Environmental factors

Environmental factors that may affect communication include physical factors (e.g., background noise, lack of privacy, uncomfortable accommodations) and societal determinants (e.g., the presence of others; expectations of others; sociopolitical, historical, and economic factors).

Relationship factors

Relationship factors refer to the status of individuals in terms of social standing, power, relationship type, age, etc. Communication is influenced by this status. Consider how you would describe your day in the clinical setting to your instructor, compared to how you would describe it to your friend. The fact that your instructor has more education than you and is in an evaluative role would likely influence how much you share and your choice of words.

Now think about the relationship between you and your patient. Your patient may be older or younger than you are, more or less educated, richer or poorer, successful at work or unemployed. These factors play into the dynamics of the communication, whether at a conscious or an unconscious level, and recognizing their influence is important. It may be difficult for you to work with a woman your mother’s age, or you may feel impatient with a patient who is unemployed and an alcoholic.

It is sometimes difficult for students to grasp or remember that patients, regardless of their relationship factors, are in a position of vulnerability. The presence of a hospital identification band is a formal indication of a need for care, and as a caregiver, you are viewed in a role of authority. Part of the art of therapeutic communication is in finding a balance between your role as a professional and your role as a human being who has been socialized into complex patterns of interactions based, at least in part, on status.

Students sometimes fall back into time-tested and comfortable roles. One of the most common responses nursing students have is in treating the patient as a buddy. Imagine a male nursing student walking onto the unit, seeing his assigned patient, and saying, “Hey, how’s it going today?” while giving the patient a high-five. Or consider the female nursing student assigned to the 60-year-old woman who used to work as a registered nurse. This relationship has the potential to become unbalanced and nontherapeutic if the patient shifts the focus of concern onto the student.

Nonverbal communication

It is often said, “It’s not what you say but how you say it.” In other words, it is the nonverbal behaviors that may be sending the “real” message through the tone or pitch of the voice. It is important to keep in mind, however, that culture influences the pitch and the tone a person uses. For example, the tone and pitch of a voice used to express anger can vary widely within cultures and families (Arnold & Boggs, 2011). The tone of voice, emphasis on certain words, and the manner in which a person paces speech are examples of nonverbal communication. Other common examples of nonverbal communication (often called cues) are physical appearance, body posture, eye contact, hand gestures, sighs, fidgeting, and yawning. Table 9-1 identifies examples of nonverbal behaviors.

Facial expression is extremely important in terms of nonverbal communication; the eyes and the mouth seem to hold the biggest clues into how people are feeling through emotional decoding. Eisenbarth and Alpers (2011) tracked how long participants looked at various parts of the face in response to different emotions. Participants initially focused on the eyes more frequently when looking at a sad face, and they initially focused on the mouth more frequently when looking at a happy face. Like sadness, anger was more frequently decoded in the eyes. When presented with either a fearful or neutral expression, there was an equal amount of attention given to both the eyes and the mouth.

Interaction of verbal and nonverbal communication

Shawn Shea (1998), a nationally renowned psychiatrist and communication workshop leader, suggests that communication is roughly 10% verbal and 90% nonverbal. The high percentage he attributes to nonverbal behaviors may best describe our understanding of feelings and attitudes and not general communication. After all, it would be difficult to watch a foreign film and completely understand its meaning based solely on body language and vocal tones; however, nonverbal behaviors and cues influence communication to a surprising degree. Communication thus involves two radically different but interdependent kinds of symbols.

Spoken words represent our public selves and can be straightforward or used to distort, conceal, deny, or disguise true feelings. Nonverbal behaviors include a wide range of human activities, from body movements to facial expressions to physical reactions to messages from others. How a person listens and uses silence and sense of touch may also convey important information about the private self that is not available from conversation alone, especially in consideration of cultural norms.

