Lesson 1, Topic 1
In Progress

Factors That Affect Communication

May 1, 2021

Posturing and Positioning

Where and how the nurse sits or stands conveys a message to the patient. Standing at the bedside while the patient lies in the bed sends the message that the LPN/LVN has power and the patient does not. The crossing of arms over the chest may convey a lack of openness to the patient. Assuming a position of total relaxation, such as leaning back into the chair, possibly even slouching, sends a message of disinterest.

The most therapeutic posture and positioning is the same position and level as the patient, or as close to it as feasible. For example, if the patient is lying in bed, the nurse should sit on a chair at the bedside facing the patient during a conversation. In addition, the head of the bed should be elevated, unless contraindicated, so the patient feels at same level as the nurse. Sitting in a comfortable position and leaning slightly forward toward the patient conveys a message of interest and openness.

Space and Territoriality

Generally, Western cultures recognize four zones of personal space. From the face to about 18 inches away is the intimate space. Because of the nature of many nursing interventions, the LPN/LVN must enter the patient’s personal space. Bathing, inserting urethral catheters, and changing dressings are just a few examples. Entering this space can cause uneasiness for both the nurse and the patient. Approaching these interventions in a professional manner can help alleviate much of the uneasiness felt by the nurse and patient (Figure 4-4). The personal space comprises the area from 18 inches to 4 ft away from a person. Sitting and talking with a patient is an example of an interaction in the personal zone. This space tends to be a comfortable space for most people during an interaction such as that between a nurse and patient. The social space is 4 to 12 ft from a person. An example of a social space is a nurse conducting a diabetes class for a group of patients. Beyond 12 ft from a person is considered public space (Krauss Whitbourne, 2013). Factors such as the patient’s culture, individual preferences, and the situation determine the level of comfort with the various zones. The nurse should be especially aware

FIGURE 4-4 Much of the nursing care provided to a patient occurs in the intimate zone.

(From Potter PA, Perry AG: Fundamentals of nursing: Concepts, process, and practice, ed. 8, St. Louis, 2013, Mosby.)
of the patient’s nonverbal communication when interacting with the patient in these zones of personal space.

Environment

The general environment surrounding an interaction often has a significant impact on the interaction’s effectiveness. A therapeutic interaction between the nurse and the patient is extremely difficult if a lot of commotion is occurring in the room. Key elements for a successful interaction are a calm relaxed atmosphere and privacy. Ideally, the initial interaction should take place in a private room with the door closed. However, this degree of privacy is not always possible. If the patient has a roommate, taking the patient to a private conference room is sometimes a good option, depending on the status of the patient and the nature of the interaction. At the very least, the privacy curtain should be pulled between the two patients during interaction with a patient.

Level of Trust

A trusting relationship is essential to an effective nurse-patient interaction. Without trust, interaction does not progress past superficial social interaction. The nurse must first gain the patient’s trust before expecting to have a meaningful or therapeutic interaction. One way for the LPN/LVN to build trust is by demonstrating confidence and competence. A trusting relationship is often difficult to establish with a patient who has had negative encounters with other health care providers. The LPN/LVN should be sensitive to the patient’s previous experiences and demonstrate a sincere effort to make the current situation a positive experience for the patient.

Language Barriers

In today’s culturally diverse society, care of a patient who speaks a different language is not unusual. Language barriers can pose a major threat to effective communication and development of a therapeutic nurse-patient relationship. Some larger hospitals or hospitals where the community has a very diverse population often have a translator on staff or one that is easily accessible. If the LPN/LVN is employed in a health care facility that does not have a translator available, the nurse should use all avenues (e.g., social services) to attempt to find one. If an interpreter cannot be located, the nurse may rely on the patient’s family members or friends to assist with communication if the family member speaks the same language as the nurse. The nurse should be very cautious that misinterpretation does not occur with use of family members as interpreters and should avoid use of younger children as the interpreter. Keeping messages simple and avoiding the use of medical terminology can help in preventing misinterpretations. Use of gestures and

Box 4-2 Guidelines for Communicating With Patients Who Are Partially Fluent in English

•Assess the patient’s nonverbal and verbal communication.
•Keep your eyes at approximately the same level as the patient’s. This probably means you will sit. Assess whether the patient is comfortable with eye contact.
•Speak slowly, and never loudly (unless the patient has a hearing impairment).
•Use pictures when possible.
•Avoid using technical terms.
•Ask for feedback. Provide the patient with paper and pencil.
•Remember that patients understand more than they can express—and they need time to think in their own language.
•Remember that stress interferes with the patient’s ability to think and speak in English.

