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Week 2- COMMUNICATION
REQUIRED READING
: Burton & Ludwig- Chapter 6
Ackley/Ladwig: Communication, verbal, impaired Communication, readiness for enhanced UNIT OBJECTIVES: Written in italics and underlined. Master answers to all objectives to assist in preparing for tests.
1.
Describe the communication process- an exchange of information, feelings, needs, and preferences between two people
a.
Styles of Communication
i.
Passive – avoidant behavior, inability to share needs
with others, ii.
Aggressive – ones own needs rights and feelings above others, try to humiliate others and hostile towards others
iii.
Assertive – standing up for oneself, act in a consistent manner that shows ones worth
2.
Describe 2 ways communication occurs
a. Verbal
i.
Verbal communication skills – conscious use of words, either spoken or written, more direct, often used to give or receive specific information
b. Non-verbal
i.
Components of non-verbal communication
1. Tone/rate/volume
2.
Eye contact
3.
Physical appearance
4.
Facial expressions
3. Describe factors that can influence communication.
a.
Personal Space
Intimate – ranging from physical contact to 18inches
Casual – 18inches to 4ft
Social – 4 to 12ft
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Public – 12ft if possible
b.
Body Position – to demonstrate a willingness to communicate effectively with your patients, you need to communicate at eye level with the other person, lean slightly forward and maintain and open body posture.
c.
Touch – keep functional/professional
d.
Culture – a person is showing cultural sensitivity when he or she refrains from using language that will be deemed offensive or disrespectful by another culture when interacting with a person of that culture.
e. Attitude
f.
Emotion – language has the ability to stir powerful feelings, language can inspire, give hope, and convey caring but can also generate negative feelings like antagonism, fear, and prejudice. 4. Describe 5 skills needed in active listening.
a. Listen up – listen more then you talk, show genuine interest in what is being said
b. Rinse and repeat – repeat the sentence that you heard
c. Problem solved – don’t try solving problems, just listen
d. Eye to eye – show eye contact, it shows your listening
e. Non-interruptus – no interrupting the speaker
5. Define therapeutic communication.
Patient-centered communication
The goal is to promote a greater understanding of patient’s needs, concerns, and feelings. When practicing therapeutic communication, the nurse helps patients explore their own thoughts and feelings, encourages expression of them and avoids barriers to communication.
a.
Conditions essential to development of a therapeutic relationship
– establishing a trusting repore, demonstrate success, empathy, hold them in a positive regard, confidentiality, knowing when to use therapeutic touch. 2
b.
Barriers to therapeutic communication – looking distracted, turning away from the patient or intimidating patient by standing
over them. 6. Describe 11 additional skills used in therapeutic communication and be able to give an example of each (Refer to box 6.2 on pg. 103 of
your text
).
Communication Technique
Example
a. Silence
Utilizes pauses or silence for up to several minutes without verbalizing. An example would be sitting quietly and waiting for the patient to explore thoughts and feelings
b. General leads
Encourages initiation or elaboration of a conversation “I see what you are saying. Then what happened?” Tell me what treatment plan Dr. Smith talked to you about yesterday?”
c. Offering Self
Shows concern and willingness to help. Example – “what can I do to help you?”
d. Using Open-ended
Questions
Encourages elaboration and discourages answering questions with one or two words. Example “Tell me more about…”
e. Restatement
Restates in different words the heart of what a patient said. Encourages further communication. Also conveys to the patient that you were actively listening. Example “My daughter made me so mad yesterday!, “Your daughter upset you?”
f. Seeking Clarification
Helps to verify that the message sent was what was
intended. This is necessary if the communication has detoured into many topics. Example “Are you saying…?”
g. Giving Information
Provides relevant information. Example “You will need to report to the x-ray department at 8am”
h. Using Reflection
Reflects the same words back to the patient. This encourages verbalization of feelings. Example “I’m so anxious about what my tests will show.” “You’re anxious about your results?”
i. Looking at Alternatives
Helps patients explore options when making decisions about their care. Example “Have you thought about…?”
j. Summarizing
Sums up the important points. Example “It looks like you have covered everything…”
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. Describe the following blocks to therapeutic communication, and be able to give examples of each and explain how each negatively impacts communication.
VERBAL BLOCKS
EXAMPLES
Changing the subject
Offering false reassurance
“don’t worry everything will be alright”
Giving advice
“I think you should…” or “If I were you…”
Defensive comments
Personal/probing Questions
“why do you think that?”
Expressing disapproval
“I would never decide against chemotherapy.”
