THE COMMUNICATION PROCESS Communication is the exchange of thoughts, feeling, and

other information ►Is the interchange of information between two or more people;
in other words the exchange of ideas or thoughts. ►Thoughts are conveyed to others
not only by spoken or written words but also by gestures or body actions. ►It can
be transmission of feelings or a more personal and social interaction between p
eople. ►It is a basic component of human relationships. ►the intent of any communica
tion is to elicit a response. It includes all the techniques by which an individ
ual affects another. *Two main purpose: a. to influence others b. to obtain info
rmation The communication Process Face-to-face communication involves a sender a
message a receiver and a response or feedback. In its simplest form, communicat
ion is a two away process involving the sending and the receiving of a message.
Sender The sender a person or groups who wish to convey a message to another can
be considered the source-encoder. This term suggest that the person or group se
nding a message must have an idea or reason communicating (source) and must put
the idea or feeling into a form that can be transmitted. Encoding involves the s
election or specific signs or symbol (codes) to transmit the message such as whi
ch language and words to use how to arrange the words to use how to arrange the
words and what tone of voice and gestures to use. Message The second component o
f the communication process is the message itself-what is actually said or writt
en the body language that accompanies the words and how the message is transmitt
ed. The
medium used to convey the message is the channel and it can target any of the re
ceiver’s senses. It is important for the to be appropriate for the message and it
should help make the intent of the message more clear. Receiver The receivers th
e third component of the communication process is the listener who must listen o
bserve and attend. This person is the decoder who must perceive what the intende
d (interpretation). Perception uses all of the senses receive verbal and nonverb
al messages. Response The fourth component of the communication process the resp
onse is the message that the receiver returns to the sender is also called feedb
ack. Feedback can be either verbal or non verbal or both. Nonverbal examples are
a nod of the head or a yawn. Either way feedback allows the sender to correct o
r record message. Modes of Communication Verbal Communication Verbal Communicati
on is largely conscious because people choose the words they use. The words used
vary among individuals according to culture socioeconomic background, age, and
education. As a result countless possibilities exist for the way ideas are excha
nge. An abundance of word can be used to form messages. In addition, a wide vari
ety of feelings can be conveyed when people talk. When choosing words to say or
write, nurses need to consider.
A. PAGE AND INTONATION. The manner of speech as in the
pace rhythm and intonation will modify the feeling and the impact of a message.
The intonation can express enthusiasm, sadness, anger, or amusement. The pace of
speech may indicate interest, anxiety, boredom, or fear. For example speaking s
lowly and softly to an excitement may help calm the client. B. SIMLPICITY. Simpl
icity includes the use of commonly under stead words brevity and completeness. M
any complex technical
C.
D.
E.
F.
G.
terms become natural to nurses. However laypersons misunderstand these terms. CL
ARITY AND BREAVITY. A message that is direct and single will be more effective.
Clarity is saying precisely what is meant and brevity is using the fewest words
necessary. The result is a message that is simple and clear. An aspect of this i
s congruence or consistency where the nurse’s behavior or nonverbal communication
matches the words spoken. TIMING AND RELEVANCE. Nurses need to be aware of both
relevance and timing when communicating with clients. No matter how clearly or s
imply words are stated or written the timing needs to be appropriate to ensure t
hat words are heard Moreover the messages need to relate to the person or to the
person’s interests and concerns. This involves sensitivity to the client’s needs an
d concerns. ADAPTABILITY. Spoken messages need to be altered in accordance with
behavioral cues fro the client. This adjustment is referred to as adaptability.
What the nurse says and how it is said must be individualized and careful consid
ered. This requires astute assessment and sensitivity to the client’s needs and co
ncerns. CREDIBILITY. Credibility means worthiness of belief trustworthiness and
reliability. Credibility may be the most important criterion of effective commun
ication. Nurses foster credibility by being consistent, dependable, and honest.
The nurse needs to be knowledgeable about what is being discussed and to have ac
curate information. Nurses should convey confidence and certainty in what they a
re saying while being able to acknowledge their limitation (e.g.,” I don’t know the
answer to that but I will find someone who does”) HUMOR. The use of humor can be p
ositive and powerful tool in the nurse client relationship but is must be used w
ith care. Humor can be used to help clients adjust to difficult and painful situ
ation. The physical act of laughter can be both emotional and physical release r
educing tension by providing a different perspective and promoting a sense of we
ll being.
