Communication and Educational Technology for Nurses BT Basavanthappa
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Communication in NursingCHAPTER 1

 
INTRODUCTION
The term ‘Communication’ has various meanings, depending on the context in which it is used. To some, communication is the interchange of information between two or more people; in other words the exchange of ideas or thoughts. This kind of communication uses methods such as talking and listening or writing and reading. However, painting, dancing, story telling are also methods of communication. Thoughts are conveyed to other not only by spoken or written words but also by gestures or body actions.
Communication can be defined as the giving or exchanging of information through verbal or written means, that is any means of exchanging information or feelings between two or more people. Communication also helps to simple transfer of information to the establishment of relationships between people such relationships are founded upon effective communication skills. Communication is a process between two or more individuals, or interpersonal communication, in which people can communicate within themselves–interpersonal communication as they reflect upon their own knowledge, ideas and feelings.
Human beings influence others primarily through communication. The human need for relatedness binds people together, and communication serves as the exchange medium in these relationships. The verbal and non-verbal messages exchanged in human relationships determine, to a large extent, the structure and function of feelings in persons. Indeed, the wide existence and the health status of human beings are dependent on communication, because the affective component of life cannot be separated from biological component.
Nursing is an interaction between nurses and clients, nurses and other health professionals, and nurses and the community. The process of human interaction occurs through communication: Verbal and nonverbal, written and unwritten, planned and unplanned. Communication between people conveys thoughts, ideas, feelings, and information. For nurses to be effective in their interactions, they must have good communication skills. They must be aware of what their words and body language are saying to others. As nurses assume leadership roles they must be effective in both verbal and written communication skills. And as nurses practice in this century, they must have effective computer and other electronic communication skills.
In the nursing process, the client and the nurse both undergo emotional experiences as a function of the communication process between them. Because the ultimate goals of the professional nurse are to maximise the client's potential for health and to actualize her own best professional abilities, the professional nurse must clearly understand the power of communication in shaping relationships. The quality of communication between the nurse and the client is, therefore, an essential determinant of the success of the professional relationship. Mutual goals cannot be defined or achieved in the relationship without effective communication that positively influences the emotions of both the client and the professional nurse.
2Communication is described as the “matrix for all thought and relationships between persons”.
 
IMPORTANCE OF COMMUNICATION
Clear and appropriate communication is essential for providing effective nursing care, and this is an unique challenge in the current health care environment. Overcoming barriers to communication is necessary in a society in which many languages are spoken and the population is multicultural. Individual nurses cannot be fluent in each language that will be encountered, nor can they be fully informed of the cultural contexts of words and phrases that may have multiple meanings. Nonverbal communication also has cultural meaning. Not only this is a challenge in providing care to clients, it is also a challenge in working with colleagues when there is diversity of cultures and languages. Clear communication about care and about client information is equally important, whether it is in the form of verbal interactions with co-workers, written records, or publications in professional journals. A challenge for nurses in this century is to become proficient in communicating via technology, including telephone communication such as telephone triage and communication using computers such as nursing-documentation systems, personal data information systems, and e-mail.
Finding effective ways to overcome communication barriers provides the opportunity for nurses to bridge cultural gaps in delivering health care. Nurses who can use available resources and solve problems when there are communication difficulties will be better able to assist clients and families to access care and benefit from health care services. Clear communication will help the health care team provide effective care. It is essential in interdisciplinary teams. When nurses are able to communicate well in verbal and written form, the quality of professional publications benefits and nurses can provide better resources to the profession. Nurses can use technology to enhance communication with clients and other health care providers, to improve access to care for people in remote areas, and to increase their own knowledge using the information resources available on the Internet.
Communication may have a more personal connotation than the interchange of ideas or thoughts. It can be a transmission of feelings, or a more personal and social interaction between people. In this context, communication often is synonymous with relating. Frequently, one member of a couple comments that the other is not communicating. Some teenagers complain about a generation gap–being unable to communicate with understanding or feeling to a parent or authority figure. Sometimes a nurse is said to be efficient but lacking in something called bedside manner. So, communication is any means of exchanging information or feelings between two or more people. It is a basic component of human relationships. The intent of any communication is to elicit a response. Thus, communication is a process. It includes all the techniques by which an individual affects another. It has two main purposes: To influence others and to obtain information. Communication can be described as helpful or unhelpful. The former encourages a sharing of information, thoughts, or feelings between two or more people. The latter hinders or blocks the transfer of information and feelings.
Communication is a significant aspect of nursing practice. Nurses who communicate effectively are better able to initiate change that promotes health, establish a trusting relationship with a client and support persons, and prevent legal problems associated with nursing practice. Effective communication is essential for the establishment of the nurse-client relationship.
Nursing practice involves three kinds of communication: Social, structured, and therapeutic. Social communication is unplanned communication, often carried out in an informal setting and usually at a leisurely pace. It is usually satisfying to all parties participating. 3Structured communication refers to definite planned content. An example of structured communication is teaching a client to give an injection or discussing postoperative care with a person anticipating surgery. Therapeutic communication is also used by nurses. It is defined as a process that helps “overcome temporary stress, to get along with other people, to adjust to the unalterable, and to overcome psychological blocks which stand in the way of self-realisation.” Therapeutic communication is used by nurses in many settings and in many circumstances, for example, to support the anxious preoperative client or to help the person who has cancer accept and cope with this diagnosis.
 
ANATOMY OF COMMUNICATION (STRUCTURE)
Human communication has been defined as “the generation and transmission of meaning”. It is dynamic interaction between two or more persons in which ideas, goals, beliefs and values, feelings, and feelings about feelings are exchanged. Experiencing even a minute communication exchange effects change in both communicants in the process. It should be noted that communication is defined only in the context of process. Because human beings are continually and irrevocably exchanging energy with the environment, and life is continually being repatterned, it can be assumed that the individual human being reflects only dynamic actions. Each person is always affected by others and is always affecting others. One constantly communicates, thereby generating change in others and experiencing change in self.
Although communication is a dynamic process, it is possible to identify components and to analyse the inter-relationships among the components. Aristotle (1960) identified the related components as the speaker, the speech, and the audience. After analysing behavioural science research and several points of view, Berlo (1960) postulated a communication model generally accepted today:
  • An (interpersonal) source: Some person(s) with ideas, needs, intentions, information, and a reason for communicating.
  • A message: A coded, systematic set of symbols representing ideas, purposes, intentions, and feelings.
  • An encoder: The mechanism for expressing or translating the purpose of the communication into the message (in human beings, these are the motor mechanisms, i.e. the vocal mechanism for oral messages, the muscles of the hands for written messages, and the muscle systems elsewhere in the body for gestures).
  • A channel: The medium for carrying the message.
  • A decoder: The mechanism for translating the message into a form that the recipient can use (in human beings, the sensory receptor mechanisms).
  • A receiver: The target or recipient of the message.
In this model, the transmission of meaning occurs via a dynamic process in which (1) a person has an intention or purpose (the communication source), (2) that purpose is translated into communicable form by the persons set of motor mechanisms and skills (encoder), (3) the message is transmitted through a channel, (4) the message is translated into receivable form by the recipients sensory mechanisms and skills (decoder), and (5) the recipient receives the message (the communication receiver).
Since this model was postulated, systems theorists have further explained the reciprocal relationship between the participants in the communication process. At any given time, the individual person is both an active initiator and a recipient of meanings in an interpersonal situation. Thus, it is important for the nurse to understand that she is simultaneously acting and reacting in the nursing process and that clients meanings have an equal effect on the outcome of purposeful relationships. The process just described has been labeled “transactional”.
4The dynamic nature of the communication process dictates the need for the professional nurse to evaluate her own actions and reactions throughout the nursing process with a client. Without such awareness and evaluation, the professional will be less likely to experience successful communication with the feeling of satisfaction associated with transmitting clear meanings and the validation that the message intended was indeed the message received. Validation of meanings is essential to achieving any therapeutic goals in helping relationships.
Synthesizing from several communication models, there are four major purposes of communication which includes: (1) to inquire, (2) to inform, (3) to persuade, and (4) to entertain. The professional nurse may attempt to achieve any of these purposes with clients, the health care delivery system, peers, other personnel, and even the self. In attempting to achieve these purposes, the nurse transmits messages in the process.
 
PHYSIOLOGY OF COMMUNICATION (COMMUNICATION PROCESS)
The communication process involves a sender, message, channel, receiver, and response or feedback. In its simplest form, communication involves the sending and receiving of a message between two people. The sender defines the original message and transmits it to the receiver through a selected channel. The receiver then interprets the message and provides a response to the sender. This enables the sender to determine if the receiver understood or interpreted the message correctly. If the message was not interpreted correctly or if additional information is needed, the process starts again. Therefore, communication is an ongoing process, in which the roles of sender and receiver transact as each transmits new information or understandings to the other.
Communication also can be an exchange of information between an individual and a group of people (e.g. by giving a lecture or teaching a class) or an exchange of information between several people (e.g. a change-of-shift report or a group meeting). The components of the communication process are sender, message, channel, receiver, and feedback.
The dashed arrows indicate interpersonal communication (self-talk). The solid lines indicate interpersonal communication (Fig. 1.1). There are two major models of nurses communication in nurse-client interaction: The therapeutic model and “interpersonally competent” model. The therapeutic model originated as part of the patient-centered approach to nursing that emphasised the nurses responsibility to the total well-being of the client. This model focuses on the learning and practicing of a now well-accepted set of skills and abilities such as listening, responding empathetically, using non-evaluative language and non-verbal cues, and demonstrating behaviours that stress confirmation and acknowledgement.
zoom view
Figure 1.1: Communication process
The interpersonally competent model was introduced by Kasch (1984). This model assumes that communication is related to health outcomes. It defines effective communication as that which is interpersonally competent rather than that which is psychologically therapeutic. It is based upon two types of abilities. The first is social cognitive competence: The ability to interpret the message content in interactions from many perspectives and to make judgements about the effectiveness and appropriateness of potential responses. The second is strategic message competence: The ability to control and strategically use language and other behavioural capabilities to achieve objectives of the nursing process.
5Both models emphasize the necessity to learn and perform certain basic communication skills, but the interpersonally competent model stresses these skills as part of the strategic message competence. It adds to these basic skills, analytic and interpretational skills in communicating. Interpretation involves perception, symbolisation, memory, and thinking.
The purpose of a model is to break down the process of communication into its essential components so that it can be better understood. A communication model has two main parts: People and messages. In face-to-face communication there is a sender, a message, a receiver, and a response (feedback). In its simplest form, communication is a two-way process involving the sending and the receiving of a message. Since the intent of communication is to elicit a response, the process is ongoing; the receiver of the message then becomes the sender of a response, and the original sender then becomes the receiver.
 