Using clichés
Belittling client feelings
“There are other patient who need more help then you”
NONVERBAL BLOCKS
Inattentive Listening
Doing something else while you’re “listening” to
your pt
Looking distracted
You’re looking out the window, at the computer, looking over or around the pt
Turning away
You have your back to the patient doing something else and clearly not paying attention to them
Intimidation by body position
Standing over the patient looking down on them.
8. Discuss the use of humor in therapeutic communication
Humor helps to create an atmosphere that is relaxed and sociable. Research
tells us that patients value informal, humouous social interaction because it allws them to step out of their sick role, helps establish rapport and trust, and passes the time. All while helping to relieve anxiety and tension. Using humor helps the patient feel they can approach staff more comfortably.
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9. Discuss effective methods of communicating with the health-care
team.
A.
Upward vs Downward Communication – refer to your placement on an organizational chart. Upward communication is the interaction with those in authority over you and is formal by nature. If you’re a team member, you will share information with your team leader. The team leader will share information with your unit manager, who will in turn report information to a supervisor, and so on up the chain of command.
B.
Communicating with Healthcare providers
a.
Information Given When Contacting a Physician
A quick assessment of the patient, pertinent background information. A concise statement of the problem and why you are calling. Current data on the patient like vitals, morning labs, medications given or recent tests.
b.
DESC Method- See Box 6.5
D= Describe the behavior – focus on what is observed or heard without a personal attack. Discuss the behavior, not the person.
E= Explain impact of behavior – do not minimize the impact of the behavior
S= State the desired outcome – when you describe what you need from the other person, s/he does not have to guess and may be more likely to make changes.
C= Consequences of not complying – you will need to restate your position and then ask the person something, such as “what else do I need to do to get your attention?” or make the statement, “if you continue what you are doing, you and I will need to meet with the supervisor to resolve this.” For most people, this will be the most difficult step to implement because nobody likes to go out of their comfort zone.
c. ISBARR
I- Introduction: Identify yourself, your credentials, and location. State name of client you are calling about.
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S- Situation: Briefly describe the current situation- provide a clear, concise overview of pertinent issues.
B- Background: Briefly state pertinent history (What got us to this point?)
A- Assessment: Summarize the facts and provide your current assessment findings.
R- Recommendation: Describe what actions you are asking for- what do you want to happen next?
R- Repeat back physician orders d.
Talking with your supervisor
Keep supervisor informed.
If problem comes up, make an appointment to discuss, have specific information/situations to discuss. Focus on resolving the problem not just the problem.
Be careful in word choice, avoid blaming others, exaggeration and overly dramatic expressions.
Try not to discuss when you’re angry and do not respond with anger. Use “I” statements and explain your thinking.
Accept feedback and learn from it.
If you are presenting a new idea, give your supervisor a written proposal and then meet to discuss further.
Never go above or around your supervisor. Always communicate directly with your supervisor before you go up the chain of command.
e.
Shift Report – communication of the patient’s condition and required nursing care by the off-going nurse to the oncoming nurse, which is necessary step in preparation for the oncoming nurse to receive the patient into his/her care. The focus of end of
shift reporting should be to pass along detailed, accurate, current information about the patient and changes in orders or plan of care, including changes that have already occurred and anticipated changes.
10. Discuss the nurse-patient relationship
A.
Establishing Trust – pts look to you to provide emotional support, encouragement, and understanding. You can provide emotional 6
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understanding and support by communicating empathy to your patients. Empathy is the ability to intellectually, not emotionally, identify with or experience the feelings, thoughts, or attitudes of others. You can understand and respect what a patient is experiencing
without taking on the burden of experiencing it yourself.
B.
Patient-Centered Communication – communication that encourages and empowers patients to participate in their care. It is an essential component to establishes a positive nurse-patient relationship. C.
Interviewing the patient – a more formal way of communicating, planned communication with a purpose.
11. Describe techniques to communicate with the following special population patients.
a. Aphasic (Box 6.7 & 6.8)
Expressive – (Broca’s) is a disturbance in speech planning and speech production. Persons with expressive aphasia cannot produce fluent speech. Their speech has been described as “halting”. Expressive aphasia presents as single word responses, inability to produce spontaneous conversation, slow,, monotone utterances, inappropriate words, hearing, reading abilities are intact.
Receptive – (Wernicke’s) is a deficit in auditory comprehension or in receiving information. The patient can hear but cannot understand what is said, may be slow to respond or may understand only a portion
of what is said. Receptive aphasia presents as abnormal language, impaired reading and writing skill because the person does not understand what is supposed to be accomplished, speech sounds with normal rhythm, rate and fluency.
