• Post category:Nursing
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Using Concrete Messages When speaking to the client, the nurse should use words that are as clear as possible so that the client can understand the message. Anxious people lose cognitive processing skills—the higher the anxiety, the less the ability to process concepts—so concrete messages are important for accurate information exchange. In a concrete message, the words are explicit and need no interpretation; the speaker uses nouns instead of pronouns—for example, “What health symptoms caused you to come to the hospital today?” or “When was the last time you took your antidepressant


medications?” Concrete questions are clear, direct, and easy to understand. They elicit more accurate responses and avoid the need to go back and rephrase unclear questions, which interrupts the flow of a therapeutic interaction.

Abstract messages, in contrast, are unclear patterns of words that often contain figures of speech that are difficult to interpret. They require the listener to interpret what the speaker is asking. For example, a nurse who wants to know why a client was admitted to the unit asks, “How did you get here?” This is an abstract message: the terms how and here are vague. An anxious client might not be aware of where he or she is and might reply, “Where am I?” or might interpret this as a question about how he or she was conveyed to the hospital and respond, “The ambulance brought me.” Clients who are anxious, from different cultures, cognitively impaired, or suffering from some mental disorders often function at a concrete level of comprehension and have difficulty answering abstract questions. The nurse must be sure that statements and questions are clear and concrete.

The following are examples of abstract and concrete messages:

Abstract (unclear): “Get the stuff from him.” Concrete (clear): “John will be home today at 5 PM, and you can

pick up your clothes at that time.” Abstract (unclear): “Your clinical performance has to improve.” Concrete (clear): “To administer medications tomorrow, you’ll have to

be able to calculate dosages correctly by the end of today’s class.”

Using Therapeutic Communication Techniques The nurse can use many therapeutic communication techniques to interact with clients. The choice of technique depends on the intent of the interaction and the client’s ability to communicate verbally. Overall, the nurse selects techniques that facilitate the interaction and enhance communication between client and nurse. Table 6.1 lists these techniques and gives examples. Techniques such as exploring, focusing, restating, and reflecting encourage the client to discuss his or her feelings or concerns in more depth. Other techniques help focus or clarify what is being said. The nurse may give the client feedback using techniques such as making an observation or presenting reality.

Avoiding Nontherapeutic Communication In contrast, there are many nontherapeutic techniques that nurses should avoid (Table 6.2). These responses cut off communication and make it


more difficult for the interaction to continue. Responses such as “everything will work out” or “maybe tomorrow will be a better day” may be intended to comfort the client, but instead may impede the communication process. Asking “why” questions (in an effort to gain information) may be perceived as criticism by the client, conveying a negative judgment from the nurse. Many of these responses are common in social interaction. Therefore, it takes practice for the nurse to avoid making these types of comments.





Interpreting Signals or Cues To understand what a client means, the nurse watches and listens carefully for cues. Cues (overt and covert) are verbal or nonverbal messages that signal key words or issues for the client. Finding cues is a function of active listening. Cues can be buried in what a client says or can be acted out in the process of communication. Often, cue words introduced by the client can help the nurse to know what to ask next or how to respond to the client. The nurse builds his or her responses on these cue words or concepts. Understanding this can relieve pressure on students who are worried and anxious about what question to ask next. The following example illustrates questions the nurse might ask when responding to a client’s cue:

Client: “I had a boyfriend when I was younger.” Nurse: “You had a boyfriend?” (reflecting) “Tell me about you and your boyfriend.” (encouraging

description) “How old were you when you had this boyfriend?” (placing events in


time or sequence)

If a client has difficulty attending to a conversation and drifts into a rambling discussion or a flight of ideas, the nurse listens carefully for a theme or a topic around which the client composes his or her words. Using the theme, the nurse can assess the nonverbal behaviors that accompany the client’s words and build responses based on these cues. In the following examples, the underlined words are themes and cues to help the nurse formulate further communication.

Theme of sadness:

Client: “Oh, hi, nurse.” (Face is sad; eyes look teary; voice is low, with little inflection.)

Nurse: “You seem sad today, Mrs. Venezia.” Client: “Yes, it is the anniversary of my husband’s death.” Nurse: “How long ago did your husband die?” (Or the nurse can use

the other cue.) Nurse: “Tell me about your husband’s death, Mrs. Venezia.”

Theme of loss of control:

Client: “I had a fender bender this morning. I’m okay. I lost my wallet, and I have to go to the bank to cover a check I wrote last night. I can’t get in contact with my husband at work. I don’t know

where to start.” Nurse: “I sense you feel out of control” (translating into feelings).

Clients may use many word patterns to cue the listener to their intent. Overt cues are clear, direct statements of intent, such as “I want to die.” The message is clear that the client is thinking of suicide or self-harm. Covert cues are vague or indirect messages that need interpretation and exploration—for example, if a client says, “Nothing can help me.” The nurse is unsure, but it sounds as if the client might be saying he feels so hopeless and helpless that he plans to commit suicide. The nurse can explore this covert cue to clarify the client’s intent and to protect the client. Most suicidal people are ambivalent about whether to live or die and often admit their plan when directly asked about it. When the nurse suspects self-harm or suicide, he or she uses a yes/no question to elicit a clear response.

