CHAPTER 2 REVIEW OF RELATED LITERATURE

Communication can be defined as "The Process of transmitting messages and interpreting

meaning." (Wilson and others, 1995) With therapeutic communication, the sender, or nurse seeks

to illicit a response from the receiver, the patient that is beneficial to the patient’s mental and

physical health. Just as stress has been proven to adversely affect the health of individuals, the

therapeutic approach to communication can actually help. In any given situation everyone uses

communication.

Everyone has seen the individual that looks like they are either angry, stressed, feeling ill

or maybe sad. These emotions are communicated to others not always by words, but by gestures

and facial expressions. A nurse must always be aware of these expressions in clients, for these

expressions may be the only way that the nurse can tell if there is something else going on that

needs their attention. The term given to this type of non-verbal communication is called, meta-

communication. In meta-communication, the client may look at their amputated stump and say

that it doesn't really look that bad, while at the same time tears are rolling down from their eyes.

Ideally, for therapeutic communication to be effective the nurse must be aware of how

they appear to the client. If a nurse appears rushed, for example, they are speaking quickly, their

countenance looks harried, and they are breathing heavily, their eyes not on the client but

perhaps on an intravenous bag on the client in the next bed. In a case like this, there is nothing

that this nurse could say to the client in a therapeutic manner that the client would believe. The

helping relationship has not been established and therefore therapeutic communication cannot be

facilitated. Some of the emotions associated with therapeutic communication include but are not

limited to the following: Professionalism, Confidentiality, Courtesy, Trust, Availability,

Empathy, and Sympathy. (Potter, Patricia A., Perry, Anne G., Co. 2003, Basic Nursing

Essentials for Practice, pg. 123, Mosby)

The importance of communication is the essential foundation of nursing practice; it is

primarily dependent upon verbal and non-verbal communication. Encompassing both speech and

behavioral aspects, efficient delivery and receiving of the nurse-patient messages initiates

advantageous relationships, or contrarily, generates significant repercussions if applied

ineffectively, thus affecting the quality of the nurse-patient relationship. This essay will discuss

how effective verbal and non-verbal communication in nursing practice will facilitate a mutually

satisfying therapeutic nurse-patient relationship. It will firstly discuss verbal communication,

followed on by the complementary non-verbal communication and lastly listening. However, for

communication to succeed properly it must be reciprocal.

(http://www.writework.com/essay/communication-nursing-1

Communication stems from the Latin word communicare, “to impart, participate, convey,

and share information about” (Webster’s New Collegiate Dictionary, 1974, p. 228). It is the act

or reciprocal process of imparting or interchanging thoughts, attitudes, emotions, opinions, or

information by speech, writing, or signs. Nurses can use this dynamic and interactive process to

motivate, influence, educate, facilitate mutual support, and acquire essential information

necessary for survival, growth, and an overall sense of well-being. (Howells, 1975; Kleinman,

2004)

Communication is essential for nurses to develop and maintain competent

communication and interpersonal skills. Effective communication skills are required to facilitate

therapeutic interactions, assess client need, and implement interventions that promote an optimal
level of functioning. Early forms of communication and interactions with primary caregivers are

the origin of trust, security and safety, and lifelong interpersonal relationships and

communication patterns.(Antai-Otong & Wasserman, 2003).

**Research findings indicate that effective communication between the nurse and

physician enhances problem solving and decision making and improves treatment outcomes

(Boyle & Kochinda, 2004; Schmidt & Svarstad, 2002). In contrast, negative or poor

communication between the nurse and physician has a deleterious impact on staff morale, staff

and client satisfaction, treatment outcomes, and quality of care. (Larson, 1999; Rosenstein, 2002;

Rosenstein & O’ Daniel, 2005).

The foundation of therapeutic communication is rapport. Rapport refers to the harmony

or accord between people. This initial alliance is vital to the formation of trust. As the therapeutic

relationship evolves, so does the client’s willingness to trust and share information. (Antai-Otong

and Wasserman 2003)

The nature of communication patterns is complex and involves several components. The

major components of communication patterns relate to an array of neurobiological, psychosocial,

and developmental issues.

People are social beings. Emotional ties foster a sense of identity, comfort, security, and

support. From birth to death, relationships with others are central to human existence.

Communication is critical to healthy human interactions. Integrating neurobiological and

psychosocial factors into the communication process enhances the nurse-client relationship.

The third major factor that influences communication is developmental stage. Four stages

have been identified in language development and communication:

 1. The first stage and initial communication begins with the birth cry, which evolves into

gurgles and variations in sounds and sucking rates that convey different needs.

2. The second stage involves cry vocalizations and variations in sounds and pitches.

3. The third stage consists of babbling, which varies with culture and is influenced by the

intonation patterns and language of the primary caregivers.