Global (expressive and receptive) a deficit of planning, production and comprehension of language. Patients with global aphasia can speak and understand only a few words. Presents as meaningless speech sounds, possibly perseveration, or the repetition of one word or thought.
o
Communication with patients with aphasia is difficult. Patients with severe impairments may have to learn to ready body language and gestures to communicate.
Communication techniques
Make sure you have the patients attention by touching him/her if necessary and addressing by their name
Speak slowly
Use short sentences
Repeat what you said
Use gestures, demonstration and facial expression
Speak in a normal tone
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Be respectful
Ask yes/no questions and write messages to help the pt understand
Listen carefully
Allow the patient to speak without interruption
Try to make the patient a “partner” in the communication
b. Hearing impaired
Find out how the person communicates best – verbalizing, writing, ASL,
lip reading
Refrain from using an intercom and developing an alternative way of communicating
Face the person
Get the person’s attention before starting to communicate
Speak clearly with adequate volume w/o shouting or mumbling
Speak to the patient not the interpreter, if present
Use short simple sentences
Do not block the view of your face with your hands
Don’t chew gum
Make sure lighting is good
Eliminate background noise
Speak normally and not overly exaggerated manner
c. Vision Impaired
Identify yourself when you enter the room, they may not be able to see
you but their sense of hearing is VERY good.
Speak naturally – there’s no reason to raise your voice
Use body language the same way you would with a sighted person
Introduce the patient to others in the room
Avoid speaking to others as though the patient isn’t in the room
Before leaving, let the patient know you’re leaving and confirm there is
nothing else you can do for them at this time.
Before providing care or touching the patient, let them know the plan and that you’re going to touch their right shoulder or arm or leg, so that they are prepared for that touch.
d. Unresponsive clients – when working with clients that are unresponsive, it
is still important to talk to them and let them know you are doing tasks related to their care “going to do some oral hygiene for you this morning” or “we are going to roll towards me ok?” even though they cannot answer you, it is believed that they can hear you. Techniques of Therapeutic Communication Guide sheet
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Technique
Description/Purpose
Examples
ENCOURAGING CONVERSATION
Broad opening statement
Initiates conversation
Allows client to set the direction of the conversation.
“How are you doing this morning?”
“What is on your mind today?”
“What are you thinking about?”
General leads
Used to encourage client to continue
“Yes?”
“Go on.”
“Hmmmm.”
Reflecting
Repeat all or part of a client’s statement.
Encourages the client to continue and expand upon his/her statement.
“You’re worried because….”
“You’re upset because…”
HELPING PEOPLE TO EXPRESS THOUGHTS AND FEELINGS
Sharing observations
Focus on client’s apparent emotional or physical state
Make client aware of nurse’s perception of client’s behavior.
“You seem upset.”
“You seem tense.”
“You don’t seem to be yourself.”
Acknowledging the client’s feelings
Verbalize acceptance and understanding of client’s feelings.
“It must be upsetting to feel…”
“It must be difficult….”
Selective reflecting
Select what seems to be the most important idea contained in what the client says and reflect (repeat) it back to them.
Encourages further exploration of main ideas client has expressed.
“Going home?”
Patient “What do you think I should do about telling my employer about my illness?” RN “What have you been thinking about this situation?”
Using silence
Slows pace of conversation.
Gives client opportunity to reflect/think.
Gives the nurse time to observe client for nonverbal cues.
Gives the nurse time to assemble own thoughts.
Maintain an interested, expectant silence. If you’re silent because you are uncomfortable or don’t know what to say, then it’s a block and should be processed as such.
Giving Information
Correct misinformation.
Give client information to further evaluate their own situation.
Answer questions
Technique
Description/Purpose
Examples
ENSURING MUTUAL UNDERSTANDING
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Clarifying
Make meaning clear & use when you want to avoid misunderstanding what client has said
“I’m not sure I follow what you mean.”
“Are you saying….?”
Verbalizing implied thoughts and feelings
Nurse verifies his/her impression of what client means and helps the client become more aware of his/her feelings.
“You’re afraid that….”
Validating
Used to determine whether or not the client’s needs have been met.
“Are you feeling better?”
“Are you feeling more relaxed.”
Summarizing
A concise review of main ideas.
Resource: Concept Media/2016
Blocks to Therapeutic Communication Guide Sheet
Block
Description/Purpose
Example
Reassuring clichés
May be used when someone does not know what to say
“Everything will be all right.”
“You don’t need to worry.”
“You’ll be fine.”
Giving advice
You impose your own opinion and solution.
