Modes of Communication

Verbal communication uses the spoken or written word;

Nonverbal communication uses other forms, such as gestures or facial expressions, and touch. Although
both kinds of communication occur concurrently, the majority of communication is nonverbal. Learning about
nonverbal communication is important for nurses in developing effective communication patterns and relationships
with clients. Another form of communication has evolved with technology

Electronic communication. The most common form of electronic communication is e-mail where an
individual can send a message, by computer, to another person or group of people.Nurses need to know when it is
and when it is not appropriate to use e-mail for communicating with clients.

Verbal Communication
Verbal communication is largely conscious because people choose the words they use. The words used vary among
individuals according to culture, socioeconomic background, age, and education. As a result, countless possibilities
exist for the way ideas are exchanged. An abundance of words can be used to form messages. In addition, a wide
variety of feelings can be transmitted when people talk. Nurses need to consider the following when choosing words
to say or write: pace and intonation, simplicity, clarity and brevity, timing and relevance, adaptability, credibility,
and humor.

PACE AND INTONATION The manner of speech, as in the rate or rhythm and tone, will modify the feeling and
impact of the message. The tone of words can express enthusiasm, sadness, anger, or amusement. The rate of speech
may indicate interest, anxiety, boredom, or fear. For example, speaking slowly and softly to an excited client may
help calm the client.

SIMPLICITY Simplicity includes the use of commonly understood words, brevity, and completeness. Many
complex technical terms become natural to nurses. However, laypersons often misunderstand these terms. Words
such as vasoconstriction or cholecystectomy are meaningful to the nurse and easy to use but are ill advised when
communicating with clients. Nursesneed to learn to select appropriate, understandable, and simple terms based on
the age, knowledge, culture, and education of the client. For example, instead of saying to a client, “The
nurses will be catheterizing you tomorrow for a urine analysis,” it may be more appropriate and understandable to
say, “Tomorrow we need to get a sample of your urine, so we will collect it by putting a small tube into your
bladder.” The latter statement is more likely to elicit a response from the client asking why it is needed and whether
it will be uncomfortable, because the client understands the message being conveyed by the nurse.

CLARITY AND BREVITY A message that is direct and simple will be effective. Clarity is saying precisely what is
meant, and brevity is using the fewest words necessary. The result is a message that is simple and clear. An aspect of
this is congruence, or consistency, where the nurse’s behavior or nonverbal communication matches the words
spoken. When the nurse tells the client, “I am interested in hearing what you have to say,” the nonverbal behavior
would include the nurse facing the client, making eye contact, and leaning forward. The goal is to communicate
clearly so that all aspects of a situation or circumstance are understood. To ensure clarity in communication, nurses
also need to speak slowly and enunciate (pronounce) carefully.

TIMING AND RELEVANCE Nurses need to be aware of both relevance and timing when communicating with
clients. No matter how clearly or simply words are stated or written, the timing needs to be appropriate to ensure
that words are heard. Moreover, the messages need to relate to the person or to the person’s interests and concerns.
This involves sensitivity to the client’s needs and concerns. For example, a client who is fearful of the possibility of
cancer may not hear the nurse’s explanations about the expected procedures before and after gallbladder surgery. In
this situation it is better for the nurse first to encourage the client to express concerns, and then to deal with those
concerns. The necessary explanations can be provided at another time when the client is able to listen. Another
problem in timing is asking several questions at once. For example, a nurse enters a client’s room and says in one
breath, “Good morning, Mrs. Brody. How are you this morning? Did you sleep well last night? Your husband is
coming to see you before your surgery, isn’t he?” The client no doubt wonders which question to answer first, if
any. A related pattern of poor timing is to ask a question and then not wait for an answer before making another
comment. On the other hand, research shows that by allowing the client to respond to the social talk or chat, the
nurse develops a rapport with the client (Segaric, 2007). This rapport can help facilitate effective therapeutic
communication.

