Communication is the basic element of human interactions that allow people to esttabilish.

Maintain and improve contract with others. Because communication is something person do every day. They often mistakenly think it is simple. However, communication is a complex process that involves behaviors and relationships and allow individual to associate with others and the world around them. It is an ongoing , dynamic series of events in which meaning is generated and transmitted. Communication is an interpersonal process that involves verbal and nonverbal exchanges fo informatn and ideas.communication refers not only to concent but also to feelings and emotion that people may convey in a relationship. Silence is also a means of communication ; for example a nurse lstening to an anguished husband whose wife has die. Communication conveys information and it is an act of sharing. Communication is one of the most inportant factors used to estabilish a therapeutic nurse client realtionship. Nurse is based on establishing a caring and helping realtionship. This relationship is the foundation to the interaction that allows the clients and health care team to trive for a mutual understanding pf the cliennts needs. In thiscollaborativenmanner the client, nurse, and other members of the health care team identify mutually agred upon goals. Communication generates a mean for bringing about change. The nurse listen, speak and acts to negotiatiate change to promote the client;s well-being and return to a level of wellness

Levels of communication Coommunication occurs at the intrapersonal, interpersonal and public levels. Intrapersonal communication accurs within an individual. It is self-talk or a internal dialogue that occurs constanly and counsciously. The goal of intrapersonal communication is self- awareness , which is influenced by self-concept and feeling of self-worth. Positiveself concept and self awareness that come through internal dialouge can help nurse axpress themselves appsopriately to others. For example, when a nurse walks in to clients room and thinks, he looks unconunfertable, id better turn him in his side the communication is intrapersonal. An other situation involving intrapersonal communication is when NURSE NOTES A GRIMACED FACIAL Expression on the face of a client and thinks is ithis clien in pain? what do i need to do for the clien? When was the last dose of painmedication administered? Interpersonal communication is the interaction betwen two people or in a small group. Iit is often face to faceand isa the type most freqwently used is nursing situation. Individual communication are continunously aware of one another . healthy interpersonal communication allows problem solving sharing of ideas decision making and personal growth . in nursing there are many situation that challenge interepersonal communication skills . each encounter with a clien such as collectiing a blood specimentor taking a health history requires exchange in information meetings with staff memberss, physiciant sosial workers and therapists test tthe nurses communication skiils with people whomay have different opinion and eksperiinces . being a member of a nurse committtee ahalanges the nurses ability to ekspress ideas clearly and decisively. Interpersonal communication is the hearth of nursing practice. A nurse can help a client by communicating at a meaningful interpersonal level.

Public communication is interaction with large groups of people. Giving a lecture to a roomful of studdents and speaking to a consumer group on health promotion are examples of public communication . being a competent communication with an audience requires the ability to envision one self speaking to a group. Special platfrom skills such as use of posture body movements and tone of voice help the speaker to ekspress ideas

Element of the communication process Examination of the components of the communication process kelp a person understand communication a model can simply and graphicially demonstrate complex processes, but it can also oversimplify. A model provides the nursing student with a framework for observing, understanding and predicting what accurs as two people communicate A communication model must incorporate several printcipples , communication is complex, involving vrbal and nonverbal symbols and messaged between perons. Communication is a process. This process . this proses allow persons to send message both intentionally and unintentionally. Often a person can send a convey a message about presonality or attitude without being aware of it. Communication is a responnse bertwen two or more persons are they send and receive stimuull and messages Communication accurs on a social level, with practicipants engaged in intrapersoonal and interpersonal contact. The process is dynamic, with the meaning of messages negotiated by participants. During communication the person my not be aware of each element of commnication . during casual conversation participants do not bother to analyze the meaning of every gesture to word. For example a person may become quite animated, using hands to express an idea without consciously thinking Iii wave my hand to stress this point. That nurse, however, learns to be consciouse of each element of the communication process. In this way . the nurse can interact effectively with clients and reamining aware of cammunications effect in them . because of the interaction between sender ans receiver involved in communication, the model tends to oversimplify a complex process. However, each elements is crucial. Information and meaning can be gained or lost if any element is altered. Referent The referent or stimullus motivates a person to communicate with another . it may be an object, eksperience, emotion , idea, or act. Individuals whoo consciously consider the referent during interpersonal interaction can carefully develop and organize messages Sender The sender alsa called encoder, is the person who initiates the iinterpersonal communication or message. The sender puts the reference into a form that can be transmitted and assumer responbility for the accuracy of the content and the emotional tone of the message. The rle of sendermay switch back and forth between participant at anytime when infoormation is transmitted.

Message The message is information that is sent or expressed by He sender. The most effective mesaage is clear and organized and is expressed in a manner familiar to the person receiving it. An appropriate amount in information must be given and the receiver must be ready to hear the message. For example, proffesional jargon needs to be reserver for interaction bertween proffesionals and not between nurses and clients. Likewise, teaching is inappropriate if nurse try to tech the client everything is one sitting to teach the client to manage a colostomy when the client is not willingto look at the stoma. The message may comprise verbal and nonverbal language symbols. Unfortunately, not all symbol have universal meaning therefore difficulties in communication may occur with the message if the sender is not aware of this factor and does not seek clarification

Channels The message is sent along a chanel of communication. Channels are means of conveying message. Such as through visual, auditory, and tactile senses. The senders facial expression visually conveys a message. The spoken word travel via auditory channels. Placing a hand on an individual while communicating uses the chanel of touch. Generally the more channels the nurse use to send a mesaage, the better the client will understand it. For example, when attemping to relieve pain, the nurse verbalize concern, expresses compassion, and reposition the client gently to lessen the pain.

