2.3 Communicating With Patients
Open Resources for Nursing (Open RN)
The Nurse-Client Relationship
The nurse-client relationship, also called a helping relationship, is crucial for holistic, compassionate nursing care. During a nurse-client relationship, the nurse builds rapport and establishes trust with the purpose of actively engaging the client in discussions about their feelings, emotions, care process, and decision-making. Establishing rapport with clients is of the utmost importance because it facilitates an open and honest dialogue between the client and the nurse. It facilitates therapeutic communication and engages the client in decision-making regarding their plan of care. The nurse-client relationship is a professional relationship in which the nurse practices the “art of nursing,” an abstract connection between the client’s needs, expressed behaviors, and the nurse’s perceptions and exploration of these concepts.[1]
Phases of the Nurse-Client Relationship
The nurse-client relationship evolves through several phases. A well-known nurse theorist named Hildegard Peplau described these three phases as the orientation phase, working phase, and termination phase. Some sources include an additional phase called the pre-interaction phase[2],[3]:
- Preinteraction Phase: The nurse reviews the medical record or other data in preparation for the orientation phase. The preinteraction phase can also be helpful in identifying preconceived notions about a client situation, acknowledging these feelings, and making a conscious effort to avoid biases.
- Orientation Phase: The orientation phase is a brief encounter where the nurse addresses the client by name and then introduces themself to the client, including their name and role. This introduction should include an estimated time frame for the conversation or encounter, and an explanation of what will occur. The nurse should begin to establish trust and rapport by ensuring privacy. This is especially important if sensitive topics will be discussed. While obtaining information about the client, it is important to realize the client is a unique individual with distinct needs, priorities, values and belief systems, and should be treated as such. While the nurse may not agree with the client’s values and belief systems, the nurse must respect them. Failure to establish rapport and trust during the orientation phase will block communication and make it difficult for the nurse to fully engage in therapeutic communication with the client.
- Working Phase: After the orientation phase is complete, the working phase begins. The majority of a nurse’s time is spent in the working phase with a client. Communication during the working phase should be client-focused and based on what is important to the client. Communication generally focuses on their reason for seeking medical care, but deeper concerns are discussed and explored as they come up. During the working phase, the nurse engages in therapeutic communication by recognizing cues, such as body language or statements about emotions, and then encourages further discussion about the client’s feelings about a particular subject. The conversation should be focused on the client’s feelings and thought processes, not the nurse’s feelings and thoughts. If rapport and trust were successfully developed during the orientation phase, the client is more likely engage in therapeutic communication with the nurse, who is perceived as an educator and counselor, in addition to a health care professional. The nurse uses therapeutic communication techniques to help the client gain an awareness of their deeper feelings, existing coping mechanisms, and overall goals for care. The nurse should remain nonjudgmental while providing feedback and reflection regarding what the client is saying, both verbally and nonverbally. Therapeutic communication techniques, as well as common communication blocks, are discussed later in this chapter.
- Termination Phase: The termination phase is the last phase of the nurse-client relationship and occurs at the end of a communication session. Termination generally occurs when the goals of the therapeutic communication session have been met. Ideally, the nurse should inform the client that termination is approaching rather than abruptly ending the interaction. Abruptly ending the conversation can lead to negative feelings about the interaction and can be perceived as uncaring by the client. The nurse should review the goals of the interaction, achievements made during the interaction, and other sources of support available to the client. Termination should be a concrete occurrence and as such, the nurse should avoid using terms such as, “I’ll see you later” or “Keep in touch,” because these terms insinuate that termination is temporary.
Therapeutic Communication
Therapeutic communication is a type of professional communication used by nurses with clients. It is defined as, “The purposeful, interpersonal information-transmitting process through words and behaviors based on both parties’ knowledge, attitudes, and skills, which leads to client understanding and participation.”[4] Therapeutic communication techniques used by nurses have roots going back to Florence Nightingale, who insisted on the importance of building trusting relationships with clients and believed in the therapeutic healing that resulted from nurses’ presence with clients.[5] Since then, several professional nursing associations have highlighted therapeutic communication as one of the most vital elements in nursing.
