Communication and the
Nursing Process
Communication Is Foundation of
Society/ Civilization
Why at this point in the course?
Aside: write less!
Factor Influencing Communication
Developmental level esp for transfer of
information.
Gender --- pt and yours.
Sociocultural differences
Language and the culture of the
hospital. We have our own language.
Not the pts job to learn it. Did you
void vs pass your water.
Health literacy ( 4-5th grade)
Fear/insecurity
Why does communication
break down?
Different communication styles
High level of activity
Frequent interruptions
Result: loss of information to death
Communication for pt safety?
Sentinel
https://www.jointcommission.org/assets/1/18/Event_type_2Q_2016.pdf
A sentinel event is a patient safety
event (not primarily related to the
natural course of the patient’s illness
or underlying condition) that reaches
a patient and results in any of the
following:
Death
Permanent harm
Severe temporary harm and
intervention required to sustain life
Root Cause - Op/Post-op Complication
Resulting in death or permanent loss of
function
N=884
Communication 463
Assessment 424
Root cause - Delay in treatment
Resulting in death or permanent loss
of function (N=1,013)
Communication 816 #I
Assessment 784
#2
The majority of events have multiple root
causes :
Jacho 2013-second quarter 2015
http://www.jointcommission.org/assets/1/18/Root_Cause
s_Event_Type_2004-2Q_2015.pdf
What Can Go Wrong?
CONCERN was communicated – BUT:
– PROBLEM:
was not clearly stated
– PROPOSED ACTION: didn’t happen
– DECISION: was not reached
In aviation, disasters triggered change
Fixation
https://www.youtube.com/watch?v=ICqPGkto3Yo
Lack of role clarity
Lack of procedure
(form/checklist)
1900’s handful of dx
Now 13,600 different dx
6,00 drugs
4,000 m/s procedures.
https://www.youtube.com/watch?v=dfl8Xt8W09A
The checklist manifesto
Lack of standardization in organizing
essential information
Speak calmly – do not raise voice
Avoid thin air statements – close the loop
Get attention, give full attention
Step back and assess for causes
SBAR
a framework for communication to keep pt safe.
Situation
Background
Assessment
Recommendation
S–B–A-R
Situation – “The situation I am calling
about”
Background – brief, related, to the point
Assessment - what you found, what you
think
Recommendation – what you want
SITUATION
OFHS state your name and unit
The situation I am calling about:
(Patient Name and issue )
The situation I am calling about:
(Patient Name and issue )
The situation I am calling about:
(Patient Name and issue )
BACKGROUND
(varies)
State the admission diagnosis
and date of admission prn
State the pertinent medical
history
A BRIEF synopsis of the
treatment to date
Assessment
Pertinent objective & subjective
information – YOU decide but know….
LOC Mental status? Neuro changes
Most recent vitals ( all aspects: Pulse rate strength
reg irreg ireg ireg – respirs rate labored)
Abnormal h/l sounds, labs I/O
RECOMMENDATION
State what you would like to see done:
– Change treatment?
– Transfer the patient?
– Come to see the patient at this time?
– Talk to the family and patient about….?
– Ask for a consulting physician to see the
patient?
Mr. Smith arrives in ER
VS 98.7 130 20 84/56 98R/A 8/10.
He came in to the ED after a motor
vehicle accident. He is AAOx 1 but
dizzy. He states he has been healthy
until this point but does take a
multivitamin daily and is on a low
carbohydrate diet.
Na 140 K 3.8 CL 104 BUN 20
Creatine 0.8 albumin 3.4
H and H 7 and 21.
Beyond sbarMany level of communication
AHRQ Team Stepps
Nurse Patient Family
Communication SBAR possible
Exchanging information.
Collect data, teach, and provide
compassionate care
- very different than communicating with
your friends.
You as the nurse, don’t say anything
without a purpose for saying it.
Communication in Helping Relationship
Not the same as a social relationship or
friendship.
Social.. Passing in street.. Hi how are
you.. Fine, how are you….Startled if
someone said:
Helping vs. Friendship
Helping occurs for a specific purpose with
a specific person.
Unequal sharing of information.. You do
not nor should not discuss your health
history. Personal data within reason.
Built on pt needs…
Purposeful and time limited.
You never know where the next ans will
take you.
Intrapersonal Level of Communication
Self talk. + or Negative Stress inducingover generalization forever, never
Catastrophizing to Disqualifying the
positive,
Pts need to know value and harm of each
without being trite. (cognitve behavior
therapy)
Positive
Steps toward goal not the goal itself
Often where spiritual aspects arise. Great
source of strength.
Verbal and non verbal communication
The pts verbal and non verbal
communication and objective data.
–Is there congruence among the 3?
Your verbal and non verbal
communication to the pt
–Is there congruence?
A message is exchanged whether
intentional or not… visual, auditory and
kinesthetic…..
Think soler
S: sitting facing the client squarely, not at
an angle
O: an open posture, arms and legs
uncrossed
L: leaning (at times) towards the person
E: eye contact, without staring
R: relaxed posture.
Communicate via ( pt to nurses and v v)
Eye contact
Facial expression
Posture Gait beyond neuro
Gestures ….
Sounds…. Cry…to hummmph to
(opps)
https://www.youtube.com/watch?v=CZ1CATNbXg0
http://video.google.com/videosearch?sourceid=navclient&gfns=1&rlz=1T4ADBF_enUS298US299&q=wall%20E&um=1&ie=UTF-8&sa=N&hl=en&tab=wv#
Communicate via Touch
Distracter from pain. Pain is worse when alone.
Hand is often most effective to show you care.