Theme of hopelessness and suicidal ideation:


Client: “Life is hard. I want it to be done. There is no rest. Sleep, sleep is good . . . forever.”

Nurse: “I hear you saying things seem hopeless. I wonder if you are planning to kill yourself” (verbalizing the implied).

Other word patterns that need further clarification for meaning include metaphors, proverbs, and clichés. When a client uses these figures of speech, the nurse must follow up with questions to clarify what the client is trying to say.

A metaphor is a phrase that describes an object or a situation by comparing it to something else familiar.

Client: “My son’s bedroom looks like a bomb went off.” Nurse: “You’re saying your son is not very neat” (verbalizing the

implied). Client: “My mind is like mashed potatoes.” Nurse: “I sense you find it difficult to put thoughts together” (translating

into feelings).

Proverbs are old accepted sayings with generally accepted meanings.

Client: “People who live in glass houses shouldn’t throw stones.” Nurse: “Who do you believe is criticizing you but actually has

similar problems?” (encouraging description of perception)

A cliché is an expression that has become trite and generally conveys a stereotype. For example, if a client says, “she has more guts than brains,” the implication is that the speaker believes the woman to whom he or she refers is not smart, acts before thinking, or has no common sense. The nurse can clarify what the client means by saying, “Give me one example of how you see Mary as having more guts than brains” (focusing).

NONVERBAL COMMUNICATION SKILLS Nonverbal communication is the behavior a person exhibits while delivering verbal content. It includes facial expression, eye contact, space, time, boundaries, and body movements. Nonverbal communication is as important as, if not more so than, verbal communication. It is estimated that one third of meaning is transmitted by words and two thirds is communicated nonverbally. The speaker may verbalize what he or she believes the listener wants to hear, whereas nonverbal communication conveys the speaker’s actual meaning. Nonverbal communication involves


the unconscious mind acting out emotions related to the verbal content, the situation, the environment, and the relationship between the speaker and the listener.

Concept Mastery Alert

Nonverbal communication is often more accurate than verbal communication when the two are incongruent. People can readily change what they say, but are less likely to be able to control nonverbal communication.

Knapp and Hall (2013) listed the ways in which nonverbal messages accompany verbal messages:

• Accent: using flashing eyes or hand movements • Complement: giving quizzical looks, nodding • Contradict: rolling eyes to demonstrate that the meaning is the opposite

of what one is saying • Regulate: taking a deep breath to demonstrate readiness to speak, using

“and uh” to signal the wish to continue speaking • Repeat: using nonverbal behaviors to augment the verbal message, such

as shrugging after saying “Who knows?” • Substitute: using culturally determined body movements that stand in for

words, such as pumping the arm up and down with a closed fist to indicate success

Facial Expression The human face produces the most visible, complex, and sometimes confusing nonverbal messages. Facial movements connect with words to illustrate meaning; this connection demonstrates the speaker’s internal dialogue. Facial expressions can be categorized into expressive, impassive, and confusing:

• An expressive face portrays the person’s moment-by-moment thoughts, feelings, and needs. These expressions may be evident even when the person does not want to reveal his or her emotions.

• An impassive face is frozen into an emotionless deadpan expression similar to a mask.

• A confusing facial expression is one that is the opposite of what the


person wants to convey. A person who is verbally expressing sad or angry feelings while smiling is exhibiting a confusing facial expression.

Facial expressions often can affect the listener’s response. Strong and emotional facial expressions can persuade the listener to believe the message. For example, by appearing perplexed and confused, a client can manipulate the nurse into staying longer than scheduled. Facial expressions such as happy, sad, embarrassed, or angry usually have the same meaning across cultures, but the nurse should identify the facial expression and ask the client to validate the nurse’s interpretation of it— for instance, “You’re smiling, but I sense you are very angry” (Sheldon & Foust, 2014).

Frowns, smiles, puzzlement, relief, fear, surprise, and anger are common facial communication signals. Looking away, not meeting the speaker’s eyes, and yawning indicate that the listener is disinterested, lying, or bored. To ensure the accuracy of information, the nurse identifies the nonverbal communication and checks its congruency with the content (Sheldon & Foust, 2014). An example is “Mr. Jones, you said everything is fine today, yet you frowned as you spoke. I sense that everything is not really fine” (verbalizing the implied).

Body Language Body language (gestures, postures, movements, and body positions) is a nonverbal form of communication. Closed body positions, such as crossed legs or arms folded across the chest, indicate that the interaction might threaten the listener who is defensive or not accepting. A better, more accepting body position is to sit facing the client with both feet on the floor, knees parallel, hands at the side of the body, and legs uncrossed or crossed only at the ankle. This open posture demonstrates unconditional positive regard, trust, care, and acceptance. The nurse indicates interest in and acceptance of the client by facing and slightly leaning toward him or her while maintaining nonthreatening eye contact.


