicate (call light/bell)Provide an interpreter as needed (Fed and State Laws about this)Avoid using family members, especially children as interpretersDevelop communication board, pictures, or cardsTranslate words from native language into English list for client to make basic requestsHave dictionary (ex. English/Spanish) available if client can read.

Evaluationo The nurse and client determine whether the plan of care has been successful by

evaluate the client communication outcomes. You evaluate nursing interventions to determine what was effective and what client changes resulted because of the interventions. Ways to evaluate skills – record a practice session with a friend/peers and evaluate the following:

Determine whether the nurse encouraged openness and allowed patient to tell his story expressing both thoughts and feelings.

Identify any missing verbal or nonverbal cues or conversational themes.

Examine whether nursing responses blocked or facilitated the client’s efforts to communicate.

Determine whether nursing responses were positive and supportive or superficial and judgmental.

Examine the type and number of questions that were asked. Determine the type and number of therapeutic communication

techniques used. Discover any opportunities to use humor, silence, or touch.