Communication Skills
‫الدكتور عبد المهدي عبد الرضا حسن‬
phD pediatric& Mental Health Nursing
The Communication Process
Communication That is what we try to do Speak to those near us
through:
Thought
Encoding
Decoding
The Communication Process cont’d..
Thought: First, information exists in the mind of the sender. This can be
a concept, idea, information, or feelings.
Encoding: Next, a message is sent to a receiver in words or other
symbols.
Decoding: lastly, the receiver translates the words or symbols into a
concept or information that he or she can understand.
The Communication Process cont’d..
During the transmitting of the message, two processes will be received
by the receiver: content and context.
Content
Is the actual words or symbols of the message which is known as
language.
The spoken and written words combined into phrases that make
grammatical and semantic sense.
We all use and interpret the meanings of words differently, so even
simple messages can be misunderstood.
Many words have different meanings to confuse the issue even more.
Context
Is the way the message is delivered and is known as Paralanguage.
It includes the tone of voice, the look in the sender's eye's, body
language, hand gestures, and state of emotions (anger, fear,
uncertainty, confidence, etc.) that can be detected.
Although paralanguage or context often causes messages to be
misunderstood as we believe what we see more than what we hear; they
are powerful communicators that help us to understand each other.
We often trust the accuracy of nonverbal behaviors more than verbal
behaviors.
Components of the Communication Process (or Model)
A sender – or encoder – person sending the message - can be verbal or
nonverbal.
A receiver - or decoder – gets the message.
A message – unit of information received.
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Message variables – verbal and nonverbal communication.
Verbal - is written and spoken – structural defects, malfunctioning due
to disease, auditory and verbal impairments, sensory deprivation,
overload or learning disabilities may affect or decrease accurate
communication. Examples: A schizophrenic person, a stutterer, a
mentally retarded or autistic person.
Voice pitch, voice quality (harsh, weak or strained), voice amplification
(soft or loud), words, grammar and understanding are included in
assessment.
Nonverbal - is gestures, facial expressions and dress and represents
65% of the communication. Examples of nonverbal behavior include:
crying, screaming, laughing, moaning, giggling and sighing, facial
expression, body posture, gait, tone of voice and gestures.
Space and territory are forms of nonverbal communication as well.
Personal space is the space preferred for interactions. Territory refers
to implied space such as a patient’s room or a specific seating
arrangement.
Intrusion or violation of these areas can distract or distort
communication.
Noise – sound interference can impair accurate transmission.
Communication skills – include being able to observe, listen, clarify and
validate by both sender and receiver.
Setting – where communication takes place.
Media – refers to sensory channels that carry the message – hearing,
sight, touch, taste and smell. Example: You get the message a patient
needs pain medication – you hear (hearing)complaints of pain, you see
(sight) tears in their eyes, they grasp (touch) your arm in pain.
Feedback – involves the continuous interpretation of response of the
sender and receiver as messages are simultaneously encoded and
decoded.
Environment – are the internal and external influences affecting the
communication process. External examples: room temperature, smells
and lighting. Internal examples: feeling cold, tired or experiencing pain
Therapeutic Communication Elements
Empathy – which is a communication skill and behavior.
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Attending – being with the patient both in physical and psychological
presence.
Observing
Listening
Communication Principles
Clarity: means that the meaning of the message is accurately
understood by both parties.
Continuity: promotes connection among ideas “and feelings, events, or
themes conveyed in those ideas”.
Communication Elements
Verbal.
Non verbal.
Verbal
10% of communication is approximately verbal.
It comprises all words a person speaks.
Can become misunderstood.
Keeping communication clear & congruent takes thoughts & insight.
Ensuring is what you mean to convey , & the message you send is the
same message that the other person receives.
Is a complicated skill.
Nonverbal
90% of our communication is non verbal.
Consist of the behaviors displayed by an individual.
Tone of voice &manner in which a person paces speech are examples of
nonverbal communication.
Other examples called cues such as eye contact, eye cast (emotion
expressed in the eyes), hand gestures, sighs, fidgeting & yawning.
Nonverbal Behaviors
To deliver the full impact of a message, use nonverbal behaviors to
raise the channel of interpersonal communication:
Eye contact: This helps to regulate the flow of communication. It signals
interest in others and increases the speaker's credibility. People who
make eye contact open the flow of communication and convey interest,
concern, warmth, and credibility.
Nonverbal Behaviors cont’d…
Facial Expressions: Smiling is a powerful cue that transmits happiness,
friendliness, warmth, and liking. So, if you smile frequently you will be
perceived as more likable, friendly, warm and approachable. Smiling is
often contagious and people will react favorably. They will be more
comfortable around you and will want to listen more.
