- Is the means to establish a helping-healing relationship. All behavior communication influences behavior.
- Communication is essential to the nurse-patient relationship for the following reasons:
- Is the vehicle for establishing a therapeutic relationship.
- It the means by which an individual influences the behavior of another, which leads to the successful outcome of nursing intervention.
Basic Elements of the Communication Process
- Sender – is the person who encodes and delivers the message
- Messages – is the content of the communication. It may contain verbal, nonverbal, and symbolic language.
- Receiver – is the person who receives the decodes the message.
- Feedback – is the message returned by the receiver. It indicates whether the meaning of the sender’s message was understood.
Modes of Communication
- Verbal Communication – use of spoken or written words.
- Nonverbal Communication – use of gestures, facial expressions, posture/gait, body movements, physical appearance and body language
Characteristics of Good Communication
- Simplicity – includes uses of commonly understood, brevity, and completeness.
- Clarity – involves saying what is meant. The nurse should also need to speak slowly and enunciate words well.
- Timing and Relevance – requires choice of appropriate time and consideration of the client’s interest and concerns. Ask one question at a time and wait for an answer before making another comment.
- Adaptability – Involves adjustments on what the nurse says and how it is said depending on the moods and behavior of the client.
- Credibility – Means worthiness of belief. To become credible, the nurse requires adequate knowledge about the topic being discussed. The nurse should be able to provide accurate information, to convey confidence and certainly in what she says.
Communicating With Clients Who Have Special Needs
1. Clients who cannot speak clearly (aphasia, dysarthria, muteness)
b. Ask simple question that require “yes” and “no” answers.
c. Allow time for understanding and response.
d. Use visual cues (e.g., words, pictures, and objects)
e. Allow only one person to speak at a time.
f. Do not shout or speak too loudly.
g. Use communication aid:Pad and felt-tipped pen, magic slate, pictures denoting basic needs, call bells or alarm.
b. Get client’s attention prior to speaking
c. Use simple sentences and avoid long explanation.
d. Ask one question at a time
e. Allow time for client to respond
f. Be an attentive listener
g. Include family and friends in conversations, especially in subjects known to client.
3. Client who are unresponsive
b. Communicate both verbally and by touch
c. Speak to client as though he or she could hear
d. Explain all procedures and sensations
e. Provide orientation to person, place, and time
f. Avoid talking about client to others in his or her presence
g. Avoid saying things client should not hear
4. Communicating with hearing impaired client
b. Pay attention to client’s non-verbal cues
c. Decrease background noise such as television
d. Always face the client when speaking
e. It is also important to check the family as to how to communicate with the client
f. It may be necessary to contact the appropriate department resource person for this type of disability
5. Client who do not speak English
b. Establish method for client o signal desire to communicate (call light or bell)
c. Provide an interpreter (translator) as needed
d. Avoid using family members, especially children, as interpreters.
e. Develop communication board, pictures or cards.
f. Have dictionary (English/Spanish) available if client can read.
- Are oral, written, or audiotape exchanges of information between caregivers.
2. Telephone report
3. Telephone or verbal orders – only RN’s are allowed to accept telephone orders.
4. Transfer report
5. Incident report
- Is anything written or printed that is relied on as record or proof for authorized person.
- Nursing documentation must be:
- flexible enough to retrieve critical data, maintain continuity of care, track client outcomes, and reflects current standards of nursing practice
- Effective documentation ensures continuity of care saves time and minimizes the risk of error.
- As members of the health care team, nurses need to communicate information about clients accurately and in timely manner
- If the care plan is not communicated to all members of the health care team, care can become fragmented, repetition of tasks occurs, and therapies may be delayed or omitted.
- Data recorded, reported, or communicated to other health care professionals are CONFIDENTIAL and must be protected.
- Nurses are legally and ethically obligated to keep information about clients confidential.
- Nurses may not discuss a client’s examination, observation, conversation, or treatment with other clients or staff not involved in the client’s care.
- Only staff directly involved in a specific client’s care has legitimate access to the record.
- Clients frequently request copies of their medical record, and they have the right to read those records.
- Nurses are responsible for protecting records from all unauthorized readers.
- When nurses and other health care professionals have a legitimate reason to use records for data gathering, research, or continuing education, appropriate authorization must be obtained according to agency policy.
- Maintaining confidentiality is an important aspect of profession behavior.
- It is essential that the nurse safe-guard the client’ right to privacy by carefully protecting information of a sensitive, private nature.
- Sharing personal information or gossiping about others violates nursing ethical codes and practice standards.
- It sends the message that the nurse cannot be trusted and damages the interpersonal relationships.
Guidelines of Quality Documentation and Reporting
b. The use of vague terms, such as appears, seems, and apparently, is not acceptable because these words suggest that the nurse is stating an opinion.
“The client seems anxious” (the phrase seems anxious is a conclusion without supported facts.)
b. Documentation of concise data is clear and easy to understand.
c. It is essential to avoid the use of unnecessary words and irrelevant details
a. The information within a recorded entry or a report needs to be complete, containing appropriate and essential information.
An organized note describes the client’s pain, nurse’s assessment, nurse’s interventions, and the client’s response
Legal Guidelines for Recording
- Draw single line through error, write word error above it and sign your name or initials. Then record note correctly.
- Do not write retaliatory or critical comments about the client or care by other health care professionals.
- Enter only objective descriptions of client’s behavior; client’s comments should be quoted.
- Correct all errors promptly
- Errors in recording can lead to errors in treatment
- Avoid rushing to complete charting, be sure information is accurate.
- Do not leave blank spaces in nurse’s notes.
- Chart consecutively, line by line; if space is left, draw line horizontally through it and sign your name at end.
- Record all entries legibly and in blank ink
- Never use pencil, felt pen.
- Blank ink is more legible when records are photocopied or transferred to microfilm.
- Legal Guidelines for Recording
- If order is questioned, record that clarification was sought.
- If you perform orders known to be incorrect, you are just as liable for prosecution as the physician is.
- Chart only for yourself
- Never chart for someone else.
- You are accountable for information you enter into chart.
- Avoid using generalized, empty phrases such as “status unchanged” or “had good day”.
- Begin each entry with time, and end with your signature and title.
- Do not wait until end of shift to record important changes that occurred several hours earlier. Be sure to sign each entry.
- For computer documentation keep your password to yourself.
- Maintain security and confidentiality.
- Once logged into the computer do not leave the computer screen unattended.