Attitude towards others is also related to the values and beliefs that a person holds about the ideas or practices of other people in society, and they are not always consciously recognised. For example, cultural values commonly lie outside conscious awareness and are often simply taken for granted as being the right values (Stein-Parbury 2005). It is natural for people’s values and beliefs to differ within and across social and cultural groups. Nurses will encounter many situations in which their own cultural values and beliefs differ from those of clients (see Chapter 9). Tolerance and understanding of differences in views and cultural practices helps to facilitate therapeutic relationships between nurses and their clients. For example, a nurse who holds strong values and beliefs about no sex without marriage will need to demonstrate acceptance that personal views are not shared when caring for a pregnant, single, female client. If the nurse is unable to accept this and put personal views to one side, it will be difficult to communicate with the client in a therapeutic manner.

While a nurse’s personal values can create interference in therapeutic relationships if they are imposed on clients or used in judgment, they can also serve to enhance therapeutic effects. For example, a nurse who holds beliefs that all people have positive qualities and that every individual is a worthwhile person will find that such beliefs enhance the establishment of effective therapeutic relationships (Antai-Otong 2007; Stein-Parbury 2005).

DIFFERENCES IN KNOWLEDGE

When the level of knowledge between two people is different, communication can be difficult. For example, an individual’s level of knowledge may be so far above that of the person being spoken to that the meaning of the message may be lost entirely. The nurse must take care to express messages in words and phrases that will be understood. For example, a nurse who is familiar with nursing or medical language, especially jargon, may forget that a client may not be, and if words or phrases are used that are not part of the client’s vocabulary the message may be misinterpreted. The use of specific language that is familiar to members of a subculture or profession may confuse, frighten or alienate people who are not part of that subculture or profession. For example, not every male client will know what the nurse means when asked, ‘Do you need a bottle?’ The word bottle is nursing jargon used to describe a portable male urinal but it could easily be perceived as meaning something entirely different.

PAST EXPERIENCES

Past experiences can have a powerful effect on a person’s perceptions of the meaning of messages. For example, a client who has had a previous traumatic and painful experience in hospital may discount, distrust or disbelieve messages from the nurse that pain after surgery will be controlled. The nurse can help by talking with the client about the past experience and explaining fully every measure that will be implemented to ensure adequate pain relief.

EMOTIONS

Emotions strongly influence how a person relates to other people, and the power of emotion in communication should not be underestimated. Nurses must also be aware that if they become too emotionally involved with the suffering experienced by a client, they may be unable to effectively meet that client’s needs. This aspect is one of the most difficult situations faced by nurses, as on the one hand nurses must become emotionally involved to assist clients, while on the other hand personal emotions cannot be allowed to adversely affect client care. All nurses need to be aware of their emotions, and many find it helpful to talk with other experienced nurses about what they are feeling and experiencing.

It is also important to realise that, if people cultivate ‘emotional distance’ in an interpersonal interaction, they prevent any deep sharing of meaning and may even arouse animosity. For example, if a client feels that a nurse is treating them as an ‘interesting case’ or a ‘problem’ rather than as a person, they are likely to feel resentful, and therapeutic communication is not likely to occur.

Another way by which emotions influence communication is when the receiver of a message becomes irritated or annoyed by any distracting mannerisms of the sender, such as irritating gestures, persistent coughing or throat clearing. Being distracted by annoying mannerisms can cause the listener to lose concentration on the message being conveyed.

It is not unusual for clients to be anxious or upset, and strong emotions interfere with the ability to absorb the information in messages such as those given by medical officers or nurses. There would be little point, for example, in a medical officer informing a client about treatment plans immediately after telling her that her breast biopsy revealed a malignant breast tumour. It would not be surprising if the client’s anxiety level increased to such an extent on hearing the diagnosis that it prevented her from absorbing any of the following information about the proposed treatment. The nurse can help in this situation by ensuring the information is repeated when the client is less anxious or distressed and by providing the information in written form for the client to absorb more effectively at a later time.

RELATIONSHIPS AND ROLES

The style and type of communication that occurs between people depends on the quality and type of relationship that exists between them. Individuals communicate in ways that they perceive are appropriate to particular relationships and the roles they have within them. For example, a woman might communicate passively and non-assertively with the medical officer and the nurse but may be assertive with her husband, dominating with her children and bossy towards her colleagues at work.

There are numerous different types of interpersonal relationships, including those between friends, acquaintances, work colleagues, family members and partners. It is usually only when there is enough trust in a relationship that totally honest communication occurs, when ideas, judgments and emotions can be revealed without fear of reprisal, humiliation or rejection.

The nurse–client relationship is unique: trust in the nurse needs to develop quickly and trust is essential if the relationship is to be therapeutic. Clients in hospital may not say what they are thinking or feeling if there is a lack of trust in the nurse; often this means that the client has a fear of being judged. A therapeutic relationship means demonstrating unconditional acceptance of all clients, without judging (Stein-Parbury 2005; Williams 2007). The nurse accepts the client as a worthwhile person even if the client’s behaviour is challenging. As a nurse’s communication skills develop they become increasingly effective and therapeutic, but even when they have been learned and practised they may still be difficult to apply in some particularly challenging situations. Clinical Interest Box 29.2 provides examples of situations where communicating effectively with clients can be challenging.