Nonverbal Behaviors cont’d…
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Gestures: If you fail to gesture while speaking you may be perceived as
boring and stiff. A lively speaking style captures the listener's attention,
makes the conversation more interesting, and facilitates understanding.
Posture and body orientation: You communicate numerous messages
by the way you talk and move. Standing erect and leaning forward
communicates to listeners that you are approachable, receptive and
friendly. Interpersonal closeness results when you and the listener face
each other. Speaking with your back turned or looking at the floor or
ceiling should be avoided as it communicates disinterest.
Nonverbal Behaviors cont’d…
Proximity: Cultural norms dictate a comfortable distance for interaction
with others. You should look for signals of discomfort caused by
invading the other person's space. Some of these are: rocking, leg
swinging, tapping, and gaze aversion.
Nonverbal Behaviors cont’d…
Vocal: Speaking can signal nonverbal communication when you include
such vocal elements as: tone, pitch, rhythm, timbre, loudness, and
inflection. For maximum teaching effectiveness, learn to vary these six
elements of your voice. One of the major criticisms of many speakers is
that they speak in a monotone voice. Listeners perceive this type of
speaker as boring and dull.
Barriers to Therapeutic Communication
Lack of planning by the nurse.
Poor data collection.
Inappropriate Nursing Diagnosis and Outcome criteria.
Lack of regard or respect for the patient.
Effective Communication Techniques
Degree of Openness:
Open-Ended Questions.
Close-Ended Questions.
Clarifying/Validating Techniques:
Paraphrasing.
Restating.
Exploring.
Use of Silence.
Active Listening.
Open-Ended Questions
Require more than one-word answers (e.g. yes or no).
Even with resistant client it encourages lengthy information on
experiences, perception of events or responses to situation.
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E.g. “will you tell me something about your family?
“share with me your feelings”.
Closed-Ended Questions
Are questions that asked for specific information (dates, age,
numbers,names, yes or no information).
Used because they limit client’s freedom of choice.
E.g. “is your mother alive?”
“when were you born?”
“do you think that medication is helping you?”.
Good during initial assessment or intake interview.
Clarifying/Validating Techniques
Understanding depends on clear communication which aided by by
verifying with a client the nurse’s interpretation of the client’s
messages.
The nurse must request feedback on the accuracy of the message
received from verbal & non verbal cues.
Paraphrasing
To restate in different (often fewer) words the basic content of client’s
messages.
Using simple, precise, & culturally relevant terms.
The nurse may say “I am not sure I understand”.
Or in other words “you seem to be saying…”.
Restating
The nurse mirror the client’s overt & covert messages.
This technique can be used to echo feeling as well as content.
It differs from paraphrasing in that it involves repetition of the same key
words the client has just spoken.
If client remarks “my life has been full of pain”, additional information
might be gained by restating “your life has been full of pain”.
The purpose is to explore more thoroughly subjects that might be
significant.
Exploring
Enable the nurse to examine important ideas, experiences, or
relationships more fully is exploring.
For example if the client tells the nurse that he does not get along well
with his wife, the nurse should explore this area further.
E.g. “tell me more about your relationship with your your wife”.
“describe our relationship with your wife”.
“give me example of you & your wife not getting along”.
Asking for examples can greatly clarify a vague statement made by the
client, e.g. “no one likes me”. Nurse: “give me an example one person
who doesn’t like you”.
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Use of Silence
The effective use of silence is helpful in communication techniques.
Is not absence of communication.
Is specific channels for transmitting & receiving messages.
The practitioner needs to understand that silence is a significant means
of influencing & being influenced by others.
There no universal rule concerning how much silence is too much.
Client silence may convey accepting or rejection.
without feedbacks client, client have no way of knowing whether what
they said was understood.
Effective Communication Techniques cont’d…
Listen Actively
Be attentive - concentrate on what is being said.
Be impartial - don't form an opinion, just listen.
Reflect back - restating what has been said helps the speaker know that
you understand.
Summarize - pull together the important messages so that you and the
speaker recognize what was important during the conversation.
Active Listening
Hearing and listening are not the same thing. Hearing is the act of
perceiving sound. It is involuntary and simply refers to the reception of
aural stimuli.
Listening is a selective activity which involves the reception and the
interpretation of aural stimuli.
It involves decoding the sound into meaning.
Listening is divided into two main categories: passive and active.
Passive listening is little more that hearing. It occurs when the receiver
or the message has little motivation to listen carefully, such as music,
story telling, television, or being polite.
