chapter 8; taylor

Chapter 8 High-Yield Nursing Student Notes

Communication

Big Picture

This chapter is about one thing:

Communication is how nursing happens.

You cannot:

• assess correctly

• build trust

• teach

• advocate

• collaborate

• prevent errors

• use the nursing process well

without strong communication.

This chapter is heavily tested because communication affects:

• patient safety

• therapeutic relationships

• clinical judgment

• teamwork

• professionalism

Core exam idea

A nurse is not just “nice” or “friendly.”

A nurse uses purposeful, therapeutic, professional communication to:

• gather data

• reduce anxiety

• support the patient emotionally

• protect dignity

• coordinate care

• escalate concerns

• prevent mistakes

What matters most for exams

You need to know:

• communication process

• verbal vs nonverbal communication

• therapeutic vs nontherapeutic communication

• phases of therapeutic nurse–patient relationship

• barriers to communication

• SBAR and CUS

• cultural and developmental effects on communication

• strategies for patients with impaired communication

• disruptive communication: incivility, bullying, aggression

• nurse’s role in maintaining professionalism and patient dignity

1. Communication Process

Definition

Communication = exchange of information and meaning between 2 or more people.

Basic communication model

Must know the parts:

• source / sender / encoder

• message

• channel

• receiver / decoder

• feedback

• noise

Chart: Communication Process

Channels

• auditory = spoken words, tone

• visual = appearance, gestures, observation

• kinesthetic = touch

Noise

Anything that interferes with message.

Examples

• TV

• alarms

• pain

• anxiety

• confusion

• language barrier

• fatigue

• hearing deficit

• emotional distress

Exam hitter

If communication breaks down, ask:

• Was the message unclear?

• Did the patient understand it?

• Was there noise?

• Was the wrong channel used?

• Did feedback confirm understanding?

2. Forms of Communication

A. Verbal communication

Use of words:

• spoken

• written

Important points

• depends on language

• affected by education, culture, development, health literacy

• medical jargon can block communication

B. Nonverbal communication

Communication without words.

Often more important than verbal communication.

If verbal and nonverbal messages conflict, people usually believe the nonverbal message.

Exam hitter

If patient says “I’m fine” but avoids eye contact, looks tense, and wrings hands:

• do not accept the words only

• explore further

• verbal and nonverbal messages are incongruent

3. High-Yield Nonverbal Communication

Must know these

Touch

Can communicate:

• comfort

• support

• caring

• reassurance

• connection

Can also be:

• threatening

• invasive

• culturally inappropriate

Eye contact

Can mean:

• interest

• respect

• attention

But may also be inappropriate in some cultures.

Facial expression

Most expressive body part.
Shows:

• fear

• pain

• disgust

• sadness

• anger

• anxiety

Posture

Can suggest:

• pain

• tension

• depression

• fatigue

• confidence

Gait

Can reveal:

• weakness

• pain

• sadness

• recovery status

Gestures

Useful, especially with language barriers.
But meanings vary by culture.

Sounds

• crying

• moaning

• gasping

• sighing

These are oral but nonverbal.

Silence

Very testable.

Can mean:

• thinking

• fear

• anger

• coping

• reflection

• comfort

• cultural pause

Exam hitter

Silence is not automatically bad.
Sometimes the best therapeutic response is to allow silence.

4. Communication Technologies

Social media, email, texting, telehealth

This area is tested as professionalism/safety/legal content.

Social media

Nurses must:

• never post identifiable patient information

• maintain professional boundaries

• remember employers/patients/colleagues may see posts

• separate personal and professional online presence

• report harmful privacy breaches

• follow institutional policy

Major exam point

Even if name is missing, patient may still be identifiable by:

• diagnosis

• room number

• photo

• situation details

Possible consequences

• board discipline

• employer discipline/termination

• legal penalties

• HIPAA violation

E-mail and text

• use concise, professional language

• avoid unsafe abbreviations/text slang

• follow policy

• protect confidentiality

• patient messages may need to become part of health record

Telehealth

Communication still must be therapeutic and professional.

Nurse should:

• dress professionally

• reduce distractions

• ensure privacy

• make eye contact

• lean in/nod

• listen carefully

• use clear verbal cues

Exam point

Technology does not change standards of nursing practice.

5. Levels of Communication

Intrapersonal

Communication with self = self-talk

Why it matters

Affects:

• confidence

• anxiety

• performance

• ability to care for others

Interpersonal

Between 2 or more people

This is the core of nurse–patient communication.

Small-group communication

Examples:

• staff meetings

• teaching sessions

• care conferences

• support groups

Organizational communication

Communication within larger systems to meet goals

Examples:

• policies

• committees

• quality improvement

• leadership communication

6. Factors That Influence Communication

These are common exam-style modifiers

Developmental level

Must match communication to age/cognition.