Nonverbal Communication Nonverbal communication is sometimes called body languag
e. It includes gestures body movements use of touch and physical
appearance including adornment. Nonverbal communication often tells other more a
bout what a person is felling than what is actually said because nonverbal behav
ior is controlled less consciously than verbal behavior. Nonverbal communication
either reinforces or contradicts what is said verbally. PERSONAL APPEARANCE. Cl
othing and adornments can be sources of information about a person. Although cho
ice of apparel is highly personal it may convey social and financial status, cul
ture, religion, group association, and self concept. Charms and amulets maybe wo
rn for decorative or for health protection purpose. When the symbolic meaning of
an object is unfamiliar the nurse can be inquire about its significance which m
ay foster rapport with the client. POSTURE AND GAIT. The ways people walk and ca
rry themselves are often reliable indicators of self concept current mood and he
alth. Erect posture and an active purposeful stride suggest a feeling of well be
ing. Slouched posture and slow shuffling gait suggest depression or physical dis
comfort. Tense posture and a rapid determined gait suggest anxiety or anger. FAC
IAL EXPRESSION. No part of the body is as expressive as his face suggests happin
ess and sadness can be conveyed by facial expression. Nurses need to be aware of
their own expression and what they are communicating to others. Clients are qui
ck to notice the nurse’s facial expression particularly when the clients feel unsu
re or uncomfortable. Eye contact is another essential element of facial communic
ation. In many cultures, manual eye contact acknowledges recognition of the othe
r person and the willingness to maintain communication. GESTURES. Hand body gest
ures may emphasize and clarify spoken word or they may occur without words to in
dicate a particular felling or to give a sign. A wave good-bye and the motioning
of a visitor toward a chair are gestures that have relatively universal meaning
.
Communication in different level of deployment. Infants *Infants communicate thr
ough their senses. Teach parents about the importance of touch. *They respond be
st to high-pitched soft or gentle tone of voice and eye contact. Toddlers and Pr
eschoolers *Allow time for them to complete verbalizing their thoughts without i
nterruption. *Provide a simple response to question because they have short atte
ntion spans. *Drawing a picture can provide another way for the child communicat
es. School-Age Children *Talk to the children at his or her eye level to help de
crease in *Include the children in the conservation when communicating with the
parents. Adolescent *Take time to build rapport with the adolescent * Use active
listening skills. *Project z nonjudgmental attitude and non reactive behavior e
ven when the adolescent says disturbing remarks. Factors influencing the Communi
cation Process A. Development Language psychosocial and intellectual development
moves through the stages across the life span. Knowledge of a client’s developmen
t stage will allow the nurse to modify the message accordingly. The use of dolls
and games with simple language may help explain a procedure to an 8-years-old.
With adolescent who have developed more abstract thinking skill a more detailed
explanation can be given wherereas a well educated middle-age business executive
may wish to have detailed technical information provided. Older clients are apt
to have a wider range of experiences with the health care system
which may influence their response and understanding. With aging also come chang
es in vision and hearing acuity that can affect nurse-client interactions. B. Ge
nder From an early age females and males communicated differently. Girls tend to
use language to seek conformation, minimize differences and establish intimacy.
Boys use language to establish independence and negotiate status within a group
. These differences can continue into adulthood so that the same communication m
ay be interpreted different a man and a woman C. Values and Perceptions Values a
re standards that influence behavior and perceptions are the personal view of an
event. Because each person has unique personality traits, values, and life expr
ession each will perceive and interpret messages and experiences differently. Fo
r example if the nurse draws the curtain around a crying woman and leaves her al
one the woman may interpret this as “The nurse thinks that will upset others and t
hat I should cry” or” The nurse respects my need to be alone”. It is important for the
nurse to be aware of client’s values and to respect or to correct perception to a
void creating bartries in nurse client relationship. D. Personal Space Personal
space is the distance people prefer in interact with others. Proxemics is the st
udy of distance between person in their interaction. Middle class North American
s use definite distances in various interpersonal relationships along with speci
fic voice tones and body language. Communication alters in accordance with four
distances each with a close to a far phase. Tamparo and Lindh (2000,p.91) list t
he following examples: 1. Intimate:Touching to 1 1/2 feet 2. Personal: 11/2 to 4
ft 3. Social: 4 to 12 ft 4. Public: 12-15 ft
Intimates distance communications characterized by body contact heightened sensa
tions of body heat and smell and vocalization that are low. Vision is intense re
stricted to a specific body part and may be distorted. Personal distance is less
overwhelming than intimate distance. Voice tones are moderate and body heat and
smell are notice less. Physical contact such as handshake or touching a shoulde
r is possible. Social distance is characterized a clear visual perception of the
whole person. Body heat and other odor are imperceptible eye contact is increas
ed and vocalizations are loud enough to be hear by others. Communication is ther
efore more formal and is limited to seeing and hearing. Public distance requires
loud clear vocalization with carefree reification although the faces and forms
of people are at public distance individuality is lost instead the person is of
the group of people or the community. E. Territoriality Territoriality is a conc
ept of the space and things that an individual considers are belonging to the se
lf. Territoriality marked off by people may be visible to others. For example cl
ients in a hospital often considered their territory as bounced by the curtains
around the bed unit or by the walls of the private room. This human tendency to
claim territory must be recognized by all health care workers. Clients often fee
l the need to defend their territory when it is invaded by others for ex. When a
visitors or nurse removes a chair to use at the other bed the visitor has inadv
ertently violated the territoriality of the client whose chair was removed. Nurs
es need to obtain permission from clients to remove rearrange or borrow object i
n their hospital area. F. Roles and Relationship The roles and the relationship
between sender and receiver affect communication process. Roles such as nursing
student and instructor client and physician or parent and child
affect the content and responses in the communication process. Choice of words s
entence structure and tone of voice vary considerably from the role to the role
In addition the specific relationship between the communicators is significant.