Active Listening cont’d…
People speak at 100 to 175 words per minute, but they can listen
intelligently at 600 to 800 words per minute (WPM).
It requires the listener attends to the words and the feelings of the
sender for understanding.
It takes the same amount or more energy than speaking.
It requires the receiver to hear the various messages, understand the
meaning, and then verify the meaning by offering feedback. The
following are a few traits of active listeners:
Active Listening cont’d…
S – Sit squarely facing the client.
O – Observe an open posture.
L – Lean forward toward the client.
E – Establish eye contact.
R – Relax.
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Traits of Active Listeners
Spends more time listening than talking.
Do not finish the sentence of others.
Do not answer questions with questions.
Are aware of biases. We all have them...we need to control them.
Never daydreams or become preoccupied with their own thoughts when
others talk.
Lets the other speaker talk. Does not dominate the conversation.
Plans responses after the other person has finished speaking...NOT
while they are speaking.
Provides feedback, but does not interrupt incessantly.
Analyzes by looking at all the relevant factors and asking open-ended
questions. Walks the person through your analysis (summarize).
Keeps the conversation on what the speaker says...NOT on what
interests them.
Takes brief notes. This forces them to concentrate on what is being
said.
Feedback
The purpose of feedback is to change and alter messages so the
intention of the original communicator is understood by the second
communicator.
It includes verbal and nonverbal responses to another person's
message.
Providing feedback is accomplished by paraphrasing the words of the
sender.
Restate the sender's feelings or ideas in your own words, rather than
repeating their words.
Your words should be saying, "This is what I understand your feelings
to be, am I correct?" It not only includes verbal responses, but also
nonverbal ones.
Nodding your head or squeezing their hand to show agreement, dipping
your eyebrows shows you don't quite understand the meaning of their
last phrase, or sucking air in deeply and blowing it hard shows that you
are also exasperated with the situation.
Feedback cont’d…
Carl Roger listed five main categories of feedback. They are listed in the
order in which they occur most frequently in daily conversations. Notice
that we make judgments more often than we try to understand:
Evaluative: Making a judgment about the worth, goodness, or
appropriateness of the other person's statement.
Interpretive: Paraphrasing - attempting to explain what the other
person's statement means.
Supportive: Attempting to assist or bolster the other communicator.
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Probing: Attempting to gain additional information, continue the
discussion, or clarify a point.
Understanding: Attempting to discover completely what the other
communicator means by her statements.
Effective Communication Techniques cont’d…
Nonverbal Message
Posture - let your body show that you are interested by sitting up and
leaning toward the speaker.
Equal positioning - if the speaker is standing, you stand. If the speaker
is sitting, you sit as well.
Facial expression - remember that feelings are reflected in facial
expressions.
Gestures - your body language reveals a lot about how you interpret a
message, so be aware of when you send signals that might cause the
speaker to believe that you are angry, in a hurry, bored, etc.
Effective Communication Techniques cont’d…
Express Thoughts and Feelings
Be open and honest - collaboration between parents and professionals
begins with the understanding that you trust each other with all
information.
Speak clearly - don't mumble and don't talk too quietly. If you don't
know the word for something, describe what you mean so that you and
the speaker can have a shared understanding of your concern or
question.
Effective Communication Techniques cont’d…
Communicate Without Being Adversarial
Express concerns non-judgmentally - talk about your questions or
concerns without blaming other people. For example, you might be
angry that your child is not receiving enough speech therapy. Rather
than talk about the speech therapist not doing his/her job, discuss your
idea of how often your child should receive this service.
Use "I" messages. Rather than say, "You didn't explain that very well,"
say, "I didn't understand what you just said. Please explain it again."
Therapeutic Communication Techniques
Using silence - allows client to take control of the discussion, if he or
she so desires.
Accepting - conveys positive regard.
Giving recognition - acknowledging, indicating awareness.
Offering self - making oneself available.
Giving broad openings - allows client to select the topic.
Therapeutic Communication Techniques cont’d…
Offering general leads - encourages client to continue.
Placing the event in time or sequence - clarifies the relationship of
events in time.
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Making observations - verbalizing what is observed or perceived.
Encouraging description of perceptions - asking client to verbalize what
is being perceived.
