1

Communication

N001Spring 2013

2

Student Learning Outcomes

In addition to course SLO # 3 Please review lecture specific SLO's on Course objectives, lecture & lab outlines

NCLEX ® Question

3

4

Overview Introduction Stress & Coping Verbal communication

Nurse client relationship Interviewing

Communication with other members of the health care team

Chain of command Define collaboration

Introduction Part I

“Communication is an essential part of patient centered care. Patient safety also requires effective communication.

(Potter 8th ed. P. 309)

5

Introduction Nurses need to know about stress so

that they can recognize it in the clients, families, & themselves

Stress ….”Physical, emotional, or psychological demand that often leads to growth or overwhelms a person and leads to illness (Varcorlis & Halter 2010) Potter & Perry p. 731

6

Caring & Empathy Caring is a universal phenomenon

influencing the ways is which people think, feel, and behave in relation to one another (Potter)

Empathy is the ability to understand and accept another person's reality …. (Potter)

7

Physiology of Stress

8

Fight or flight response due to the arousal of SNS Increased heart

rate, shift of blood from extremities to core

Engaging the Medulla oblongata, reticular formation, & pituitary gland

General Adaptation Syndrome Alarm reaction

Hormones activated Pupils dilate

Resistance stage Stabilization and repair

Exhaustion stage Body can no longer resist effects Death may result

9

Coping Individual’s effort to manage

physiological stress Coping strategies

Effectiveness impacted by age, experience & cultural background

Strategies differ according to the stressor

10

Coping Individual’s effort to manage

physiological stressCoping strategies

Effectiveness impacted by age, experience & cultural background

Strategies differ according to the stressor

11

Coping Strategies Effectiveness impacted by age,

experience & cultural background Strategies differ according to the

stressor Most individuals use a combination of

problem focused and emotion focused coping strategies

12

Coping Strategies An individual may seek info and takes

action as way to deal with it (problem focused)

While others or at another time might avoid thinking about the situation (emotion focused coping)

13

Ego Defense Mechanisms Help regulate emotional distress

DenialRegression

See (Potter & Perry) for a more complete list

14

Impact on Nursing Nursing is responsible for developing

interventions to prevent or reduce stress

Client must initiate the change Accurate assessment critical Effective communication vital

15

Critical ThinkingIncludes:

Curiosity Motivated to learn more

Creativity & Perseverance Attitudes that assist the nurse

to communicate and identify innovative solutions

16

Critical ThinkingA self confident attitude

Attitude of fairnessListens to both sides of the

issue

17

Critical ThinkingHumility

Willingness to ask for helpAppropriate approach for each

situation

18

19

II. Elements of Communication

The referent – motivation

The sender – encodes & sends message Includes feelings Ensures accuracy

The receiver – decodes & receives message Sender’s message acts as referent Must translate & respond to message

Elements The message – verbal, nonverbal, &

symbolic language “Meaning comes from individuals and their

unique perspective” (Schuster & Nykolyn 2010)

“ Exciting” – means … The channels–means of conveying &

receiving messages Auditory, tactile, & visual Written or non written

Feedback – message thru receiver receives and returns

20

Elements of Communication Interpersonal variables- factors

within both the sender & receiver Impacts perception

Environment- where the communication process takes place Example need for privacy

21

Verbal Communication: Overview Vocabulary Denotative meaning

Common meaning Connotative meaning

Interpretation of the word based on thoughts or feelings people have about the word

Pacing Intonation

22

Verbal Communication ClarityBrevityTiming Relevance

23

Nonverbal Personal appearance / Presentation of

self Posture & Gait Facial expression Eye contact

Cultural ramifications Gestures Sounds

24

25

Presentation of Self Breath and depth of

knowledgeFlexibility Enthusiasm Sincerity Self perception

26

. Presentation of Self First impressionsCommunication enhanced by your

credibilityGood personal hygieneGood groomingAppropriate uniform

27

Types of Personal Space Intimate – 0 to 18 inches

May produce discomfort, anxiety or fight or flight response

Explain to client what & why Respect client’s space Do not whisper but speak quietly & clearly Avoid eye contact during intimate care

28

Personal Space Personal zone - 1.5 to 4 feet

May produce discomfort, anxiety or fight or flight response

Usually maintained with friends Able to read nonverbal communication Conversation One to one teaching