ADAPTABILITY The nurse needs to alter spoken messages in accordance with behavioral cues from the client. This
adjustment is referred to as adaptability. What the nurse says and how it is said must be individualized and carefully
considered. This requires astute assessment and sensitivity on the part of the nurse. For example, a nurse who
usually smiles, appears cheerful, and greets the client with an enthusiastic “Hi, Mrs. Brown!” notices that the client
is not smiling and appears distressed. It is important for the nurse to then modify his or her tone of speech and
express concern by facial expression while moving toward the client.

CREDIBILITY Credibility means worthiness of belief, trustworthiness, and reliability. Credibility may be the most
important criterion of effective communication. Nurses foster credibility by being consistent, dependable, and
honest. The nurse needs to be knowledgeable about what is being discussed and to have accurate information.
Nurses should convey confidence and certainty in what they are saying, while being able to acknowledge their
limitations (e.g., “I don’t know the answer to that, but I will find someone who does”).

HUMOR The use of humor can be a positive and powerful tool in the nurse–client relationship, but it must be used
with care. Humor can be used to help clients adjust to difficult and painful situations. The physical act of laughter
can be an emotional and physical release, reducing tension by providing a different perspective and promoting a
sense of well-being. When using humor, it is important to consider the client’s perception of what is considered
humorous. Timing is also important to consider. Though humor and laughter can help reduce stress and anxiety, the
feelings of the client need to be considered (Moore, 2008).

Nonverbal Communication
Nonverbal communication, sometimes called body language, includes gestures, body movements, use of touch, and
physical appearance, including adornment. Nonverbal communication often tells others more about what a person is
feeling than what is actually being said, because nonverbal behavior is controlled less consciously than verbal
behaviour. Nonverbal communication either reinforces or contradicts what is said verbally. For example, if a nurse
says to a client, “I’d be happy to sit here and talk to you for a while,” yet glances nervously at a watch every few
seconds, the actions contradict the verbal message. The client is more likely to believe the nonverbal behavior,
which conveys “I am very busy and need to leave.” Observing and interpreting the client’s nonverbal behaviour is
an essential skill for nurses to develop. To observe nonverbal behavior efficiently requires a systematic assessment
of the person’s overall physical appearance, posture, gait, facial expressions, and gestures. The nurse, however,
needs to exercise caution in interpretation, always clarifying any observation with the client. Clients who have
altered thought processes, such as in schizophrenia or dementia, may experience times when expressing themselves
verbally is difficult or impossible. During these times, the nurse needs to be able to interpret the feeling or emotion
that the client is expressing nonverbally.An attentive nurse who clarifies observations very often portrays caring and
acceptance to the client. This can be a beginning for establishing a trusting relationship between the nurse and the
client, even in clients who have difficulty communicating appropriately.
PERSONAL APPEARANCE Clothing and adornments can be sources of information about a person. Although
choice of apparel is highly personal, it may convey social and financial status, culture, religion, group association,
and self-concept. Charms and amulets may be worn for decorative or for health protection purposes. When the
symbolic meaning of an object is unfamiliar, the nurse can inquire about its significance, which may foster rapport
with the client. How a person dresses is often an indicator of how the person feels. Someone who is tired or ill may
not have the energy or the desire to maintain their normal grooming. When a person known for immaculate
grooming becomes careless about appearance, the nurse may suspect a loss of self-esteem or a physical illness. The
nurse must validate these observed nonverbal data by asking the client. For acutely ill clients in hospital or home
care settings, a change in grooming habits may signal that the client is feeling better. For example, a man may
request a shave, or a woman may request a shampoo and some makeup.