4. The evolution of “true speech” begins in the fourth stage, which ends the first year, and is

described as prelinguistic vocabulary. These stages parallel cognitive and neurobiological

development, which influence refinement of schemata and systematic growth of logical

operations or understanding of self and the world. In applying Piaget’s theory, nurses can

interpret a child’s behaviors (both verbal and nonverbal), depending on the stage of

cognitive functioning, that is, sensory-motor, preoperational, concrete operational, or

formal operational stage of reasoning. Several theorists have defined communication.

According to the dyadic interpersonal communication model described by Berlo in 1960,

communication is a dynamic interaction that consists of a source, which has a purpose that is

understandable to another person, and an encoder, who is able to understand the meaning of the

message. The message is processed and decoded and understood by the recipient, or decoder. In

essence, people must convey clear messages if they expect the information to be understood.

The goal of therapeutic interactions is congruence between nonverbal and verbal

communication.

Nonverbal communication has a greater impact than verbal communication and yet not

enough attention in nursing is focused on this area in communication training programs.

(Krujiver, Kerkstra, Franke, Bensing, & Van de Wiel, 2000)

 Empathy communicates understanding and concern. Interestingly enough, a review of the

literature reveals a lack of clarity and consensus on what exactly is meant by “empathy”

(Reynolds, Scott, & Austin, 2000), yet it is always viewed as a critical aspect of therapeutic

relationships.

This powerful communication tool conveys “I am with you and I have a sense of what

you are experiencing,” without totally losing one’s identity. More specifically though, empathy

involves the sensitivity to current feelings and the ability to communicate this understanding in

language attuned to the client’s feelings (Truax, 1961), thus promoting change, growth, and

health restoration.

Verbal cues consist of using words to communicate ideas, thoughts, and feelings.

Language is a complex phenomenon and the tool we use to communicate with each other. It

activates higher cognitive processes such as understanding, thinking, remembering, and

reasoning. Through language we learn, educate, socialize, create, and validate perceptions of the

world and ourselves by sharing feelings and thoughts. Effective communication through

language is linked with health.

Culturally sensitive care is crucial to therapeutic communication. Whereas it may not be

possible to know all cultural nuances, being attentive to understanding various influences may

facilitate the delivery and quality of health care. Communication is difficult at best, but when the

sender and receiver are from different cultures, the difficulty becomes even more pronounced.

Perception is the way events are interpreted through sensory stimulation. Past and present

experiences and innate traits that validate or correct the receiver’s interpretation determine

perception. Thoughts are stimulated by perceptions, and feelings respond to thoughts. In the

following example, the nurse’s perception interferes with objective client care.
 Self-concept refers to one’s beliefs and feelings about self. It serves as a frame of

reference for life experiences and perceptions of the world. It evolves over time and arises from

interactions with others. Self-concept plays a major role in adaptation and the maturational

process. Successful resolution of development tasks or stressors shapes a positive self-concept.

Client interactions normally produce anxiety in both the client and the nurse. Anxiety is

described as a vague, uncomfortable feeling and manifests itself psychologically and

biologically. Response to anxiety varies among people and can be both motivating and

distressful. Lower levels of anxiety increase alertness and enhance problem-solving abilities.

However, heightened levels of anxiety decrease cognitive processing, causing disruption and

distress.

Sullivan (1954) described anxiety as the chief barrier to effective communication because

it threatens self-esteem and self-respect. As a natural part of human experiences, nurses need to

take steps to help clients handle anxiety. Reducing anxiety and redirecting it into useful channels

enhances communication.

Hall (1966) introduced the concept personal space in interpersonal relationships. He

believed that human beings are constantly changing positions and that social interactions are

affected by space. He defined space or zone norms from a Western cultural perspective as the

following: Intimate distance: 6 to 18 inches (between people touching). Personal distance: 1 ½ to

4 feet (arms length). Social distance: 4 to 12 feet (most frequently used in business activities).

Public distance: 12 to 25 feet (entertainer, public speaker). It is important for the nurse to respect

comfort zones and be aware of any boundary violations that may threaten one’s safety.

A question often posed by students and nurses is, “What are therapeutic communication

techniques?” A simple definition is that a therapeutic communication technique is one that

facilitates therapeutic communication. In reality, the ability to communicate effectively is an art

that uses basic listening and communication skills. The nurse can use this collaborative

interaction to assess the client’s needs, formulate client outcomes, and evaluate the effectiveness

of interventions. Therapeutic technique includes active listening, questioning, clarifying

technique

There are Principles of Communication. Acceptance is one of the principles needed by

the nurse to bear in mind, favorable reception of another person by implying a client has the right

to exist, to live and to have somebody to care about. Second is interest, nurses communicate

when they are genuinely curious and express a desire to know another person. Interest is

conveyed by asking about those aspects of a client’s life that others often reject. Another is show

consideration for another by communicating their willingness to work with the client and accept

the client’s ideas, feelings, and rights. This is all conveyed with respect. Next is honesty, nurses