From Balzer Riley J: Communication in nursing, ed. 7, St. Louis, 2012, Mosby.

pictures might also be helpful in communicating with the patient. The LPN/LVN must also comply with Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations and guidelines when using a family member or friend as an interpreter.

Some health care institutions may have resources such as translation dictionaries in the languages most common to its geographic location available, or the nurse may use an online resource (Boxes 4-2 and 4-3). The LPN/LVN should use these resources with caution. There is a high risk of mispronouncing words or using incorrect words, and doing so can convey unintended or inaccurate messages. The nurse should also consider information concerning barriers in language and communication that may exist between subcultures of a group, including the use of slang terms.

Culture

Nursing is concerned with holistic care of the patient. Culture is a significant component of a patient’s psychosocial well being. The nurse must make an effort to seek specific information regarding cultural practices and beliefs of the patients being cared for, especially when the patient is from a culture different than that of the nurse. The effect of culture on communication is immense, and a complete discussion is beyond the scope of this chapter. Julia Balzer Riley (2012) offers useful guidelines when relating to patients of different cultures (see Cultural Considerations box). For more complete information, refer to Chapter 6.

Age and Gender

The effects of age and gender on communication are largely influenced by cultural or societal beliefs and attitudes. A significant age difference between the nurse and the patient does, in some cases, raise a

Box 4-3 Guidelines for Communicating With Non–English-Speaking Patients

If an interpreter is available:

•Use dialect-specific interpreters, not translators.
•Give the patient and interpreter time alone together.
•Build in time for translation and interpretation.
•Avoid using children and relatives as interpreters.
•Select same-age and same-gender interpreters.
•Address your questions to the patient, not the interpreter.

If an interpreter is not available:

•Use a translator.
•Determine whether there is a third language that both you and the patient speak. In many cultures, it is common for patients to speak several languages.
•Remember that nonverbal communication is more important than verbal communication.
•Be attentive to both your own and the patient’s nonverbal messages.
•Pantomime simple words and actions.
•Use pictures when appropriate.
•Talk with your institution’s administration about the importance of using trained medical interpreters when caring for the non–English-speaking patient.
•Until medical interpreters are available, use both formal and informal networking to locate a suitable interpreter. If all else fails, owners of ethnic restaurants and grocery stores are possible resources to use to locate interpreters or translators.
From Balzer Riley J: Communication in nursing, ed. 7, St. Louis, 2012, Mosby.

barrier to communication. Nurses who have had limited interaction with children may find it difficult to communicate effectively with children in the health care setting. Teenagers may also present a unique challenge when communicating with nurses. Their vocabulary and expressions are often unique to their age group with the use of slang terms. At the other end of the spectrum, the nurse may find an older adult who does not have confidence in a very young nurse or has some physiologic or cognitive impairment that hampers effective communication. Communication is most effective if the nurse tries to understand as much about patients across the life span as possible and selects the most appropriate communication techniques for a variety of circumstances.

When communicating with older adults who may have communication barriers because of hearing loss or cognitive barriers, the nurse must consider ways to improve communication. Speaking directly to patients by getting their attention and facing them enhances the interaction. If the patient wears a hearing aid, the nurse should be sure it is in place and in working order. The LPN/LVN should eliminate background noise when speaking with the patient and should not shout at the patient. The nurse also must give the patient time to process what has been said and allow

Cultural Considerations: Communicating With Patients of Different Cultures From Your Own

Dominant Language and Dialects

•Identify the dominant language of the group.
•Identify dialects that have the potential to interfere with communication.
•Explore contextual speech patterns of the group. What is the usual volume and tone of speech?

Cultural Communication Patterns

•Explore the willingness of individuals to share thoughts, feelings, and ideas.
•Explore the practice and meaning of touch in the given society: within the family, among friends, with strangers, with members of the same gender, with members of the opposite gender, and with health care providers.
•Identify typical personal spatial and distancing characteristics during one-to-one communication. Explore how distancing changes with friends compared with strangers.
•Explore the use of eye contact within the group. Does avoidance of eye contact have special meanings? How does eye contact vary among family, friends, and strangers? Do eye contact practices change when communication occurs between members of different socioeconomic groups?
•Explore the meaning of various facial expressions. Do specific facial expressions have special meanings? Do people tend to smile a lot? How are emotions displayed or not displayed in facial expressions?
•Are there acceptable ways of standing and greeting outsiders?

Attitudes Toward Time

•Explore attitudes in the group toward time. Are individuals primarily oriented to the past, present, or future? How do individuals see the context of past, present, and future?
•Identify differences in the interpretation of social time versus clock time.
•Explore how time factors are interpreted by the group. Are individuals expected to be punctual in arrival to jobs, appointments, and social engagements?