Read an example of a nursing student effectively using therapeutic communication with clients in the following box.
An Example of Nursing Student Using Therapeutic Communication
Ms. Z. is a nursing student who enjoys interacting with clients. When she goes to clients’ rooms, she greets them and introduces herself and her role in a calm tone. She kindly asks clients about their problems and notices their reactions. She does her best to encourage problem-solving and answer questions. Clients perceive that she wants to help them. She treats clients professionally by respecting boundaries and listening to them in a nonjudgmental manner. She addresses communication barriers and respects clients’ cultural beliefs. She notices clients’ health literacy and ensures they understand her messages and client education. As a result, clients trust her and feel as if she cares about them, so they feel comfortable sharing their health care needs with her.[6],[7]
Active Listening and Attending Behaviors
Listening is obviously an important part of communication. There are three main types of listening: competitive, passive, and active. Competitive listening happens when we are focused on sharing our own point of view instead of listening to someone else. Passive listening occurs when we are not interested in listening to the other person and we assume we understand what the person is communicating correctly without verifying. During active listening, we are communicating verbally and nonverbally that we are interested in what the other person is saying while also actively verifying our understanding with the speaker. For example, an active listening technique is to restate what the person said and then verify our understanding is correct. This feedback process is the main difference between passive listening and active listening.[8]
Touch
Therapeutic use of touch is a powerful way to professionally communicate caring and empathy if done respectfully while being aware of the client’s cultural beliefs. Nurses commonly use professional touch when assessing, expressing concern, or comforting clients. For example, simply holding a client’s hand during a painful procedure can be very effective in providing comfort. However, nurses must be aware that therapeutic touch may not be appropriate in all situations. It is essential to respect personal boundaries and avoid touch if the client is not receptive. For example, cultural beliefs may view touch by a member of the opposite sex as inappropriate, or the client may have previously experienced trauma that causes touch to be uncomfortable or trigger negative emotions. See Figure 2.7[9] for an image of a nurse using touch as a therapeutic technique when caring for a client.
Therapeutic Techniques
Therapeutic communication techniques are specific methods used to provide clients with support and information while focusing on their concerns. These techniques encourage clients to explore their feelings, solve problems, and cope responses to medical conditions and life events. Nurses assist clients to set goals and select strategies for their plan of care based on their needs, values, skills, and abilities. They recognize the autonomy of the clients to make their own decisions, maintain a nonjudgmental attitude, and avoid interrupting while communicating therapeutically. Depending on the developmental stage and educational needs of the client, appropriate terminology should be used to promote understanding and rapport. When using therapeutic communication, nurses often ask open-ended statements and questions, repeat information, or use silence to prompt clients to work through problems on their own.[10] Table 2.3a describes a variety of therapeutic communication techniques.[11],[12]
Table 2.3a Therapeutic Communication Techniques
| Therapeutic Technique | Description |
|---|---|
| Active Listening | By using nonverbal and verbal cues such as nodding and saying, “I see,” nurses can encourage clients to continue talking. Active listening involves showing interest in what clients have to say, acknowledging that you’re listening and understanding, and engaging with them throughout the conversation. Nurses can offer general leads such as “What happened next?” to guide the conversation or propel it forward. |
| Providing Silence | At times, it’s useful to not speak at all. Deliberate silence can give both nurses and clients an opportunity to think through and process what comes next in the conversation. It may give clients the time and space they need to broach a new topic and allows quiet time for self-reflection. When providing silence, the nurse does not verbally respond after a client makes a statement, although they may nod or use other nonverbal communication to demonstrate active listening and validation of the client’s message. |
| Acceptance | Sometimes it is important to acknowledge a client’s message and affirm that they’ve been heard. Acceptance isn’t necessarily the same thing as agreement; it can be enough to simply make eye contact and say, “Yes, I hear what you are saying.” Clients who feel their nurses are listening to them and taking them seriously are more likely to be receptive to care. |