Receiver The receiver, alsa called the decoder is the person to whom the message is send. For communication to be effective the receiver must perceive or become aware of the message. The messsage from the sender acts as one of the receiversreferents. It prompts the receiver to decode and respond to the senders message. The nurse learns to engage in intrapersonal communication to analyze and interpret the clients comments. Ideally the senders intention is perceived by the receiver. There is no guarantee that this will occur because words and syimbols have multiple meanings. However, the more that the sender and receiver have in common, th more likely that the senders meaning will be communicated.

Feedback Communication is an ongoing process. The receiver returns a message to the sender. This feedback help to reveral whether the meaning of the message is received. Mere intent to communicate is insufficient to ensure that a message is accurately received. The receivers verbal and non verbal response sends feedback to the sender to reveral the receivers understading of the message. To be effective, the two must be sensitive and open to each others message, clarify the message and modify behavior accordingly. In a social relationship both persons involved assume equal responsibility for sekking openness and clarification, whereas the nurse assumes major responsibility in the nurse assumes major responsibility in the nurse-client relationship

Modes of communication People send message in the verbal and nonverbal modes, which are closely bound together during interpersonal interaction. As we speak, we express ourselves through movements, tone of voice , facial expressions, and general apparence. These modes can convey the same or different messages. The nyrse who learns skills of communication masters techniques of each mode

Verbal communication Verbal communication involves spoken or written word. Words are tools or symbols used to express ideas or feelings, arouse emotional responses, or describe objects, observations, memories, or inferences. Words may also be used to convey hidden meanings, test the others interest or degree of concern, or express hostility, of fear. Language is a code that conveys meaning. A single word can change the meantng of a pharese or sentence. Language is effective only when each person communication understands the message clearly A nurse encounters clients of variouse cultures who speak different languages. Also, some clients speak the same languanges. Also, some slients speak the same languange as the nurse but use subcultural variation of certain words. For example, the word dinner may mean a midday meat to ne person and the last meal of the day to another. These dialects and subdialects cofused meaning. Consequently, a nurse often works with clients who speak the same languange but interpret message differently from the way the nurse intended. To make a message clear the nurse uses effective verbal communication techniques clea andefeective words and phreses at the level understanding for the client. The nrse freqwently incorporates gestures to sterangthen the verbal message. For example in carng for the hearing impaired client, the nurse utilites an interpreter to facilitate the sending of the verbal message

Clarity and brevity Effective communication is ismple, short and direct. Fewer words spoken result in lest confusio. Because of the intrapersonal variables involved, human communication is imprectise is many ways. Vague phrases such as you know add little clarity to a message. Clarity is achieved by speaking slowly and enunciating cleary. Using examples can make an explanation easier to understand . for instance, instructing a client with arthritis about self care measures at home is more meaningful when the nurse provides spesific examples, including demonstration demonstration to reinforce the verbal message. Repaiting important parts of a message also mekes communication clearer the receiver should know the what why, how, when, who and where of ideas communicated Brevity is the best acchived by using word that expres an idea simply. tell me where your pain is is better than i would like you to describe for me the location of your disconfort a simple, clear phrase communicates more effecttively

Vocabulary Communication is unsuccesful if receifer is unable to translate the senders words and phareses. In nursing and medicine there are many technical terms and jargon. If the nurse uses these terms, the clients may become confused and unable to follow instructions or learn important information. Rather than telling the client . the firs statment might make the client feel anxious. A message spoken in terms the client understand makes communication more effective

Denotative and connotative meaning A single word can have several meanings. A detonative meaning is one shared by individuals who use a commonlanguage. For example, the wordbase ball has the same meaning for all individuals who speak english, and the word code denotes cardiac arrestto nurse. The denotative meaning is used to define aword so that it means the same to everyone The connotative a meaning of a word reflects the shade or interpretation of a words meaning reather than the definition. For example, using the word the serious to describe a client condition may suggest to families thattheclient may be closed tto death unless the word critical or guarded are used. Nurse must carefully select words that cannot be easily misinterpreted. This is important throughout thr communicationprocess. For example , when charting how a client tolerated endotrecheal suctioning, the nurse should avoid using word such aas tollereted well. Instead, the nurse should describe clear objective assessment finding, such as respiratory rate, depth, regularity of respiration, and lung sounds Pacing Vebal communication is more succesfull when expessed at an appropriate speed or pace talking rapidly using awkward pauses, or speaking too slowly and deliberately can convey an unintended message.in the following example, the nurse uses awkward pauses during an explanation to a client: The speed with which amessage is verbalized, in addition to the presence, absence, and leght of pauses, candetermine the degreeto which communnication satisfies the listener. The nurse should not talk so quickly that words ar unclear. Pauses should be used to accentuate or stress a paraticural point, giving the lstener time to hear and comperenhend the meaning of words. Proper pacing is achivied by thinking about what to say before saying it. Looking for nonverbal cues from the listener that might suggest confusion or misunderstanding is also useful a person can also ask a listener if the pace is too factors or too slow or if the messageneedsreperating.