• children: simple, concrete

• adolescents: more detailed

• adults: affected by experiences and literacy

• older adults: assess hearing, vision, cognition, depression

Sociocultural differences

Culture affects:

• eye contact

• touch

• meaning of illness

• communication style

• family roles

• privacy preferences

• decision making

Health literacy

Patient may not understand:

• jargon

• written instructions

• diagnosis terms

• medication schedules

Roles and responsibilities

Patient identity affects communication:

• parent

• worker

• spouse

• health professional

• caregiver

Avoid stereotyping.

Space and territoriality

People are more comfortable in their own territory.
Personal space matters.

Four zones

• intimate

• personal

• social

• public

Physical, mental, emotional state

Pain, fear, confusion, depression, fatigue, anxiety all impair communication.

Values

Your values and the patient’s values influence how messages are sent/received.

Environment

Best communication occurs in a setting that is:

• calm

• private

• nonthreatening

• low distraction

7. Communication and the Nursing Process

This section is very high yield because it ties communication to practice.

Assessment

Use communication to gather data.

Nurse should first ask:

• does patient need glasses?

• hearing aid?

• interpreter?

• AAC device?

Need both:

• verbal data

• nonverbal data

Diagnosis / Problem identification

Communication problems themselves may become nursing problems.

Examples

• impaired verbal communication

• hearing impairment

Planning

Need communication to:

• set mutual goals

• explain plan

• coordinate with team

• write care plan

Implementation

Communication is used when:

• teaching

• encouraging

• counseling

• supporting

• coordinating interventions

Evaluation

Use patient verbal and nonverbal responses to judge whether outcomes were met.

8. SBAR and CUS

Must know these cold

SBAR

Standardized handoff communication.

S = Situation

What is happening right now?

B = Background

Relevant history/context

A = Assessment

What I think the problem is

R = Recommendation

What I need / what should happen next

Why it matters

Used to reduce:

• incomplete handoff

• delay in treatment

• falls

• medication errors

• wrong-site surgery

• communication breakdown

Exam point

SBAR is used for:

• nurse-to-nurse report

• nurse-to-provider communication

• transfers

• escalation of concerns

I-SBAR-R

Adds:

• I = identify yourself and patient

• R = read back / respond to questions

CUS

Used to escalate safety concerns.

C = I am Concerned

U = I am Uncomfortable

S = This is a Safety issue / unSafe

Exam point

CUS is assertive, structured language for escalating patient safety concerns.

9. Therapeutic Relationship

Definition

Professional, purposeful, patient-centered relationship focused on patient needs and health goals.

Not a friendship.

Therapeutic vs social relationship

Exam hitter

The nurse should not use the relationship to meet personal emotional needs.

10. Characteristics of the Therapeutic Nurse–Patient Relationship

• caring

• person-centered

• dynamic

• purposeful

• time-limited

• goal-directed

• professionally accountable

The nurse is accountable for the relationship and outcomes.

11. Phases of the Therapeutic Relationship

Must know goals and nurse actions

1. Orientation phase

Beginning phase.

Goals

• introduce self

• identify roles

• establish trust

• explain purpose

• orient patient to setting/routines

• set goals/contract

Patient goals

• call nurse by name

• know roles

• understand goals of relationship

2. Working phase

Longest phase.

What happens

• nurse and patient work on goals

• patient expresses concerns/feelings

• teaching and counseling happen here

• ADLs, care, emotional support, problem solving

Patient goals

• actively participate

• cooperate with care

• express feelings and concerns

3. Termination phase

Ends relationship:

• discharge

• transfer

• change of shift

• end of clinical rotation

What happens

• review progress/goals

• discuss feelings about ending relationship

• plan continuation of care if needed

Patient goals

• identify progress

• verbalize feelings about termination

Exam hitter

Nurse should not disappear without acknowledging termination.
Ending the relationship professionally is part of care.

12. Traits That Promote Effective Therapeutic Communication

These are high-yield nursing traits

Warmth and friendliness

Helps patient feel safe.

Openness and respect

Nonjudgmental attitude.
Respect identity, culture, values, pronouns, preferences.

Empathy

Very testable

Empathy = understanding another person’s feelings from their perspective and communicating that understanding.

Example

“This must be really hard for you.”

Sympathy

Feeling sorry for patient; shifts focus to nurse’s feelings.

Exam hitter

Empathy is therapeutic. Sympathy is less therapeutic.

Honesty / authenticity / trust

Patient must believe:

• you are truthful

• you are competent

• you are reliable

Caring

Patient should feel like a person, not a task.

Competence

Patients trust nurses who appear capable and prepared.

