What Is communication?

a process by which information is exchanged between individuals through a common system of

symbols, signs, or behavior. Interpersonal communication is a transaction between the sender
and the receiver. In the transactional model of communication, both participants simultaneously
perceive each other, listen to each other, and are mutually involved in creating meaning in a
relationship.

Impact of preexisting conditions

In every interpersonal exchange, both the sender and receiver impacts both the intended
message and exchange as well as how it is interpreted. One's value system, internalized
attitudes and beliefs, culture or religion, social status, gender, background knowledge and
experience, and age or developmental stage are a few examples of these factors. The type of
atmosphere in which the communication occurs could also have an impact on how the deal
turns out.

1. Values, Attitudes and Belief

Values, attitudes, and beliefs are learned ways of thinking. It is an individual belief that motivates
people to act one way or another, they serve as a guide for human behavior. Values, attitudes,
and beliefs can influence communication in numerous ways.expressed verbally through
negative stereotyping. One’s value system may be communicated with behaviors that are more
symbolic in nature.

2. Culture or religion
Communication has its roots in culture. Culture is the basis for thinking, cultural values are
learned and differ from society to society.

3. Social status
Studies of nonverbal indicators of social status or power have suggested that high-status
persons are associated with gestures that communicate their higher power position.

4. Gender
Gender influences the manner in which individuals communicate. Most cultures have gender
signals that are recognized as either masculine or feminine and provide a basis for
distinguishing between members of each gender.

5. Age or Developmental Level

Age influences communication and it is never more evident than during adolescence. In their
struggle to separate from parental confines and establish their own identity, adolescents
generate a unique pattern of communication that changes from generation to generation. Words
such as dude, groovy, clueless, awesome, cool, and wasted have had special meaning for
certain generations of adolescents. Developmental influences on communication may relate to
physiological alterations.
 6. Environment
The place where the communication occurs influences the outcome of the interaction.
Territoriality, density, and distance are aspects of the environment that communicate messages.
Territoriality is the innate tendency to own space. Individuals lay claim to areas around them as
their own.

Territoriality, density, and distance are aspects of the environment that communicate messages.

a. Territoriality is the innate tendency to own space, Individuals lay claim to areas around
them as their own.

b. Density refers to the number of people within a given environmental space. It has been
shown to influence interpersonal interaction. Some studies indicate that a correlation
exists between prolonged high-density situations and certain behaviors, such as
aggression, stress, criminal activity, hostility toward others, and a deterioration of mental
and physical health.

c. Distance is the means by which various cultures use space to communicate. Hall (1966)
identified four kinds of spatial interaction, or distances, that people maintain from each
other in their interpersonal interactions and the kinds of activities in which people engage
at these various distances.

● Intimate distance is the closest distance that individuals will allow between themselves
and others.

● Personal distance is approximately 18 to 40 inches and reserved for interactions that

are personal in nature, such as close conversations with friends or colleagues.

● Social distance is about 4 to 12 feet away from the body. Interactions at this distance
include conversations with strangers or acquaintances, such as at a cocktail party or in a
public building.
Nonverbal Communication
● 70% to 80% of effective communication is nonverbal.
● This includes physical appearance and dress, body movement and posture, touch, facial
expressions, eye behavior, and vocal cues or paralanguage.
● Nonverbal messages vary from culture to culture.