CLINICAL INTEREST BOX 29.2 Communication challenges in nursing

• Chatty, lonely clients who want someone to talk to all the time

• Clients or others who are too angry and hostile to listen to explanations

• Clients who are excessively demanding, constantly wanting someone to wait on them or meet their requests

• Silent, withdrawn clients who do not express any feelings or needs

• Sad, depressed, despondent clients who have slow mental and motor responses

• Irritable, annoyed clients or relatives who blame nursing staff unfairly

• Sensory impaired clients who cannot hear or see well

• Clients who have cerebral impairments and cannot articulate or understand words well

• Gossiping, catty or manipulative people who violate confidentiality and cause friction

• Bitter, complaining people who are negative about everything

• Mentally impaired clients who are frightened or distrustful

• Confused, disoriented clients who are bewildered and uncooperative

• People who speak very little English

• Anxious, nervous people who cannot cope with what is happening

• Grieving, crying, distressed people who are suffering a major loss

• Screaming, kicking toddlers, who fight against treatment

• Unresponsive or comatose clients who do not communicate at all

• Flirtatious, sexually inappropriate advances

• Loud, obscene or poorly behaved individuals causing a disturbance

• People violating a rule (e.g. smoking or using mobile phones in a restricted area)

• Clients who are dying and want to talk about it

(adapted from Potter & Perry 2008: 342)

ENVIRONMENTAL SETTING

Effective communication is more likely to occur if it takes place within a setting that is conducive to listening and concentrating. An area that is at a comfortable temperature, private and free from noise and other distractions is suitable, whereas an area where there is noise or a lack of comfort or privacy may create tension and confusion, making effective communication difficult. For example, background noise and the movements of other people in the environment may distract the listener, and even missing one or two vital words in a sentence can result in the meaning of a whole sentence being lost.

Ideally clients should be able to communicate with health professionals and other people in a private room, but this is sometimes difficult to achieve in busy health care facilities. Nurses should, whenever possible, talk with clients about personal issues in a private area. Clients can be accompanied to an interview room or even a quiet garden area to gain privacy. The very least that nurses can do if the client does not have a single room is to close the curtains surrounding the bed, speak quietly and avoid discussing personal details while visitors are in the area.

Two other factors, physical discomfort and pressure of time, are particularly important in nurse–client interactions because they can seriously interfere with the quality of therapeutic communication.

PHYSICAL DISCOMFORT

Communication is likely to be less effective if one or both participants are experiencing fatigue, pain or other physical discomfort. Like its emotional counterpart, physical discomfort can distract a person so that it is not possible to concentrate on what is being said. The nurse who is about to engage in a therapeutic dialogue with a client is advised to ensure that the client is free of pain, lying or sitting in a comfortable position and not needing to go to the toilet. It is also important to consider that some medications, including those administered for pain relief, can affect a client’s memory and the ability to concentrate or to think clearly.

PRESSURE OF TIME

Because most people have many pressures on their time, the urge to speed up communication is increasing. Nurses need to overcome feelings of urgency to complete other tasks while communicating with clients. This is not always easy, but even a few minutes of attentive listening can be very therapeutic for a client. Not all interactions with clients need to be lengthy but it does take time to explain, to listen, to reduce fears or anxieties and to assimilate facts. A client who is sensitive to the nurse’s need to get on with other things is unlikely to raise any issues of concern that need to be talked about. It is one of the major challenges in contemporary nursing practice to prioritise tasks and manage time so that the psychological as well as the physical needs of clients are met.

THE ROUTE OR CHANNEL OF COMMUNICATION

The meaning in a message is at greater risk of being misconstrued if the channel of communication is not the most appropriate. For example, the oral route may not effectively communicate a long and involved message — it may be better transmitted in written form. It is sometimes difficult to relay messages of caring and concern with words; a gentle touch can be more eloquent than the spoken or written word in many situations.

FORMS OF COMMUNICATION

Communication is the process of sharing information and understanding, using verbal and non-verbal methods. Verbal communication involves the use of words and how they are delivered. Words can be written or spoken (vocal). Non-verbal communication involves facial expressions, body posture and gestures, touch and the use of space.

VOCAL COMMUNICATION

In addition to the words used, vocal communication involves the tone and pitch of the voice, the rate and volume of speech and the use of pauses, all of which provide information about the speaker’s message.

NON-VERBAL COMMUNICATION

In nearly every interaction, words are accompanied by simultaneous non-verbal messages that the sender may not be consciously aware of. Non-verbal communication refers to messages transmitted without using words. They include those transmitted via:

• Facial expressions

• Body movements and gestures

• Eye behaviour

• Touch

• Use of space

• Personal appearance.

It is generally accepted that non-verbal messages form the most significant component of communication. Research conducted by Professor Albert Mehrabian (1972) first identified that in conversations messages transmitted and received are about 7% words, 38% tone and pitch of voice and 55% non-verbal clues. These percentages have not been contradicted by any other research, neither has the proposition, identified by Mehrabian (1972), that most non-verbal messages are about emotions and that they are mostly automatic, and so more reliable than words because they are not as easy to fake (Mehrabian 1972). Perhaps that is why there is a saying that ‘actions speak louder than words’.

During interpersonal communication with clients it is essential for the nurse to look as well as listen. Concentrating only on words means that much of what could be discerned is being missed. Non-verbal communication comes from many sources and it is easy to miss something significant. For example, while watching a person’s foot tapping, a significant hand gesture or eye movement may not be noticed. Generally, non-verbal messages are not received in isolation and they are interpreted subconsciously but nurses need to develop the skills of consciously considering verbal and non-verbal messages, together and in context, and validating the meanings perceived in the messages.