Purpose

To establish nurse-patient relationship
To be effective in expressing interest/concern for patient/family
To provide health care information

Personal insight
Sensitivity
Knowledge of communication strategies

Definition: complex process of sending and receiving verbal and non-verbal messages.

Allows for exchange of information, feelings, needs, and preferences

Source/sender and receiver encode and decode message in a cyclic pattern.

Goal: Shared Meaning
Mutual understanding of the meaning of the message
Feedback/response indicates if the meaning of the message was communicated as intended:

Levels of communication

Social: safe
Structured: interviewing, teaching
Therapeutic: patient focused, purposeful, time limited
Nurse comes to know the patient as a unique individual.
Patient comes to trust nurse
Context set for nurse to provide care and to help patient identify, resolve, or adapt to health problems

Types of Communication

Verbal: conscious use of spoken or written word
Choice of words can reflect age, education, developmental level, culture
Feelings can be expressed through tone, pace, etc.

Non-verbal: use of gestures, expressions, behaviors (body language)

85% of communication
Less conscious than verbal
Requires systematic observation and valid interpretation
Nurse must be aware of personal style
How we communicate non-verbally:
physical appearance, posture/gait, facial expressions, gestures, touch (tactile defensiveness)

Nurse states observations and validates with patient

Nurse to crying patient: "You seem upset today."
Patient: "I'm fine thanks."

Factors that affect communication: 

Nurse needs to assess and consider when communicating with patient:

culture, developmental level, physical & psychological barriers, personal space (proxemics), territoriality, roles and relationships, environment, attitudes and values, level of self esteem

Communication Strategies: 

Active Listening is most critical strategy

Strategies that encourage Conversation and Elaboration:

broad opening statements, general leads, reflecting, open-ended and directing questions

Strategies that help patient express thoughts and feelings:

stating observations, acknowledging feelings, reflecting, using silence

Blocks/Barriers to Communication: 

Behaviors or comments of the nurse that have a negative effect:

Not Listening is most harmful behavior!

reassuring cliches, giving advice, expressing approval/disapproval, requesting an explanation (asking why?), defending, belittling feelings, stereotyped comments, changing the subject

Reporting: oral, written, or computer account of patient status; between members of health care team.  Report should be clear, concise, and comprehensive.

Documenting: patient record/chart provides written documentation of patient’s status and treatment

Purpose: continuity of care, legal documentation, research, statistics, education, audits

Patient Privacy: Related terms

Confidential Information: is specific to patients, their diagnosis and treatment.

Privacy: refers to the patient’s right to control access to confidential information.

Confidentiality: refers to the professional responsibility to protect patient privacy.

Need to Know: who has access to what information.

Protection of Patient Privacy

Health Insurance Portability and Accountability Act (HIPAA)

Federal guidelines: effective April, 2003

1. Prohibit disclosure for reasons unrelated to health services.

2. Set civil and criminal penalties for violators.

3. Give patients the right to inspect and copy their records.

4. Require providers to notify patients of privacy policies.

Legal Concerns :

Record/chart is a legal document; may be admissable in court

If it’s not documented, it didn’t happen!

assessment, plan of care, nursing interventions (care, teaching, safety measures), outcome of care, change in status, health care team communication, how the nurse left the patient

Use ink
Write legibly
Spell correctly
Use standard abbreviations
Date, time, chronological order
Errors and blanks
Signature and title

Characteristics of documentation: 

brief, concise, comprehensive, factual, descriptive, objective, relevant/appropriate, legally prudent

Types of documentation: Based on how record is organized

Problem-Oriented (Weed)
Source-Oriented (traditional)
Case Management