must show consistency, open and frank. Nurses do not take refuge behind a professional mask

but instead communicate with the client as an authentic person. Nurses must be honest and

nondefensive about their thoughts and feelings that they discover through self-assessment. Also

concreteness is one of the principles of therapeutic communication, being specific, to the point

and clear when they communicate with the client should be practiced. Client’s who speak in

vague, general, unfocused ways are helped to be more specific and focused. And the sixth is

assistance, nurses assist clients by committing time and energy to therapeutic relationships. They

convey that they are present and available and have tangible aid to offer that will help the client

to choose and develop more functional ways of living. Permission also is a principle; nurses

communicate permission by conveying the massage that it is acceptable to try new ways of

behaving. Often clients are afraid to choose freely and autonomously. They are bound by
misconceived archaic rules and magical thinking and need to be given permission and

encouragement to see and to things in new ways. Lastly the principle of protection, nurses

protect clients by ensuring client’s safety, and assumes responsibility of working with the client

to anticipate trouble spots with new behavior and develop effective ways of dealing with

anticipated or actual problems, thus maximizing the possibility of success. (Haber et al., 2007)

There are barriers of therapeutic communication. Giving advice is a barrier to good

therapeutic communication. The nurse offers solutions and advices the client about what course

of action to take. This approach denies the client’s ability to formulate solutions to problems and

assume responsibility for direction of his/her life. Second is giving assurance, nurses offer

information to the client that it is not based on fact and truth and differs from conveying

information or giving realistic feedbacks. Reassurance denies the client’s right to the feelings

being experienced and closes off communication about them. Next is changing the subject. The

nurse diverts the focus of the interaction at crucial times to something less threatening. Changing

the subject usually occurs when the nurse is unwilling or unable to lessen the painful feelings

being expressed by the client. Also being judgmental is a barrier to good therapeutic

communication. The nurse responds to the client with value-laden judgments that come from the

nurse’s value system. The fifth barrier is giving directions. The nurse approaches the client with

specific directions to be followed and frequently lectures the client about advisability of

following this course of action. Sixth is excessive questioning, on the part of the nurse it controls

the nature of range of the client’s responses. The nurse can be perceived by the clients as an

interrogator who is demanding information without respect for the client’s ability or readiness to

respond. Another one is using emotionally charged words. The nurse uses emotionally charged

words with the client who cannot tolerate or accept such feelings. The client may withdraw
physically and emotionally. Next is challenging, nurse sometimes feels that if the client is

challenged to prove unrealistic ideas or perception, the client will realize that there is no proof to

support such ideas and will be forced to acknowledge what is true. Making stereotypical

comments is also a barrier. Offering trite expressions and meaningless clithes as responses

diminishes the value of the nurse-client interaction. The tenth barrier is self focusing behavior. It

is characterized by the nurse’s excessive interest in or preoccupation with his/her own thoughts,

feelings, or actions. And lastly is double-bind message. The nurse delivers two conflicting

messages, one verbal, the other is nonverbal. The nonverbal message contradicts the verbal

message. It is unclear which message is to be obeyed. Public Distance: 12 to 25 feet. It is

important for the nurse to respect comfort zone and be aware of any boundary violations that

may threaten one’s safety.

A question often posed by student and nurses is, “What are therapeutic communication

techniques?” A simple definition is that a therapeutic communication technique is one of that

facilities therapeutic communications. In reality, the ability to communicate effectively is an art

that uses basic listening and communication skills. The nurse can use this collaborative

interaction to assess the client’s needs, formulate the client outcomes, and evaluate the

effectiveness of interventions. Therapeutic techniques include:

Active listening is the basis of all nurse client interactions. Listening is more than

hearing. It is a dynamic and active process that requires enormous concentration and energy. It

literally means using all the senses to assess verbal and non-verbal message.

Active Listening conveys concern and respect for the client. It fosters a trusting

relationship that encourages the client to express feelings and share thought. “Knowing the
patient” and encouraging her to “tell their story”. (Chamber Evans , Stelling & Goodwin, 1999)

is essential in providing individualized and quality nursing care.

Focusing refers to clarifying a perception or spotlighting certain aspects of

communication. This technique is useful when clients are vague and need assistance with goal

directed communication. Focusing is useful when clients don not express their feelings clearly,

when they ramble, or when they discussed several issue at one time.

Confrontation refers to an encounter or face-to-face meeting. Nurses often associate this

term with conflict or angry discussion between opposing bodies. In reality, confrontation is

necessary aspects of Nurse-clients interaction. Like other techniques, it is and art that involves

pointing out contradictions or incongruities between feelings, thoughts, and behaviors.

Summarizing is a communication tool that helps clients explores key points of a nurse-

client interaction. This dynamic and collaborative process integrates perceptions from the nurse

and client. Major points are reviewed and used to generate future client outcomes.