Communication involves the ability to interact with people at a variety of levels and in a range of situations. Effective communication is important in all areas of everyday life; the quality of relationships between people depends on it. Nurses need to communicate effectively with everyone in the health care environment, and therapeutically with clients. The ability of nurses to communicate therapeutically is a critical factor in how clients experience illness. Nurses need to be skilful in what they do for clients but at the same time they need to be communicating with them in ways that are supportive and helpful and promote feelings of trust. While the focus of this chapter is on therapeutic nurse–client interactions, the skills involved will enhance communication in all relationships between people.

The nurse who has effective communication skills:

All communication is a two-way process in which messages are conveyed by verbal and/or non-verbal means by one person, and received by another. All behaviour conveys some message and is therefore a form of communication. For example, even a client refusing to speak or acknowledge the presence of a nurse conveys a message that the nurse will attempt to interpret (decode). Non-verbal communication includes the messages sent by facial expression, gestures, body posture and appearance, and those that are written (see Chapter 20 for information concerning written communication in nursing).

Communication is an ongoing dynamic series of events in which meaning is generated and transmitted. Communication occurs when a person responds to a message and assigns meaning to it. Meanings are mental images that are created to develop a sense of understanding. During interactions people respond to messages they receive and create meanings for those messages. If the intended meaning of a message is misunderstood by the recipient, communication has not occurred effectively.

Communication takes place at many different levels and, depending on their area of practice, nurses may need competence in all of them. While the various levels are outlined briefly, the focus of this chapter is primarily on communication at the interpersonal level, between nurse and client in the therapeutic relationship.


The most basic level at which communication occurs is the intrapersonal level. Others include the interpersonal, small-group, organisational, public and mass communication levels.

Intrapersonal communication is a process that occurs within individuals. For example, if a person looks outside and sees that it is raining and thinks ‘I had better bring the washing in’, the person is communicating intrapersonally. Thus, intrapersonal communication involves an ongoing dialogue of thoughts. A dialogue of thoughts is a process that can help in deciding about future plans, resolving internal conflict and evaluating personal behaviour and relationships with others.

Interpersonal communication usually refers to communication that occurs between two people (a dyad). It can occur face to face, or via means such as a telephone. Interpersonal communication is at the heart of nursing practice.

Small-group communication occurs between three or more people interacting with one another. Small-group communication usually occurs face to face, but it may also develop through the use of a communication medium, for example when several people hold a conference via a telephone or video link-up. There is generally a common purpose for a group of people interacting.

Organisational communication refers to a system of disseminating and transferring information within an organisation, for example when hospital management personnel are communicating with medical officers and staff at ward level to determine bed availability for clients waiting for admission. This level of communication often encompasses the other three levels of intrapersonal, interpersonal and small-group communication.

Public communication involves interaction with large groups of people, for example when a speaker addresses an audience.

Mass communication occurs when a small number of people send messages to a large, anonymous audience through the use of some specialised media, such as film, television, radio, newspapers, magazines or books.

Communication with clients in health care settings is often at the interpersonal level, between two people only, commonly the nurse and the client. It has a different purpose from communication in social situations. Social communication is initiated for the purpose of friendship and enjoying the company of others. Mutual needs are met through social interaction. The aim of the communication between a nurse and client is to establish a therapeutic relationship to benefit the client, even when the contact is brief. In any therapeutic relationship the needs of the other person are always placed ahead of personal needs.

Therapeutic communication is client focused, purposeful and time limited. It involves the nurse coming to know and respond to the client as a unique person, and the client coming to trust the nurse. Within a therapeutic relationship the nurse and client communicate comfortably during times of the most intimate nursing care or emotional significance. Throughout the relationship the nurse remains continually sensitive to the client’s feelings and needs. A therapeutic relationship is purposeful in that it involves the nurse assisting clients identify, adapt to or resolve health problems.


Communication is a multidimensional and complex process in which ideas, thoughts, values, knowledge or feelings are shared and interpreted. During the process people simultaneously send and receive numerous messages at many different levels. To simplify understanding of this complex process, models of communication have been developed. Figure 29.1 is an example of one such model. It depicts the basic elements of communication and shows that communication is an active process between sender and receiver. The process of communication involves:

The sender is the individual who initiates the communication. The receiver is the person to whom the message is transmitted. The role of sender and receiver may alternate between participants at any time during the period messages are being transmitted.