The nurse who meets with a client for the first time communicates differently fr
om the nurse, who has previously developed a relationship with that client, G En
vironment People usually communicate most effectively in a comfortable environme
nt. Temperature extremes excessive noise and a poorly ventilated environment can
all interfere with communication Also lack of privacy may interfere with a clie
nts communication about matter that clients considers private. For Ex. A client
who is worried about the ability of his wife to care for him after discharge fro
m hospital may not wish discuss concern with a nurse hearing of others clients i
n the room. Environmental distraction can impair and distort communication. H. C
ongruence In Congruence communication the verbal and non verbal aspects of the m
essage match. Clients more readily trust the nurse when they perceive the nurse’s
communication as congruent. This will also help to prevent miscommunication. Con
gruence between verbal expression and non verbal expression is easily seen by th
e nurse and the client. Nurses are taught to asses clients but clients often jus
t adept at reading a nurses expression or body language If there are incongruenc
e the body language or nonverbal communication is usually the one with the true
meaning For ex, when teaching a client how to care for a colostomy the nurse mig
ht say “You won’t have any problem with this.” However if the nurse looked worried or
disgusted while saying this the clients are less likely to trust the nurse’s words
. Therapeutic Communication Therapeutic communication promotes understanding and
can help establish a constructive relationship between the nurse and the client
. Unlike the social relationship where there
way not be a specific purpose of direction the therapeutic helping relationship
is client and goal directed. Nurses needed to respond not only the content of cl
ient’s verbal message but also the felling expressed. It is important to understan
d how the clients view the situation and feels about it before responding. Atten
tive Listening Attentive Listening is listening actively using all these senses
as opposed to listening passively with just the ear It is probably the most impo
rtant technique in nursing and is based all other techniques attentive listening
is an active process that requires energy and concentration. It involves paying
attention to the total message both verbal and nonverbal. Barriers to communica
tion THE HELPING RELATIONSHIP Nurse client relationship are referred to by some
as interpersonal relationship by other as therapeutic relationships and by still
others as helping relationship Helping is a growth facilitating process that st
rives to achieve two basic goals (Egan 1998) 1. Helps client manage their proble
ms more effectively and develop unused or underused opportunities more fully. 2.
Helps client become better at helping themselves in their everyday lives. A hel
ping relationship may be develop over weeks of working with a client, or within
minutes. The keys o the helping relationship is {the development of trust and ac
ceptance between he nurse and {b} an underlying belief that the nurse cares abou
t and wants to help the client. The helping relationship is influenced by the pe
rsonal and professional characteristics of the nurse and the client. Age, sex, a
ppearance, diagnosis, education, values, ethnic, and cultural background, person
ality, expectations, and setting can all affect the development of the nurse- cl
ient relationship.
Phases of the Helping Relationship The helping relationship process can be descr
ibed in terms of four sequential phases, each characterized by identifiable task
s and skills. The relationship must progress through the stages in succession be
cause each builds on the one before. Nurses can identify the progress of a relat
ionship by understanding these phases. Preinteraction Phase The preinteraction p
hase is similar to the planning stage before an interview. In most situations, t
he nurse has information about the client before the first face-to-face meeting.