Timing and relevance Timing is critical to reception of the message. Ifthe boss is in a bad mood, the time is wrong to ask fora raise. If a client is in pain, the time is wrong to explain the risks of surgery. Even though amessage is cleary and concisely stated, poor timing can prevent it from being accurately received. Therefore the nurs must be sensitive to the appropriate time for discussion. Often the best time for interaction is when a client expresses an interest in communicating. By asking a simple question such

as, would you like to talk about your surgery? can nurse can avoid wasting time and energy if the client does not A person is more likely to communicate whwn a message is important. For example, when a client is facing open heart surgery the next day, a disccusion of the risk of cigarette smoking has less relevance than review of birth control pills is relevant t the young woman who has received her first prespectioon for the medication. Verbal communication is more likely to have anampact when message pertain to an individualss interests and needs Humor Humor can be a powerful tool in promoting well-being. The phrase, lauhgter is the best medicine applies when nurses use humor to help clients adjust to stess imposed by illness. Wootsen(1993) notes that laughter helps relive stress-related tention and pain, increases the nurses effectiveness in prividing amotional support to clients,and hurmanizes the experience of illness. Laughter serves as a psychological and physial release. Humor can enhance feelings of weel-being, reduce anxiety, and increasepain tolerance (beare and Myres,1994) Nurses can appropriately use humor with clients and coleagues by telling jokes, sharing humorous incidents or situation, and using puns. Wootsens(1993)discussion of the use of humor reveals that clients and peers relax mere readily and feel ore at ease when humor is employed in conversation. This also opens the interaction process, facilitating the ease of message sending and receiving. Also, the release of emotional tentionaltention with humor improves comfort levels of clients and peers Humor is not always appopriate, however. Nurses need to be cautious inusing humor to mask their own fears and discomforts or their inability to communicate with clients. Humor therefore should not become the only means of communication, but it can be an effective approach in helping clients to interact more openly and honestly Nonverbal commuication Action often speak louder that words. Nonverbal communication is transmission of message without the us of word. It is one of the most powerful ways people convey message to others . we continounsly communicate nonverbally in every face-to-face encounter. Gestures impart meaning that are more significant that word in a classic text.ekman (1965) describes the ways in which nonverbal communication and verbal communication are interrelated. Nonverbal cues add meaning to the verbal message(table 14.1) Nonverbal communication is more powerful than verbal communication. The nurse needs to e alert to nonverbal messages accompanying verbal message sent to clients. Match sxists betwen a nurses verbal and nonverbal message. The phrase googd morning, hoe are you? can convey a number of meanings to the clients in the nurses tone of voice and facial expression do not match the words spoken. A verbal message should be reinforced or complemented by appropriate nonverbal cues. For example, when a nurse initially greets a clients, maintaining eye contact and speaking in a calm voice can relay a sense of security to the client. During assessment, the nurse observes slients verbal and nonverbal message. Clients who say that they feel fine but grimace during movement are communniating two defferent message. Becoming a

goodobserver of nonverbal behavior requires timme and practice. the nurse who perceives nonverbal message isbeter able to understand clients, detect changes in condition, determine nursing care needs. Meta communication Metacommunication is a message within a message that convey a senders attitude toward the self and themessage and the attitudes, feelings and intention toward the listener. It can be an explicit statement (verbal) or an implicit demonstration of feelings( nonverbal).for example, the client states to the nurse i know things are getting better the nurse notes that the client is teary-eyed and has a facial grimace. In this situation, the nurse needs to further explore the true meaning of the clients statement as the message has more meaning than of the spoken words. Personal appearance The generalimpression formed of another personinfluences the response to that person. A persons appearance is one of the first think noticed during an interpersonal encounter. People form an impression abut another person witthin 20 seconds to 4 minutes. This impression is based mostly on appearance. Physicial characteristics, dress, grooming, and the presence of jewelry and adornment provide clues to the persons physicial well-being, personality, social status, occupation, religion, culture, and self-soncept. Paying attentionto ones apperance can contribute topositive self-image and professional image. Nurse can help clients maintain a sense of worth by allowing them to wear their own clothes if possible or if not contraindicated by treatment. Hospital gowns are drab and ill fitting. In restorative care setttings, as well as in the home setting, clients are strongly ancouraged to wear comportable, washable, casual slothes. Personal clothes and grooming (make-up, combinf hair) give a sense of physicial recovery and mental alertness. Physical charateristics, such as the condition of hair, color of skin, weight, energy level andpresence of a physical detormity, also communicate information about the level healyh. Also communicate information about the level to health. There are not established standards for physicial characteristics that demonstrate good health.each individual display individual displays combination of physicial appearance because they can be sicnificant signs of disease. The nurse may interpret from the finding early signs of depression and recommend further evaluation of the potential identified health alteration Physial appearance often leads to impression about personality and self-concept. Unfortunately, stereotyped views regarding the perfecf body also influence the image of a persons body. Nurses asses the importance of physicial appearance to a client threatened with loss of body parts or function. They also need to consider their own views and value about body immage The nurses physial appearance influences the clients perception of care received. Each client has a preconceived image of a nurse. The traditional white uniform can be a symbol of cleanliness of abilities, it may become more dificult to establish a sense or trust and reliability if the nurse does not meet the clients mage. A professional nurse today may wear uniform, scrubsuits and laboratory coats, as well as stret clothes, to perform duties. A neat, well tailored look cenveys the message of