a. Physical Appearance and Dress

● Physical appearance and dress are part of the total nonverbal stimuli that
influence interpersonal responses and, under some conditions
- They are primary determinants of these responses.
● Body coverings—both dress and hair—are manipulated by the wearer in a
manner that conveys a distinct message to the receiver.
● It can be formal or casual, stylish or unkempt.
● Hair can be long or short, and even the presence or absence of hair conveys a
message about the person.
● Other body adornments can also be a potential communicative stimuli.
-ex. Makeup, eyeglasses, pins
b. Body Movement and Posture
● This is the way an individual positions his or her body.
● Reece and Whitman (1962) identified response behaviors that were used to
designate individuals as either “warm” or “cold” persons.
- Individuals who were perceived as warm responded to others with a shift
of posture toward the other person, a smile, direct eye contact, and hands
that remained still.
- Individuals who responded to others with a slumped posture, by looking
around the room, drumming fingers on the desk, and not smiling were
perceived as cold.
c. Touch
● A powerful communication tool.
● According to Knapp & Hall, touch can be categorized according to the message
communicated.
a. Functional-Professional
- is impersonal and businesslike. It is used to accomplish a task.
- Ex. Nurse having physical assessment
b. Social-Polite
- This type of touch is still rather impersonal, but it conveys an
affirmation or acceptance of the other person.
- Ex. handshake
c. Friendship-Warmth
- Touch at this level indicates a strong liking for the other person, a
feeling that he or she is a friend.
- Ex. laying one’s hand on the shoulder
 d. Love-Intimacy
- This type of touch conveys an emotional attachment or attraction
for another person.
- Ex. strong, mutual embrace
e. Sexual Arousal
- Touch at this level is an expression of physical attraction only.
- Ex. touching another in the genital region.
● Some cultures encourage more touching of various types than others.
- “Contact cultures” (e.g.,France, Latin America, Italy) use a greater frequency of
touch cues than do those in “noncontact cultures”(e.g., Germany, United States,
Canada)
d. Facial expressions
● Primary source of communication
● Reveals the emotional states (happiness, sadness, anger, and fear)
● Face is a complex multi message system
● These expressions can complement and qualify other communication behaviors.

e. Eye behavior
● Eyes have been called the “windows of the soul.”
● An interpersonal connection occurs through eye contact.
● person. Eye contact indicates that the communication channel is open, and it is
often the initiating factor in verbal interaction between two people.
● Eye behavior is regulated by social rules.
- These rules dictate where, when, for how long, and at who we can look.
Staring is often used to register disapproval of the behavior of another.
 ● Gazing at another’s eyes arouses strong emotions.
- Thus, eye contact rarely lasts longer than 3 seconds before one or both
viewers experience a powerful urge to glance away. Breaking eye contact
lowers stress levels
-
f. Vocal cues or Paralanguage
● The gestural component of the spoken word.
● It consists of pitch, tone, and loudness of spoken messages; the rate of speaking;
expressively placed pauses; and emphasis assigned to certain words.
● Vocal cues greatly influence the way individuals interpret verbal messages.
messages.
- A normally soft-spoken individual whose pitch and rate of speaking
increases may be perceived as being anxious or tense.
● Different vocal emphases can alter interpretation of the message.

Therapeutic Communications
Caregiver verbal and nonverbal techniques that focus on the care receiver’s needs and
advance the promotion of healing and change. Therapeutic communication encourages
exploration of feelings and fosters understanding of behavioral motivation. It is nonjudgmental,
discourages defensiveness, and promotes trust.

❖ Therapeutic Communication Techniques

Hays and Larson (1963) identified a number of techniques to assist the nurse in
interacting more therapeutically with clients. These are important “technical procedures” carried
out by the nurse working in psychiatry, and they should serve to enhance development of a
therapeutic nurse-client relationship.

TECHNIQUE EXPLANATION/RATIONALE EXAMPLES

Using silence Gives the client the

opportunity to collect and
organize 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 “Yes, I understand what you

reception and regard. said.” Eye contact; nodding.

Giving Recognition Acknowledging and indicating “Hello, Mr. J. I notice that you
awareness; better than made a ceramic ashtray in
complimenting, which reflects OT.” “I see you made your
the nurse’s judgment. bed.”

Offering Self Making oneself available on “I’ll stay with you awhile.” “We
 an unconditional basis, can eat our lunch together.”
increasing client’s feelings of “I’m interested in you.
self-worth.

Giving Broad Openings
Allows the client to take the “What would you like to talk
initiative in introducing the about today?” “Tell me what
topic; emphasizes the you are thinking.”
importance of the client’s role
in the interaction.

Offering General Leads Offers the client “Yes, I see.” “Go on.” “And
encouragement to continue. after that?”

Placing the event in time or Clarifies the relationship of “What seemed to lead up to .
sequence events in time so that the . .?” “Was this before or after
nurse and client can view . . .?” “When did this
them in perspective. happen?”