Closed body position


Accepting body position

Hand gestures add meaning to the content. A slight lift of the hand from the arm of a chair can punctuate or strengthen the meaning of words. Holding both hands with palms up while shrugging the shoulders often means “I don’t know.” Some people use many hand gestures to demonstrate or act out what they are saying, whereas others use very few gestures.

The positioning of the nurse and client in relation to each other is also important. Sitting beside or across from the client can put the client at ease, whereas sitting behind a desk (creating a physical barrier) can increase the formality of the setting and may decrease the client’s willingness to open up and communicate freely. The nurse may wish to create a more formal setting with some clients, however, such as those


who have difficulty maintaining boundaries.

Vocal Cues Vocal cues are nonverbal sound signals transmitted along with the content: voice volume, tone, pitch, intensity, emphasis, speed, and pauses augment the sender’s message. Volume, the loudness of the voice, can indicate anger, fear, happiness, or deafness. Tone can indicate whether someone is relaxed, agitated, or bored. Pitch varies from shrill and high to low and threatening. Intensity is the power, severity, and strength behind the words, indicating the importance of the message. Emphasis refers to accents on words or phrases that highlight the subject or give insight into the topic. Speed is the number of words spoken per minute. Pauses also contribute to the message, often adding emphasis or feeling.

The high-pitched rapid delivery of a message often indicates anxiety. The use of extraneous words with long, tedious descriptions is called circumstantiality. It can indicate the client is confused about what is important or is a poor historian. Slow, hesitant responses can indicate that the person is depressed, confused, and searching for the correct words, having difficulty finding the right words to describe an incident, or reminiscing. It is important for the nurse to validate these nonverbal indicators rather than to assume that he or she knows what the client is thinking or feeling (e.g., “Mr. Smith, you sound anxious. Is that how you’re feeling?”).

Eye Contact The eyes have been called the mirror of the soul because they often reflect our emotions. Messages that the eyes give include humor, interest, puzzlement, hatred, happiness, sadness, horror, warning, and pleading. Eye contact, looking into the other person’s eyes during communication, is used to assess the other person and the environment and to indicate whose turn it is to speak; it increases during listening but decreases while speaking (DeVito, 2013). Although maintaining good eye contact is usually desirable, it is important that the nurse doesn’t “stare” at the client.

Silence Silence or long pauses in communication may indicate many different things. The client may be depressed and struggling to find the energy to talk. Sometimes, pauses indicate the client is thoughtfully considering the question before responding. At times, the client may seem to be “lost in his or her own thoughts” and not paying attention to the nurse. It is important


to allow the client sufficient time to respond, even if it seems like a long time. It may confuse the client if the nurse “jumps in” with another question or tries to restate the question differently. Also, in some cultures, verbal communication is slow with many pauses, and the client may believe the nurse is impatient or disrespectful if he or she does not wait for the client’s response.

UNDERSTANDING THE MEANING OF COMMUNICATION Few messages in social and therapeutic communication have only one level of meaning; messages often contain more meaning than just the spoken words (DeVito, 2013). The nurse must try to discover all the meaning in the client’s communication. For example, the client with depression might say, “I’m so tired that I just can’t go on.” If the nurse considers only the literal meaning of the words, he or she might assume the client is experiencing the fatigue that often accompanies depression. However, statements such as the previous example often mean the client wishes to die. The nurse would need to further assess the client’s statement to determine whether or not the client is suicidal.

It is sometimes easier for clients to act out their emotions than to organize their thoughts and feelings into words to describe feelings and needs. For example, people who outwardly appear dominating and strong and often manipulate and criticize others in reality may have low self- esteem and feel insecure. They do not verbalize their true feelings but act them out in behavior toward others. Insecurity and low self-esteem often translate into jealousy and mistrust of others and attempts to feel more important and strong by dominating or criticizing them.

UNDERSTANDING CONTEXT Understanding the context of communication is extremely important in accurately identifying the meaning of a message. Think of the difference in the meaning of “I’m going to kill you!” when stated in two different contexts: anger during an argument and when one friend discovers another is planning a surprise party for him or her. Understanding the context of a situation gives the nurse more information and reduces the risk for assumptions.

To clarify context, the nurse must gather information from verbal and nonverbal sources and validate findings with the client. For example, if a client says, “I collapsed,” she may mean she fainted or felt weak and had


to sit down. Or she could mean she was tired and went to bed. To clarify these terms and view them in the context of the action, the nurse could say,

“What do you mean collapsed?” (seeking clarification) or “Describe where you were and what you were doing when you

collapsed” (placing events in time and sequence).

Assessment of context focuses on who was there, what happened, when it occurred, how the event progressed, and why the client believes it happened as it did.