13. Rapport Builders

Rapport = mutual trust in relationship

What builds rapport

• clear purpose

• comfortable environment

• privacy

• confidentiality

• patient focus, not task focus

• good observation

• appropriate pacing

Exam hitter

A rushed, distracted nurse destroys rapport fast.

14. Core Therapeutic Communication Skills

High-yield list

Conversation skills

• controlled tone

• accurate information

• flexibility

• clear, simple statements

• truthful responses

• open mind

• patient-centered focus

Listening skills

• sit if possible

• face patient

• eye contact if culturally appropriate

• think before responding

• don’t fake listening

• listen for repeated themes

• observe nonverbal messages

Silence

Use purposefully.
Do not rush to fill every pause.

Touch

Use thoughtfully and respectfully.
Ask/assess if appropriate.

Humor

Can reduce stress and build connection, but must be used carefully and respectfully.

15. Interviewing Techniques

These are classic exam favorites

Open-ended question/comment

Allows broad response.

Example

“Tell me what brought you in today.”

Best for:

• starting assessment

• exploring feelings

• collecting detailed data

Closed question/comment

Limited response, often yes/no or specific fact.

Example

“Did you take your insulin today?”

Best for:

• specific facts

• clarification

• focused assessment

Problem

Can shut down discussion if overused.

Validating question/comment

Checks whether nurse understood correctly.

Example

“So you took both pills this morning?”

Clarifying question/comment

Used when message is vague or confusing.

Example

“When you say dizzy, what do you mean exactly?”

Reflective question/comment

Repeats patient’s feeling/idea to encourage elaboration.

Example

“You’re feeling overwhelmed…”

Sequencing question/comment

Places events in order.

Example

“Did the nausea begin before or after the medication?”

Directing question/comment

Introduces or returns to important topic.

Example

“You mentioned chest pain earlier—tell me more about that.”

16. Assertive vs Aggressive vs Nonassertive Communication

This is very testable

Assertive

Open, honest, direct, respectful.
Focuses on issue, not attacking person.

Uses “I” statements

• “I’m concerned…”

• “I need clarification…”

• “I’m uncomfortable proceeding…”

Aggressive

Harsh, threatening, disrespectful, intimidating.

Nonassertive

Passive, apologetic, avoids saying what needs to be said.

Best nursing style = assertive

Especially when:

• questioning unsafe order

• escalating concern

• dealing with conflict

• advocating for patient

17. Barriers to Communication

Know these because they show up in NCLEX-style questions

Failure to see patient as human being

Task focus instead of person focus.

Failure to listen

Misses subtle cues and blocks trust.

Nontherapeutic comments/questions

These are classic test items.

18. Nontherapeutic Communication

Must know examples

Clichés

• “Everything will be fine.”

• “Don’t worry.”

• “Cheer up.”

Why bad?

They minimize feelings and sound insincere.

Yes/no questions when more detail is needed

Can shut down communication.

Why / how questions

Can sound accusatory.

Instead of:

• “Why did you do that?”

Try:

• “What led up to that?”

• “Tell me more about what happened.”

Probing

Feels like interrogation.

Leading questions

Push patient toward answer nurse wants.

Example:
“You’ve been taking your meds, haven’t you?”

Giving advice

Can take away patient autonomy and increase dependence.

Judgmental comments

Make patient defensive/shamed.

Changing subject

Blocks what patient is trying to discuss.

False reassurance

Pretending things will be okay when that is uncertain.

Gossip and rumor

Damage trust, teamwork, and professionalism.

19. Disruptive Communication and Behavior

This is a major chapter theme.

Incivility

Rude, disrespectful, disruptive behavior.

Bullying

Persistent intimidating behavior causing harm.

Can be:

• overt

• covert

Horizontal / lateral violence

Nurse-to-nurse hostility.

Overt bullying examples

• humiliation

• scapegoating

• yelling

• public criticism

Covert bullying examples

• withholding information

• gossip

• eye-rolling

• exclusion

Effects

• stress

• anxiety

• low self-esteem

• burnout

• turnover

• errors

• poor teamwork

• poor patient outcomes

Aggressive patients/families

Can be:

• verbally abusive

• threatening

• physically violent

Important point

Violence is not an acceptable “normal part of nursing.”

First line of defense

Good communication:

• build trust

• validate feelings

• reduce escalation

• remain calm

• use assertive, professional responses

20. How to Respond to Disruptive Behavior

High-yield response steps

• stay professional

• respond assertively

• address issue directly if safe

• speak privately if appropriate

• use chain of command

• document behavior factually

• report according to policy

• support zero-tolerance culture

Organizational expectations

• code of conduct

• education for staff

• reporting systems

• leadership accountability

• protection for reporters

• documentation of incidents

21. Impaired Verbal Communication

Definition

Decreased, delayed, or absent ability to use speech.