acompetent profesional. Conversely, anurse who has bad breath of cigarette breath. messy hair, poorly manicured nails, dirty shoes or excessively strong perfume. Intination The tone of speaks voice can have a significant effect on a messages meaning. Depending on intonation, a message can express enthusiams, concert, hostility or indifference. the intonation of the message is affected by the persons emotions. It is important for nurses to be aware of how they are sending a message. A simple question such as how are you doing? canexpressgenuine interest to in difference depending on the tone of voice used in the message. Voice tone can be cue to a clients emotionalstate and energy level. Facial ekspresion The face has rich COMMUNICAtion potential. A mutual glance or meeting of eyes betwen two people can set the tone for an interpersonal encounter. The face and eyes send overt and subtle cues that assist in interpratation of message. Facial expression often become the basis for important interpersonal jugdment. Because if diversity in facial expression, their meaning may be difficult to judge. The face may reveral genuine emotion or contradict true emotion, or facial expression my be suppressed. Often people are unaware of the message and exspression convey. Providing clear feedback help lesson confusion created by conflicing message and expression. When facial expression fail to reveral clear message, the receiver should seek verbal feedback to be sure of the speakers intent For exsample, nurses are freqwently watched by clients. Consider the imopact of a nurses facial expression on a client who asks,; am i going to dia? th slightest change of expression can reveral the nurses true feelings. It is difficult to control all facial expression, but the nurse learns to be aware of what they can reveral. For example when caring for a debilated client, the nurse should avoid expression of disgust eye contact is an important facial expression. Wide eyes are assosiated whit frankness, teror and naivete. Raised upper eyelids reveal displeasure, and a stare is often associated with anger and coldness. When two people canfront each other, eye contac often prefaces a message. Initiating eye contact shows a willingness to communicated. Person who maintain eye contact during a conversation are preceived as believable. Maintaining eye contact allows a person to become a good observer.the nurse should avoid looking down at a cilint during a discussion. One way this can be avoided is for the nurse to sit down. The nurse appears less dominant and threatening sitting near the client at the same eye level. Posture and gait The way that people stand and move is a visible form of self-expression. Posture and gait reflect attitudes, emotions,self-concept and phycial wellnest. Leaning forward or to ward a person convey attention to that person. Leaning backward in a more relaxed attention manner shows less interest and caution An erect posture and quick, purposeful gait communicate a senseof well-being and assuredness. A slumped posture and a slow, shuffling gait may indicate depression or dis confort. A bent-over psture may be a protective response to ahysicial disiase and injury. Nurses can collect usefulinformation by observing cliients poture and gait. Specific illnesses cause identifiable gait such

as the shuffle of parkinsonism. , a neuromoscular disorder gait may be altered by many physicial factors such as pain, drugs or fractures Gestures Gestured are used to illustrate an idea that is difficult or inconvenient to describe in a words. They are visual enhancers that emphasize, punctuate, and clarify the spoken word. Pointing to an ares of pain may be more accurate that describing the pains location. Gestures may reveral specific meanings, or with other communication cues, they may send message. Touch Touch is personal form of nonverbal communication. Person engaged in communication must be close to each other when touch is used. Because touch is more spontan than verbal communnication, it generally seems more authentic, variouse messag, such as affection, omosianal support encouragement, tenderness and personal attention, are conveyed throught touch. Touch is an important part of the nurse-client relationship, but is must be used with descrimination because strong social norms govern its use. Who. When, why and where people touch are deterninated by unwritten. The nurse must always be aware of the appropriate use of touch in varied situation and settings. The nurse should especially exercise discretion with the use of touch in the paranoid individuals as the interpretation could be misconstrued by the client as a different meaning than intended by tne nurse. Nurse realy on touch when carrying out interventions. Nurses can touch clients while performing physicial assessment, giving baths, providing backrubs, and assisting with dressing. The nurse who is unaccustomed to tuching or being touched may feel uncomfortable when performing interventions. Simillary person who are ill must permit closer physicial contact than they normally tolerate. Illness places people in dependent roles that call for the nurse to inittiateand maintain closer interpersonal contactit is important to remain sensitive to clients dispointion toward touching. If client shy away from the nurses hand during pain, they are probably uncomfortable with beingtouched. Finally, touched can be a usefulling clients can often convey understanding better then words or other gestures. Although touch can be helpful to client, its use must be cleary understood and accept Factors influencing communication Preception, values, cultural background, knowledge, roles and the setting of interaction influence the content of a message and the manner in whitch it is shared. Interpresonal communicated is made more complex because each person is influenceddifferently by these intrapersonal variables. Intra personal variables make each interpersonal communication enique. Each person makes different Associaltions and interprets message diffeerently. An understanding of these factors helps a nurse know the reason that a client may have dificultty communicating and the strategies needed to help Development Most childeren are born with the physicial mechanisme and kapacity to develope speech and languange skills. Childeren with development disorders such as cerebral palsy,autism, and down;s syndrome may have varied capasity levels for the development varies and is directly related to

