The important nonverbal skill of a nurse during client interview & history taking must be

Effective verbal communication is the bedrock of high-quality, patient-centered care. Healthcare providers undoubtedly are aware of the continued emphasis and importance placed on verbal communication through various quality measures and standards. However, good nonverbal communication — facial expressions, gestures, eye contact, posture, and tone of voice — also is essential. Research suggests that the majority of daily communication is nonverbal, which stresses the importance that this aspect of communication plays in human interactions.1

The ability to understand and use nonverbal communication, or body language, is a powerful tool that can help healthcare professionals connect with patients in a positive way and reinforce mutual understanding and respect.2

Providers should have situational awareness of their nonverbal communication so they can recognize potentially problematic body language and consciously change it. For example, certain situations might trigger negative nonverbal reactions, such as seeing a difficult patient, managing a patient complaint, or dealing with stress. A number of strategies can help healthcare providers consciously improve nonverbal communication. For example:

• Smile and maintain appropriate eye contact, but do not stare.
• Show interest in what the patient is saying and avoid tapping your fingers, gazing out of the window, looking at the clock, yawning, and other nonverbal actions that might indicate that you're bored or in a hurry.
• Sit when you can, and lean forward to show that you're engaged. Don't stand looking down on the patient in a paternalistic stance.
• Nod your head to show you are listening.
• Maintain an open and relaxed posture and avoid crossing your arms or other gestures that might suggest unwillingness to listen, disapproval, or a judgmental attitude. Encourage the patient to share relevant and complete information.3

The use of technology also can result in nonverbal cues that might frustrate or alienate patients. Providers should take care to avoid habits associated with electronic health records (EHRs) that create barriers to patient engagement, such as turning your back on the patient while typing information, looking at the computer during sensitive discussions, or failing to explain to the patient what you’re including in the record. Some strategies that might help include explaining the EHR and some of its benefits to the patient, setting the computer aside during discussions with the patient, or using a scribe to document the clinical encounter.

For more communication techniques and guidance, see MedPro's Communicating Effectively With Patients to Improve Quality and Safety guideline.

Endnotes

1 Thompson, J. (2011, September 30). Is nonverbal communication a numbers game? Psychology Today. Retrieved from www.psychologytoday.com/us/blog/beyond-words/201109/is-nonverbal-communication-numbers-game

2 Segal, J., Smith, M., Boose, G., & Jaffe, J. (2016, April). Nonverbal communication. Retrieved from www.helpguide.org/articles/relationships/nonverbal-communication.htm

3 Rogers, C. (2002, February). Your body language speaks loudly: Nonverbal communication makes patient more comfortable. The American Academy of Orthopaedic Surgeons. Retrieved from www2.aaos.org/acadnews/2002news/b16-7.htm

Learning Objectives

1.    Define communication and list the five components of communication.

2.    Discuss the three parts of the communication process.

3.    Explain rapport and its importance in nursing.

4.    Differentiate between verbal and nonverbal communication. Give examples of each.

5.    Discuss factors that influence the effectiveness of communication.

6.    Demonstrate the interviewing and communication skills of questioning, therapeutic silence, and clarifying.

7.    Demonstrate a teaching session for the clients of different age levels, clients with sensory problems, and clients who do not speak the same language as the nurse.

8.    Describe the relationships between communication and the nursing process.

Acronyms

NVC

ROI

Communication means the giving, receiving, and interpreting of information through any of the five senses by two or more interacting people. Therapeutic communication is an interaction that is helpful and healing for one or more of the participants; the client benefits from knowing that someone cares and understands, and the nurse derives satisfaction from knowing that he or she has been helpful. A nurse must have self-awareness and interpersonal skills to communicate therapeutically. Successful therapeutic communication encourages client coping and motivation toward self-care (Fig. 44-1).

Effective use of communication will play an important role in your nursing career and personal life. It is the foundation on which interpersonal relationships are built. The art of therapeutic communication does not come naturally; it must be learned. Pointers for using therapeutic communication are listed in the accompanying In Practice: Nursing Care Guidelines 44-1.