Therapeutic Communication Techniques cont’d…
Encouraging comparison - asking client to compare similarities and
differences in ideas, experiences, or interpersonal relationships
Restating - lets client know whether an expressed statement has or has
not been understood
Reflecting - directs questions or feelings back to client so that they may
be recognized and accepted
Therapeutic Communication Techniques cont’d…
Focusing - taking notice of a single idea or even a single word
Exploring - delving further into a subject, idea, experience, or
relationship
Seeking clarification and validation - striving to explain what is vague
and searching for mutual understanding
Presenting reality - clarifying misconceptions that client may be
expressing
Therapeutic Communication Techniques cont’d…
Voicing doubt - expressing uncertainty as to the reality of client’s
perception
Verbalizing the implied - putting into words what client has only implied
Attempting to translate words into feelings - putting into words the
feelings the client has expressed only indirectly
Formulating plan of action - striving to prevent anger or anxiety
escalating to unmanageable level when stressor recurs
Nontherapeutic Communication Techniques
Giving reassurance - may discourage client from further expression of
feelings if client believes the feelings will only be downplayed or
ridiculed
Rejecting - refusing to consider client’s ideas or behavior
Approving or disapproving - implies that the nurse has the right to pass
judgment on the “goodness” or “badness” of client’s behavior
Nontherapeutic Communication Techniques cont’d…
Agreeing or disagreeing - implies that the nurse has the right to pass
judgment on whether client’s ideas or opinions are “right” or “wrong”
Giving advice - implies that the nurse knows what is best for client and
that client is incapable of any self-direction
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Probing - pushing for answers to issues the client does not wish to
discuss causes client to feel used and valued only for what is shared
with the nurse
Nontherapeutic Communication Techniques cont’d…
Defending - to defend what client has criticized implies that client has
no right to express ideas, opinions, or feelings
Requesting an explanation - asking “why” implies that client must
defend his or her behavior or feelings
Indicating the existence of an external source of power - encourages
client to project blame for his or her thoughts or behaviors on others
Nontherapeutic Communication Techniques cont’d…
Belittling feelings expressed - causes client to feel insignificant or
unimportant.
Making stereotyped comments, clichés, and trite expressions - these
are meaningless in a nurse-client relationship.
Using denial - blocks discussion with client and avoids helping client
identify and explore areas of difficulty.
Nontherapeutic Communication Techniques cont’d…
Interpreting - results in the therapist’s telling client the meaning of his
or her experience.
Introducing an unrelated topic - causes the nurse to take over the
direction of the discussion.
Techniques to Monitor & Avoid
Asking excessive questions.
Giving advise.
Giving false reassurance.
Requesting explanation.
Giving approval.
Asking Excessive Questions
Excessive questioning , especially closed ended questions, puts the
nurse in the role of demanding information without respect for client
willingness or readiness to respond.
This approach conveys lack respect & sensitivity to the client’s needs.
Can result a shut-down interview.
Client may feel lack of security in letting to tell his own story.
Better to ask more open-ended question.
Excessive questions such as “why did you leave your wife?” “did you
feel angry at her?” “what did she do to you?” “are you going back to
her?”.
Better to say “tell me about the situation between you & your wife”.
Giving Advise
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Giving people advise undermines their feelings of adequacy &
competence.
It can foster dependence on the adviser.
Giving advise can devalues the other individual & prevent the other
person from working through and thinking through other options either
on their own or with nurse.
E.g. “I don’t know what to do about my brother. He is so lost”. You say
“what do you see as some possible actions you can take?”, encourage
problem solving.
Giving False Reassurance
Underrates a person’s feelings and belittles a person’s concerns.
This causes people to stop sharing feelings because they feel they are
not taken seriously.
The person’s real feelings remain undisclosed & unexplored.
Invalidates the client’s experience & can lead to increase negative
affect.
False reassurance: “every body feels that way”, “it’s not that bad”.
Better to say “what specifically are you worried about?”, “what do you
think could go wrong?”, “what do you see as the worst thing that could
happen?”.
Requesting an Explanation “why?” Questions
Might out people on the defensive & serve to close down
communication.
Much useful to ask “what is happening?” rather than why it is
happening.
People always have no idea why thy did something, although almost
everyone can make up a ready answer on the spot.
Giving Approval
In nurse-patient relationship is more complex.
Client may feel its just to please him.
Client may need more ways of assertiveness skills and
useful coping.
Client must be given
recognition for the change
in behavior, and the topic
is also open for further
discussion.
Barriers to Communication
Anything that prevents understanding of the message is a barrier to
communication. Many physical and psychological barriers exist:
Culture, background, and bias
Noise
Ourselves
Perception
Message
Environmental
Smothering
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Stress
Barriers to Communication cont’d…
These barriers can be thought of as filters, that is, the message leaves
the sender, goes through the above filters, and is then heard by the
receiver. These filters muffle the message. And the way to overcome
filters is through active listening and feedback.
Culture, Background, & Bias
We allow our past experiences to change the meaning of the message.