29

Personal Space Social zone– extends 4 to 12 feet

Communication – formal Conducting a group Sensory involvement less intense Increased eye contact

Personal Space Public zone

12 feet and beyondLecturing in a classroom

30

Zones of Touch Nurses use touch

Caring touch, Task touch, Protective touch (Schuster & Nykolyn )

Social –permission not needed ex. hands Consent – permission is needed

Mouth, wrists, feet Vulnerable – special care

Face neck / front of the body Intimate – sensitivity important

Genitalia & rectum (Potter box 24 –3)

31

Forms of Communication Symbolic

Art & Music Metacommunication

All factors that influence communication Written communication

32

IiI. Nurse Patient Helping Relationships

33

http://www.mynursesregistry.net/Portals/0/my_nurses_201.jpg

Nurse Patient Relationship

Nurse Client RelationshipStudent/RN – professional

relationshipTherapeutic climate that

facilitates positive change Goal

- clients to achieve optimal personal growth (Potter & Perry 8th ed. )

34

Nurse Patient Relationship

IncludesSpecific time frameGoal directed approachConfidentiality NonjudgmentalFocus on client's needs

35

Phases of the helping relationship Pre interaction

Before meeting the client Review data Anticipate concerns Plan time frame and location

Orientation Client and nurse begin to know one another Nurse presents positive attitude Client may test RN Prioritize client’s needs identify problems Clarify roles Discuss termination (Potter)

36

Phases of the helping relationship Working

RN & client work together to solve the issues Assist the client with self exploration Take action Use therapeutic communication to achieve

goals Termination

Ending of relationship Remind client end of relationship is near Evaluate goal achievement

(Potter)

37

Professional Relationships Nurse family relationships

Process is similar to assisting individuals Take into account family & group dynamics Family roles & responsibly

Nurse Community relationships Participation in local activities Leadership

38

Health Care Team Relationships Collegial relationships Focused on the client safety and the

role that the health professional s have in taking care of that client

Communication Respectful Clear Concise

Collaboration

39

Strategies for Health Care Team Communication & Collaboration Respectful Active listening Try to understand the other individual’s

view point Identify bottom line – client safety Be direct Use “I” statements Learn to say I was wrong Adaptability Flexibility & Adaptability

40

Clinical Assignment Interviewing members of the health care

team

41

Institutional Relationships Chain of command

Process for communication client status Process of communicating concerns Important to identify the sequence Example - EVC Nursing students

Collaboration “Different perspectives are synthesized

for better understanding of complex problems

42

SBAR

43

IV. Application of the Nursing Process

44

Assessment* Note the context(helps determine

meaning) of the situation that influences the communication (Potter) Psycho physiological context

Internal factors State of health & age, attitudes, perceptions

etc. Rational Context

Relationship between participants Trust & Caring

45

Assessment Client interview Situational context

Reason for the communication Environmental context

Privacy Noise level

Cultural Context Socio cultural elements that impact the

communication Culture influences feelings, perceptions & behaviors Language Spoken (use of interpreter) Gender, education level, economic status

46

Nursing Diagnosis 1.2.3.4.

47

Nursing Process (Goals & Planning) Planning your interventions – to meet

the needs of your specific clients Motivation Priority setting Setting goal for interview or intervention Insuring continuity of care

Communication with others caring for these clients

Will need to apply refine these concepts when education clients

48

Implementation Therapeutic communication techniques Active listening

Attentive to client Sit facing client Observe open posture Lean toward client Establish and maintain intermittent eye

contact Relax (calmness)

49

Implementation Sharing observations

Comment on how other person looks, sounds or acts

Sharing observations “I see you have not eaten today.”

Sharing empathy “Ability to understand and accept another

person’s reality” Reflect the importance of what the other person

has said on a feeling level “It must be very frustrating to know what you

want and not be able to do it.” (Potter)

50

Implementation Sharing hope

“ “

Sharing humor ‘ ‘ ‘

51

Implementation Sharing feelings

Making observations Acknowledging feelings Give permission to express negative feelings Sharing feelings of caring are appropriate The focus should be on the client not on the

nurse Using touch

Most personal Appropriate – example touching some one’s

hand is ok Gentle yet firm

52

Implementation Use of silence

‘ ‘ ‘

Providing information Relevant Sensitively

Clarifying Check if the interviewer's understanding is accurate Ask the client to restate “I am not sure I understand what you mean when you

use the phrase …”

53

Implementation Focusing

Centering on key elements Use to guide the discussion – so not interrupt

the client Paraphrasing

Briefly restating the other’s message Requires practice

States “I have been overweight my whole life.”