COMMUNICATION

Communication and the Nursing Process

Communication is related to the nursing process in many ways:

•    Problem-solving depends on individual and group communication.

•    The nurse must be able to collect client data accurately by paying attention to both verbal and nonverbal cues and information.

•    The statement of the nursing diagnosis must be clear and concise.

•    Planning involves accurate communication among all members of the healthcare team, as well as with the client and the family.

FIGURE 44-1 · This nurse uses principles of therapeutic communication when interacting with his client. He uses appropriate positioning (eye level), does not invade the client’s personal space, makes appropriate eye contact, and generally mirrors the client’s body position. He speaks and then carefully listens to what the client has to say.

•    During implementation of the nursing care plan, the nurse communicates with the client and family and communicates his or her impressions and observations to other members of the healthcare team.

•    Ongoing evaluation of the effectiveness of nursing interventions depends on clear and coherent communication among all persons concerned.

•    Client teaching and preparation for discharge depend on accurate and empathic communication and client understanding.

Without accurate and therapeutic communication, the nursing process cannot exist.

Personal characteristics of genuineness, caring, trust, empathy, and respect promote harmony among individuals. This feeling of harmony is called rapport. Conveying these attitudes to another person creates a social climate that communicates goodwill and empathy, even when fears or concerns cannot be fully expressed verbally. It is important to be able to provide unbiased nursing care. To be most helpful, the nurse develops the ability to convey a nonjudgmen-tal attitude, especially if another person’s beliefs and values differ from the nurse’s own. Clients must experience a feeling of rapport with the nurse in order to share personal, and sometimes embarrassing, information. The client and the nurse are working toward a common goal.

Key Concept In some cases, the nurse has the right to request a different assignment if he or she believes that working with this client may cloud professional judgment. For example, a nurse whose religion forbids abortion may request not to assist in the operating room with this procedure. The client has the right to his or her own beliefs and so does the nurse. In addition, it is usually advisable not to care for a family member or close friend.

IN PRACTICE :NURSING CARE GUIDELINES 44-1

USING THERAPEUTIC COMMUNICATION

The nurse who is using therapeutic communication will:

•    Put the client at ease and develop rapport.

•    Provide privacy

•    Respect the client’s rights.

•    Respect the client’s personal space.

•    Try to be at eye level with the client.

•    Use appropriate eye contact.

•    Be a good listener

•    Keep information confidential, as appropriate.

•    Begin the interview with general information and ask emotionally difficult questions after the client gains confidence and trust.

•    Adjust language level, as appropriate, for the client.

•    Not use complex medical terms or "talk down to” the client.

•    Ask an interpreter to assist, if the client speaks a language different from that of the staff or is hearing impaired.

•    Make sure interpreters are approved by the facility and certified before becoming involved in the client’s care.

•    Establish a communication system to be used if the client cannot speak or hear or if the client speaks a different language than the nurse (see Box 44-3).

•    Be attentive, and concentrate on what the person says.

•    Make appropriate and congruent eye contact.

•    Try not to write or use a computer during the interview. Pay close attention. Clarify details with the client later

•    Show sincere interest in the client’s responses.

•    Ask the client about his or her perceptions. Why did he or she come to the facility?

•    Pay attention to the client’s choice of words; any repetition; variations in tone of voice; silence; body language; assertiveness; repetitive behaviors; anxiety; and specific movements, such as tics or unusual speech patterns.

•    Determine if the client is confused or is not making sense.

•    Be careful in touching the client; assess the client’s attitudes or ask about touch before using that technique.

•    Include the family in conversations, if the client prefers. Be aware of client confidentiality at all times. If the client seems uncomfortable with others present, ask to speak to the client alone.

•    Consider the client’s cultural background and life experiences in all interactions and assessments.

NCLEX Alert When reading NCLEX questions relating to communication, look for the best possible and most beneficial response for the client. Therapeutic communication options typically differ from conversations that you have in a social setting.