“You should do…”
“Why don’t you…”
Giving approval
Shift focus from client’s concerns to nurse’s values or feelings.
Nurse imposes their own beliefs and values instead of helping client explore their own feelings and evaluation actions.
“You’ve got the right attitude.”
“That’s the thing to do.”
Probing/Prying; Requesting an explanation
May cause uneasiness and put client on the spot.
Often begin with “Why”
Threatening approach and can be intimidating.
“Why are you upset?”
“Why did you do that?”
Agreeing with the client
Makes it difficult for the client to later change their mind
If the client has said something other than what they believe to be true, they may be prevented from later saying what they really mean.
“You’re right.”
“I agree.”
Expressing disapproval
Negative value judgment. Indicates that you have not accepted client’s feelings.
“You shouldn’t feel that way.”
“You should stop worrying like 10
this.”
Belittling client’s feelings
Minimizes client’s feelings.
Indicates the client’s feelings are not unusual or
important.
“I know just how you feel.”
“Everyone feels that way.”
Disagreeing with the client
Indicate that you do not accept client’s feelings.
‘That’s not true.”
“You’re wrong.”
“No it isn’t”
Defending
Indicates that you do not accept client’s criticism and they have no right to express opinions or feelings.
“The staff is very difficult.”
“The doctor only has your best interests in mind.”
“Your doctor is quite capable.”
Changing the subject
Nurse directs conversation instead of the client.
Anything that redirects the conversation to another topic
Stereotyped comments
Common comments made to clients
Usually occur because we do not know what to say and keeps conversation superficial- do not get into meaningful conversations.
“How are you doing?”
“Isn’t the weather great?”
Resource: Concept Media/2016
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How Well Do You Listen?
SLO- Human Flourishing-Perform nursing skills in a manner that is culturally responsive and promotes self-determination, integrity, and ongoing growth towards one’s maximum potential.
The following listening assessment provides the opportunity to examine your listening behavior
patterns. In other words, it will help you answer the question, "how well do you listen"? Remember, there are no "right" or "wrong" answers.
Choose the letter that best describes your first response to the person in the situation who is expressing a problem. You are not looking for the "right" response or how you would like to respond, but how you would, indeed, respond to people in these situations.
1. One supervisor to another supervisor: "The company policy is supposed to be to hire from within the company. And now I find out that this new guy is coming in to replace my boss. I had
my eyes on that job; I've been working hard for it. Well, if that's what they think of me, I know when I'm not wanted."
_____a. "It can be disappointing when the company seems to have forgotten about you by hiring outside the company, especially when you put a lot of hard work into your job.
_____b. "Maybe your qualifications don't compare with those of the new person's."
_____c. "I would make sure they know your views and let them know your interest in advancement."
_____d. "Did they discuss it with you at all?"
2. "It happens every time my manager appears in my department. He just takes over as if I weren't there. When he sees something he doesn't like, he tells the employee what to do and how to do it. The employees get confused, I get upset, and finally he leaves. I'm responsible to him, so what can I do?" _____a. "You should discuss your problems with your boss."
_____b. "When did this start to happen?"
_____c. "The boss must be the boss, I suppose, and we all have to learn to live with it."
_____d. "It upsets you that your manager takes over and gives conflicting directions. You're not
sure what would be the most appropriate way to confront him about your feelings regarding his
behavior."
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3. "It's happened again! I was describing an office problem to my manager and she starts staring out the window. She doesn't seem to be really listening to me because she has to ask me to repeat things. I feel she's superficially giving me the time to state my problems, but she ends upside-stepping the issue." _____a. "You should stop talking when you feel she's not listening to you. That way she'll start paying attention to you."
_____b. "You can't expect her to listen to every problem you have; anyway... you should learn to solve your own problems."
_____c. "What kind of problems do you talk to her about?"
_____d. "It's frustrating to have your boss behave this way when you're talking about problems
that are important for you to solve."
4. "I think I'm doing all right, but I don't know where I stand. I'm not sure what my boss expects of me, and he doesn't tell me how I'm doing. I'm trying my best, but I wonder who else knows that. I wish I knew where I stood." _____a. "Has your boss ever given you any indication of what he thinks of your work?"
_____b. "If I were you, I'd discuss it with him."
_____c. "Perhaps others are also in the same position, so you shouldn't let it bother you."
_____d. "Not knowing if you're satisfying your boss leaves you feeling unsure, and you'd like to know just what he expects from you."