Format for Names

•Explore the format for personal names.
•How does the individual expect to be greeted by strangers and health care practitioners?

From Balzer Riley J: Communication in nursing, ed 7, St. Louis, 2012, Mosby.

ample time for the patient to respond. Lastly, the LPN/LVN should not talk to the patient as a child, or in a simplified and slow manner, with terms of endearment such as “honey” or “sweetie,” commonly referred to as “elder speak.�

Male and female patterns of communication are often closely related to cultural, familial, and lifestyle patterns developed over a lifetime. The beliefs, values, and attitudes that an individual or a society in general

Box 4-4 Communicating With Patients Who Are Cognitively Impaired

•Reduce environmental distractions while conversing.
•Get patient’s attention before speaking.
•Use simple sentences and avoid long explanations.
•Ask one question at a time.
•Allow time for patient to respond.
•Be an attentive listener.
•Include family and friends in conversations, especially in subjects known to patient.

Modified from Potter PA, Perry AG: Fundamentals of nursing, ed. 8, St. Louis, 2013, Mosby.

holds regarding male or female status and expectations are likely to affect how messages are sent and received (Balzer Riley, 2012).

Physiologic Factors

Many physiologic factors may interfere with the patient being able to communicate effectively. Pain is a common example. While a patient is experiencing pain, all available energy is focused on coping with the pain; it is difficult, if not impossible, for the patient to communicate about anything except the pain. The LPN/LVN should first address the patient’s pain before trying to communicate with the patient, especially before performing any patient teaching.

Altered cognition is another physiologic factor that frequently hinders effective communication. If the patient lacks the cognitive ability to receive, process, and send information, communication is disrupted. Several factors have the potential to affect a patient’s cognitive ability. A cerebrovascular accident (stroke), sedative effects of medication, dementia, and developmental delays are examples of such factors.

Careful assessment of a patient’s level of cognitive function is important when beginning any interaction. The nurse should keep the patient’s sensory abilities operating at their maximum potential. For example, if the patient wears glasses or a hearing aid, the nurse should ensure these assistive devices are in place to help the patient to process information accurately. If there is decreased ability to comprehend, the environment should be kept quiet during communicating. Box 4-4 lists strategies for communicating with patients who are cognitively impaired.

Impaired hearing is another common physiological factor that impedes communication. Hearing impairment may lead to misinterpretation of messages, and frustration on the part of both the sender and the receiver. The LPN/LVN should be sure that all efforts are made to ensure that effective communication is not sacrificed because of a patient’s impaired hearing. See Box 4-5 for strategies for communicating with the patient with a hearing impairment.

Box 4-5 Communicating With Patients Who Have Hearing Impairment

•Check for hearing aids and glasses.
•Reduce environmental noise.
•Get patient’s attention before speaking.
•Face patient with your mouth visible.
•Do not chew gum.
•Speak at normal volume; do not shout.
•Rephrase rather than repeat if misunderstood.
•Provide a sign language interpreter if indicated.

From Potter PA, Perry AG: Fundamentals of nursing, ed. 8, St. Louis, 2013, Mosby.
Psychosocial Factors

A multitude of factors place patients under stress. The patient might be frightened, in pain, deprived of sleep, nauseated, or experiencing a host of other unpleasant circumstances. Stress can lead to problems with communication between the patient and the nurse. While experiencing increased stress, the patient may respond to the nurse with anger, impatience, or even withdrawal. The nurse must realize that these behaviors are not directed at the nurse personally but are coping mechanisms used by the patient.
When the patient is experiencing stress, especially extreme stress, the nurse may need to modify communication methods. The LPN/LVN can find it helpful to keep information simple, basic, and concrete and offer only essential information. The nurse may find it helpful to let the patient direct the conversation. Being supportive of the patient aids in keeping the lines of communication open and effective.

An illness is often accompanied by some degree of grieving as a result of actual or perceived loss. This loss can take many possible forms, including role or lifestyle change, physical change, altered function, terminal prognosis, and anticipated or actual loss of a loved one.
Nurses often feel uncomfortable interacting with a grieving patient for fear of not knowing what to say or saying the wrong thing. Because of this uneasiness, nurses may find themselves sometimes saying nothing or avoiding the subject entirely. The challenge for the LPN/LVN in dealing with patients and their loved ones who are grieving is to attempt communication with them despite any feelings of personal inadequacy. A silent presence is often all that is necessary. The grieving process may be facilitated by using therapeutic touch, displaying warm and caring behaviors, and using open-ended statements to listen and assist those who are grieving to understand their own feelings and behaviors.