Components of Communication

Communication requires several components (Fig. 44-2):

Sender: The originator or source of the idea

Message: The idea

Medium or channel: A means of transmitting the idea, which can be verbal or nonverbal

Receiver: The person who receives and interprets the message

Interaction: The receiver’s response to the message through internal feelings and verbal and nonverbal feedback

FIGURE 44-2 · Components in the process of communication. Communication can be carried out in person or by telephone, or by text messaging, alpha paging, AudioVox, Vocera transmission, or other electronic methods.

Think of communication as a reciprocal process in which both the sender and the receiver of messages participate simultaneously. All the senses can be involved in communication. We see and hear other people through conversations. Nurses sometimes touch others to express concern or care. The sense of smell or taste can also convey information. Sometimes, a combination of factors affects communication. For example, noise, a TV playing, or other people talking in the background can distort interactions. Conducting therapeutic communication in privacy or in a quiet area helps to avoid distractions that detract from its effectiveness.

NCLEX Alert The NCLEX options can provide examples of comments that you might make when caring for a client. Therapeutic communication skills, such as listening, restating, silence, and so forth, might be the best form of client care.

Types of Communication

Nurses communicate with clients often and in various ways. Two types of communication are verbal communication (using words) and nonverbal communication (using facial expressions, actions, and body position). Verbal communication is sometimes differentiated from oral communication. Effective communication occurs when words and actions convey the same message (congruency). This is essential for therapeutic communication to occur. When a “mixed message” is sent, communication is not effective or is confusing (Box 44-1).

Key Concept In general, verbal communication is used to communicate information. Nonverbal communication conveys feelings and attitudes. Nonverbal communication occurs whether we want it to or not.

Verbal Communication

Verbal communication is sharing information through the written or spoken word. Nurses use verbal communication extensively. They converse with clients, write care plans, document information and assessments, input data into the electronic record, and give oral or written change-of-shift reports.

Much verbal information is related through vocabulary, sentence structure, spelling, and pronunciation. People reveal their education, intellectual skills, interests, and ethnic, regional, or national background through verbal communication. Voice inflections and sounds reveal messages. Although a client may say what the nurse wants to hear, his or her tone of voice may imply a totally different meaning. (This is an example of noncongruency between verbal and nonverbal communication.) The person may make sounds that indicate true feelings. A snort, for example, may denote disgust.

Be aware that some responses stop the communication process. These blocks are called verbal barriers. Table 44-1 gives examples of such barriers and more effective responses that encourage further discussion.

Key Concept Remember that how you write or input data indicates information about you, as well as about the client. Try to use correct grammar and spelling in your documentation. This is particularly difficult when English is a second language for the nurse.

TABLE 44-1. Verbal Barriers

Characteristics of Speech. It is important to note the volume of the client’s speech. Speaking loudly may be culturally based. However, it may also indicate conditions, such as a hearing impairment, mania, or difficulty in speaking the language. Speaking softly may imply such things as nervousness, paranoia, shyness, or lack of self-confidence. This may also be a reflection of the client’s culture.

Consider also the rate and rhythm of the client’s speech. Speaking very fast may imply anxiety, mania, flight of ideas, or impatience. Speaking very slowly may be the result of a brain disorder, mental illness, or minimal knowledge of English. Medications can influence the client’s speech. Hesitation in speaking, thought-blocking, difficulty in finding words, or total aphasia may indicate that the client does not speak English well, has a brain disorder, or is hallucinating (seeing or hearing things that others do not perceive). These are just examples; many other factors influence a client’s speech patterns.

Aphasia is a defect in, or loss of, the ability to speak, write, or sign, or of the ability to comprehend speech and communication. Aphasia is usually caused by an injury or disorder of the brain’s speech centers or by a mental illness. Expressive aphasia refers to difficulty in speaking or in finding the correct or desired word. Receptive aphasia refers to a disorder of the brain that interferes with the comprehension or understanding of what one is hearing.

Listening. Thoughtful listening is a vital component of communication. The nurse learns a great deal about the client by carefully listening to what the person has to say. Listening skills also include paying attention to nonverbal cues exhibited by the client (see Fig. 44-1).

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