Some elements of nonverbal communication, such as facial expressions, seem to be inborn and are similar across cultures (Matsumoto, 2006; Matsumoto & Sung Hwang 2011). Some cultural groups (e.g., Japanese, Russians) may control their facial expressions in public while others (e.g., Americans) tend to be open with facial expressions. Gender also plays a role in facial expressions; men are more likely to hide surprise and fear while women control disgust, contempt, and anger.

Other types of nonverbal behaviors, such as how close people stand to each other when speaking, depend on cultural conventions. Some nonverbal communication is formalized and has specific meanings (e.g., the military salute, the Japanese bow).

Messages are not always simple; they can appear to be one thing when in fact they are another. Often persons have greater conscious awareness of their verbal messages than their nonverbal behaviors. The verbal message is sometimes referred to as the content of the message (what is said), and the nonverbal behavior is called the process of the message (nonverbal cues a person gives to substantiate or contradict the verbal message).

When the content is congruent with the process, the communication is more clearly understood and is considered healthy. For example, if a student says, “It’s important that I get good grades in this class,” that is content. If the student has bought the books, takes good notes, and has a study buddy, that is process. Therefore, the content and process are congruent and straightforward, and there is a “healthy” message. If, however, the verbal message is not reinforced or is in fact contradicted by the nonverbal behavior, the message is confusing. For example, if the student does not have the books, skips several classes, and does not study, that is process. Here the student is sending two different messages.

Messages are sent to create meaning but also can be used defensively to hide what is actually going on, create confusion, and attack relatedness (Ellis et al., 2003). Conflicting messages are known as double messages or mixed messages. One way a nurse can respond to verbal and nonverbal incongruity is to reflect and validate the patient’s feelings. For example, the nurse could say, “You say you are upset you did not pass this semester, but I notice you look relaxed. What do you see as some of the pros and cons of not passing the course this semester?”

Bateson and colleagues (1956) coined the term double-bind messages. They are characterized by two or more mutually contradictory messages given by a person in power. Opting for either choice will result in displeasure of the person in power. Such messages may be a mix of content (what is said) and process (what is conveyed nonverbally) that has both nurturing and hurtful aspects. The following vignette gives an example.

The recipient of this double-bind message is caught inside contradictory statements, so she cannot decide what is right. If she goes, the implication is that she is being selfish by leaving her sick mother alone, but if she stays, the mother could say, “I told you to go have fun.” If she does go, the chances are she will not have much fun, so the daughter is trapped in a no-win situation.

With experience, nurses become increasingly aware of patients’ verbal and nonverbal communication. Nurses can compare patients’ dialogue with their nonverbal behaviors to gain important clues about the real message. What individuals do may either express and reinforce or contradict what they say. So, as in the saying “actions speak louder than words,” actions often reveal the true meaning of a person’s intent, whether the intent is conscious or unconscious.

Using silence

Students and practicing nurses alike may find that when the flow of words stops, they become uncomfortable. They may rush to fill the void with “questions or chatter,” thus cutting off potentially important thoughts and feelings the patient might be taking time to think about before articulating. Silence is not the absence of communication but a specific channel for transmitting and receiving messages; therefore, the practitioner needs to understand that silence is a significant means of influencing and being influenced by others.

Talking is a highly individualized practice. Some people find the telephone a nuisance whereas others believe they cannot live without their cell phones on their persons at all times. In the initial interview, patients may be reluctant to speak because of the newness of the situation, the fact that the nurse is a stranger, or feelings of distrust, self-consciousness, embarrassment, or shyness. The nurse must recognize and respect individual differences in styles and tempos of responding. People who are quiet, those who have a language barrier or speech impediment, older adults, and those who lack confidence in their ability to express themselves may communicate a need for support and encouragement through their silence.

Although there is no universal rule concerning how much silence is too much, silence has been said to be worthwhile only as long as it is serving some function and not frightening the patient. Knowing when to speak during the interview largely depends on the nurse’s perception about what is being conveyed through the silence. Icy silence may be an expression of anger and hostility; being ignored or given “the silent treatment” is recognized as an insult and is a particularly hurtful form of communication.