Sender
The sender is the person or group who wishes to transmit a message to another. Another term for sender is source encoder. This means that the originator of the message, or source, has a purpose for the message and determines its content. The content of the message must be put in a form that is understandable to the receiver, called encoding. Encoding involves ‘the selection of specific signs or symbols (codes) to transmit the message’. Encoding includes the choice of specific words and the language of the message. It also includes the speech inflection and body language used to accompany the message. For example, when nurses are communicating with other nurses about a client's condition, they may use medical terminology (e.g. hypertension); however, when they are talking with the client or family, they may use lay terminology (e.g. high blood pressure).
The sender, a person or group who wishes to convey a message to another, is sometimes called the source-encoder. This term suggests that the person or group sending the message must have an idea or reason for communicating (source) and must put the idea or feeling into a form that can be transmitted. Encoding involves the selection of specific signs or symbols (codes) to transmit the message, such as which language and words to use, how to arrange the words, and what tone of voice and gestures to use. For example, if the receiver speaks English, English words will usually be selected. If the message is “No, Mahesh, you may not have any more cookies before dinner!” the tone of voice selected will be one of firmness, and a shake of the head or a pointing index finger can reinforce it. The nurse must not only deal with dialects and foreign languages but also must cope with two language levels—the lay-person's and the health professionals.
 
Message
The second component of the communication process is the message itself–what is actually said or written, the body language that accompanies the words, and how the message is transmitted. Various channels can be used to convey messages, and frequently combinations are used. It is important that the channel be appropriate for the message and make the intent of the message clear.
Talking face-to-face with a person may be more effective in some instances than telephoning or writing a message. Recording messages on tape or communicating by radio or television may be more appropriate for larger audiences. Written communication is often appropriate for long explanations or for a communication that needs to be preserved. The nonverbal channel of touch is often highly effective.
The second part of the communication process is the encoded message itself–the information or feelings to be transmitted and the content and context of the message. Messages between nurses and clients include verbal and written discharge instructions, interactions of support and caring, and information gathering.6
 
Channel
The channel is the method selected to convey the message, including whether the message is spoken or written, the choice of words or language, and the choice of accompanying body language. A change of shift report between nurses may be verbal in a face-to-face interaction or it may be recorded on audiotape. Client-discharge instructions may be written or verbal. Communications with physicians may be face-to-face, via telephone, or through the client record. The channel can be visual, auditory, or through touch. Some of the most effective communication interactions use more than one sensory channel.
 
Receiver
The receiver, the third component of the communication process, is the listener, who must listen, observe, and attend. This person, sometimes called the decoder, must perceive what the sender intended (sensation) and then analyse the information received (interpretation). Perception involves use of all the senses to receive all verbal and nonverbal messages. To decode means to relate the message perceived to the receivers storehouse of knowledge and experience and to sortout the meaning of the message. Whether the message is decoded accurately by the receiver, according to the sender's intent, depends largely on their similarities in knowledge and experience.
The receiver, also called the decoder, is the one who receives the message, interprets (decodes) it, and makes a decision about how to respond. If the message is aural, the receiver must be able to hear or attend to the message and the sender. If the message is written or visual, the receiver must be able to see and read. The receiver decodes or interprets the message in relation to his or her past experiences, knowledge, and personal characteristics. If the receiver interprets the message congruently with the intent of the sender, then communication has been effective. Ineffective communication occurs when the message is not understood or is interpreted inaccurately. For example, a nurse may instruct the client to take his medication three times a day with meals. The client, however, eats only twice a day. This difference could result in the client not taking the medication as required. Feedback, or response, from the client is essential to validate interpretation and understanding of the message.
 
Response
The fourth component of the communication process, the response, is the message that the receiver returns to the sender. It is also called feedback. Feedback can be either positive or negative. Nonverbal examples are a nod of the head or a yawn. Either way, feedback allows the sender to correct or reword a message. The sender then knows the message was interpreted accurately. However, now the original sender becomes the receiver, who is required to decode and respond.
The receiver is not the sole source of feedback. Communicators constantly receive internal feedback from themselves. Internal feedback is often used for written messages. For example, after composing a letter, a person will read it silently or out loud to see how it sounds; or a person who makes a social blunder (faux pas) may instantly realise the mistake and say, “That is not what I really meant” or “I did not mean it that way.”
The receivers response is the feedback that enables the sender to know if the message was received and interpreted correctly. Feedback is the message that the receiver returns to the sender. Failure to obtain a response or feedback can result in ineffective communication. Feedback also can be verbal or nonverbal. Feedback may be verbal clarification or acceptance or rejection of the information or feelings. It may also be nonverbal. Examples of nonverbal feedback are nodding of the head, a facial expression of confusion or understanding, or signs 7of boredom, such as yawning. It is important to use verbal feedback to be sure that nonverbal language has not been misinterpreted. For example, clients may nod their head indicating understanding, but further questioning might show that they misunderstood the message.
 
FACTORS INFLUENCING THE COMMUNICATION PROCESS
Many factors influence the communication process. These include the developmental stage, gender, roles and relationships, sociocultural characteristics, values and perceptions, space and territoriality, environment, congruence, and interpersonal attitudes.
 
Developmental Stage
As individuals grow and develop, language and communication skills develop through various stages. It is important for a nurse to understand the developmental processes related to speech, language, and communication skills. Knowledge of the client's developmental stage enables the nurse to select appropriate communication strategies. For example, when communicating with infants and toddlers whose language skills are not well developed, the nurse may rely more on the child's nonverbal communications to assess comfort and pain. The nurse may hold the child and use touch to provide comfort and demonstrate caring. For older children, nurses may use pictures as an adjunct to verbal language to communicate. For adolescents and adults, nurses are more able to rely on verbal language for communication. With older adults, physical changes associated with the aging process may affect communication. For example, it may be more effective to use visual communication methods for clients who are hearing impaired or aural communication methods for clients who are visually impaired. Also, intellectual processes develop across the life span as people acquire knowledge and experience. The knowledge and experiences that people have, influence their understanding and acceptance of transmitted information and feelings.
 
Gender
Males and females tend to communicate differently. They may give different meanings to transmitted information or feelings. This may be the result of differences during psychosocial development, because boys use communication to establish independence and negotiate status within a group, whereas girls use communication to seek confirmation, minimize differences, and establish or reinforce intimacy. It is important that nurses, when working with clients or colleagues of the opposite gender, be aware that the same communication may be interpreted differently by a man and a woman.
 
Roles and Relationships
The roles and relationships between the sender and the receiver can influence communication. Roles such as nurse and client, nurse and colleague, nurse and physician, and nurse and administrator/supervisor can affect the content and response in communication. Roles may influence choice of message content, communication vehicle, tone of voice, and body language. For example, nurses may choose face-to-face communication for interaction with clients or health providers on the nursing unit, whereas they may use e-mails or telephones to communicate with physicians or administrators. Nurses may choose a more informal or comfortable stance when communicating with clients or colleagues and a more formal stance when communicating with physicians or administrators. The length of the relationship may also affect communication. For example, nurses may use more formal language and a more formal stance when meeting clients or colleagues for the first time but use a more relaxed stance when interacting with clients or colleagues with whom they have an established relationship.8
 
Sociocultural Characteristics
Sociocultural characteristics such as culture, education, or economic level can influence communication. Nonverbal communication characteristics such as body language, eye contact, and touch are influenced by cultural beliefs about appropriate communication behaviour. Some cultures may believe direct eye contact is disrespectful, whereas other cultures believe that direct eye contact shows trustworthiness. In some cultures, touch would be appropriate to communicate caring and concern, but in other cultures physical touch would be offensive. Verbal communication may be difficult for the receiver whose primary language is not that of the sender.
People's level of education may affect the extent of their vocabulary or their ability to read written communication. Economic level may affect a persons ability to access written communication. Today, when many people are using e-mail to communicate or the Internet to obtain health information, people who cannot afford a computer or who do not have access to one will not be able to communicate using that means.
 
Values and Perceptions
Communication is influenced by the values people hold about themselves, others, and the world in which they live. Because all people have values and perceptions based on their own experiences and characteristics, people who hold different values may send, receive, and interpret messages differently. For example, a client who values stoicism in managing his or her pain may not tell the nurse about the pain and may be offended when the nurse inquires about pain or offers pain medication.
 