Making observations Verbalizing what is observed “You seem tense.” “I notice

or perceived. This you are pacing a lot.” “You
encourages the client to seem uncomfortable when
recognize specific behaviors you . . .”
and compare perceptions
with the nurse.

Encouraging description of Asking the client to verbalize “Tell me what is happening

perceptions what is being perceived; often now.” “Are you hearing the
used with clients voices again?” “What do the
experiencing hallucinations. voices seem to be saying?”

Encouraging comparison Asking the client to compare “Was this something like . .
similari- ties and differences .?”
in ideas, experi- ences, or “How does this compare with
interpersonal relationships. the time
This helps the client when . . .?”
recognize life experiences “What was your response the
that tend to recur as well as last time this
those aspects of life that are situation occurred?”
changeable.

Restating Repeating the main idea of Cl: “I can’t study. My mind

what the client has said. This keeps wandering.”
lets the client know whether Ns: “You have trouble
or not an expressed concentrating”
statement has been Cl: “I can’t take that new job.
understood and gives him/her What if I can’t do it?”
the chance to continue, or to Ns: “You’re afraid you will fail
clarify if necessary. in this new position.”

Reflecting Questions and feelings are Cl: “What do you think I

referred back to the client so should do about my wife’s
 that they may be recognized
and accepted, and so that the
client may recognize that
his/her point of view has
value - a good technique to
use when the client asks the
nurse for advice
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 a client who is
very anxious. Focusing
should not be pursued until
the anxiety level has
subsided.
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
Seeking Clarification and Striving to explain that which
Validation is vague or incomprehensible
and searching for mutual
understanding. Clarifying the
meaning of what has been
said facilitates and increases
understanding for both client
and nurse
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.
drinking problem?”
Ns: “What do you think you
should do?”
Cl: “My sister won’t help a bit
toward my mother’s care. I
have to do it all!”
Ns: “You feel angry when she
doesn’t help”
“This point seems worth
looking at more closely.
Perhaps you and I can
discuss it together”
“Please explain that situation
in more detail”
“Tell me more about that
particular situation”
“I’m not sure that I
understand. Would you
please explain?”
“Tell me if my understanding
agrees with yours”
“Do I understand correctly
that you said…?”
“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 Doubts Expressing uncertainty as to
the reality of the client’s
perceptions; often used with
clients experiencing
delusional thinking
“I understand that you believe
that to be true, but I see the
situation differently.”
“I find that hard to believe (or
accept)”
“That seems rather doubtful
to me.”

Verbalizing the Implied
Putting into words what the
client has only implied or said
indirectly; 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.
Cl: “It’s a waste of time to be
here. I can’t talk to you or
anyone.”
Ns: “Are you feeling that no
one understands?”
Cl: (Mute)
Ns: “It must have been very
difficult for you when your
husband died in the fire”

Attempting to Translate When feelings are expressed Cl: “I’m way out in the ocean”
Words into Feelings indirectly, the nurse tries to Ns: “You must be feeling very
“desymbolize” what has been lonely right now”
said and to find clues to the
underlying true feelings.

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 TECHNICQUES
There are several Nontherapeutic Communication Techniques identified by Hays and
Larson, being able to identify and eliminate the use of these patterns in their relationship of the
nurses with their clients will maximize the effectiveness of communication and enhance the
nurse-client relationship.