RN responds “You are not convinced you need a diet”

54

Implementation Asking relevant questions

Seeking information necessary for decision making

Summarizing Concise review of key aspects of the

interaction Self disclosure by the nurse

‘ ‘ ‘

55

ImplementationConfrontation

Assist the individual to become aware of inconsistencies

Improves client self awareness Only use after trust has been established

56

Implementation * Open ended and closed ended questions Open- ended questions

Ask for longer interpretative response Phrased as a request “Describe your symptoms

Closed questions Call for specific, short, responses Do you have pain

57

Clinical Skills Lab Assignment

Posted on Moodle

58

Implementation: Focus older adults Obtain the client’s attention before

beginning Assist client with glasses and hearing aides

if necessary Make sure your face is visible to the client Well lit environment No glare Lower register of voice Provide time for questions Approach client as adult

59

Implementation: Cultural competence Keep instructions simple & to the point Incorporate member of community or family Negotiate if necessary Interpreter:

Professional Working with

Written materials – can client read in their own language

Videos

60

Implementation Be sure and review the chart in Potter &

Perry Page 357 – that focuses on clients with

special needs.

61

Implementation Documentation

62

Evaluation Communication analysis Are client able to state in their own

words – what was discussed. In lab exercise

Were the goals of the therapeutic communication met?

Were there any missed verbal and nonverbal cues?

63

Nontheraepeutic Communication Techniques

64

Asking personal questions

Giving personal opinions

Changing the subject

Autonomic responses

False reassurance Sympathy

Asking for explanations

Approval or disapproval

Defensive responses Passive or aggressive

responses Arguing Use of idioms

V. Student responsibilities Communication with team leaders

Check in – Report Check out – Report to RN

Update client status – ex vital signs, care etc (SBAR)

Situation Background Assessment

Recommendation

65

66

Clinical applications Address client formally –

“Introduce yourself “Tell them what you are going to do and

obtain their consent. (within reason) Remember – do not whisper and avoid eye

contact during intimate care

Demonstrating Caring by Expressing Empathy

Adapted from Marilyn Tagatac’s Presentation Physiology of

Compassion 8/5/2009

Slides 48-50

67

Empathy

Use of Therapeutic communication Giving broad openings Encouraging description of perceptions Verbalize the implied Inquiring about client’s decisions

Empathetic response can be learned Sincere Inquire about client’s feelings Validate your observations with the client Try to be in tune with client’s style

68

Empathy Steps

Enquire/explore client’s feelings in order to accurately identify them

You feel __________________-? Because _________________ the reason the

client identifies the feeling

69

Class exercise #1

70

In class exercise Part II

71

72

Remember “I feel” statementsReflectionCiting specific behaviors Asking for feed backOpen ended questions

Final WordsCommunication Should Be

Complete Clear Concise Cohesive Courteous

73

74

Summary All parties must participate in the

communication process. The verbal and nonverbal message must be

congruent How you present your self can impact the

dialogue Important to treat everyone in a respectful

manner

75

References Doenges, M.E, , Moorhouse, M.F. & Murr, A.,

(2010) Nursing diagnosis manual (3 rd ed.) Philadelphia, PA: F.A. Davis.

Potter, P.A., Perry, A. G. (2013) Fundamentals of nursing (8th ed.) St. Louis, MO: Mosby.Schuster, P. M. & Nyklolyn, L. (2010) Communication for Nurses. Philadelphia, PA: F.A. Davis. Tagatac, M. , Presentation Physiology of Compassion 8/5/2009

References http://www.azhha.org/patient_safety/sbar.as

px

http://www.stanly.edu/educational/public_services/ps_images/36.jpg (this link does not open)

http://vtlmi.labor.state.vt.us/occvid/images/29-1111.00-1.jpg (this link does not open)

http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/SBARTechniqueforCommunicationASituationalBriefingModel.htm

76

References Google Images Microsoft Word images

77