POSTURE AND GAIT The ways people walk and carry themselves are often reliable indicators of self-concept,
current mood, and health. Erect posture and an active, purposeful stride suggest a feeling of well-being. Slouched
posture and a slow, shuffling gait suggest depression or physical discomfort. Tense posture and a rapid, determined
gait suggest anxiety or anger. The posture of people when they are sitting or lying can also indicate feelings or
mood. Again, the nurse clarifies the meaning of the observed behavior by describing to the client what the nurse sees
and then asking what it means or whether the nurse’s interpretation is correct. For example, “You look like it really
hurts you to move. I’m wondering how your pain is and if you might need something to make you more
comfortable?”

FACIAL EXPRESSION No part of the body is as expressive as

the face (Figure 26–5 ■). Feelings of surprise, fear, anger, disgust,
happiness, and sadness can be conveyed by facial expressions GESTURES Hand and body gestures may emphasize
and clarify
the spoken word, or they may occur without words to indicate a
particular feeling or to give a sign. A father awaiting information
about his daughter in surgery may wring his hands, tap his foot,
pick at his nails, or pace back and forth. A gesture may more
clearly indicate the size or shape of an object. A wave good-bye
and the motioning of a visitor toward a chair are gestures that have
relatively universal meanings. Some gestures, however, are culture specific. The Anglo American gesture meaning
“shoo” or “go
away” means “come here” or “come back” in some Asian cultures. In the Hmong culture it is considered rude to
point at something with your toe.
For people with special communication problems, such as
the deaf, the hands are invaluable in communication. Many
people who are deaf learn sign language. Ill persons who are
unable to reply verbally can similarly devise a communication
system using the hands. The client may be able to raise an index finger once for “yes” and twice for “no.” Other
signals can
often be devised by the client and the nurse to denote other
meanings.
COMMUNICATION WITH CHILDREN

INFANTS
■ Infants communicate nonverbally, often in response to body
feelings rather than in a conscious effort to be expressive.
■ Infants’ perceptions are related to sensory stimuli, so a
gentle voice is soothing, for example, while tension and
anger around them create distress.
TODDLERS AND PRESCHOOLERS
■ Toddlers and young children gain skills in both expressive
(i.e., telling others what they feel, think, want, care about)
and receptive (hearing and understanding what others are
communicating to them) language.
■ Allow time for them to complete verbalizing their thoughts
without interruption.
■ Provide a simple response to questions because they have
short attention spans.
■ Drawing a picture can provide another way for the child to
communicate.
SCHOOL-AGE CHILDREN
■ Talk to the child at his or her eye level to help decrease
intimidation.
■ Include the child in the conversation when communicating
with the parents.
ADOLESCENTS
■ Take time to build rapport with the adolescent.
■ Use active listening skills.
■ Project a nonjudgmental attitude and nonreactive behaviors,
even when the adolescent makes disturbing remarks.
Nurses can use the following communication techniques to
work effectively with children and their families:
■ Play, the universal language, allows children to use other
symbols, not just words, to express themselves.
■ Drawing, painting, and other art forms can be used by even
nonverbal children.
■ Storytelling, in which the nurse and child take turns adding
to a story or putting words to pictures, can help the child
feel safer in expressing emotions and feelings.
■ Word games that pose hypothetical situations or put the
child in control, such as “What if . . .?” “If you could . . . ,”
“If a genie came and gave you a wish . . . ,” can help a child
feel more powerful or explore ideas about how to manage
the illness.
■ Read books with a theme similar to the child’s condition or
problem, then discuss the meaning, characters, and feelings
generated by the book. Movies or videos can also be used
in this way.
■ Writing can be used by older children to reflect on their
situation, develop meaning, and gain a sense of control.
In all interactions with children, it is important to give them
opportunities to be expressive, listen openly, and respond
honestly, using words and concepts they understand.