The message is the information that is transmitted by the sender, and may be comprised of both verbal and non-verbal information.

The channel is the means by which the message is conveyed, for example, through the visual, auditory, olfactory or tactile routes. The sender’s facial expressions and body gestures visually convey a message to the receiver; for example, a facial grimace or tense body posture sends a visual message to the nurse that the client may be in pain. The spoken word is conveyed via the auditory channel and touching a person while communicating uses the tactile channel. A nurse can convey a message of caring and compassion to a distressed client by a simple touch of the hand. The olfactory route is particularly important in nursing. Unpleasant odours can indicate a variety of conditions, including incontinence of urine or faeces or the onset of a urinary tract or other infection; a smell of acetone on a client’s breath can indicate a serious lack of insulin in the body (diabetic ketoacidosis).

Feedback helps the sender recognise whether the meaning of the message conveyed has been perceived as intended. The receiver’s verbal and non-verbal responses convey feedback to the sender to reveal the receiver’s understanding of the message. Feedback helps to clarify communication as it guides people in adjusting the messages they send to one another. Effective communicators continuously seek feedback from the people with whom they are communicating, to determine whether the information they are transmitting is being received and understood as intended — that there are no misinterpretations of the meaning of the messages.

Variables are the factors that influence the quality and effectiveness of the communication. They include factors such as the setting in which communication takes place, the presence of distractions such as background noise, and the language, perceptions, values, knowledge, cultural background, role and emotions of each person taking part in the communication. Variables can enhance the effectiveness of communication between people but they are often barriers. A setting that does not provide adequate privacy may be a significant barrier when a nurse and client are attempting to communicate about the client’s personal concerns.

When communication is occurring and information is being transmitted from one person to another, two processes must take place: encoding and decoding. Encoding refers to the cognitive processes that occur in the mind of the person who is to send the message. These thoughts must be translated into a code, such as verbal language, to be transmitted to the person who is to receive the message. Decoding refers to the cognitive processes used by the receiver of the message to make sense of what is seen or heard. Generally the sender and the receiver encode and decode messages in a cyclic pattern while communication is taking place. Clinical Interest Box 29.1 illustrates the communication process in action.


Even during a simple act of interpersonal communication between two people, many factors can influence how effectively messages are conveyed and understood. These factors are frequently referred to as the variables (Figure 29.1); they relate to anything that influences or interferes with how the sender transmits a message, how the recipient perceives (interprets) the meaning of the message and the route or channel of communication.


Attitude is the way one person behaves towards another. A person’s attitude can be positive, or negative and unpleasant. An unpleasant attitude in the workplace makes other people feel uncomfortable and it is detrimental to the wellbeing of clients. Attitude can be influenced by what is happening in a person’s life. For example, a fight with a friend may create feelings of anger or distress. Such feelings can be reflected in a negative, even hostile, attitude towards others, which can change the way messages are transmitted and received. Nurses have a professional responsibility to maintain a positive attitude towards clients at all times, so every effort must be made to put personal concerns and feelings aside when communicating with clients, relatives and other health professionals in the workplace.

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).


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.


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

(adapted from Potter & Perry 2008: 342)


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.


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.

The use of pauses

Pauses can provide time for clients to think about what they want to say, but pauses that are too long may seem awkward or uncomfortable. In normal conversation the style of communication that individuals use is generally not thought about consciously. When engaged in therapeutic relationships, nurses need to consciously evaluate the way they communicate and develop a conscious awareness of the tone, pitch, rate and volume at which they speak. Other basic aspects of vocal communication that are helpful to be aware of are the need to:


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:

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.

Facial expressions

Facial expressions convey emotional states, and so a great deal of information can be obtained about clients’ feelings by observing their facial expressions. For example, a frown or an eyebrow raised in disbelief reveals something of how a client is reacting to what is being said. Some specific facial expressions of emotion seem to be universal across cultures. They are those that convey surprise, fear, disgust, anger, happiness and sadness (Ekman 1997). Facial expressions provide the nurse with continual non-verbal feedback from most clients, but some people have expressionless mask-like faces that reveal little or nothing of what they are thinking or feeling. This may be a client’s usual demeanour but sometimes it is due to the effects of an illness such as Parkinson’s disease, Alzheimer’s dementia or severe depression. In such cases the nurse must detect the client’s mood from other clues such as body posture, activity level, appetite or simply by asking how the client is feeling.