| Giving Recognition | Recognition acknowledges a client’s behavior and highlights it without giving an overt compliment. A compliment can sometimes be taken as condescending, especially concerning routine tasks. An example of a nurse giving recognition would be saying something such as, “I noticed you took all of your medications today.” This statement draws attention to the positive action and encourages it. |
| Offering Self | Hospital stays can be lonely and stressful at times. When nurses are present with their clients, it shows clients they value them and are willing to give them time and attention. Offering to simply sit with clients for a few minutes is a powerful way to create a caring connection. |
| Giving Broad Openings/Open-Ended Questions | Therapeutic communication is often most effective when clients direct the flow of conversation and decide what to talk about. To that end, giving clients a broad opening statements such as “Tell me about your concerns,” can be a good way to allow clients an opportunity to discuss what’s on their mind. |
| Seeking Clarification | Similar to active listening, asking clients for clarification when they say something confusing or ambiguous is important. Saying something such as “I’m not sure I understand. Can you explain it to me?” helps nurses ensure they understand what’s actually being said and can help clients process their ideas more thoroughly. |
| Placing the Event in Time or Sequence | Asking questions about when certain events occurred in relation to other events can help clients (and nurses) get a clearer sense of the whole picture. It forces clients to think about the sequence of events and may prompt them to remember something they otherwise wouldn’t. |
| Making/Sharing Observations | Observations about the appearance, demeanor, or behavior of clients can help draw attention to areas that may indicate a problem. For example, stating an observation that a client looks tired may prompt them to explain why they haven’t been getting much sleep lately, or making an observation they haven’t been eating much may lead to the discovery of a new symptom. |
| Encouraging Descriptions of Perception | For clients experiencing sensory issues or hallucinations, it can be helpful to ask about these perceptions in an encouraging, nonjudgmental way. If the client looks distracted or frightened as if they see or hear something, it is helpful for the nurse to use phrases such as “It looks like you may be hearing something. What do you hear now?” or “It looks as though you may be seeing something. What does it look like to you?” These phrases give clients a prompt to explain what they’re perceiving without casting their perceptions in a negative light. Nurses also establish safety by asking the client if the hallucinations are encouraging the client to harm themselves or others. |
| Encouraging Comparisons | Clients often draw upon previous experiences to deal with current problems. By encouraging them to make comparisons to situations they have coped with before, nurses can help clients discover solutions to their problems. For example, the following exchange demonstrates encouraging comparisons. Nurse: “It must have been difficult when you went through a divorce. How did you cope with that?” Client: “I walked my dog outside a lot.” Nurse: “It sounds like walking your dog outside helps you cope with stress and feel better?” |
| Summarizing | It is often useful to summarize what clients have said. This demonstrates to clients that the nurse was listening and allows the nurse to verify information. Ending a summary with a phrase such as “Does that sound correct?” gives clients explicit permission to make corrections if they’re necessary. For example, the following exchange demonstrates summarizing. Client: “I don’t like to take my medications because they make me feel tired and I gain a lot of weight.” Nurse: “You haven’t been taking your medications this month because of the side effects of fatigue and weight gain. Is that correct?” |
| Reflecting | Clients often ask nurses for advice about what they should do about particular problems. Nurses can ask clients what they think they should do, which encourages them to be accountable for their own actions and helps them come up with solutions themselves. For example, the following exchange demonstrates reflecting. Client: “Do you think I should do this new treatment or not?” Nurse: “What do you think are the pros and cons for the new treatment plan? |
| Focusing | Sometimes during a conversation, clients mention something particularly important. When this happens, nurses can focus on their statement, prompting clients to discuss it further. Clients don’t always have an objective perspective on what is relevant to their case, but as impartial observers, nurses can more easily pick out the topics on which to focus. For example, the following exchange demonstrates focusing. Client: “I am nervous about going home.” Nurse: “You’re feeling anxious about going home, tell me more about that.” |