COMMUNICATION WITH OLDER ADULTS

Older adults may have physical or cognitive problems that

necessitate nursing interventions for improvement of
communication skills. Some of the common ones are as follows:
■ Sensory deficits, such as vision and hearing
■ Cognitive impairment, as in dementia
■ Neurologic deficits from strokes or other neurologic
conditions, such as aphasia (expressive and/or receptive)
and lack of movement
■ Psychosocial problems, such as depression.
Recognition of specific needs and obtaining appropriate
resources for clients can greatly increase their socialization and
quality of life. Interventions directed toward improving
communication in clients with these special needs are as follows:
■ Make sure that assistive devices, glasses, and hearing aids
are being used and are in good working order.
■ Make referrals to appropriate resources, such as speech
therapy.
■ Make use of communications aids, such as communication
boards, computers, or pictures, when possible.
■ Keep environmental distractions to a minimum.
■ Speak in short, simple sentences, one subject at a time—
reinforce or repeat what is said when necessary.
■ Always face the person when speaking—coming up behind
someone may be frightening.
■ Include family and friends in conversation.
■ Use reminiscing, either in individual conversations or in
groups, to maintain memory connections and to enhance
self-identity and self-esteem in the older adult.
■ When verbal expression and nonverbal expression are
incongruent, believe the nonverbal. Clarification of this and
attentiveness to their feelings will help promote a feeling of
caring and acceptance.
■ Find out what has been important and has meaning to the
person and try to maintain these things as much as
possible. Even simple things such as bedtime rituals
become important if they are lost in a hospital or extended
care setting.

Implementing
Nursing interventions to facilitate communication with clients
who have problems with speech or language include manipulating the environment, providing support, employing
measures to enhance communication, and educating the client and
support person.
MANIPULATE THE ENVIRONMENT
A quiet environment with limited distractions will make the
most of the communication efforts of both the client and the
nurse and increase the possibility of effective communication.
Sufficient light will help in conveying nonverbal messages,
which is especially important if visual or auditory acuity is impaired. Initially, the nurse needs to provide a calm,
relaxed environment, which will help reduce any anxiety the client may
have. Remember that any factor that affects communication
can create feelings of frustration, anxiety, depression, or hostility in the client. Communication normally contributes
to a
client’s sense of security and feelings that he or she is not alone,
so communication problems may cause some clients to feel
isolated and confused. To further reduce these emotions, the
nurse should acknowledge and praise the client’s attempts at
communication.
PROVIDE SUPPORT
The nurse should convey encouragement to the client and provide nonverbal reassurance, perhaps by touch if
appropriate. If
the nurse does not understand, it is critical to let the client know
so that he or she can provide clarification with other words or
through some other means of communication. When speaking
with a client who will have difficulty understanding, the nurse
should check frequently to determine what the client has heard
and understood. Using open-ended questions will assist the
nurse in obtaining accurate information about the effectiveness
of communication. For example, a female client, who has limited English skills, is being taught about diet related to
her
Crohn’s disease. If the nurse asks, “Do you understand what to
eat?” The client may nod her head yes. However, this does not
give the nurse confirmation that the client received the message
given. Rather the nurse needs to say, “What do you think will be
good for you to eat when you go home?” The nurse’s body language (e.g., gestures, posture, facial expression, and
eye contact)
should convey acceptance and approval.
EMPLOY MEASURES
TO ENHANCE COMMUNICATION
First determine how the client can best receive messages: by
listening, by looking, through touch, or through an interpreter.
Ways to help communication include keeping words simple
and concrete and discussing topics of interest to the client. It is
often helpful to use alternative communication strategies such
as word boards, pictures, or paper and pencil.
Often interpreters can assist a client and nurse to communicate when the client lacks fluency in the dominant
language.
Some hospitals have a list of interpreters for various languages
who can assist at the bedside. If the client’s support person offers to interpret it is important to ask the client’s
permission, for
the sake of confidentiality. Then instruct the person interpreting to translate as precisely as possible, without
interruption.
EDUCATE THE CLIENT AND SUPPORT PERSONS
Sometimes clients and support people can be prepared in advance for communication problems, for example, before
an intubation or throat surgery. By explaining anticipated problems,
the client is often less anxious when problems arise.