Causes

• hearing loss

• stroke

• dementia

• autism

• brain injury

• intubation

• laryngectomy

• developmental disorders

• neurologic disease

22. High-Yield Strategies for Special Communication Needs

Patients with visual impairment

• announce presence

• identify self

• explain before touching

• say when leaving

• orient room

• keep call bell accessible

Patients who are deaf/hard of hearing

• face patient directly

• speak clearly, naturally

• do not cover mouth

• use gestures/writing

• ensure hearing aids work

Patients with physical barrier to speech

Examples:

• endotracheal tube

• laryngectomy

Use

• yes/no signals

• writing pad

• communication board

• picture board

• call bell system

Patients who are cognitively impaired

• keep communication simple/concrete

• reduce distractions

• ask one thing at a time

• avoid abstract language

• give time to respond

• use choices rather than broad questions

Patients who are unconscious

Very testable

• assume they can hear

• speak before touching

• talk respectfully

• avoid careless bedside talk

• reduce environmental noise

Patients who do not speak English

• use interpreter

• use simple sentences

• speak normally, not loudly

• use gestures appropriately

• avoid relying on family as interpreter when possible

23. Exam-Level Connections to Patient Cases

Susie Musashi (3-year-old with burns)

What matters

• nonverbal behavior is data

• crying/turning away/curling up may mean fear, pain, loneliness, or distrust

• preschool child needs simple, gentle, reassuring communication

• facial expression and tone matter a lot

• child may watch nurse’s face for cues

Irwina Russellinski (older adult, HOH, “pleasantly confused,” limited English)

What matters

• assess hearing, cognition, language

• slow, clear communication

• interpreter/resources

• gestures/simple terms

• patience and validation

• do not assume confusion = cannot communicate

Randolph Gordon (comatose ICU patient)

What matters

• communicate as if he can hear

• protect dignity

• do not discuss him as object

• touch and respectful speech still matter

• focus on whole person, not only machines

Concept Mastery Alerts

Concept Mastery Alert

When verbal and nonverbal messages conflict, the nonverbal message usually reflects the true meaning.

Concept Mastery Alert

Therapeutic communication is patient-centered, purposeful, and professional.

Concept Mastery Alert

SBAR improves safety by structuring communication and reducing incomplete handoffs.

Concept Mastery Alert

Empathy is therapeutic; sympathy shifts focus away from the patient.

Concept Mastery Alert

Silence can be therapeutic if used intentionally.

Concept Mastery Alert

The unconscious patient should be treated as if able to hear.

High-Yield “You Must Know” List

• Communication is essential to every step of the nursing process.

• Good communication improves patient safety, trust, outcomes, and teamwork.

• Sender, message, channel, receiver, feedback, and noise are the basic parts of communication.

• Noise is anything that interferes with understanding.

• Verbal and nonverbal messages must both be assessed.

• If words and body language conflict, believe the body language more.

• Nonverbal communication includes touch, eye contact, facial expression, posture, gait, gestures, sounds, and silence.

• Social media errors can cause legal, licensure, and job consequences.

• Therapeutic relationships are purposeful, time-limited, patient-centered, and professional.

• Orientation = establish trust/roles/goals.

• Working = longest phase; teaching/counseling/problem solving happen here.

• Termination = review progress and acknowledge ending.

• SBAR = Situation, Background, Assessment, Recommendation.

• CUS = Concerned, Uncomfortable, Safety issue.

• Assertive communication is the professional standard.

• Aggressive communication is disrespectful and harmful.

• Nonassertive communication fails to advocate.

• Open-ended questions are best for broad assessment.

• Closed questions are best for specific facts.

• Clarifying and validating questions improve accuracy.

• Avoid clichés, false reassurance, advice, judgment, leading questions, and changing the subject.

• Incivility and bullying harm nurses and patients.

• Unconscious patients should be spoken to respectfully.

• Use interpreters and adaptive methods for patients with language or communication barriers.

• Communication must be individualized to age, culture, cognition, literacy, hearing, vision, and emotional state.

Final Chapter Takeaways

1. Communication is not extra. It is the mechanism of nursing care.

2. The best nurses are as skilled in communication as they are in procedures.

3. Therapeutic communication is purposeful, respectful, and patient-focused.

4. Nonverbal cues often tell you more than words.

5. Standardized tools like SBAR and CUS prevent errors and protect patients.

6. Professionalism in communication matters just as much as kindness.

7. Bullying, incivility, and aggressive communication are safety issues, not personality issues.

8. Patients with impaired communication still have needs, dignity, and a voice—you must adapt.

9. If you want better clinical judgment, get better at listening, clarifying, and observing.

10. Strong communication turns technical care into actual nursing.