You are there esp. if eyes covered.
You are the human being touching the human
being in a mass of chaos.
You understand.
You know words are useless.
Communicate via Actions
Actions speak:
– Cool cloth.
– Dim the lights.
– Push med slowly
Explain your actions when they can be
misconstrued. (looking at IV or Computer. I
need to check your labs Mr. Smith….your
urine output is good sir..is a little low.
Communicate with Space
Space esp. if angry.
Often evaporates in emergency.
Try to reestablish as much as
possible even if only with a warning
that “I am going to….”conveying
respect.
Remember esp for long term facilities
There are no professional pts.
Extreme Caution with Humor
Laughter communicates humor to mortal
fear. Must look at pt situation and clues.
You use humor very cautiously.
Report (no pts) often see as a release.
How you say = what you mean?
I’ll be back when I can….
I’ll be checking on my other pts, I expect to be
back in about 2 hours, please put your light on
if you need anything.
Allow me
Still
FOR YOU” does a lot!
“Yet” ?
But
‘Why’ questions vs what questions?
Why didn’t you take your medication?
What stopped you from taking your
medication?
Why did you discharge yourself?
What happened that led you to
discharge yourself from hospital?
Why did you say that?
What caused you to say that?
Sit with silence - takes practice
5 seconds without “filling” the space
– You have time
– Not a casual conversation
– You are thinking
How was your day ( but mean it)
If it is not a question then don’t make it a
question.
Would you please stop hitting your little
brother?
Is it nice to throw the cat in the washing
machine?
Would you like to get oob today?
Open vs closed questioning
Each has its place
I am having chest pain
– – focus this down - close it up…Not .”would
you like to tell me more about you chest pain ”
– go to 7 attributes
I don’t feel so well – open this up
Factor Influencing Communication
Physical, Mental, Emotional State
Yours also…..not the best time to enter
into a tough conversation ?..try and control
the environment.
Factor Influencing Communication
Roles and Responsibilities: Pt
roles…watch taking care of dr or
nurse…lawyer….stereotyping.
The professional is in charge and
accountable for outcomes.
Your ability determines outcomes of care.
Caring .. “I will be your nurse today.. how is
your pain…”
Competence.. “if you are ok, allow me to….”
places the pt ahead of the task and
establishes a level of competence.”
Pt at center of task - Again, “for you”
“ Why vs what”
Listen to your pt. Reflect back. I hear you
saying
Barriers to communication
Hearing.
Mental, physical, emotional, state.
Foreign language.
Special needs – coma, vents, aphasia, infant,
etc.
You want things to be OK…can not mislead..
they know anyway…Kind and supportive…give
a plan…deal with this
Communication for
Teaching – Learning
Teaching…active, goal-directed process
where learning is invited in order to
provide the tools for bringing about
changed behavior. 1st step
Learning….Assimilation of information that
may or may not result in a change of
behavior.
Professional Responsibility
ANA
– Teaching is an essential function of nursing
State Board of Nursing
– teaching as a function
JCAHO
– Mandates evidences of education.
– Why do you care: If Joint say jump we say how high.
Patient Bill of Rights
– Calls for patient understanding of treatment
Patient Teaching
Find start point ( pt determined)
Here is what I am going to teach you
Here is why it is important.
Get feedback
Tell me what you know
Teach
This is what I taught you.
Teach back
You are teaching all the time
Book stress formal plan…when you are ready…
You are ready now for informal teaching…..it is basic part
of care.
SCD are needed because…
We need to get you OOB….;
do not get OOB until….
You can’t eat because…
This medicine is for your.. You will be going home on
Coumadin
When you go home you may shower, but not bath
because…
Here is your call light
Every one in the hospital is at risk for falling.
All pts are at risk of falling.
Teach all pts
could open incision
on an anticoagulant
You are at risk or likely to fall because
New med step the last 3 days in bed.
New surroundings
ABCS Age bone Coags Surgery- high risk
for serious injury
For all learners
– Attention to physical comfort
– Mutual Respect
– Motivation
Felt need to know or it must be explained…
Application to current situation
Process
– Active involvement.
– Series of learning plateaus (first plateau
may simply be allowing the lesson to
begin)
– Variety of formats and activities.
Example: Pain on admission
We will work together to be control your
pain to make you as comfortable as
possible.
We use a scale to allow us to evaluate …..
Example: Orient to room/unit/hospital
Most important for safety?
Example: Discharge teaching
Activity
– Walk, stairs, drive, sex, shower, bath
Diet
Care of drains
Medications
Follow up visits
Sometimes you do have to push
– Motivation
– Family esp. spouse may need separate
support. They are to be the rock, but they are
afraid repulsed etc. yet may still very much
love and want to support the pt.
Education does not = change in behavior,
but do not expect change in behavior
without education.
Motivational teaching
Raise subject: Is it okay if I talk with you
about some of the questions you
answered?
Enhance motivation: On the scale of 0 to
10 how ready are you to cut back on your
use of
If zero:
Have you ever done anything while
drinking that you later regretted?
I can tell you drinking/ smoking at this
level can be harmful .. And responsible
for…..
“How would your drinking have to you
have to impact your life in order for you to
start thinking about cutting back?”
Or you ask
Enhance motivation: On the scale of 0 to
10 how ready are you to cut back on your
use of
They answer 4
…..? Why not
If greater than zero why that number and not
a lower number!!
Why not 3
List problems cause by
Benefits hoped for- disadvantages too
How to avoid
Keep record
Keep diary/log post on fridge
Slips are lessons, not failure
Quitting. Reducing. Safer
The End