| Confronting | Confronting presents reality, challenges a client’s assumptions, or points out inconsistencies with behaviors, feelings, or thoughts. Nurses should only apply this technique during the working phase after they have established trust. Confrontation, when used correctly, can help clients break destructive routines or understand the state of their current situation. For example, the following exchange demonstrates therapeutic confrontation with a client who has been admitted for alcohol withdrawal. Client: “I haven’t drunk much alcohol this year.” Nurse: “Yesterday you told me that every weekend you go out and drink so much that you don’t know where you are when you wake up.” |
| Voicing Doubt | Voicing doubt can be a gentler way to call attention to incorrect or delusional ideas and perceptions of clients. By expressing doubt, nurses can force clients to examine their assumptions. |
| Offering Hope | Because hospitals can be stressful places for clients, sharing hope that they can persevere through their current situation can help promote coping. However, nurses must avoid giving false reassurance. For example, telling a client who was recently diagnosed with a serious medical condition, “You’ll be fine,” is false reassurance and not therapeutic. On the other hand, stating, “I remember you shared with me how well you have coped with difficult situations in the past,” is an appropriate therapeutic use of offering hope. |
| Using Humor | Lightening the mood with humor can help nurses establish rapport and promote positive state of mind. However, the client should not be given the impression that their situation is not serious or that the nurse is minimizing their feelings or concerns. Humor must be tailored to the client’s sense of humor or clients may take offense. |
| Offering Empathy | Empathy is the ability to recognize, understand, and share feelings with another person. Empathy involves showing understanding or another’s situation or perspective and enables helping behaviors.[13] |
| Paraphrasing | Paraphrasing rephrases the client’s words and key ideas to clarify their message and encourage additional communication. For example, if a client states, “I’ve been way too busy today,” the nurse can therapeutically respond by stating, “Participating in physical and occupational therapy today has kept you busy.” |
| Presenting Reality | Presenting reality restructures the client’s distorted thoughts with valid information. For example, if a client who is hallucinating states, “I can’t go into that room, there are spiders on the walls,” the nurse can therapeutically respond, “I see no evidence of spiders on the walls.” |
| Restating | Restating uses different word choices for the same content stated by the client to encourage elaboration. For example, if a client states, “The nurses hate me here,” the nurse can respond therapeutically, “You feel as though the nurses dislike you?” |
Communicating honestly, genuinely, and authentically is powerful. It opens the door to creating true connections with others. Communicating with empathy has also been described as providing “unconditional positive regard.” Research has demonstrated that when health care teams communicate with empathy, there is improved client healing, reduced symptoms of depression, and decreased medical errors.[14]
Nontherapeutic Responses
Nurses and nursing students must be aware of potential barriers to communication. In addition to considering common communication barriers discussed in the previous section, there are several nontherapeutic responses or communication blocks/barriers to avoid. These responses often block the client’s communication of their feelings or ideas. See Table 2.3b for a description of nontherapeutic responses.[15],[16]
Table 2.3b Nontherapeutic Responses
| Nontherapeutic Response | Description |
|---|---|
| Asking Personal Questions | Asking personal questions that are not relevant to the situation is not professional or appropriate. Don’t ask questions just to satisfy your curiosity. For example, asking, “Why have you and Mary never married?” is not appropriate. A more therapeutic question would be, “How would you describe your relationship with Mary?” |
| Giving Personal Opinions | Giving personal opinions takes away the decision-making from the client. Effective problem-solving must be accomplished by the client and not the nurse. For example, stating, “If I were you, I’d put your father in a nursing home” is not therapeutic. Instead, it is more therapeutic to say, “Let’s talk about what options are available to your father.” |
| Changing the Subject | Changing the subject when someone is trying to communicate with you demonstrates lack of empathy and blocks further communication. It implies you don’t care about what they are sharing. For example, stating, “Let’s not talk about your insurance problems; it’s time for your walk now” is not therapeutic. A more therapeutic response would be, “After your walk, let’s talk some more about what’s going on with your insurance company.” |
| Stating Generalizations and Stereotypes | Generalizations and stereotypes can threaten nurse-client relationships due to preconceived assumptions about clients that may or may not be true. For example, it is not therapeutic to state the stereotype, “Older adults are always confused.” A more therapeutic response is to focus on the client’s concern and ask, “Tell me more about your concerns about your father’s confusion.” |