neurogical and intelectual development must also ofter stimulation for normal development. The nurse used special tehniques to communicate with children of different development stages. To communicated effeftively with children, the nurse must understand the influence of development on languange and thought processes. Both affect the way children communicate and the manner in which the nurse can succesfully interact with them Preception Each pereson sensen, interprets and understand events diferently. Preception is the personal view of events. A nurse might state, i ve noticed yot have been quite since your familly left. Would you like to talk about it? The clients preception of the nurses intent will affect the willingness to talk. Preseption are formed by expetaction and expences. Differences is preception betwen people who are interacting can be a barrier to commnucation. Emotion Emotion are a persons sebjective feelings about evnt. The way a person relates or communicates with others is influenced by emotion. A client who is angry may ract to nurses instructioon defferently than one who is frightened. Emotions influences can also cause a person to misinterpretor not hear a message. Nurse should not take it personally if calients ventilate their smotion on them. Nurses can assess clients emotions bw observing their interaction with fammily, physicians, or other nurse. When nurses care for clients they must be aware of their own emotion. It is dificult to hide emotion. Clients are precpective and can senses anger, frustration or sadness. It is usually inappropriate to discus personal omootion with clients. A social support system of colleagues allows nurses to express emotion. Utilization of employee assistance programs, peer group meeting, and the use of interdisciplinary teams such as social work and pastoral care allow the nurse to espress felling and emotions at an appropriate time and place. Sosiocultural background Culturel is the sum total to learned ways of doing, feeling, and thinking, it is a form of conditioning that shows it self throught behavior. Languange, gestures, values and attitudes reflect cultural origin. Cultural influences the manner in which the clint and nurse related to be congizat of cultural meanings in the communication process. The influence of culture sets limits for the way people act and communicate Culture also influences methods of communicating symptoms or feeling of disstress to other. Different exsisting self-disclosure or the willingnest to convey emoton and psychologicial information to others. In others groups, taling about oneself is consideret bragging, narative americans, for example, value silence and are comfortable whit it. For a number of ethnic or facial group, an inhibited silence occurs only in the presence of stranger or proffesional to the dominant culture, sometimes this is do to historical distrust based on discrimination. At other times it can be attributed to famli loyalities and agreement not to share problems aoutside of the family Languange different can also hemper commnunication and relationships. When a nurse cares for a client who speaks another languange, an interpreter may be necessary. Except on a social basis or

for care activities, a hospital interpretes is prefereable to a family member. Hospital interprates generally understand medical terminology hospital policies and can convey hospital policies and procedures. If a family members serves as an interpreter, it may be easier for the nurse to devisey ways to communicate with the client. The nurse can learn key words such as water, pain or bathroom to ensure that the clients basic needs are asessed and understood Gender Sex different affect the communication procces. Men and woman have different communication styles and each influences the communication syles and each influences the communication process eniquely. Discusses diferent communication styles of men and woman. From 3 age, girl play with a best friend or in small group and use language to seek confirmation, minimize differences and establish or reinforce inimacy. Boys on the others hand, usse activities in largr groups, even when they want to make frinds, they are to do it by play fully butting heads. In adulthood, women and men have completely different impressions of the same conversation. Claims that the frictions between the sexes arise because girls and boy grow up in essentially different cultural. This approach differs from the diference-dominance theories and focuses instead on a predominate female, pattern of seeking relationship and conection with others anr a predominate male pattern an accomplishing tasks and seeking indepedence and status. It makes it possible to explain dissatisfactions without blame and without discarding the relationship Certainly nurses need to be aware of these differences when working with clients or others health team members of the opposite sex. Active listening and seeking clarification will help prevent mispreceptions and misunderstandings Knowledge Communication can be difficult when person communicating have defferent levels of knowledge. A message will not be clear if the words or phrases are not part of the listeners vocabulary. Nurses communicate with clients and proffesionals who have different levels of knowledge. A common language when communicating across different knowledge levels. Nurses assess clients knowledge by noting their respons es to question, abilities to discuss health problems, and question tat they ask. After assessment, nurse use terms pharases that clients uunderstand to promote attention and interest Roles and relationship People communicatie in a style appropriate to their roles and relationship. Students talk differently with friends than they do with instructors, physicians, or clergy. Words, facial exprression, tone of voice and gestures depend on the person receiving the communication Nurse may feel comfortable communicating with colleangue, joking about daily events and sharing amusing stories. Anticipating apprehension, nurse convey respect by using the client last name and avoid humor until they can determine the client;s reaction to them, the client is probably looking for support rather than funny stories. Later, when the relationship between nurse and client on a first name bbasis may be appropriate, but only with the clients permission

People feel more comfortable when expressing ideas to individuals with whom they have develope positive, statisfying relationship. As a nurse-client relatig ideas and feeling. Communication is more effective when the participants remain aware of their roles in a relationship. The nurse must avoid using terms of endearment such as honey or sweetie when addressing and client terms such as these may be interpreted as innapropriate and of-fensive by the client. Environment People tend to communicate better in a comfortable environment. Awarm room, free of noise and distraction is best. Noise and lack of privacy or space my create confunsion, tention, or discomfort. Environmental distraction can distort the message send between teo people The nurse has some control when selecting the setting for communicating with clients. A quite office or lounge is ideal. When the client is visited at home, a bedroom or den may be best. In today health care environment, there is often less time to speend with clients, in the actute care setting a nurse must learn how to use time with clients wisely because of shortened lengeht of hospital stay The nurses efferts to convey information must not be blocked by enviromental distraction. Communication must be concise and relevant based on the client.s plane of care. This communication process continues as the client enters the posthospitalization phase of care. Clients frequently the transferred to various setting. Communication may various helath care setting. Communication continues in these varied setting such as skillednursing unit or home. Creative methods such as phone interaction or computer faxed reference are commonly employed in facilitating the communication process in todays changing health care environment Space and territoriality Territoriality defines the meaning of a persons right on a n area of space and surroundings. Tettitory is important because it provides people with a sensesof identity, secirity, and control. In the word, individuals feel threatened when others invade their territory because it dissrups pyschological homeostasis, creates anxiety and produces feelings of lost control. Personal space is an invisible bubble and is is mobile it goes with a person, teritory can be sparated and made visible to athers, such as a fenced-in yard, towel on the beach, or hospital bed, when personal space is threatened by instrusion, a defensive response accurs. Preventing effecting communication. Nurse often work with clients must be judged by the situasion and culture. Physicially restraining clients in danger of selfinjury, giving mouth-to-mouth resustitscion, holding crying infants, and facilitating the excretory function of incontinent clients require invasion of intimate space Inntimate distance or space includes an area of 18 inchies in which people are able to touch one another or make physicial contact. Clients are sensitive about how nurses use distance. As the distance becomes, the client and nurse feel more at ease. Greater flexibility is afforded when intimate contact is not required. Siitng with a client to conduct an interview. Making rounds with physiciant is an example of group interaction. Communication at a social distance is lest threatening than communication in a intimate or personal space because intimate sharing of thoughts and feelings is less likely to occur. Public distance. Is the distance maintained for formal speaking. A