Our culture, background, and bias can be good as they allow us use our
past experiences to understand something new.
It is when they change the meaning of the message then they interfere
with the communication process.
Noise
Equipment or environmental noise impede clear communication.
The sender and the receiver must both be able to concentrate on the
messages being sent to each other.
Ourselves
Focusing on ourselves, rather than the other person can lead to
confusion and conflict.
The "Me Generation" is out when it comes to effective communication.
Some of the factors that cause this are defensiveness (we feel someone
is attacking us), superiority (we feel we know more that the other), and
ego (we feel we are the center of the activity).
Perception
If we feel the person is talking too fast, not fluently, does not articulate
clearly, etc., we may dismiss the person.
Our preconceived attitudes affect our ability to listen.
We listen uncritically to persons of high status and dismiss those of low
status.
Message
Distractions happen when we focus on the facts rather than the idea.
Our educational institutions reinforce this with tests and questions.
Semantic distractions occur when a word is used differently than you
prefer. For example, the word chairman instead of chairperson, may
cause you to focus on the word and not the message.
Environmental
Bright lights.
An attractive person.
Unusual sights.
Or any other stimulus provides a potential distraction.
Smothering
We take it for granted that the impulse to send useful information is
automatic. Not true! Too often we believe that certain information has
no value to others or they are already aware of the facts.
Stress
People do not see things the same way when under stress.
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What we see and believe at a given moment is influenced by our
psychological frames of references - our beliefs, values, knowledge,
experiences, and goals.
General Advices
When speaking or trying to explain something, ask the listeners if they
are following you.
Ensure the receiver has a chance to comment or ask questions.
Try to put yourself in the other person's shoes - Consider the feelings of
the receiver.
Be clear about what you say. Look at the receiver.
Make sure your words match your tone and body language (Nonverbal
Behaviors).
Vary your tone and pace.
Do not be vague, but on the other hand, Do not complicate what you are
saying with too much detail.
Do not ignore signs of confusion.
Clinical Interview
Clinical Interview
Anxiety during the first interview is to be expected as in any meeting
between strangers.
Client might be anxious about their problems about the nurse’s reaction
to them, or about their treatment.
Conditions Essential to Development
of a Therapeutic Relationship
Rapport
Trust
Respect
Genuineness
Empathy
How to Begin the Interview
Setting.
Seating.
Introduction.
How to start.
Setting
Effective communication can take place almost anywhere.
Establish a setting that enhances feelings of security can be important
to the relationship.
A health care setting, conference room, or quite part of the unit that has
relative privacy but is within view of others is ideal.
Seating
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In all settings, chairs need to be arranged so that conversation can take
place in normal tone of voice, and eye contact.
Non threatening physical environment for nurse and client would
involve:
assuming the same height “both sitting or standing”.
leaving plenty of space between them.
Making sure that the door is easily accessible to both.
avoiding a desk barrier between them.
Introduction
Tell the client the purpose of the meeting, and how long and at what
time they will be meeting.
The issue of confidentiality is also covered at some point during the
initial interview.
The nurse then can ask client he/she would like to be addressed.
How to Start
Once introductions have been made, nurse can turn the interview over
to the client by using one number of open-ended questions.
“where should be start?”
“tell me a little about what has been happening in the past couple of
weeks”
“tell me about your difficulties”.
Phases of a Therapeutic Nurse-Client Relationship
Orientation/Introductory Period
Working
Termination
Orientation/Introductory Period
Can last for few meetings or can extend for a longer.
Goal of that phase:
To establish relationship.
To effect some degree of anxiety reduction in the client.
To instill hope & ensure that the client will remain
compliant with tretment.
To develop an assessment from which nursing diagnosis can be
formulated.
To develop appropriate tretment goals (outcome criteria) and plan of
care.
Orientation/Introductory Period
During this phase the nurse addresses 4 specific issues:
The parameters of the relationship.
The formal or informal contract.
Confidentiality.
Termination.
Working
During this phase the nurse & cinet together identify & explore areas in
the client’s life that are causing problems.
Some of specific tasks includes in this phase are:
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Maintaining the relationship.
Gathering additional data.
Promoting the client’s problem-solving ability.
Facilitating behavior change.
Overcoming resistance.
Evaluating problems & goals, & redefining them as necessary.
Participating & experiencing alternative adaptive behavior.
Termination Phase
Reason for termination phase:
Symptoms relief.
Improved social functioning.
Greater sense of identity.
More adaptive behaviors in place.
Accomplishment of the client’s goals.
An impasse in therapy.
End of student rotation.
End of health-maintenance organizations contact.
Discharge or death.
Thank You
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