| Providing False Reassurances | When a clientis seriously ill or distressed, the nurse may be tempted to offer hope with statements such as “You’ll be fine,” or “Don’t worry; everything will be alright.” These comments tend to discourage further expressions of feelings by the client. Additionally, these comments may not present reality. If a client is terminally ill, telling them, “You’ll be fine in no time” is not realistic and provides false reassurance. The client may perceive these statements as a minimization of their situation and associated feelings. A more therapeutic response would be, “It must be difficult not to know what the surgeon will find. What can I do to help?” |
| Showing Sympathy | Sympathy focuses on the nurse’s feelings rather than the client. Saying “I’m so sorry about your amputation; I can’t imagine losing a leg.” This statement shows pity rather than trying to help the client cope with the situation. A more therapeutic response would be, “The loss of your leg is a major change; how do you think this will affect your life?” |
| Asking “What” or “Why” Questions | A nurse may be tempted to ask the client to explain “why” they believe, feel, or act in a certain way. However, clients and family members may interpret “what” or “why” questions as accusations and become defensive. It is best to phrase a question by avoiding the words “what” or “why.” For example, instead of asking, “Why are you so upset?” it is more therapeutic to rephrase the statement as, “You seem upset. Tell me more about how you are feeling.” |
| Showing Approval or Disapproval | Nurses should not impose their own attitudes, values, beliefs, and moral standards on others while in the professional nursing role. Judgmental messages contain terms such as “should,” “shouldn’t,” “ought to,” “good,” “bad,” “right,” or “wrong.” Agreeing or disagreeing sends the subtle message that nurses have the right to make value judgments about the client’s decisions. Approving implies that the behavior being praised is the only acceptable one, and disapproving implies that the client must meet the nurse’s expectations or standards. Instead, the nurse should help the client explore their own values, beliefs, goals, and decisions. For example, it is nontherapeutic to state, “You shouldn’t consider elective surgery; there are too many risks involved.” A more therapeutic response would be, “So you are considering elective surgery. Tell me more about the pros and cons of surgery” gives the client a chance to express their ideas or feelings without fear of being judged. |
| Giving Defensive Responses | When clients or family members express criticism, nurses should listen to what they are saying. Listening does not imply agreement. To discover reasons for the client’s anger or dissatisfaction, the nurse should listen without criticism, avoid being defensive or accusatory, and attempt to defuse anger. For example, if the client states, “Everyone here is lying to me,” it is not therapeutic to state, “No one here would intentionally lie to you.” Instead, a more therapeutic response would be, “You believe people have been dishonest with you. Tell me more about what happened.” (After obtaining additional information, the nurse may elect to follow the chain of command at the agency and report the client’s concerns for follow-up.) |
| Providing Passive or Aggressive Responses | Passive responses serve to avoid conflict or sidestep issues, whereas aggressive responses provoke confrontation. Passive responses serve to avoid conflict or sidestep issues, whereas aggressive communication provokes confrontation. Nurses should use assertive communication. For example, it is not therapeutic to state, “It’s your fault you are feeling ill because you don’t take your medication.” A therapeutic response would be, “Taking your prescribed medications every day can prevent symptoms from returning.” Nurses should use assertive communication as described in the “Basic Communication Concepts” section. |
| Arguing | Challenging or arguing against client perceptions denies that they are real and valid to the other person. They imply that the other person is lying, misinformed, or uneducated. The skillful nurse can provide information or present reality in a way that avoids argument. For example, it is not therapeutic to state, “How can you say you didn’t sleep a wink when I heard you snoring all night long!” A more therapeutic response would be, “You don’t feel rested this morning? Let’s talk about ways to improve your rest.” |
Process Recordings
Process recordings are reflective learning activities with an objective to improve a student’s therapeutic communication skills. They include a transcript of the verbal and nonverbal responses between a student and a client during a therapeutic communication session. After the session, the transcript is analyzed by the student to identify therapeutic techniques, communication barriers or blocks, and the phases of the nurse-client relationship. The student evaluates the interaction to determine if the overall client-centered goal was met or not met, what went well during the conversation, and what they could improve in their therapeutic communication. As a result of the analysis, the student gains self-awareness regarding the effectiveness of their communication and sets goals for self-improvement in future therapeutic communication sessions.