Such information may include the client’s name, address, age, medical history and
or social history. Planning for the initial visit may generate some anxious and
feeling specific information to be read positive outcomes can evolve. Introduct
ory Phase Introductory phase, also referred to as the orientation phase, is impo
rtant because it sets the tone for the rest of the relationship. During this ini
tial encounter, the client and the nurse closely observe each other and form jud
gments about the others’ behavior. The tree stages of this introductory phase are
opening the relationship, clarifying the problem, and structuring and formulatin
g the contact. Other important tasks of the introductory phase include getting t
o know each other and developing a degree of trust. After introductions, the nur
se may initially engage in some social interaction to put the client at ease. Fo
r example nurse and client may talk about what a nice day it is and what they wo
uld like to do if at home. Characteristics of a Helping Relationship A helping r
elationship * Is an intellectual and emotional bond between he nurse and the cli
ent and is focused on the client. *Respect the client as an individual, includin
g *Maximizing the client’s abilities to participate in decision making and treatme
nts * Considering ethnic and cultural aspects * Considering family relationship
and values *Respects client confidentiality
*Respect on the client’s well- being *Is based on mutual trust, respect, and accep
tance. By the end pf the introductory phase, clients should begin to *Develop tr
ust in the nurse. *View the nurse as a competent professional capable of helping
. ►View the nurse as honest, open, and concerned about their welfare. ►Believe the n
urse will try to understand and respect their cultural values and beliefs. ►Believ
e the nurse will respect client confidentiality. ►Fell comfortable talking with th
e nurse about feeling and others sensitive issues. ►Understand the purposes of the
relationship and the roles. ►Feel that they are active participants in developing
a mutually agreeable plan of care. Working Phase During the working phase of a
helping relationship, the nurse and the client begin to each other as unique ind
ividuals. They begin to appreciate this uniqueness and care about each other. Ca
ring is sharing deep and genuine concern about the welfare of another person. On
ce caring develops the potential for empathy increases. The working phase has tw
o major stages: exploring and understanding thought and feelings, and facilitati
ng and talking action. The nurse helps the client to explore thought, feelings,
and actions and helps the client plan a program of action to meet preestablished
goals. EXPLORING AND UNDERSTANDING THOUGHT AND FEELINGS. The nurse requires the
following skills for this phase of the helping relationship. ● Empathetic listeni
ng and responding nurses must listen attentively and communicate (respond) in wa
ys that indicate they have listened to what was said and understand how the clie
nt feels the nurses respond to content and feeling or both as appropriate. The n
urse’s nonverbal behaviors are also important. Nonverbal behaviors indicating empa
thy include moderate gesturing and little activity or body movement. According t
o Egan (1998) empathy “can be seen as an intellectual process that involves unders
tanding correctly another
person’s emotions state and point of view” and also as an emotional response experie
nced by the helper. Empathetic listening focuses on a kind of “being with” clients t
o develop an understanding of them and their world. This understanding, however,
must also be communicated effectively to the client-emphasis response. The end
result of empathy is comforting and caring for the client and a helping, healing
relationship. ● Respect. The nurse must show respect for the client’s willingness t
o be available, desire to work with the client, and a manner that conveys the id
ea of taking the clients point of view seriously. ● Genuineness. Personal statemen
ts can be helpful in solidifying the rapport between the nurse and the client. T
he nurse might offer such comments as “I recall when I was in (similar situation),
and I felt angry about being put down.” Egan outlines five behaviors that are com
ponents of genuineness. Nurses need to exercise caution when making references a
bout themselves. These statements must be used with discretion. The extreme of m
atching case of the client’s problems with a better story of the nurse’s own is of l
ittle value to the client. ● Concreteness. The nurse must assist the client to be
concrete and specific rather than to speak in generalities. When the client says
, “I’m stupid and clumsy.” The nurse narrows the topic to the specific by pointing out
, “You tripped on the rugs.” ● Confrontation. The nurse points out discrepancies betwe
en thoughts, feelings, and actions that inhibit the clients self understanding o
r exploration of specific areas. This is done empathetically, not judgmentally.
During the first stage of the working phase, the intensity of interaction increa
ses, and feelings such as anger, shame, and selfconsciousness may be expressed.
If the nurse is skilled in this stage and if client is willing to pursue self-ex
ploration the outcome is a beginning understanding on the part of the client abo
ut behavior and feelings.
Termination Phase The termination phase of the relationship is often expected to
be difficult and filled with ambivalence. However, if the previous phases have
evolved effectively, the client generally has a positive outlook and feels able
to handle problems independently. On the other hand, because caring attitudes ha
ve developed, it is natural to expect some feeling loss, and each person needs t
o develop a way of saying good-bye. Many methods can be used to terminate relati
onships. Summarizing or reviewing the process can be produced a sense of accompl
ishment. This may include sharing reminiscences of how things were are the begin
ning of the relationship and comparing them to how they are now. It is also help
ful for both the nurses and the client to express their feelings about terminati
on openly ad honestly. Thus termination discussions need to start to advance of
the independence. In some situations referrals are necessary or it may be approp
riate to offer an occasional standby meeting to give support as needed. Follow-u
p Phone calls or e-mails are other interventions that ease the client’s transition
to independence.