community helath nurse presenting a semiinar on hypertention to lder adults,or the lecturing to a class are examples Therapeutic communication Therapeutic communiation is the process in which the nurse, utilizing a planned approach, learn about the client. This process focussed on the client but is planned and directind by the professional. Therapeutic communication develops and interpersonal relationship betwennthe client and nurse, this process involves significant skill since the nurse must pay attention to multiple interacting and nonverbal behaviors. Therapeutic communication conveys confidentiality. Since the klient know an information shared with the nurse remain parts of the medical record and is not shared as gossip, the client feel comfortable disclosing pertinenth health data, concerns, fears, or familu issues. In ideal situation the nurse is alret to the need to share information obtained from the client during disclosure. The nurse purposefully shares the information to benefit the client and maximize the plan of care, only health care team members directly involved with the clients plan of care are privilaged to the information. Confidentiality must be secured at all times in dealing with disclosure statement Therapeutic communication iltimately communication ultimately enablkes the nurse to establish a working relationship with the client and family. The nurse must be aware of cultural differances in which some client population may be rectulant to share information openly with proffesionals. The process of therapeutic communication involves skill and genuine comitment on the part of the nurse to assist the client in the attainment of mutual care goals Social interaction The first attemp at communicating with a client usually consists of a brief social interaction. The message conveyed are superficial in that neithers the nurse nor client discucsses deeply personal matters of consert. Interpersonal exchange tends to be based on intuitive, unthinking and automatic responses. Superficial interaction makes participant feel save because the disscussion has no hidden intent for personal desclosures A nurse often usus superficial social interaction at the beginning of a conversation with a client to lay a foundation for a closer relationship. The skilful nurse does not allow social interaction to dominate a conversation but does maintain a congenial and warm style to buikd the clients trust. The goal is to help the client feel comfortable in sharring attitudes and feelings.

Caring and methods of Efective communication. The nurse uses communication skills while establishing a therapeutic relationship. There is no formula for forming a relantionship with a client. Each person communicates uniquely, and each client requires different communication techniques. The nurse ahould be flexible in techniques used to foster communication with each client.

Listening attentively Listening is one of the most effective therapeutic communication techniques. It is a nonverbal method to convey interest in the clients need, concerns, and problem. It requires to nurses complete attention and involves an attempet to understand the entire verbal and nonverbnal mesage that the person is communicating. Listening is an active learned process, while hearing is a passive, neurological process of receiving information. Listening effectively may at first seem awkward and time consuming, but like any skill, it requires practice. An effective listener, however gains satisfaction from working with people and understanding theire deeper health concerns. To be an attentive listener, the nurse uses the following skills: 1. Face client while they speak, 2. Maintain natural eye contact to show willingness to listen, 3. Assume an attentive posture. Avoid crossing the legs and arms because this conveys a defensive posture, 4. Avoid distracting body movements, such as wringing hands, tapping feet, or fidgeting with an object in the hands, 5. Nod in acknowledgment when clients talk about important points or look for feedback. 6. Lean toward speakers to communicate involvement. The nurse must appear natural while listening to clients. Nonverbal cues, such as leaning toward the speaker, should not become overbearing or threaten intimate space. Listening skillfully durring a nursing procedure is benificial and is an efficient of time. For example, much can be learned and conveyed by the nurse who listens while giving clients baths. Clients, not the bath procedures, become the center of attention. Conveying acceptance. Showing acceptance means not judging another person and demonstrates the interviewers willingness to listen to the clients beliefs, values, and practices. This is difficult at times because nurse meets clients of diverse backgrounds. Acceptance is not the same as agreement. Accptance is a willingness to hear the person without conveying doubt or disagreement. Certainly a nure does not accept all aspects of a clients bahavior or illness. The nurse works to bring about change that improves a clients level or health. Acceptance, is tolerance toward others that foster a relationship between nurse and client. To show acceptance the nurse remains aware of personal nonverbal expressions. The nurse avoids facial expressions and gestures that suggest disapproval, such as frowning, rolling the eyes upward, or shaking the head in disbelief. The following show that the nurse accepts what a client has to say: 1. 2. 3. 4. Listening without interrupting, Providing verbal feedback that demonstrates understanding, Being sure that nonverbal cues match verbal communication, Avoiding arguing, expressing doubts, or attempting to change the clients mind.