5. "As long as I've got a goal ahead, I'll keep striving for it. I'm determined to advance my career; hard work never bothered me. I know it won't be easy, and I'll probably have to climb over a few people. This is important to me!" _____a. "You shouldn't have to climb over people to get what you want."
_____b. "Getting ahead is very important in your life, even if it means hard work, and it won't be easy."
_____c. "What in particular do you want to achieve?"
_____d. "You should take some management classes to help you advance." http://www.onlinewbc.gov/docs/manage/listen.html
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How Well Do You Listen Scoring:
If you answered as follows: 1-a, 2-d, 3-d, 4-d, 5-b
Empathetic Response:
A nonjudgmental response that captures the essential theme and/or feeling expressed, a potential for building rapport and mutual understanding.
If you answered as follows: 1-c, 2-a, 3-a, 4-b, 5-d
Recommendation Response: A response that offers advice, tells the talker what to do or what not to do, solves the problem or does the thinking for the talker.
If you answered as follows: 1-d, 2-b, 3-c, 4-a, 5-c
Asking for Information Response: A response that asks for additional information to get a clear understanding before responding. Used to excess, the talker may feel “grilled”.
If you answered as follows: 1-b, 2-c, 3-b, 4-c, 5-a
Critical Response: A response that expresses a form of criticism resulting from a natural tendency to judge, approve, or disapprove a message received.
Think About and Answer:
1.The response I use most often is:
2. The response I use the least is:
3.What does this listening response pattern tell you about yourself?
4.What do you want to maintain?
5.What would you like to change/modify?
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Chapter 6 Communication: Student Review
Choose the correct answer:
1. Today is your first day on an Alzheimer’s unit in a long-term care facility. Which of the following is the best way to begin to establish a connection with your clients?
a. Have a peer formally introduce you to the clients.
b. Smile at the clients.
c. Sit among the clients.
d. Read aloud to the clients.
2. Multiple areas of the brain are involved with all forms of communication. Which of the following is the likely outcome if your client has a stroke that affects the left frontal lobe (Broca area)?
a. Loss of ability to perceive touch
b. Loss of vision
c. Loss of ability to formulate thoughts
d. Loss of movement in muscles that control speech
3. Which communication form will be compromised if your client has a stroke that affects the occipital lobe?
a. Loss of ability to perceive touch
b. Loss of vision
c. Loss of ability to make gestures
d. Loss of movement in muscles that control speech
4. Which communication form will be compromised if your client has a stroke that affects the parietal lobes?
a. Loss of ability to perceive touch
b. Loss of vision
c. Loss of ability to make gestures
d. Loss of movement in muscles that control speech.
5. When communicating with older adults, it is important to be aware of (Select all that apply):
a. Any impairments in vision or hearing.
b. Chronic pain issues.
c. Dementia that interferes with communication.
d. The need to speak more slowly and loudly than usual.
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Indicate whether the following statements are true (T) or false (F).
6. ___F__ Communication between two people is called one-sided communication because one side gives communication, and the other side receives the communication.
7. __F___ Communication is the process of informing.
8. __F___ Interpreting information is not part of communication but is part of listening.
9. __T___ People will let you know how well you are communicating by giving you feedback.
10. __F___ Shared meaning refers to two people deciding what another person meant.
11. You enter your client’s room and find him sitting in a chair with his eyes closed. He has a grimace on his face and is holding his body rigidly. You ask him if he is feeling ok, and he says, “Yes, I’m fine. Really.” Which of the following best explains this situation in terms of
communication?
a. He is communicating to you that he is fine.
b. His verbal and nonverbal messages are congruent.
c. His verbal and nonverbal messages are incongruent.
d. He is sarcastic, but it is understandable.
12. You ask an LPN on your team to interview a client to be admitted for surgery. You walk by the room and observe that the nurse is seated in the chair while the client is seated on the bed. The nurse is leaning forward slightly. By her body position, you would conclude that;
a. She is conducting the interview in an appropriate manner.
b. She is too casual and should not be sitting.
13. Acceptable, polite communication styles between professionals and their clients vary greatly
among different cultures. Acceptable styles also vary within cultures. When approaching a client from a cultural background other than your own, you should (Select all that apply):
a. Maintain distance and avoid eye contact to be on the safe side.
b. Observe how the family interacts and take your cues from that.
c. Ask another professional from that cultural background for advice, if possible.
d. Find out information about that culture from a different source, such as a pertinent website or text.
e. Communicate in the way that makes you feel most comfortable.
SLO: Nursing Judgment- Demonstrate the knowledge, skills, and attitudes in the development of clinical reasoning necessary to perform psychomotor skills safely and efficiently within the context of the established plan of care.
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