Strategies for Effective Communication
In addition to using therapeutic communication techniques and avoiding nontherapeutic responses, there are additional strategies for promoting effective communication when providing client-centered care. Specific questions to ask clients are as follows:
- What concerns do you have about your plan of care?
- What questions do you have about your medications?
- Did I answer your question(s) clearly or is there additional information you would like?[17]
Listen closely for feedback from clients. Feedback provides an opportunity to improve client understanding, improve the client-care experience, and provide high-quality care. Other suggestions for effective communication with hospitalized clients include the following:
- Round with the providers and read progress notes from other health care team members to ensure you have the most up-to-date information about the client’s treatment plan and progress. This information helps you to provide safe client care as changes occur and also to accurately answer the client’s questions.
- Review information periodically with the client to improve understanding.
- Use client communication boards in their room to set goals and communicate important reminders with the client, family members, and other health care team members. This strategy can reduce call light usage for questions related to diet and activity orders and also gives clients and families the feeling that they always know the current plan of care. However, keep client confidentiality in mind regarding information to publicly share on the board because the board can be seen by anyone entering the room.
- Provide printed information on medical procedures, conditions, and medications. It helps clients and family members to provide information in multiple ways.[18]
Adapting Your Communication
When communicating with clients and family members, take note of your audience and adapt your message based on their characteristics such as age, developmental level, cognitive abilities, communication disorders, and language differences.
Adapting communication according to the client’s age, developmental level, and language differences includes the following strategies:
- When communicating with children, speak calmly and gently. It is often helpful to demonstrate what will be done during a procedure on a doll or stuffed animal. To establish trust, try using play or drawing pictures.
- When communicating with adolescents, give freedom to make choices within established limits.
- When communicating with older adults, be aware of potential vision and hearing impairments that commonly occur and address these barriers accordingly. For example, if a client has glasses and/or hearing aids, be sure these devices are in place before communicating. See the following box for evidence-based strategies for communication with clients who have impaired hearing and vision.
- For clients with language differences, it is vital to provide trained medical interpreters when important information is communicated. Family members should not be used as translators because medical terms may not translate directly in the native language and there is no way to determine if the information is being translated accurately. It is also possible that certain information is withheld from the client in the event the family does not want to burden them with upsetting information.
Strategies for Communicating With Clients With Impaired Hearing and Vision[19]
Impaired Hearing
- Gain the client’s attention before speaking (e.g., through touch)
- Minimize background noise
- Position yourself 2-3 feet away from the client
- Facilitate lip-reading by facing the client directly in a well-lit environment
- Use gestures, when necessary
- Listen attentively, allowing the client adequate time to process communication and respond
- Refrain from shouting at the client
- Ask the client to suggest strategies for improved communication (e.g., speaking toward better ear and moving to well-lit area)
- Face the client directly, establish eye contact, and avoid turning away mid-sentence
- Simplify language (i.e., do not use slang but do use short, simple sentences), as appropriate
- Note and document the client’s preferred method of communication (e.g., verbal, written, lip-reading, or American Sign Language) in plan of care
- Assist the client in acquiring a hearing aid or assistive listening device
- Refer to the primary care provider or specialist for evaluation, treatment, and hearing rehabilitation
Impaired Vision
- Identify yourself when entering the client’s space
- Ensure the client’s eyeglasses or contact lenses have current prescription, are cleaned, and stored properly when not in use
- Provide adequate room lighting
- Minimize glare (i.e., offer sunglasses or draw window covering)
- Provide educational materials in large print
- Apply labels to frequently used items (i.e., mark medication bottles using high-contrasting colors)
- Read pertinent information to the client
- Provide magnifying devices
- Provide referral for supportive services (e.g., social, occupational, and psychological)
- Identify item locations on a meal tray using the clock method. For example, the nurse states, “Your milk is at 2:00, the potatoes are at 3:00, and the meat is at 9:00. on your plate.”