Space and Territoriality
Space involves the distance at which an interaction takes place. Territoriality involves the space and contents of the space that the individual considers belonging to him or her.
Hall (1969) describes four distances at which interactions take place: Intimate distance, personal distance, social distance, and public distance.
Intimate distance ranges from physical contact to 1½ feet. Nurses interact with clients within the intimate range when they assess and provide some direct care activities for clients. Taking blood pressure, listening to body sounds with a stethoscope, assessing pulse, changing a dressing, or giving an injection are all performed with physical contact. The manner in which the tasks are performed and the conversation during these activities communicate to the client in various ways. If the nurse is brusque when changing a dressing, the client may interpret the nurse's behaviour as uncaring. If the nurse is gentle and shows concern, the client may perceive that the nurse is caring and feel comforted. Clients may feel uncomfortable when others enter their intimate space, especially if a trusting relationship has not been established. Nurses can alleviate this discomfort by telling the client before moving into the intimate distance range.
Personal distance is less overwhelming than intimate distance. Voice tones are moderate, and body heat and smell are noticed less. Physical contact such as a handshake or touching a shoulder is possible. More of the person is perceived at a personal distance, so that nonverbal behaviours such as body stance or full facial expressions are seen with less distortion. Much communication between nurses and clients occurs at this distance. Examples occur when nurses are sitting with a client, giving medications, or establishing an intravenous infusion. Communication at a close personal distance can convey involvement by facilitating the sharing of thoughts and feelings. At the outer extreme of 4 ft, however, less involvement is conveyed. Bantering and some social conversations are usual at this distance.
Personal distance ranges from 1½ to 4 feet. Most one-to-one communication takes place within this range. Nurses interact with clients in the personal distance range when they sit with a client 9to obtain a health history or when they teach clients self-care. Nurses also interact with colleagues in the range of personal distance when they exchange information with a nursing colleague or physician.
Social distance is characterised by a clear visual perception of the whole person. Body heat and odor are imperceptible, eye contact is increased, and vocalisations are loud enough to be overheard by others. Communication is therefore more formal and is limited to seeing and hearing. The person is protected and out of reach for touch or personal sharing of thoughts or feelings. Social distance allows more activity and movement back and forth. It is expedient in communicating with several people at the same time or within a short time. Social distance is important in accomplishing the business of the day. However, it is frequently misused. For example, the nurse who stands in the doorway and asks a client “How are you today”? will receive a more noncommittal reply than the nurse who moves to personal distance to inquire.
Social distance ranges from 4 to 12 feet. Interactions with clients and family members or groups of clients are more likely to occur in the range of social distance. This is also the range of distance within which nurses interact with groups of colleagues, such as during a group change of shift report. It is important to note that usually the voice is louder when communicating in this range; therefore, a nurse must be aware of issues of client confidentiality. Communication with a client who is in a semiprivate room may be compromised if the nurse asks personal questions at this range while in the presence of other clients or caregivers.
Public distance requires loud, clear vocalisations with careful enunciation. Although the faces and forms of people are seen at public distance, individuality is lost. Instead, a general notion is perceived about a group of people or a community.
Public distance starts at 12 feet and goes beyond that distance. This is the distance at which interactions with larger groups take place. There is less individual interaction or awareness of individual needs when communicating at this distance. Nurses communicate in public distance when they conduct community health education classes.
It is human nature to establish a boundary or territory that is considered to be one's own. Whether clients are being cared for in their own home, their own room in a long-term care facility, or in a hospital room, they create a personal environment that gives them comfort. They may have photographs, religious materials, or other personal items on a nearby table or bed tray. If the nurse attempts to change or rearrange furniture or objects in the client's environment, the client may perceive this as not caring or devaluing. Similarly, nurses who have their own desk or locker often have personal objects that create their personal work territory or environment.
Territoriality: Territoriality is a concept of the space and things that an individual considers as belonging to the self. Territories marked off by people may be visible to others. For example, clients in a hospital often consider their territory as bounded by the curtains around the bed unit or by the walls of a private room. This human tendency to claim territory must be recognised by all health care workers. Clients often feel the need to defend their territory when it is invaded by others; for example, when a visitor removes a chair to use at another bed, the visitor has inadvertently violated the territoriality of the client whose chair was moved.
 
Environment
The nature of the environment can also affect communication. Communication occurs best in an environment that supports the exchange of information, ideas, or feelings. Loud noises, poor lighting, noxious odors, or an uncomfortable temperature can all interfere with effective communication. The arrangement of furniture can affect communication. For example, communicating across a desk conveys a more formal interaction than when the nurse sits in a 10chair next to the client. When interacting with clients, their families, or others, nurses should try to create an environment that is conducive to effective communication and minimizes environmental distractions.
Environment: People usually communicate most effectively in a comfortable environment. Temperature extremes, excessive noise, and a poorly ventilated environment can all interfere with communication. Also, lack of privacy may interfere with a client's communication about matters the client considers private. For example, a client who is worried about the ability of his wife to care for him after discharge from hospital may not wish to discuss this concern with a nurse within the hearing of other clients in the room. Environmental distraction can impair and distort communication.
In addition to factors such as a persons sociocultural background, language, age, and education, and the limitations and attributes of nonverbal communication, the following factors affect the communication process: Ability of the communicator; perceptions; personal space; territoriality; roles and relationships; time; environment; attitudes; and emotions and self-esteem.
 
Congruence
Roles and relationships: The roles and the relationship between sender and receiver affect the communication process. Roles such as nursing student and instructor, client and physician, or parent and child will affect the content and responses in the communication process. Choice of words, sentence structure, and tone of voice vary considerably from role to role. In addition, the specific relationship between the communicators is significant. The nurse who meets with a client for the first time will communicate differently from the nurse who has previously developed a relationship with that client.
When communication is congruent, the nonverbal behaviours match the verbal message. Nurses may state that they want clients to call if they have any questions or need anything. However, if a nurse appears to be rushed or distracted, a client may be unsure about calling the nurse when he or she has a question or is experiencing pain.
 
Interpersonal Attitudes
Positive attitudes of respect, acceptance, trust, and caring facilitate communication, whereas negative attitudes of mistrust, rejection, and condescension inhibit effective communication. When one person is interacting with another, attitudes are conveyed by facial expression, tone of voice, the choice of words, and other body language. It is important to convey a nonjudgemental attitude during interactions. If the client feels that the nurse disapproves of some aspect of his or her lifestyle (e.g. smoking, promiscuity, addiction to drugs or alcohol), the client might not share the information.
Attitudes: Attitudes convey beliefs, thoughts, and feelings about people and events. They are communicated convincingly and rapidly to others. Attitudes such as caring, warmth, respect, and acceptance facilitate communication, whereas condescension, lack of interest, and coldness inhibit communication.
Caring and warmth convey a feeling of emotional closeness, in contrast to impersonal distance. Caring is more enduring and intense than warmth. It conveys deep and genuine concern for the person. Warmth, on the other hand, conveys friendliness and consideration, shown by acts of smiling and attention to physical comforts. Caring involves giving feelings, thoughts, skill, and knowledge. It requires psychologic energy and poses the risk of gaining little in return, yet by caring, people usually reap the benefits of greater communication and understanding.
11Respect is an attitude that emphasizes the other persons worth and individuality. It conveys that the persons hopes and feelings are special and unique even though similar to others in many ways. People have a need to be different from and at the same time similar to others. Being too different can be isolating and threatening. Respect is conveyed by listening open-mindedly to what the other person is saying, even if the nurse disagrees. Nurses can learn new ways of approaching situations when they conscientiously listen to another persons perspective.
Acceptance emphasizes neither approval nor disapproval. The nurse willingly receives the clients honest feelings and actions without judgement. An accepting attitude allows clients to express personal feelings freely and to be themselves. The nurse may need to restrict acceptance in situations where clients actions are harmful to themselves or to others.
In contrast, condescension is an attitude that conveys superiority over the other person. Clients who feel helpless often perceive nurses to be in a superior position because of their knowledge and skill. In these instances, the nurse may convey condescension by an air of superiority and intellectualism. One common condescending act by nurses is to call clients “honey” or “dear”. This casts the nurse in the role of the superior mother and the client in the role of the inferior child. Another condescending act is patting an elderly client on the head.
Lack of interest also inhibits communication by saying “I'm not concerned” or “What you say is not important”. The nurse conveys lack of interest by forgetting part of the client's conversation or not concentrating on it sufficiently to respond. Being tired near the end of a long day's work or in a hurry to complete tasks may contribute to giving the appearance of not being interested in the client.
Coldness is the opposite of caring and warmth. Nurses convey this attitude to clients by appearing more interested in the technical and procedural aspects of nursing than in the concerns of the person receiving the therapy. For example, the nurse can convey coldness by appearing more concerned about the neatness of the client's bed than about the clients restlessness or more interested in the efficient functioning of a cardiac monitor than in the client's anxiety. A rigid body posture and aloof tone of voice also convey a nurse's lack of genuine concern for the client.
Emotions and self-esteem: Most people have experienced overwhelming joy or sorrow that is difficult to express in words. Anger may produce loud, profane vocalisations or controlled speechlessness. Fright may produce screams of terror or paralysed silence.
Emotions also affect a persons ability to interpret messages. Large parts of a message may not be heard, or the message may be misinterpreted when the receiver is experiencing strong emotion. This situation occurs frequently in nursing. For example, the client feeling great fear may not remember all the preoperative instructions offered by a nurse.
Self-esteem also influences communication patterns. People whose self-esteem is high communicate honestly, with confidence, and with congruence (agreement or coinciding) between verbal and nonverbal messages. For example, a nurse explaining the importance of preoperative exercises would present a sincere and serious facial expression. Those with low self-esteem or under high stress tend to give double messages; that is, their verbal and nonverbal messages are incongruent (lack consistency). For example, while explaining about a client's colostomy to the client's family, a nurse laughs.
Time: The time factor in communication includes the events that precede and follow the interaction. The hospitalised client who is anticipating surgery or who has just received news that a spouse has lost a job will not be very receptive to information. A client who has had to wait for some time to express needs may respond quite differently from one who has endured no waiting period. The setting also influences communication. If the room lacks privacy or is hot, noisy, or crowded, the communication process can breakdown.
12Nurses’ use of time can facilitate or inhibit a client's communication. The nurse who tells a client “I'll be back in a moment” while delivering medications is likely to convey “I have not time now” or “I have got work to do”. This inhibits client communications. However, if this nurse says to the client, “Would you tell me now what your concern is about, and then when I have finished delivering medications I'll come back and help you with it”, the communication process is facilitated.
Ability of the communicator: The persons abilities to speak, hear, see, and comprehend stimuli influence the communication process. People who are hard of hearing may require messages that are short, loud, and clear. Those who are unable to read will be unable to comprehend written information. Some, because of disease processes, are unable to see or to speak, and individual methods for communication need to be devised with them.
The receiver of a message also needs to be able to interpret the message. Mental faculties can be impaired for such reasons as brain damage or use of sedative drugs or alcohol. Even if a client is free of physical impairments, the nurse needs to determine how many stimuli the client is capable of receiving in a given time frame. Frequently, the receiver is expected to assimilate too much information. The nurse may be talking too quickly or presenting too many ideas at once. This is of particular importance when offering health instruction.
 
CLASSIFICATION OF COMMUNICATION
Communication can be classified as verbal and nonverbal. Verbal communication may be spoken or written and involves words. Verbal communication is mainly conscious because people choose the words they use. Verbal communication depends on language mastery. Language mastery includes vocabulary and grammar and is dependent on one's culture, educational level, socioeconomic background, and age. Because of these factors, information can be given, ideas discussed, and feelings exchanged using many different words and word configurations. Nonverbal communication uses other forms such as facial expression, gestures, touch, or other types of body language. Nonverbal communication also includes the use of pictures to communicate. Although, both verbal and nonverbal communication occur simultaneously, the majority of communication during face-to-face interactions is nonverbal.
 