Silence may provide meaningful moments of reflection for both participants and gives an opportunity to contemplate thoughtfully what has been said and felt, weigh alternatives, formulate new ideas, and gain a new perspective on the matter under discussion. If the nurse waits to speak and allows the patient to break the silence, the patient may share thoughts and feelings that would otherwise have been withheld. Nurses who feel compelled to fill every void with words often do so because of their own anxiety, self-consciousness, and embarrassment. When this occurs, the nurse’s need for comfort has taken priority over the needs of the patient.

It is crucial to recognize that some psychiatric disorders, such as major depression and schizophrenia, and medications may cause an overall slowing of thought processes. This slowing may be so severe that it may seem like an eternity before the patient responds. Patience and gentle prompting (e.g., “You were saying that you would like to get a pass this weekend to visit your niece”) can help patients gather their thoughts.

Conversely, silence is not always therapeutic. Prolonged and frequent silences by the nurse may hinder an interview that requires verbal articulation. Although a less-talkative nurse may be comfortable with silence, this mode of communication may make the patient feel like a fountain of information to be drained dry. Moreover, without feedback, patients have no way of knowing whether what they said was understood. Additionally, children and adolescents in particular tend to feel uncomfortable with silence.

Active listening

People want more than just a physical presence in human communication. Most people want the other person to be there for them psychologically, socially, and emotionally. Active listening in the nurse-patient relationship includes the following aspects:

Sommers-Flanagan and Sommers-Flanagan (2013) advise students, as well as experienced clinicians, to learn to quiet themselves: “They need to rein in any natural urges to help, personal needs, and anxieties” (p. 5). Relaxation techniques may help some before an interview with the patient (e.g., closing one’s eyes and breathing slowly for a few minutes or using mindfulness training/meditation). This usually results in more concentration on the patient and less distraction by personal worries or personal thoughts of what to say next.

Effective interviewers learn to become active listeners when the patient is talking as well as when the patient becomes silent. During active listening, nurses carefully note verbal and nonverbal patient responses and monitor their own nonverbal responses. Using silence effectively and learning to listen actively—to both the patient and your own thoughts and reactions—are key ingredients in effective communication. Both skills take time to develop but can be learned; you will become more proficient with guidance and practice.

Active listening helps strengthen the patient’s ability to solve problems. By giving the patient undivided attention, the nurse communicates that the patient is not alone. This kind of intervention enhances self-esteem and encourages the patient to direct energy toward finding ways to deal with problems. Serving as a sounding board, the nurse listens as the patient tests thoughts by voicing them aloud. This form of interpersonal interaction often enables the patient to clarify thinking, link ideas, and tentatively decide what should be done and how best to do it.

Clarifying techniques

Understanding depends on clear communication, which is aided by verifying the nurse’s interpretation of the patient’s messages. The nurse can request feedback on the accuracy of the message received from verbal and nonverbal cues. The use of clarifying techniques helps both participants identify major differences in their frame of reference, giving them the opportunity to correct misperceptions before they cause any serious misunderstandings. The patient who is asked to elaborate on or clarify vague or ambiguous messages needs to know that the purpose is to promote mutual understanding.

Exploring.

A technique that enables the nurse to examine important ideas, experiences, or relationships more fully is exploring. For example, if a patient tells you he does not get along well with his wife, you will want to further explore this area. Possible openers include the following:

“Tell me more about your relationship with your wife.”

“Describe your relationship with your wife.”

“Give me an example of how you and your wife don’t get along.”

Asking for an example can greatly clarify a vague or generic statement made by a patient.

Patient: ”No one likes me.”

Nurse: ”Give me an example of one person who doesn’t like you.”

or

Patient: ”Everything I do is wrong.”

Nurse: ”Give me an example of one thing you do that you think is wrong.”

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