Clients with communication disorders require additional strategies to ensure effective communication. For example, aphasia is a communication disorder that results from damage to portions of the brain that are responsible for language. Aphasia usually occurs suddenly, often following a stroke or head injury, and impairs the client’s expression and understanding of language. Expressive aphasia refers to difficulty putting thoughts into words. The client may cognitively know what they want to say but are unable to express their thoughts. Receptive aphasia refers to difficulty in understanding what is being communicated to them. The client may be able to verbalize their thoughts and feelings but do not understand what is spoken to them. Global aphasia is caused by injuries to multiple language-processing areas of the brain, including those known as Wernicke’s and Broca’s areas. These brain areas are particularly important for understanding spoken language, accessing vocabulary, using grammar, and producing words and sentences. Individuals with global aphasia may be unable to say even a few words or may repeat the same words or phrases over and over again. They may have trouble understanding even simple words and sentences.[20]
The most common type of aphasia is Broca's aphasia. People with Broca’s aphasia often understand speech and know what they want to say, but frequently speak in short phrases that are produced with great effort. For example, they may intend to say, “I would like to go to the bathroom,” but instead the words, “Bathroom, Go,” are expressed. They are often aware of their difficulties and can become easily frustrated. See the box below for evidence-based strategies to enhance communication with a person with impaired speech.
Strategies to Improve Communication With Clients With Impaired Speech[21]
- Modify the environment to minimize excess noise and decrease emotional distress
- Phrase questions so the client can answer using a simple “Yes” or “No,” being aware that clients with expressive aphasia may provide automatic responses that are incorrect
- Monitor the client for frustration, anger, depression, or other responses to impaired speech capabilities
- Provide alternative methods of speech communication (e.g., writing tablet, flash cards, eye blinking, communication board with pictures and letters, hand signals or gestures, and computer)
- Adjust your communication style to meet the needs of the client (e.g., stand in front of the client while speaking, listen attentively, present one idea or thought at a time, speak slowly but avoid shouting, use written communication, or solicit family’s assistance in understanding the client’s speech)
- Ensure the call light is within reach and central call light system is marked to indicate the client has difficulty with speech
- Repeat what the client said to ensure accuracy
- Instruct the client to speak slowly
- Collaborate with the family and a speech therapist to develop a plan for effective communication
Maintaining Confidentiality
When communicating with clients, their friends, their family members, and other members of the health care team, it is vital for the nurse to maintain client confidentiality. The Health Insurance Portability and Accountability Act (HIPAA) provides standards for ensuring privacy of client information that are enforceable by law. Nurses must always be aware of where and with whom they share client information. For example, information related to client care should not be discussed in public areas, paper charts must be kept in secure areas, computers must be logged off when walked away from, and client information should only be shared with those directly involved in client care. For more information about client confidentiality, see the “Legal and Ethical Considerations” section in the “Scope of Practice” chapter.