VERBAL COMMUNICATION
 
Oral Communication
Oral communication is a spoken exchange of information, ideas, or feelings using words. Words can have different meanings for different people. The concepts related to word meanings–denotative meaning, connotative meaning, private meaning, and shared meaning. Denotative meaning is the way in which the word is generally used by people who share a common language. Connotative meaning is the meaning of a word that derives from one's personal experiences; for example, the word love may have different meanings when used with a parent, a child, a spouse, or a lover or to describe one's favourite flavour of ice cream. Private meanings are those held by the individual. Shared meanings are the mutual understanding of the word or words between people who are trying to communicate effectively.
It has been stated that when choosing words for oral communication, nurses must consider: (1) pace and intonation, (2) simplicity, (3) clarity and brevity, (4) timing and relevance, (5) adaptability, (6) credibility, and (7) humour.
  1. Pace and intonation: Pace is the speed or rapidity of speech. Intonation is the tone, accent, or inflection used when speaking. Pace and intonation can express a variety of states, including interest, happiness, anxiety, boredom, anger, fear, or depression. For example, 13when people speak in a monotone, not changing the pace or tone of their speech, they may be expressing boredom or apathy.
  2. Simplicity: Simplicity in communication is the choice of commonly understood words. Nurses must remember to use language that is clearly understood when communicating with clients. This may/mean avoiding complex medical terminology when discussing a client's illness or injury. It also means that the nurse must clarify that the client understands the word meanings in the same way that the nurse does.
  3. Clarity and brevity: Clarity means choosing words that say unmistakably what is meant. Brevity is using the fewest words necessary to convey a message. It is important to communicate clearly so that the message is understood.
  4. Timing and relevance: Timing is an important aspect of effective communication. If the client is experiencing pain or is otherwise distracted, it is not an appropriate time to give complex instructions in self-care. Communication must also be relevant to the receiver. If the receiver is not interested in the information at the time it is being given, he or she may be less attentive.
  5. Adaptability: When speaking with clients and others, nurses must be cognisant of verbal and nonverbal cues from the receiver and adapt their communication accordingly. If the receiver appears confused after instructions have been given, the nurse must clarify understanding by restating or rephrasing the instructions.
  6. Credibility: Credibility means being believable and trustworthy. To be credible when communicating, nurses must be consistent, dependable, and honest. Nurses must give accurate information and be willing to say when they do not know something or do not have information. It is more credible to state, “I do not know, but I'll find out for you” than to give inaccurate information that must be corrected later. Consistency is important when communicating to avoid confusion or misunderstanding. When a nurse is consistent and accurate in communicating, he or she is more believable or credible.
  7. Humour: Humour can be effective in communication when used appropriately. It can help people adjust to difficult situations and decrease tension. Laughter can release endorphins that promote a sense of well-being. However, one must be careful in using humour, especially when communicating with people whose primary language is different or who are from a different culture. For example, jokes may seem funny only when used within a particular culture; they may be offensive to or not understood by people of a different culture.
Paralanguage or paralinguistic sounds are the sounds that accompany verbal language and add to the message being given by the spoken word. The tone and volume of the voice, the rate of speech, hesitation, and the emotions expressed that accompany speech as paralanguage. Emotions that accompany speech may include anger, laughter, crying, fear, anxiety, or nervousness. Because these sounds accompany speech they influence the message that is received by the listener so that the same words accompanied by different paralinguistic cues may be interpreted differently. It is important, however, to consider these sounds in the context of the culture of the client because they may have different meanings in different cultures.
Communication is generally carried out in two different modes: Verbal and nonverbal. Verbal communication uses the spoken or written word; nonverbal communication uses other forms, such as gestures or facial expressions. Although/both kinds of communication occur concurrently, the majority of communication (some say 80 to 90%) is nonverbal. This may be surprising to those who associate communication with only verbal expression. Learning about nonverbal communication is thus an important consideration for nurses in developing effective communication patterns and relationships with clients.
Messages are transmitted verbally and nonverbally. Further, implicit in all models of communication is the concept that communication has two interacting components: (1) the content 14value of the message, and (2) the interactional or perceptual value of the message and its participants. The informational aspect of the message, the content value, is expressed in verbal or nonverbal forms. The interactional or perceptual value of the message (referred to as “metacommunication”) identifies how the content is to be interpreted as well as how the relationship is perceived between the participants. Metacommunication may also be expressed in both verbal and nonverbal forms.
Verbal communication in nursing is primarily associated with the spoken word. It requires functional physiological and cognitive mechanisms that potentiate speech production and reception. Although, the greatest influence on communication is not the specific words (but rather, the nonverbal message), words are an essential tool of personal and cultural communication. Language comprises an elaborate system of symbols. Words are symbolic of actual objects or concepts. Lack of congruence in language between the nurse and the client usually interferes with initiating relationships and creates obstacles to validation of meanings–the essential characteristic of an effective message.
Two primary influences on verbal communications are: (1) developmental age, (2) cultural heritage. Developmental age affects verbal abilities through the persons physiological ability to change sounds into words and the cognitive ability to symbolise through language. Through the process of acculturation, the person develops culture-based variations from others in defining meanings for words. Although denotative meanings are equal among different persons (i.e. the concrete representations of words are the same), connotative meanings often vary among persons of varying cultures and their accompanying acculturation. Associated with the act that words are the symbols of communication are three types of problems with which the nurse needs to be concerned.
  • The technical problem: How accurately can one transmit the symbols of communication?
  • The semantic problem: How precise are the symbols in transmitting the intended message?
  • The influential problem: How effectively does the received meaning affect conduct?
The verbal content of communication can be used to evaluate the content theme of the communication process. If one evaluates the seemingly varied topics of discussion, the words that underlie or link together several ideas will reflect the what of the communication.
Verbal communication 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 in the way ideas are exchanged. An abundance of words can be used to form messages. In addition, a wide variety of feelings can be conveyed when talking. The intonation of the voice can express animation, enthusiasm, sadness, annoyance, or amusement. The number of different intonations heard when people say “hello” or “good morning” illustrates the variety that is possible. The pacing or rhythm of a person's communication is another variable. Monotonous rhythms or very rapid rhythms can be products of lack of energy or interest, anxiety, or fear.
As stated earlier when choosing words to say or to write, nurses need to consider several criteria of effective communication. These include: (a) simplicity, (b) clarity, (c) timing and relevance, (d) adaptability, and (e) credibility.
 
NONVERBAL COMMUNICATION
Nonverbal communication is sometimes called body language. It includes gestures, body movements, and physical appearance, including adornment. The majority of communication is nonverbal. Nonverbal communication often tells others more about what a person is feeling than what is actually said, because nonverbal behaviour is controlled less consciously than verbal behaviour. Nonverbal communication either reinforces or contradicts what is said verbally. For example, a nurse may say to a client, “I'd be happy to sit here and talk to you 15for a while”, yet if she glances nervously at her watch every few seconds, the actions contradict the verbal message. The client is more likely to believe the nonverbal behaviour, which conveys “I am very busy”.
Observers cannot always be sure of the correct interpretation of the feelings expressed nonverbally. On the one hand, the same feeling can be expressed nonverbally in more than one way. For example, anger may be communicated by aggressive or excessive body motion, or it may be communicated by a frozen stillness. On the other hand, a variety of feelings, such as embarrassment, pleasure, or anger, can be expressed by a single nonverbal cue, such as blushing.
Observing and interpreting the client's nonverbal behaviour are essential skills for nurses. Interpreting the observations requires validation with the client. The nurse's own nonverbal behaviour is under constant scrutiny by clients. It is therefore, necessary for nurses to gain awareness of their actions and to learn to convey understanding, respect, and acceptance to clients.
To observe nonverbal behaviour efficiently requires a systematic approach. As part of an initial assessment, the nurse should observe the persons overall physical appearance, including adornments, posture, and gait, and then assesses specific parts of the body, such as the face and the hands for nonverbal cues. The persons overall appearance includes physical characteristics and manner of dress. Physical characteristics can denote the persons state of health. Skin colour and texture, length of fingernails, weight, and deformities causing physical limitations are a few examples. The skin may appear dry, mottled, or pale. Weight may indicate malnourishment. Nails may be well manicured or extremely short. Whatever is observed, the nurse needs to exercise caution in interpretation. For example, pale skin may be normal for that person. Nails may be short because they were bitten nervously or because they were broken by hard manual labour.
Clothing and adornments are sometimes rich sources of information about a person. Choice of apparel is highly personal. Clothing may convey social and financial status, culture, religion, group association, and self-concept. Adornments such as jewellry, perfume, and cosmetics reveal additional information.
How a person dresses is often an indicator of how the person feels? People who are tired or ill may not have the energy or the desire to maintain their normal grooming. The nurse also needs to be alert to sudden changes in a person's dress. When a person known for immaculate grooming becomes lax about appearance, the nurse may suspect a loss of self-esteem or a physical illness. For clients in acute general hospital settings, a change in grooming habits or personal adornment often signals that the client is feeling better. A male client may request a shave, or a female client may request a mirror and her lipstick.
Posture and Gait: The ways people walk and carry themselves are often reliable indicators of self-concept, current mood, and health. Erect posture and an active, purposeful stride suggest a feeling of well-being. Slouched posture and a slow, shuffling gait suggest dejection or physical discomfort. Tense posture and a rapid, determined gait suggest anxiety or anger. Likewise, the sitting or lying postures of clients can communicate feelings.
Facial Expression: No part of the body is as expressive as the face. Feelings of joy, sadness, fear, surprise, anger, and disgust can be conveyed by facial expressions. The muscles around the eyes and the mouth are particularly expressive. Although actors learn to control these muscles to convey emotions to audiences, facial expressions generally are not consciously controlled.
Clients are quick to notice the nurse's facial expression, particularly when they feel unsure or uncomfortable. The client who questions the nurse about a feared diagnostic result will 16watch the nurse to see whether the nurse maintains eye contact or looks away when answering. The client who has had disfiguring surgery will examine the nurse's face for signs of disgust. Nurses, like actors, need to be aware of their facial expressions and what they are communicating to others. Although, it is impossible to control all facial expressions, the nurse must learn to control feelings such as fear and disgust in certain situations.
Many facial expressions convey a universal meaning. The smile conveys happiness. Contempt is conveyed by the mouth turned down, the head tilted back, and the eyes directed down the nose. No single expression can be interpreted accurately, however, without considering: (a) Other reinforcing physical cues, (b) the setting in which it occurs, and (c) the expression of others in the same setting.
Eye contact is another essential element of facial communication. Traditionally, in society mutual eye contact acknowledges recognition of the other person and a willingness to maintain communication. Often a person initiates contact with another person with a glance, capturing the persons attention prior to communicating. A person who feels weak or defenseless often averts the eyes or avoids eye contact. The communication received may be too embarrassing or too dominating. Animals are known to succumb to dominance by averting first their eyes and then their presence.
Hand Movements and Gestures: Like faces, hands are expressive. They can communicate feelings at any given moment. An anxious person, for instance a man awaiting word about his KIN in surgery, may wring his hands or pick his nails; relaxed persons may interlock their fingers over their laps or allow their hands to fall over the ends of armrests. Hands also communicate by touch: Slapping someone's face or caressing another's head communicates obvious feelings. Hands are frequently involved in gestures. The handshake, the victory sign, the wave good-bye, the hand motion to ask a visitor to sit down are gestures that have relatively universal meanings. Some gestures, however, are culture-specific. Women walk together are culture-specific. Women walk together holding hands as a sign of friendship. Even the same gesture can have different meanings in different cultures.
Hands are also very expressive in illustrating or stylising verbal communication. The French and Italians are noted for using their hands in this manner. When describing the shape and size of an object, a French person uses the hands to reinforce the verbal message. For people with special communication problems, such as the deaf, the hands are invaluable in communication. Many deaf people learn sign language. Ill persons who are unable to reply verbally can similarly devise a unique communication system using the hands. The client may be able to raise an index finger once for “yes” and twice for “no”. Other signals can often be devised by the client and the nurse to denote other meanings.
The following properties of space are useful to the nurse's purposeful use of space:
  • Pointing (i.e. directional) behaviours occur in space. Body parts move within space and orient themselves in some direction (e.g. the direction of the eyes’ gaze gives a specific message).
  • Positional behaviours occur in space. Four regions of the body (head and neck, upper torso, pelvis and thighs, and lower legs and feet) are oriented in space, in either the same or different directions, dependent on the message to be conveyed.
  • The position and orientation of the participants in the communication space represent the degree of affiliation between them. Persons use point and positional behaviours to show they are with someone (i.e. affiliated and sharing the same space) or not with someone (i.e. unaffiliated with one another and sharing different spaces).
  • Orientation and position of bodies in space represent patterns of commitment between the parties. Some configurations represent involvement and commitment between the parties in the spatial relationship. Other configurations represent lack of involvement and commitment between the parties.
17With an awareness of what a client perceives as acceptable use of space and how body position and direction affect the meaning of the relationship, the professional nurse can manipulate personal and environmental space for the benefit of the client in the nursing process. For example, the nurse attempting to teach a client how to take himself insulin cannot see the full picture of the client's nonverbal behaviour if she sits side by side with him. In this position, the nurse's torso is not directed toward the client's, she must turn her head awkwardly to see his facial expressions, and so forth. This position gives the client a message that the nurse is not being with the client.
 