Facial expressions can attempt to mask true emotions, for example, a client may smile to hide feelings of sadness, anxiety or boredom. This may be so as to not worry loved ones, not to concern the nurse, or to keep feelings private. Facial expression may be incongruent with what a person is saying; for example, a client may be smiling while talking about a very sad event, such as the death of their child. In such cases the client would be described as having ‘an inappropriate affect’ (Varcarolis 2006).

Clients are often very sensitive to the facial expressions of the nurse and it is imperative that, even though it is sometimes difficult to control, nurses make every effort not to facially express feelings of shock, alarm, repulsion or any other negative emotion in front of the client. Imagine the effect on a client with a stoma, an amputation or serious burns who detects repulsion on the face of a nurse. Additionally, nurses need to develop awareness of the effect their facial expressions may have on clients during procedures and interactions of any sort. For example, frowning in concentration while dressing a wound may be interpreted by the client as the nurse being worried and concerned about the look of the wound.

Body movements and gestures (body language)

The way individuals move, walk, sit or stand communicates information about their mood, attitude, state of mental and physical health, and self-esteem. An upright posture together with decisive, quick and purposeful movements communicates a sense of wellbeing and self-confidence. A slumped posture, hesitant movements and a slow shuffling or stumbling gait may indicate depression, physical illness or impairment or that a person is drug affected or fatigued.

Gestures are motions of the limbs or body made to express thoughts or feelings, to emphasise or clarify what is being said or to replace the spoken word. For example, a shrug of the shoulders can replace the words, ‘I don’t know’ and pointing to an object is easier than explaining where or what it is. Some basic communication gestures convey the same message in almost every culture. For example, nodding the head is almost universally used to indicate ‘yes’, or affirmation.

Conversely, a specific gesture may be meaningless or assume a different meaning in another culture. For example, the ‘V’ sign made with two fingers may mean victory, the number two, or something rather rude. Even within one culture the meaning may be different according to whether the gesture is made with the palm facing out or facing in. In most European countries the V sign means victory when gestured with the palm facing away from the body and a rude ‘shove it’ when the palm is facing towards the body of the person gesticulating (Haynes 2002). It is not uncommon for an acceptable gesture in one culture to be considered rude in another. For example, pointing at an object with the index finger is considered impolite in the Middle and Far East. In Indonesia it is common and more acceptable to use an open hand or thumb (Haynes 2002). (See Chapter 9 for more information on cultural difference.)

Although body language can communicate much about how a client is feeling, it is a mistake to interpret a single movement, gesture or facial expression in isolation. For example, a person with arms folded across the chest and stomping about might simply be protecting himself from the cold, but if this was accompanied by sobbing, shouting or facial grimacing it may indicate severe pain, distress or anger. All non-verbal clues need to be observed together when considering what is really happening.

When a person’s actions or gestures do not match spoken words, the messages are said to be incongruent. This means that the body movements or gestures are conveying one message, while the verbal words are conveying a different message. When a client conveys incongruent messages it is important that the nurse tries to clarify what is happening even though it may at first feel awkward doing so. Clinical Interest Box 29.3 provides an example of how a nurse can explore incongruence between verbal and non-verbal messages.

Eye behaviour

Eye contact is one of the most crucial aspects of communication. How often people make eye contact or how long they hold a gaze can make a vital difference to the quality of an interaction. Eye contact and behaviour can convey openness and sincerity, and an individual’s emotional state and level of interest in a person or what is being said, and a failure to make eye contact can reduce the effectiveness of communication. Causes for failing to make eye contact include shyness, nervousness, low self-esteem, embarrassment or defensiveness.