Read more information about the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
- Ernstmeyer, K., & Christman, E. (2022). Nursing: Mental health and community concepts. Open RN. https://wtcs.pressbooks.pub/nursingmhcc/ ↵
- Ernstmeyer, K., & Christman, E. (2022). Nursing: Mental health and community concepts. Open RN. https://wtcs.pressbooks.pub/nursingmhcc/ ↵
- O'Brien, P. (n.d.). The nurse client relationship and therapeutic communication. https://samples.jbpub.com/9781449651749/46080_ch03_obrien.pdf ↵
- Abdolrahimi, M., Ghiyasvandian, S., Zakerimoghadam, M., & Ebadi, A. (2017). Therapeutic communication in nursing students: A Walker & Avant concept analysis. Electronic Physician, 9(8), 4968–4977. https://doi.org/10.19082/4968 ↵
- Karimi, H., & Masoudi Alavi, N. (2015). Florence Nightingale: The mother of nursing. Nursing and Midwifery Studies, 4(2), e29475. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4557413/. ↵
- Abdolrahimi, M., Ghiyasvandian, S., Zakerimoghadam, M., & Ebadi, A. (2017). Therapeutic communication in nursing students: A Walker & Avant concept analysis. Electronic Physician, 9(8), 4968–4977. https://doi.org/10.19082/4968 ↵
- “beautiful african nurse taking care of senior patient in wheelchair” by agilemktg1 is in the Public Domain ↵
- Anonymous. (2024). Human relations (dias). LibreTexts: Social Sciences. https://socialsci.libretexts.org/Bookshelves/Communication/Human_Relations/Human_Relations_(Dias) ↵
- “Flickr - Official U.S. Navy Imagery - A nurse examines a newborn baby..jpg” by MC2 John O'Neill Herrera/U.S. Navy is in the Public Domain ↵
- American Nurse. (n.d.). Therapeutic communication techniques. https://www.myamericannurse.com/therapeutic-communication-techniques/ ↵
- American Nurse. (n.d.). Therapeutic communication techniques. https://www.myamericannurse.com/therapeutic-communication-techniques/ ↵
- Ernstmeyer, K., & Christman, E. (2022). Nursing: Mental health and community concepts. Open RN. https://wtcs.pressbooks.pub/nursingmhcc/ ↵
- Sussex Publishers. (2025). Empathy. Psychology Today. https://www.psychologytoday.com/us/basics/empathy ↵
- Morrison, E. (2019). Empathetic communication in Healthcare. https://www.cibhs.org/sites/main/files/file-attachments/empathic_communication_in_healthcare_workbook.pdf?1594162691 ↵
- Burke, A. (2021). Therapeutic communication: NCLEX-RN. https://www.registerednursing.org/nclex/therapeutic-communication/ ↵
- Ernstmeyer, K., & Christman, E. (2022). Nursing: Mental health and community concepts. Open RN. https://wtcs.pressbooks.pub/nursingmhcc/ ↵
- Smith, L. L. (2018, June 12). Strategies for effective patient communication. American Nurse. https://www.myamericannurse.com/strategies-for-effective-patient-communication/ ↵
- Smith, L. L. (2018, June 12). Strategies for effective patient communication. American Nurse. https://www.myamericannurse.com/strategies-for-effective-patient-communication/ ↵
- Wagner, C. M., Butcher, H. K., & Clarke, M. F. (2024). Nursing interventions classification (NIC) (8th ed.). Elsevier. ↵
- National Institute on Deafness and Other Communication Disorders (NIDCD). (2017). Aphasia. https://www.nidcd.nih.gov/health/aphasia ↵
- Wagner, C. M., Butcher, H. K., & Clarke, M. F. (2024). Nursing interventions classification (NIC) (8th ed.). Elsevier. ↵
The purposeful, interpersonal information transmitting process through words and behaviors based on both parties’ knowledge, attitudes, and skills, which leads to patient understanding and participation.
Process by which we are communicating verbally and nonverbally that we are interested in what the other person is saying while also actively verifying our understanding with the speaker.
Techniques that encourage patients to explore feelings, problem solve, and cope with responses to medical conditions and life events.
Responses to patients that block communication, expression of emotion, or problem solving.
A communication disorder that results from damage to portions of the brain that are responsible for language.
The impaired ability to form words and speak.
Difficulty in understanding what is being communicated
A type of aphasia that results from damage to extensive portions of the language areas of the brain. Individuals with global aphasia have severe communication difficulties and may be extremely limited in their ability to speak or comprehend language. They may be unable to say even a few words or may repeat the same words or phrases over and over again. They may have trouble understanding even simple words and sentences.
A type of aphasia where patients understand speech and know what they want to say, but frequently speak in short phrases that are produced with great effort. People with Broca's aphasia typically understand the speech of others fairly well. Because of this, they are often aware of their difficulties and can become easily frustrated.
Standards for ensuring privacy of patient information that are enforceable by law.