NON-THERAPEUTIC COMMUNICATION TECHNIQUES

TECHNIQUE EXPLANATION/RATIONALE EXAMPLES

Giving Reassurance May give the patient the idea “I wouldn’t worry about that if
that you are invalidating their I were you.” “Everything will
feelings; may also discourage be all right.” Better to say:
the client from expressing “We will work on that
 their feelings in the future.
Rejecting Refusing to consider or
showing interest to hear the
client’s ideas or behavior.
This may result for client to
discontinue interaction with
the fear of rejection from the
nurse in the future.
Approving or disapproving This implies that the nurse
has a right to pass judgement
of the client’s behavior or
ideas and set them as “good”
or “bad”. The client may
expect to please the nurse to
seek acceptance.
Agreeing or disagreeing This implies that the nurse
has a right to pass judgement
of the client’s behavior or
ideas and set them as “right”
or “wrong”. Agreement
prevents the client from
modifying their own point of
view without admitting error.
Disagreement provokes the
need for defensiveness.
Giving advice It prevents the client from
independent thinking by
implying that the nurse what
is best for them though telling
the client what to do or how
to behave.
Probing This pressures the client to
answer issues they are not
ready to answer or discuss by
persistent questioning of the
nurse.
Defending This may lead the client to “No one here would lie to
feel that he or she has no you.” “You have a very
right to express their ideas, capable physician. I’m sure
together.”
Let’s not discuss . . .” “I don’t
want to hear about . . .” Better
to say: “Let’s look at that a
little closer.
That’s good. I’m glad that you
. . .” “That’s bad. I’d rather
you wouldn’t . . .” Better to
say: “Let’s talk about how
your behavior invoked anger
in the other clients at dinner.
That’s right. I agree.” “That’s
wrong. I disagree.” “I don’t
believe that.” Better to say:
“Let’s discuss what you feel is
unfair about the new
community rules.
“I think you should . . .” “Why
don’t you . . .” Better to say:
“What do you think you
should do?” or “What do you
think would be the best way
to solve this problem?
“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 . . .” Better technique:
The nurse should be aware of
the client’s response and
discontinue the interaction at
the first sign of discomfort.
 opinions or feelings on a he only has your best
person or object. interests in mind.” Better to
say: “I will try to answer your
questions and clarify some
issues regarding your
treatment.

Requesting an explanation
Inquire with the client about "why do you think that" "why
the reasons for his or her do you feel this way"
thoughts, feelings, behavior, Better to say: describe what
and events. Asking a client you were feeling just before
"why" he did something or that happened
feels a certain way can be
scary since it suggests that
the client must defend his
actions or sentiments.

Indicating the existence of
an external source of
power
Attributing the cause of one's
thoughts, feelings, and
behavior to others or external
forces. This encourages the
client to blame others for his
ideas and behaviors rather
than embracing personal
responsibility.
"what makes you say that"
"what made you do that"
Better to say: you became
angry when your brother
insulted your wife"

Falsely reassuring
Undervalues and dismisses "I wouldn't worry about that."
the patient's feelings and "Everything will be all right."
worries. "You will do just fine; you'll
If the patient believes he or see."
she will be ridiculed or not
taken seriously, he or she
may refrain from disclosing
feelings.

Changing the subject
It is possible that the patient's
feelings and needs may be
dismissed. Can make the
client feel alienated and
alone, as well as worsen
feelings of despondency.
Patient: "I'd like to die."
Nurse: "Did you go to
Alcoholics Anonymous like
we discussed?"
Active Listening
● Active listening involves paying close attention to the client's verbal and nonverbal cues.
● Trust is increased when a nurse actively listens to the patient and conveys acceptance
and regard for them
● Numerous nonverbal actions have been identified as attentive listening facilitative skills.
The acronym SOLER serves to identify those on this list:
○ S - Sit squarely facing the client.
○ O - Observe an open posture
○ L - Lean forward toward the client
○ E - Establish eye contact.
○ R - Relax

Process recording
● Are written reports of verbal interactions with clients and used as a tool for improving
interpersonal communication techniques.
● It usually includes the verbal and nonverbal communication of both the nurse and the
client
● It also provides a means for the nurse to analyze both the content and the pattern of the
interaction, which is why this is intended to be used as a learning tool for professional
development and not as documentation.
Feedback
- A method of communication for helping the client consider a modification of behavior. It
gives information to clients about how they are being perceived by others.
Criteria for a useful feedback:
● Should be descriptive rather than evaluative and focuses on the behavior rather than on
the client
● Should be specific rather than general. Information that gives details about the client’s
behavior can be used more easily than a generalized description for modifying the
behavior.
● Should be directed toward behavior that the client has the capacity to modify
● Should impart information rather than offer advice
● Should be well timed. Feedback is most useful when given at the earliest appropriate
opportunity following the specific behavior.