In some cultures the norms about what eye contact means, how often it should occur and with whom, are quite different to those of the white Anglo Saxon population. According to their cultural norms, people try to balance their eye contact somewhere between staring and avoiding all contact. Some of the differences in eye behaviour include that Japanese people tend to gaze at the neck rather than at the face when conversing; Southern Europeans tend to have a high frequency of gaze that may be offensive to others; people from Arab countries tend to use prolonged eye contact to gauge trustworthiness; in Asia, Africa and Latin America people avoid eye contact as a sign of respect (Stern 2004), and eye contact can make Aboriginal people feel awkward, so they may look the other way during conversations (Kimberley Interpreting Service 2003). Nurses therefore need to consider cultural differences when using eye contact with clients.

Looking down on a client from a higher position can be intimidating. When clients are in bed it is preferable for the nurse, or any other health professional, to sit down and make eye contact at eye level because communicating at eye level indicates equality in a relationship. Conversely, rising to the same eye level as a person who is angry, bossy or intimidating in any way may reduce feelings of vulnerability because it helps to establish a more equal sense of power (Crisp & Taylor 2005).


Touch (tactile communication) is one of the most powerful and personal forms of expression. A person’s first comfort in life comes from touch, and so, frequently, does their last, as touch may communicate with a dying person when words cannot. There is no way to practise nursing without touching and, in nursing, touch may be the most important of all non-verbal communications. Touch occurs in everyday procedures such as taking vital signs and assisting clients with showers or baths. It also occurs at times of joy, fear, stress and loss (see Chapter 14 concerning loss and grief). How nurses use touch in client care conveys a great deal about the way they feel towards their clients and their illnesses.

Some people, including nurses, appreciate the significance of touch as a therapeutic act so much that they perform the techniques of relaxation massage or the ‘laying on of hands’. Massage, performed skilfully and sensitively, can produce relaxation and can communicate caring. Laying on of hands involves placing the hands on or near the body of an ill person in an attempt to heal (Rankin-Box 2001). In nursing, touch can be used therapeutically to transmit positive feelings of understanding, compassion or reassurance. To be effective, tactile communication must be used at the appropriate time and place. Not all people like to be touched and all individuals consider a certain amount of space around them as private. Touch can be seen as an invasion of that privacy unless it is desired. Touch must be used at the right time and in the right way, otherwise the message may be misinterpreted. Nurses always need to assess and be sensitive to how comfortable the client is with being touched.


The concept of ‘space’ is important in communication, as it determines the distance a person usually keeps between themself and other people. The individuals involved and the context or situation dictate acceptable distance zones. People surround themselves with their own ‘informal’ personal space, which is invisible and mobile. There are four categories of space or zone (Figure 29.2).

The intimate zone (between 15 cm and 45 cm from the body surface) is the most important to a person, who guards it as if it were personal property. Usually only those who are emotionally close to the person are permitted to enter this zone, such as spouses, partners or lovers, parents, children, close friends and relatives. The personal zone (between 46 cm and 1.2 m) is about the distance individuals keep between them at friendly gatherings and social functions. The social zone (between 1.2 m and 3.6 m) is the distance individuals keep between themselves and strangers or people who are not well known to them. The public zone (over 3.6 m) is a comfortable distance at which an individual generally chooses to stand when addressing a large group of people.

Individuals have their own personal tolerance for touch, closeness and distance, which is often also influenced by cultural conditioning. For example, some Asian people may feel very uncomfortable if they are touched on the head because the head is the repository of the soul in the Buddhist religion (Haynes 2002). When two people are communicating, each person makes personal space decisions and attempts to maintain an ‘acceptable’ boundary of personal space. Sometimes the personal space expectations of each person conflict and the result is spatial invasion. Spatial invasion makes people very uncomfortable and precipitates a communication reaction of either fight or flight, neither of which is helpful in promoting communication. Most people have experienced a situation when, during a conversation with another person, that person moves in uncomfortably close to make a point. The first person often feels this as an invasion of personal space and responds first by pulling the head away. If this first non-verbal cue is not received, the person may even step back and move away.

The nature of nursing practice means that nurses frequently invade a client’s intimate or personal space. Many clients will be uncomfortable with this closeness, and nurses should be sensitive to how each client is responding. Conversely, such necessary closeness when handled sensitively may promote rapport between a nurse and a client.

Feb 12, 2017 | Posted by in NURSING | Comments Off on COMMUNICATION

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