THERAPEUTIC COMMUNICATION
Therapeutic communication is defined as “an interactive process between nurse and client that helps the client overcome temporary stress, to get along with other people, to adjust to the unalterable, and to overcome psychological blocks which stand in the way of self-realisations”. Therapeutic communication differs from social communication in that there is always a specific purpose or direction to the communication; therefore, therapeutic communication is planned communication. Communication is most therapeutic when the nurse demonstrates an attitude of trust and caring for the client. There are specific verbal and nonverbal techniques of communication that express such an attitude.
Presence, or an attitude of being wholly there for the client, is part of therapeutic communication. A nurse cannot appear to be distracted; rather, a client must feel that he or she is the primary focus of the nurse during the interaction. Being there for a client is conveyed by presenting an open and relaxed posture and leaning toward the client. The nurse fates the client directly and maintains eye contact.
Listening, sometimes referred to as attentive listening, is active listening. Listening is the most important communication technique. To be therapeutic, listening must be active and involve all the senses rather than passively involving only the ear. Silence is a part of attentive listening. Nurses need to become comfortable with silence. Silence allows clients to think about or reflect upon what has been said. Sometimes silence can communicate more than words; it can enable the expression of feelings or emotions.
 
Techniques of Therapeutic Communication
Therapeutic communication techniques facilitate effective communication and enhance the nurse-client interaction. This communication focuses on the client's thoughts and concerns (Table 1.1).
Therapeutic communication promotes understanding by both the sender and the receiver. A number of techniques can help establish a constructive relationship between the nurse and the client, although the use of the techniques is no guarantee of effective communication. So many factors are involved in communication that the nurse is ill-advised to rely on anyone technique or even several techniques. Not all people feel comfortable with all techniques, and skill in using them appropriately is essential. The nurse must be comfortable with the technique used and convey sincerity to the client. A phony or false response is usually quickly identified by clients and hinders the development of an effective relationship.
Nurses can learn much by examining and becoming aware of their own reactions (feelings) and responses. Although, it is difficult for nurses to see their own nonverbal communication other than by videotape feedback, much can be learned by reflecting on what was heard, what the nurse said, and when and how it was said. Methods such as role playing, process recordings, and audiotapes can be useful.18
TABLE 1.1   Therapeutic communication techniques
Technique
Description
Illustration
Using silence
Gives the client the opportunity to collect and organise thoughts, to think through a point, or to consider introducing a topic of greater concern than the one being discussed.
Accepting
Conveys an attitude of reception and regard.
“Yes, I understand what you said.” Eye contact; nodding.
Giving recognition
Acknowledging and indicating awareness; better than complimenting, which reflects the nurse's judgement.
“Hello, Mr. Krishna, I notice that you made a ceramic ash tray in OT.” “I see you made your bed.”
Offering self
Making oneself available on an unconditional basis, increasing client's feelings of self-worth.
“I'll stay with you a while.” “We can eat our lunch together.” “I'm interested in you.”
Giving broad openings
Allows the client to take the initiative in introducing the topic; emphasizes the importance of the client's role in the interaction.
“What would you like to talk about today?” “Tell me what you are thinkings.”
Offering general leads
Offers the client encouragement to continue.
“Yes, I see.” “Go on.” “And after that?”
Placing the event in time or sequence
Clarifies the relationship of events in time so that the nurse and client can view them in perspective.
“What seemed to lead up to…?” “Was this before or after…?” “When did this happen?”
Making observations
Verbalising what is observed or perceived. This encourages the client to recognise specific behaviours and compare perceptions with the nurse.
“You seem tense.” “I notice you are pacing a lot.” “You seem uncomfortable when you…”
Encouraging description of perceptions
Asking the client to verbalise what is being perceived; often used with clients experiencing hallucinations.
“Tell me what is happening now.” “Are you hearing the voices again?” “What do the voices seem to be saying?”
Encouraging comparison
Asking the client to compare similarities and differences in ideas, experiences, or interpersonal relationships. This helps the client recognize life experiences that tend to recur as well as those aspects of life that are changeable.
“Was this something like…?” “How does this compare with the time when…?” “What was your response the last time this situation occurred?”
Restating
The main idea of what the client has said is repeated; lets the client know whether or not an expressed statement has been understood and gives him or her the chance to continue, or to clarify if necessary.
Client: “I can't study. My mind keeps wandering.” Nurse: “You have difficulty concentrating.” Client: “I can not take that new job. What if I can not do it?” Nurse: “You are afraid you will fail in this new position.”
Reflecting
Questions and feelings are referred back to the client so that they may be recognised and accepted, and so that the client may recognise that his or her point of view has value–a good technique to use when the client asks the nurse for advice.
Client: “What do you think I should do about my wife's drinking problem?” Nurse: “What do you think you should do?” Client: “My sister won't help a bit toward my mother's care. I have to do it all!” Nurse: “You feel angry when she does not help.”
Focusing
Taking notice of a single idea or even a single word; works especially well with a client who is moving rapidly from one thought to another. This technique is not therapeutic, however, with the client who is very anxious. Focusing should not be pursued until the anxiety level has subsided.
This point seems worth looking at more closely. Perhaps you and I can discuss it together.
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Exploring
Delving further into a subject, idea, experience, or relationship; especially helpful with clients who tend to remain on a superficial level of communication. However, if the client chooses not to disclose further information, the nurse should refrain from pushing or probing in an area that obviously creates discomfort.
“Please explain that situation in more detail.” “Tell me more about that particular situation.”
Seeking clarification and validation
Striving to explain that which is vague or incompre-hensible and searching for mutual understanding. Clarifying the meaning of what has been said facilitates and increases understanding for both client and nurse.
“I am not sure that I understand. Would you please explain?” “Tell me if my understanding agrees with yours.” “Do I understand correctly that you said…?”
Presenting reality
When the client has a misperception of the environment, the nurse defines reality or indicates his or her perception of the situation for the client.
“I understand that the voices seem real to you, but I do not hear any voices.” “There is no one else in the room but you and me.”
Voicing doubt
Expressing uncertainty as to the reality of the client's perceptions; often used with clients experiencing delusional thinking.
“I find that hard to believe.” “That seems rather doubtful to me.”
Verbalising the implied
Putting into words what the client has only implied or said indirectly; it can also be used with the client who is mute or is otherwise experiencing impaired verbal communication. This clarifies that which is implicit rather than explicit.
Client: “It is a waste of time to be here. I can not talk to you or anyone.” Nurse: “Are you feeling that no one understands?” Client: (Mute) Nurse: “It must have been very difficult for you when your husband died in the fire.”
Attempting to translate words into feelings
When feelings are expressed indirectly, the nurse tries to “desymbolize” what has been said and to find clues to the underlying true feelings.
Client: “I am way out in the ocean.” Nurse: “You must be feeling very lonely now.”
Formulating a plan of action
When a client has a plan in mind for dealing with what is considered to be a stressful situation, it may serve to prevent anger or anxiety from escalating to an unmanageable level.
“What could you do to let your anger out harmlessly?” “Next time this comes up, what might you do to handle it more appropriately?”
 
NONTHERAPEUTIC COMMUNICATION TECHNIQUES
Many approaches are considered to be barriers to open communication between the nurse and client. Nurses should recognize and eliminate the use of these patterns in their relationships with clients. Avoiding these communication barriers maximizes the effectiveness of communication and enhances the nurse-client relationship Table 1.2 gives some non-therapeutic techniques with illustrations and there modification.
 