Asking related questions Questioning is adiret method of communicating. The nurses aim isto gain specific information about the client. Quetions used during a conversation set the tone of the verbal interaction and control its derection. Question are mos effective when they relat to the topic or subject being disccused and use words and word patterns in the clients normal sociocultural context. During assessment ofthe clients health status, question follow a logicalsequebce. The following example demonstrates this technique: Nurses: Mr. James, can you tell me where you are having pain? Client: well, it seems to be in my back. Nurses: What part of your back? Client: Here, in the lower part. Nurses: How would you describe the pain? Client: It feels like a knife went through me. The nurses line of questioning helps the client tell a story. Each question focuses on a specific aspect of the story. The nurse is careful not to ask more than one question at a time or move on to another subject until the current topic is adequately explored. The nurse selects a question onthe basis of the clients previous response so that information flows logically. If the nurse wants the client to elaborate, opend-ended questions are most effective. They give a client a chance to talk more completely about problems or concerns. Such questions cannot be answered with yes or no. Examples of open-ended questions are: 1. Would you describe the pain you have been feeling? 2. What seems to be problems? 3. Explain to me how your familiy feels about your illness? Asking the client open-ended questions alllows the nurse to assess a number of factors. The clients verbal responses can reveal emotions. The nurse may be able to judge the level of clients vocabulary and understanding og health by the response. Often the nurse seeks details of physical signs and symptoms, and the open-ended question elicits more accurate and detailed descriptions. Because an open-ended question prompts a lengthy response, the nurse can assess gaps or discreapancies. Paraphrasing Paraphrasing is restating clients messages in the nurses own words. Ussualy a paraphrased statement uses fewer word then the original statement. Through paraphrasing, the nurse sends feedback that lets clients know whether their messages were understood and propmts further communication. The following example ilustrates this point: Client: Ive had it. My doctor wont tell me whats going on. He doesnt seem to care what i think.

Nurse: youre frustrated because you and your doctor havent talked about your diagnosis? Client: yes, he obviously doesnt know what its like to be sick. Practise is required to paraphrase accurately. If the maning of a messages is changed or distorted through paraphrasing, communication may become ineffective. For example, a client may say Ive been overwight all my life and never had any problems. I cant understand why I need to be on diet. Paraphrasing this statement by saying, You mean you dont care if youre overwight or not? is incorrect. it seems that youre not convinced you need a diet because youve remained healthy, is a more accurate way of paraphsing the statement. clarifying despite efforts at paraphrasing, the nire may not understand the clients message. When a misunderstanding occurs, the nurse momentarily stop the discussion to clarify meaning . clarification may be defined as the act of restating what has been stated or send to the receiver of the message. Without clarification, valuable information can be lost. Information critical to the client canre plan can be incomplete unless confusing or conflicting data area clarified. Thenurse can attemp to repart the message or adminfusion and ask the client to restate the message. In the following example, a client has come to the clinic for a chekup : client : i knew have a problrm. It seems to be in my family. The las time i was here, thought is wasnt bad so i didnt mention it nurse : excuse me, Mr brewer, can yot tell me what type of problem youre having? the nurse must also clarify message. Example can be used to clarify a vague, abstract idea. When using examples, the nurse describes ideas or situation to which the client can easly relate. In following dialog, a nurse is explaining activity restriction to a client who has had aye surgery: nurse : now, Mr. Lee, once you go home tou are not supposed to place stress on you eye client : Im not sure i know what you mean nurse : Well. You;re not alloed to stop or bend over with your head down. For examples, if you want to pick up your slippers off the floor or pick up a basket of laundry, dont bend over, instead, bend your kness and keep your head up client : i have a dog at home. I guess i cant bend over to pick him up? Nurse : thats right. Bend you knees to lower yourself down if you want to pick up your dog The more specific a clarifiying message, the more lekely it will be understood. Clients who are easly confused by the complex terms and jargon of medicine appreciate a simple, down-to-earth explanation that uses familiar examples Focusing Focusing may be defined as centering information on the key elements or concepts of the message that has been sent. Focusing eliminates vagueness in communication by limiting the area of

discussion. As clients discuss topics related to health, theiir messages often become vague. For example, a client may say to the nurse, well, i;ve just been feeling funny lately. It doesnt rally bother me that much it;s just this feeling im having in my head. this description tells little except that the client does not feel well. If the nurse does not help focus speceficically on the phycsicial complaint, the client will likely continue to use vague description To focus the discussion, the nurse might respond the client by sating, as in clarifying, the nurse seeks meaning in the clients message . in the case of focussing, however, the nurse understands the clients message but realizes that it is nonspecific or vague The nurse does not use focusing if it interrupts clients while discussing an important issue. If conversation continue without new information or clients begin to repeat themselves, focusing is useful Stating observation When communicating, people are often unawere of the way yhat yheir message are received. Feedback frim others tells them wheather they communicated the indent message. One way the nurse can provide feedbaack is by sharing with clients observation of their behavior during communication. The nurse describes the impressions created byy the nonverbal cues. The following example illustrates this point:

Sumarrizing
Sumarrization is a concise review of main ideas that have between the nurse and client. Beginning a new interaction by summarizing a previous one help the client recall topisc discussed and show the client that the nusre has analyzed their communication. In the following example, the nurse, ms. Spier, has been working for several days to help the client mrs. Ramos, learn about diabetes. Case study Ms spier enters the client room and says, good morning mrs.ramos. i will come to talk with you more about your diabetes. If you recall, yesterday we discussed the purpose of insulin, its side effect, and how to give an injection. Summaring help the nurse review key aspect of an interaction. Further communication can then focus on relevant issues. Client will be able to sense whatever the nurse understood their part of massage. With a summary and make additions or correction.

Giving an opinion
Giving an opinion take decision making away from the client. It inhibits spontaniety, stall problem solving, and creates doubt. The following example demonstrates how giving an opinion can be harmfull Nurse: mr.jones, you look likr you arre deep bin thought. client: oh, no, not really. I was just thingking about whatever my daughter is coming to see me. nurse: well, if you ask me, she should have been here before now. It wound so musch to you Often the client simply needs an opportunity to express feeling. Giving an opinion prevent the client from developion solutions to problem.