Written Communication and Nurse
Nurses have many requirements as well as opportunities for written communication. The most common form of written communication in nursing are the notes made in the medical record about a client's status. Nurses also write discharge instructions for clients and their families, memos to nursing colleagues and other health professionals, and client educational materials. Nurse-managers write employee evaluations, policies and procedures, and other communications to administrators, colleagues, and nursing staff. Nurse-educators write educational handouts and course syllabi. An important consideration in written communication is that decoding often occurs when the writer is not present and may occur long after the document is written. Therefore, clarity is important because it may not be possible to ask questions or clarity areas of confusion.20
TABLE 1.2   Non-therapeutic communication techniques
Technique
Description
Illustration with Modification
Giving reassurance
Indicates to the client that there is no cause for anxiety, thereby devaluing the client's feelings; may discourage the client from further expression of feelings if he or she believes they will only be downplayed or ridiculed.
“I would not worry about that if I were you” “Everything will be all right.” Modification: “We will work on that together.”
Rejecting
Refusing to consider or showing contempt for the client's ideas or behaviour. This may cause the client to discontinue interaction with the nurse for fear of further rejection.
“Let's not discuss… “ “I do not want to hear about…” Modification: “Let's look at that a little closer.”
Giving approval or disapproval
Sanctioning or denouncing the client's ideas or behaviour; implies that the nurse has the right to pass judgment on whether the client's ideas or behaviors are “good” or “bad,” and that the client is expected to please the nurse. The nurse's acceptance of the client is then seen as conditional depending on the client's behaviour.
“That's good. I am glad that you…” “That's bad. I did rather you would not…” Modification: “Let's talk about how your behaviour invoked anger in the other clients at dinner.”
Agreeing/ disagreeing
Indicating accord with or opposition to the client's ideas or opinions; implies that the nurse has the right to pass judgment on whether the client's ideas or opinions are “right” or “wrong.” Agreement prevents the client from later modifying his or her point of view without admitting error. Disagreement implies inaccuracy, provoking the need for defensiveness on the part of the client.
“That's right. I agree.” “That's wrong. I disagree.” “I don't believe that.” Modification: “Let's discuss what you feel is unfair about the new community rules.”
Giving advice
Telling the client what to do or how to behave implies that the nurse knows what is best, and that the client is incapable of any self-direction. It nurtures the client in the dependent role by discouraging independent thinking.
“I think you should…” “Why don't you…” Modification: “What do you think you should do?”
Probing
Persistent questioning of the client; pushing for answers to issues the client does not wish to discuss. This causes the client to feel used and valued only for what is shared with the nurse and places the client on the defensive.
“Tell me how your mother abused you when you were a child.” “Tell me how you feel toward your mother now that she is dead.” “Now tell me about…” Modification: The nurse should be aware of the client's response and discontinue the interaction at the first sign of discomfort.
Defending
Attempting to protect someone or something from verbal attack. To defend what the client has criticised is to imply that he or she has no right to express ideas, opinions, or feelings. Defending does not change the client's feelings and may cause the client to think the nurse is taking sides against the client.
“No one here would lie to you.” “You have a very capable physician. I am sure he only has your best interests in mind.” Modification: “I will try to answer your questions and clarify some issues regarding your treatment.”
Requesting an explanation
Asking the client to provide the reasons for thoughts, feelings, behaviour, and events. Asking “why” a client did something or feels a certain way can be very intimidating, and implies that the client must defend his or her behaviour or feelings.
“Why do you think that?” “Why do you feel this way?” “Why did you do that?” Modification: “Describe what you were feeling just before that happened.”
Indicating the existence of an external source of power
Attributing the source of thoughts, feelings, and behaviour to others or to outside influences. This encourages the client to project blame for his or her thoughts or behaviour on others rather than accepting the responsibility personally.
“What makes you say that?” “What made you do that?” “What made you so angry last night?” Modification: “You became angry when your brother insulted your wife.”
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Belittling-feelings expressed
When the nurse misjudges the degree of the client's discomfort, a lack of empathy and understanding may be conveyed. The nurse may tell the client to “perk up” or “snap out of it.” This causes the client to feel insignificant or unimportant. “When one is experiencing discomfort, it is no relief to hear that others are or have been in similar situations.
Client: “I have nothing to live for. I wish I were dead.” Nurse: “Everybody gets down in the dumps at times. I feel that way myself sometimes.” Modification: “You must be very upset. Tell me what you are feeling right now.”
Making stereotyped comments
Cliches and trite expressions are meaningless in a nurse-client relationship. When the nurse makes empty conversation, it encourages a like response from the client.
“I'm fine, and how are you?” “Hang in there. It's for your own good.” “Keep your chin up.” Modification: “The therapy must be difficult for you at times. How do you feel about your progress at this point?”
Using denial
When the nurse denies that a problem exists, he or she blocks discussion with the client and avoids helping the client identify and explore areas of difficulty.
Client: “I am nothing.” Nurse: “Of course you are something. Everybody is somebody. Modification: “You are feeling like no one cares about you right now.”
Interpreting
With this technique the therapist seeks to make conscious that which is unconscious, to tell the client the meaning of his experience.
“What you really mean is…” “Unconsciously you are saying…” Modification: The nurse must leave interpretation of the client's behaviour to the psychiatrist. The nurse has not been prepared to perform this technique, and in attempting to do so, may endanger other nursing roles with the client.”
Introducing an unrelated topic
Changing the subject causes the nurse to take over the direction of the discussion. This may occur in order to get to something that the nurse wants to discuss with the client or to get away from a topic that he or she would prefer not to discuss.
Client: “I do not have anything to live for.” Nurse: “Did you have visitors this weekend?” Modification: The nurse must remain open and free to hear the client, to take in all that is being conveyed, both verbally and nonverbally.
In addition to simplicity, brevity, clarity, relevance, credibility, and humour (characteristics of effective oral communication), written communication must contain (1) appropriate language and terminology; (2) correct grammar, spelling, and punctuation; (3) logical organisation; and (4) appropriate use and citation of resources.
  1. Appropriate language and terminology: Language and terminology must be appropriate for the age, education and reading level, and culture of the reader. Health education materials written for children should be different than materials written for adults. For people whose primary language is other than English, it may be more effective to have written materials translated into their primary language by a professional translator. Appropriate lay terminology may be substituted for medical terminology; for example, high blood pressure may be used instead of hypertension. The nurse as learner and teacher, for more information about reading level of written materials.
  2. Correct grammar, spelling, and punctuation: Using correct grammar, spelling, and punctuation provides clarity for the reader. Misspelled words, misplaced punctuation, or incorrect grammar can change the intended meaning and lead to confusion on the part of the reader. Most computer word-processing programmes have spelling and grammar checking features that assist writers in improving their writing.
  3. 22Logical organisation: Written materials are well organised when they are logical and easy for readers to follow. Consider what the reader needs to know first. Simple and foundational information is usually provided first, followed by more complex information. Using examples can also assist readers.
  4. Appropriate use and citation of resources: Information taken from other sources must always be credited to the original source. Failure to reference work taken from another writer is called plagiarism, is considered unethical, and may violate copyright laws. Similarity of the most concept of communication can be applied to nursing education where teacher and students interacting to achieve the objectives of teaching-learning effectively.
 
BARRIERS TO COMMUNICATION
Just as there are characteristics of effective communication, there are identified barriers to effective communication. Nurses need to be cognizant of these barriers and avoid them. Nurses also need to recognize them when they occur so that they can change to more effective communication. It has been stated that “failure to listen, improperly decoding the client's intended message, and placing the nurse's needs above the client's needs are major barriers to communication.” Additional barriers to effective communication are given in Table 1.3.
TABLE 1.3   Barriers to communication
Technique
Description
Illustration
Stereotyping
Offering generalised and oversimplified beliefs about groups of people that are based on experiences too limited to be valid. These responses categorize clients and negate their uniqueness as individuals.
Two-year-olds are brats.”
“Women are complainers.”
“Men do not cry.”
“Most people do not have any pain after this type of surgery.”
Agreeing and disagreeing
Similar to judgmental responses, agreeing and disagreeing imply that the client is either right or wrong and that the nurse is in a position to judge this. These responses deter clients from thinking through their position and may cause a client to become defensive.
Client: “I don't think Dr Ramachandrappa is a very good doctor. He does not seem interested in his patients.”
Nurse: “Dr Ramachandrappa is head of the Department of medicine and is an excellent physician.”
Being defensive
Attempting to protect a person or health care services from negative comments. These responses prevent the client from expressing true concerns. The nurse is saying, “You have no right to complain.” Defensive responses protect the nurse from admitting weaknesses in the health care services, including personal weaknesses.
Client: “Those night nurses must just sit around and talk all night. They did not answer my light for over an hour.”
Nurse: “I will have you know we literally run around on nights. You are not the only client, you know.”
Challenging
Giving a response that makes clients prove their statement or point of view. These responses indicate that the nurse is failing to consider the client's feelings, making the client feel it necessary to defend a position.
Client: “I felt nauseated after that red pill.”
Nurse: “Surely you do not think I gave you the wrong pill?”
Client: “I feel as if I am dying.”
Nurse: “How can you feel that way when your pulse is 60?”
Client: “I believe my husband doesn't love me.”
Nurse: “You can not say that; why, he visits you every day.”
Probing
Asking for information chiefly out of curiosity rather than with the intent to assist the client. These responses are considered prying and violate the client's privacy. Asking “why” is often probing and places the client in a defensive position.
Client: “I was speeding along the street and did not see the stop sign.”
Nurse: “Why were you speeding?”
Client: “I did not ask the doctor when he was here.”
Nurse: “Why did not you?”
23
Testing
Asking questions that make the client admit to something. These responses permit the client only limited answers and often meet the nurse's need rather than the client's.
“Who do you think you are?” (forces people to admit their status is only that of client)
“Do you think I am not busy?” (forces the client to admit that the nurse really is busy)
Rejecting
Refusing to discuss certain topics with the client. These responses often make clients feel that the nurse is rejecting not only their communication but also the clients themselves.
“I don't want to discuss that. Let's talk about… ”
“Let's discuss other areas of interest to you rather than the two problems you keep mentioning.”
“I can't talk now. I'm on my way for coffee break.”
Changing topics and subjects
Directing the communication into areas of self-interest rather than considering the client's concerns is often a self-protective response to a topic that. causes anxiety. These responses imply that what the nurse considers important will be discussed and that clients should not discuss certain topics.
Client: “I'm separated from my wife. Do you think I should have sexual relations with another woman?”
Nurse: “I see that you are 36 and that you like gardening. This sunshine is good for my roses. I have a beautiful rose garden.”
Unwarranted reassurance
Using clichés or comforting statements of advice as a means to reassure the client. These responses block the fears, feelings, and other thoughts of the client.
“You'll feel better soon.”
“I'm sure everything will turn out all right.”
“Don't worry.”
Passing judgement
Giving opinions and approving or disapproving responses, moralizing, or implying one's own values. These responses imply that the client must think as the nurse thinks, fostering client dependence.
‘’That's good (bad).”
“You should not do that.”
“That's not good enough.”
“What you did was wrong (right).”
Giving common advice
Telling the client what to do. These responses deny the client's right to be an equal partner. Note that giving expert rather than common advice is therapeutic.
Client: “Should I move from my home to a nursing home?”
Nurse: “If I were you, I did go to a nursing home, where you will get your meals cooked for you.”
 
NURSING DOCUMENTATION AS EFFECTIVE COMMUNICATION
Documentation of clients care and their responses to that care is essential for effective communication of clients status between health care providers. When such documentation is complete, accurate, and clearly understood by all health care professionals involved in providing the care, the quality of clients’ care is improved. Although the primary purpose of documenting care in clients records is for communication between health care providers so that they can plan appropriate care, there are other uses of the information provided in clients’ records: (1) auditing for quality assurance, (2) research, (3) education, (4) reimbursement, (5) legal documentation, and (6) health care analysis.
  • Auditing for quality assurance: The client record is used by accrediting organisations to review and evaluate the quality of care given in health care institutions.
  • Research: Information in a client record can be used as a source of data for health care research. Data gathered from the medical records of numerous clients with the same health problem may yield information about (1) the effectiveness of specific treatment methods, (2) the effectiveness of specific nursing interventions, or (3) specific client characteristics that enhance or impede the effectiveness of a specific treatment or intervention.
  • 24Education: Client records are used by students in the health professions as educational tools. Although textbooks provide generalised information about pathophysiology, signs and symptoms, usual treatment, and outcomes of a specific health problem, client records provide a comprehensive view of specific clients, their health problems, their medical treatments and nursing interventions, and their responses to the treatment and interventions. A client record provides a case study of the unique experience of one client with a specific health problem. This helps students understand the individual experience of the client with the health problem.
  • Reimbursement: Documentation of care helps the health care organisation receive reimbursement from third-party payers, including private insurance companies and governmental sources of reimbursement such as Medicare and Medicaid. Medicare requires that the client record must contain the correct diagnosis, related group codes and document that the appropriate care was given for the health care provider to receive payment.
  • Legal documentation: The client's record is considered a legal document that can be used as evidence in a legal action. Such a record is a major source of information about the care that a client received when there is an accusation of negligence or malpractice against a health care provider.
  • Health care analysis: In addition to being used by accrediting organisations to review the quality of care in a health care agency, client records can also help the health care agency analyze and plan the agency's needs. For example, analysis of client records can help the agency identify services that are underutilised or overutilised such as specific diagnostic studies or medications. This analysis can help the agency determine which services generate revenue and which cost the agency money.
 
Computers in Nursing Education
Just as computers have become standard instructional tools in the primary and secondary school systems, they are used extensively in all aspects of nursing education. Nursing programmes require computerised libraries, faculty members use technological teaching strategies in the classroom and for outside assignments, and academic record keeping is facilitated by data program.
In educational systems, computer-assisted instruction allows students to proceed at their own speed, provides immediate feedback, and allows dissemination of information to remote areas.
Computers enhance academics for both students and faculty in at least four ways. There include access to literature, CAI, classroom technologies, and strategies for learning at a distance.
Literature access and Retrieval: In our information age, it is a challenge to keep [abreast of the information on any subjects. Computers have significantly improved our abilities in this area by presenting catalogues and text of materials in a way that can be searched systematically. Previously, users needed to leaf through multiple collections of printed indexes, one keyword or topic at a time. Now continuously updated cumulative indexes of related materials can be searched electronically in a fraction of the time. These bibliographic retrieval systems may be stored on CD-ROM or on a mainframe computer that can be accessed online. The searcher can specify the recency, language, document type, and other characteristics of the citations for desired materials. Once a list of search matches is displayed on the computer screen, users can select all or certain citations and either print them or store them on their own local computers. Search results can include journals and other magazines, 25books, videotapes, computer programmes, dissertations, or other documents. Following lists are commonly used bibliographic systems and databases:
Acquired Immune deficiency Syndrome information online (AIDS LINE)
CANCER literature (CANCER LIT)
Cumulative Index to Nursing and Allied Health Literature (CINAHL)
Educational Resources Information Center (ERIC)
Medical Literature Analysis and Retrieval System (MEDLARS)
Mental Measurements Yearbook
Psychological Abstracts (Psych INFO)
In addition to searching lists of documents, actual complete publications and materials are available in computerised formats. These include medical textbooks, the full text of journals, drug references, digitised X-rays or scans, and graphics including clip art. Through the internet and the world wide web, both classic and the most current information can be found on any topic. Users can access statistics from the Centres for Disease Control and Prevention, census data, and the National Library of Medicine.
Computer Assisted Instruction: Nursing has enjoyed the computers revolution in the form of computer-assisted instruction (CAI). Dozens of software programmes help nursing students and nurses learn and demonstrate learning. These have been created by individuals, educational institutions, technology companies, or print publishers. Programmes over topics form drug dosage calculations to ethical decision making and are classified according to format, tutorial, drill and practice, simulation, or testing. CAI can contain diagrams, graphics, animation, video, and audio. A variation of CAI is interactive videodisc, which combines full motion and sound video with text on a laser videodisc, controlled by the user through the computer. CAI programme and can be designed to branch to different sections depending on the users response.
Tutorials on electrocardiogram (ECG, EKG) interpretation, drug interactions, and legal aspects of nursing are examples of these programmes. At some schools, faculties author their own programmes to meet the unique needs of their students. Course syllabi that contain worksheets or activities students can complete on the computer may be distributed on disk, through the college network, or via internet. Students who become familiar with CAI will also find that they have an easier time adjusting to the software programmes, many employers requires them to complete for annual c competency testing mandated by accrediting bodies in certain areas (e.g. bloodborne pathogens and fire safety). Completion of CAI programmes may also be an acceptable means of demonstrating continuing education activities required for license renewal.
Classroom Technology: Most new educational buildings are wired to accommodate technology. This includes adequate electric outlet for students to plug in laptop computers and wiring (or wireless technology) for network or internet access. For the faculty, projectors and liquid crystal display (LCD) panel that allow computer screens to be displayed to the entire classroom are becoming standard. These enhancements allow faculty to use the full text, motion, and audio capabilities of computers instead of over head transparencies, slides, or writing on the board.
Distance Learning: Computers allow people to communicate effectively across large distances. This technology is extended to nursing education where students at satellite sites participate in educational experiences. There are several different models of distance learning. In one model, the students receives course materials, communicates with the faculty and other students, and submits assignments completely through the mail, phone or fax, e-mail, website, and electronic “dropbox” (a server folder accessible from the Internet). This may be referred 26to as an asynchronous mode because the persons involved are not interacting at the same “real” time. Another model of distance education involves groups of students in classrooms at different education involves groups of students in classroom session through two-way audio and video transmission. Computers are used to code and decode the sounds and visuals for transmission. Students who are not the site where the faculty member is located can also communicate via voice-activated microphones or response pads. These pads have buttons that permit the students to indicate that they wish to ask a question or even to respond to multiple choice test questions. As computer technology becomes more cost effective and increases its transmission quality, it is anticipated that more schools will use distance learning strategies to reach students around the globe.
Testing: The computer is ideal for conducting certain types of learning evaluations. Surveys can be completed online, including anonymous questionnaires. For testing, large banks of potential items can be written and the computer can generate different exams for each student depending on the selection criteria designated by the faculty. In addition, the students answers can be scored electronically and the overall exam results analysed quickly. In 1994, the National Council Licensure Examination for RNs in the United States (NCLEX-RN) moved form paper and pencil tests to computer tests. Applicants can complete the computerised exam in less than 5 hours compared to 2 days for the written exam, test results are available in about half the time, and exams can be taken at the applicants convenience as opposed to two scheduled sessions each year. The computer determines if the applicant passed the examination by using a scoring algorithm that ensures all required competencies have been evaluated fairly.
Student and Course Record Management: Computers are also very useful for maintaining results of students grades or attendance using spreadsheets. Often faculty are able to scan student exam answer sheets directly into a grade a book on the computer. The programme can then calculate percentages, sort student scores in order, and print results for both students and faculty. Grades from multiple exams plus scores on essays or other projects are calculated into final grades.
Students are frequently asked to evaluate faculty and course using machine readable forms. These data are also scanned into the computer so that cumulative results can be calculated and stored. Such data can be compared later across different course, faculty, and terms. That is an example of what is called data warehousing- the accumulation of large amounts of data that are stored overtime and can be examined for output in different types of reports (Charts and Tables).
Most schools now have all student record on computer. From the students initial application to the nursing programme through graduation, the registrar's office keeps track of names, addresses, courses taken, grades, and all other pertinent students data. Students may also be able to sign up for classes, check their tuition bills, and see their transcripts on computer terminals on campus or at home. These capabilities are making it much easier for programmes to collect and report data for accreditation and internal evaluation purposes.
 