At time, client may require suggestion. For example, when a client selecting a special diet, the nurse help may be needed to choose the right food. Suggestion are present ed to client as option because the final decision rest with their the client

Offering false reassurance

When a client is sariously ill,bthe nurse is tempted to ofer hope to the client with statsment such as you will be fine or there nothing to worry about when a client is reaching out of for understanding. False Client: i am so affraid of becoming dependent on my wife. I feel i am never going to get any better. nurse: there noi reason to be so affraid. Thing will get better Genuine, thurtful reassurance, however, is important and help validate a client self-worth and sense of hope. Bradley and edinberg(1990) have identified six basic condition in which verbal ressurance can be given in a client can be ressuranced: 1. 2. 3. 4. 5. 6. That there is hope That the nurse is listening That care avaliable That certain undesirable change can be expected That the client will be treated like a person That the client problem is understood

The following dialog show how the nurse convey a williness to understand a client concent without falsely reassuring her that the illness or symptoms are minor

Being defensive
Defensiveness is response to criticism suggest that the client has no right to an opinion. When a nurse become defensive the client concern are often ignored. The following example illustrates the point: The nurse has threatned the relationship with mr.locker. he will probably not thrust the nurse to keep his concern confidental. The nurse is ignoring the client feeling and will probably not take any action to remedy the problem. After this coversation, the nurse will have difficulty continuing a raport that will prompt the client to discuss additional problem. When client express criticism, the nurse should listen to what they have to say. Listening does not imply aggrement. To learn the reason behind the client criticism, the nurse avoids becoming defensive. There are two sides to any story, and the nurse attemp to learn why client have demonstration this technique:

client: well, i hope i dont have to see dr.warren today nurse: you seem upset. Would you like to talk about it? client: i just dont think he should have to put me in the hospital nurse: you believe hospitaization was unnecessary? client: yes, they really didnt do much af anything they took a few test and did some x-rays nurse: mr.locker, did you doctor tell you what the test showed? client: no, not really. Taht why i am so anggry

showing aprroval or disaprroval

exprresing excessive approval can be as harmful to a nurse-client relationship as starting disaprroval. Oofering excessive praise implies that behavior being praised is the only acceptable one. Often the client shares a decision with the nurse not in a effort to seek approval but to provide a mean to discuss feelings. The following example illustrates this point: client: aku memutuskan bahwa when i leave the hospital i will stay with my son. He does not want me to go home and be alone. nurse: oh. I am so glad to hear that. I think you definitely made the right decision. It is best for you to be with your son this nurse comment will likely and further discussion of the topics. The client may percieve that the nurse agrees with son. Perhaps teh client would be better off with the son. On the other hand. The client may have a strong desire to remain independent, and now that has been discouraged. The nurse excessive approval did not allow the client to think or act freely and inhibited the potential for decision making a better response by the nurse response may hinbder the client positive attitude and recovery: client: oh, i feel good, I was able to get up in the chair once today nurse: oh, i am so glad to hear that. I think you definitely made the right decision. It is best for you to be with your son it would have been better for the nurse to say you are making fine progress. Your doctor would like you to try to be up at least three time today. Do you think you would like to sit up just before going bed?. A disapproving statsment cause the client to feel rejected. The client may avoid further in interaction with the nurse, thus potentially slowing recovery.

Sterotyping
Everyone is unique. However, stereotypedresponses inhibit uniqueness and oversimplity the situation. Stereotypes are generalized beliets held about people. The use of stereotypes inhibits communication and can threaten a nurse-client relationship. Stereotyping statements, such as Older adults are always confused or Clients with back problems cannot tolerate pain seriously impair interpersonal communication. Another nontherapeutic communication is the use of meaningless, stereotype responses. Their use minimizes the importance of a persons message. The following example illustrates this point: Client: I slept poorly last night. My incision seemed to be pulling. Nuse: You cant win them all. At least the incision is healing well.

ASKING WHY
When people disagree withn of fail to understand theothers, they are temted to ask way the others belive or have acted in such a way. Clients frequently interpret why questions can cause resentment, insecurity, and mistrust. If the nurse wants additional information, thereare more effective ways of phrasing questions. For example, rather than asking, Why didnt you do your exercises ? the nurse could say, You didnt do your exercises. Is somethingwrong ? Rather than asking, Why are you anxious? the nrse could say, You appear upset. Would you like to talk?

CHANGING THE SUBJECT INAPPROPRIATELY

A nurse might inadvertently stop a client from discussing a subject of importance by changing the subject. Abruptly interrupting conversation is rude and shows a lack of empathy, as the following example shows: Nurse: Good morning, Mr. Jones. How are you feeling ? Mr. Jones: ( facial expression shows doscofort ) Oh, not so good. My incision is rather sore. Nurse: well, lets get you up in a chair. We need to discuss you exercises. The nurses comment shows an unwillingness to discuss Mr. Jones discomfort. The chance for a therapeutic assessment of his discomfort is lost. In this example, changing the subject was not therapeutic because the nurse ignored a potentially serious problem. Changing the subject stalls progress of a therapeutic communication. The clients thoughts and sponttaneity are interrupted, ideas become tangled, and as a result, the information provided may be inadequate. It is particularly important to avoid changing the subject during assessment. If the client has the opportunity to complete a mesage, the information shared will be more thorough and useful.