Computers in Nursing Administration
Many activities of the registered nurse involve collecting, recording, and using data. Computers are well suited to assist the nurse in these functions. Specifically, the nurse records client information in computer records that replace or supplement the written medical record, access other departments information on the client form centralised computers, use computers to manage client scheduling, and use programmes for unique applications such as home health nursing and case management.
27Documentation of client status and Medical Record Keeping: How might a computer assist individual nurses with their daily activities? In the typical 8 hour day of a nurse providing direct client care, as much as one-third of the time is spent trying to access data about the client that may be somewhere in the medical record or elsewhere in the health care agency. Nurses need access to standardize forms, policies, and procedures. Also, nurses need to be able to gather broader client information such as length of stay for specific diagnoses. Computers can assist with each of these.
Bedside Data Entry: Several different types of computers and systems are designated as bedside data entry or bedside terminals. These allow recording of client assessments, medication administration progress notes, care plan updating, patient acuity, and accrued charges. The terminal can be fixed or hand held, and hardwired to the central system or cordless with the ability to transmit the data to distant sites, such as from the client's home to the agency office. A slightly different type of bedside terminal is the point of care or point of service computer. In this case the terminal is located near, but not necessarily at the client.
Computer-based patient records: Computer-based patient records (CPRs) or electronic medical records (EMRs) permit electronic client data retrieval by care givers, administrators, accreditors, and other persons who required the data. The computer based Patient Record Institute, established in 1992, identified four ways the CPR could improve health care; (a) constant availability of client health information across the life span. (b) ability to monitor quality, (c) access to warehoused (stored) data, and (d) ability for clients to share in knowledge and activities influencing their own health.
Because of the way computers provide access to the CPR, providers can easily retrieve specific data such as trends in vital signs. Immunisation records, and current problems. The systems can be parameters that indicate dangerous conditions. Sophisticated systems can also allow replay of audio, graphic, or video data for comparison with current status. All text is legible and can be searched for keywords.
There are several areas of concern wit CPRs. Maintain privacy and security of data is a significant issue. One easy that computers can protect data is by the use passwords- only those persons who have a legitimate need to access the data receive the password. Additional policies and procedures for protecting confidentially of CPRs are evolving as the use of computers systems becomes more widespread. Following several previous reports, the ANA developed a position statement on privacy, confidentially of medical records, and the nurses role. One role of the nurse informaticist, and expert who combines computer, information, and nursing science, is to develop policies and procedures that promote effective use of computerised records by nurses and other health care professionals.
Another concern is the diverse system setups offered by manufactures and used by health care agencies. To get the greatest benefits from the computer's ability to manage and report data between institutions requires using one set of terms and a standardised organisation of database records. Currently, there are no national standards for CPRs: not for the specific data that should be included nor for how the record should be organised. Nurse will need to be involved in the design, implementation, and evaluation of CPRs to maximize their use and effectiveness.
Data Standardization and Classifications: There are many reasons why nursing would benefit from standard classifications of terms used to describe and measure clinical, nursing to be recognised for the value it add to client well being requires research –based findings showing client improvement by accepted standards. This requires agreement to use common, consistent, clear, and rule-based standards.
Standards for clinical data such as laboratory test results and their documentation in the CPR have been proposed. Disease classification standards are in use in a variety of forms. 28The most common are the World Health Organization's International Classification of Diseases (ICD – 9 and ICD-10); the World Organisation of National Colleges International Classification of Primary Care (ICPC); the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM).
In nursing also, classifications or taxonomies have been developed. The Nursing Minimum Data Set (NMDS) contains 16 elements of nursing data, along with their definitions, in three categories: nursing care, client demographics, and service. The NMDS can be used for data collection and documentation and allows sharing of information regarding the quality, cost, and effectiveness of nursing. In addition, the International Council of Nurses has proposed an International Classification for Nursing Practice, a common language for describing nursing problems (or diagnoses), interventions, and outcomes. It may take years to determine which standards will allow optimal access to and manipulation of computerised records.
Tracking Clients Status: Once a CPR has been established, the nurses can retrieve and display a client's physiologic parameters across time. In addition to the rather straightforward viewing of trends in vital signs, for example, the nurses can also track more global client progress. Standardised nursing care plans, care maps. Critical pathways, or other prewritten treatment protocols can be stored in the computer and easily placed in the CPR electronically. Then the nurse and other health care personnel can examine progression and variance from the expected plan directly on the computer.
The role of nursing in privacy and confidentiality related to access to electronic data.
Advances in technology have led to the development of computerised medical databases and telehealth systems and have raised serious concerns about patient privacy and the confidentiality of health care information. Threats to confidentiality of medical records and health care information affect the kinds of care that patients seek and potentially undermine the relationship of trust between health professionals and patients that is essential to quality health care. Nursing play a critical role in preserving patient privacy and confidentiality and should participate in the ongoing debate about and development of federal laws designed to ensure patient privacy/confidentiality.
In keeping with the nursing profession's commitment to patient advocacy and the trust that is essential to the preservation of the high quality of care patients have come to expect from nurses, the nurses association supports the following principles with respect to patient privacy and confidentiality:
  • A patient's right to privacy with respect to individually identifiable health information, including genetic information, should be established statutorily. Individuals should retain the right to decide to whom, and under what circumstances, their individually identifiable health information will be disclosed. Confidentiality protections should extend not only to health records, but also to all other individually identifiable health information, including genetic information, clinical research records, and mental health therapy notes.
  • Use and disclosure of individually identifiable health information should be limited.
  • A patient should have the right to access his or her own health information and the right to supplement such information so that they are able to make informed health care decisions, to correct erroneous information, and to address discrepancies that they perceive.
  • Patients should receive written, easily understood notification of how their health records are used and when individually identifiable health information is disclosed to third parties.
  • The use or disclosure of individually identifiable health information absent an individuals informed consent should be permitted only if a persons life is endangered, if there is a threat to the public, or if there is a compelling law enforcement need. In the case of such exceptions, information should be limited to the minimum amount necessary.
  • 29Appropriate safeguards should be developed and required for the use, disclosure and storage of personal health information.
  • Legislative or regulatory protections on individually identifiable health information should not unnecessarily impede public health efforts or clinical, medical, nursing or quality of care research.
  • Strong and enforceable remedies for violations of privacy protections should be established, and health care professionals who report violations should be protected from retaliation.
  • Federal legislation should provide a floor for the protection of individual privacy and confidentiality rights, not a ceiling. Federal legislation should not preempt any other federal or state law or regulation that offers greater protection.
Besides computers designed for record keeping, other computers are used extensively in health care to assess and monitor client's conditions. The data accumulated from various electronic devices can be part of the CPR and also stored for research purposes. Electronic records take up much less space than paper records and may be stored more securely. Copies can be made easily onto different electronic media (e.g., magnetic tape, microfiche) that tend to be more compact and durable that paper. Data can also be transmitted to a consulting specialist in another location.
Client Monitoring and Computerised Diagnostics: Nursing have benefited greatly from the myriad of client monitors. Examples in every day practice are the digital or tympanic thermometers, digital scales, pulse oximetry, ECG/telemetry/haemodynamic monitoring, apnea monitors, feral heart monitors, blood glucose analysers, ventilators, and intravenous (IV) pumps. These instruments can be used in any care setting, from intensive care to the home. Most keep a record of the most recent values. Some can transmit their data to a more sophisticated computer or print out a paper record. Some have digital displays that ‘talk” to the user, giving instructions or results. Most also have error detection or alarms that indicate either that the instruments is malfunctioning or that the assessed value is outside predetermined parameters. These devices, with their minute but powerful computer chips, make it possible to extend the nurse's observations and provide valid and reliable data.
In various specialty areas of health care, clients undergo diagnostic procedures in which computers play a major role. Computerised axial tomography (CAT) scans and magnetic resonance imaging (MRI) use computers extensively to perform tests and analyse the finding. Blood gas analysers, pulmonary functions test machines, and intracranial pressure monitors all use computers processing. All of these can be linked directly to store data in the CPR. There are many more examples of ways that computers assist us in monitoring and diagnosing client conditions.
Telemedicine/Telehealth: One of the most exciting areas being developed in computer assisted health care is telemedicine. Telemedicine uses technology to transmit electronic data about clients to persons at distant locations. In one example, two-way audiovisual communication allows an international expert to examine and consult on a client's case from thousands of miles away. X-rays, scans, stored computer data, and almost anything imaginable can be “sent” using computers. Another example is the ability for a few providers to provide primary health care to people living in remote areas using the kinds of monitors described previously plus telephone, fax, and other relatively simple equipment in the client's home.
Concerns regarding telehealth relate to legal and ethical issues. Who has responsibility for the client when a teleconsult is used? Does the care providers need to be licensed in the state or province where the client's primary care is given? The National Council of State Boards of Nursing has declared that the applicable regulations are those for where the patient resides and not where the provider is located. This is also one of the reasons for the initiation 30of the mutual recognition (Compact that boards of nursing are promulgating to facilitate nurse licensure in several states). How is the client's privacy protected? HIPAA and several other projects are under way to answer these questions and to determine the most effective designs for telehealth programs.
Practice Management: Beyond direct client care, computers also assist nurses in many ways in the management of their work. In hospitals, data terminals are commonly used to order supplies, tests, meals and services from other departments. Tracking of these orders allows the nursing services to determine the most frequent or most costly items used by a particular nursing unit. This information may lead to decisions to modify a budget, provide different staffing, move supplies to a different location, or make other changes for more efficient and higher quality care.
Computers are used extensively for scheduling. Client appointments can be easily entered or changed. Special notes or tags can be applied to the appointment as a reminder to the provider to perform particular services. The schedule for a single day can be printed so that all personnel have a copy. Staffing patterns must also be coordinated. Special requests for days off or continuing education classes can be entered and the schedule can be viewed for a day, week, month, or year.
Each practice needs to keep track of procedures health care workers perform, client diagnoses, and time spent with clients so that billing can be accurate. With managed care, information tracking is also aimed at determining trends in health problems and the need for providers with specific skills. The use of computerised databases filled with unique codes for each medication, medical and nursing diagnoses, treatment and supply allows for accurate and timely management of these data.
Specific applications of computers in nursing practice: As previously described, numerous systems are in use for collecting and classifying the various types of data used in nursing practice. Some of these systems have been found particularly useful in specific settings.
  • Community and home health: Computer networks are being used in innovative ways in home settings. A computer terminal placed in a high-risk client's or family's home allows them to access information on a variety of topics, search the internet, or e-mail a health care provider with questions or concerns. Clients can be also record data about their health status that can be transmitted to the health care provider at the central network computer. Examples that have been successful using this approach include monitoring women at risk for preterm labour, persons with AIDS, and Alzheimer's patients. Home alert systems that allow the client to signal the base station in an emergency are also widely used.
    Nurses who visit clients in their homes are using notebook computer systems to record assessments and transmit data to the main office. Similar systems have been developed for nursing students in community health courses to communicate with their faculty.
  • Case management: Case managers must be able to track a group of clients the caseload. Software programmes allow the case manager to enter client data and integrate this with predesigned care tracking templates. In addition, the case manager must keep abreast of the latest regulations affecting eligibility for health care benefits, the reporting requirements of the payer agencies, and detailed facts about the variety of services providers the client may need to access. All of these data can be placed in integrated computer software programmes (Finally, the case manager must document quality; that is demonstrate client outcomes related to dollars spent).