Learning Objectives
By the end of this section, you will be able to:
- Discuss maintaining a professional nurse-patient relationship.
- Describe methods of communication in medical-surgical nursing
- Define models of communication about patient care
Nurses develop and maintain various professional relationships in their careers, such as those with colleagues and mentors. The nurse-patient relationship is unlike any other professional or personal relationship. It is essential that nurses understand the rules that govern this unique and important relationship to protect themselves and their patients. This section defines the nurse-patient relationship and explains how it is established and maintained. It also discusses communication methods used in medical-surgical nursing, including the models that are used to convey information about patient care.
The Nurse-Patient Relationship
The path to becoming a nurse takes time, energy, resources, and dedication. As nurses progress through their careers, they gain knowledge, develop their skills, and hone their intuition, all while maintaining their values and having their own life experiences. Yet every patient they encounter will also bring their own needs, beliefs, and life experiences to the nurse-patient dynamic. Balancing each side of the relationship requires a deep understanding of effective communication, the nuances of human behavior, emotional intelligence, and cultural competence. The nurse must also be versed in the state and federal laws and regulations that govern the nurse-patient relationship.
The ability to forge therapeutic relationships with patients is central to patients’ experience of receiving care (Molina-Mula & Gallo-Estrada, 2020), and the relationship serves more than one function. For the patient, the relationship is a safe, supportive space for asking questions and expressing needs. For the nurse, it is an invaluable tool for providing compassionate care (ANA, 2023). In both facets, the nurse-patient relationship can evolve and change over time. Given how important and complex the nurse-patient relationship is, there are standards of care and scopes of practice to guide the formation and maintenance of these beneficial and effective partnerships with patients. These guidelines also ensure that the nurse-patient relationship is appropriate and safe for everyone involved.
Cultural Context
Nurse-Patient Relationship for Muslim Patients
Islam is the second largest religion in the world, and non-Muslim nurses may find themselves caring for Muslim patients. Asking Muslim patients questions and listening actively to their answers creates a safe space for discussing religious and cultural needs a Muslim patient may have. Many Muslim patients pray multiple times a day; spiritual practices are an important part of the healing process. It is important for the nurse to respect religiosity, dietary restrictions, the strong patriarchal presence, and the preference of female nurses for female patients when caring for Muslim patients. Accommodating such cultural needs enhances the nurse-patient relationship by showing that the nurse cares about the unique religious needs and customs of their patient (Alfar, 2023).
The pillars of the nurse-patient relationship—trust, respect, empathy, and communication—are foundational to most other important relationships as well (Allande-Cussó et al., 2021). The nurse needs to understand other key elements, such as power imbalances and breaches of confidentiality, that have the potential to weaken rather than strengthen the nurse-patient relationship.
The nurse can uphold the pillars of this special dynamic by conducting the relationship within professional boundaries. A professional boundary is the clear separation between personal and work life when interacting with patients, designed to protect both the patient and the nurse. While the nurse must establish and then maintain professional boundaries at all times, it is not always easily done. The nurse must strike a balance: they need to be empathetic without being too personal. They need to use therapeutic intimacy from a professional and objective distance. They must nurture a rapport with patients but not befriend them. Although the nurse-patient relationship exists within the safety of professional boundaries, it does not mean it has to be unfeeling or cold. The nurse will always respect the patient and work to earn their trust. Professional boundaries are a way to recenter the patient as the focus of care and prevent violations that could undermine trust and erode the therapeutic relationship (National Council of State Boards of Nursing, 2018).
Establishing and enforcing boundaries is the nurse’s responsibility, not the patient’s. At times, professional boundaries may blur or be challenging to maintain. The nurse may even unintentionally cross a line without realizing it. This is why it’s crucial for the nurse to take a proactive approach to prevent lines from being crossed within the nurse-patient relationship. Here are just a few examples of potential boundary violations that nurses may encounter:
- Oversharing personal information with patients
- Being too emotionally vulnerable with patients
- Touching patients in any nontherapeutic way that could be construed as overly familiar or potentially romantic/sexual
- Uncomfortably infringing on a patient’s personal space (e.g., sitting very close to them on the bed)
- Talking about patients with family or friends
- Posting about work experiences on social media and/or sharing personal information on public accounts (HIPAA violation)
- Adding patients on social media (HIPAA violation)
- Spending time with patients outside of work in a way that would be considered more of a casual friendship (e.g., taking part in shared hobbies together)
- Accepting gifts, money, or any business-type exchange with patients
It may seem that these boundary violations would be obvious, but they can be subtle and exist more on a spectrum than being clear “stop signs.” For example, a nurse who lives and works in a small community may frequently run into patients at the grocery store. They might be members of the same gym or have children that attend the same school. These interactions will not always be avoidable, and the nurse still needs to maintain professional boundaries. The nurse must be vigilant and ensure that their behavior is always professional and focused on the patient.
Methods of Nurse-Patient Communication
The nurse-patient relationship hinges not only on trust, respect, and empathy, but also on communication (Afriyie, 2020). It is only through effective, therapeutic communication that the nurse can establish trust and rapport with the patients in their care (Kwame & Petrucka, 2021). Effective, therapeutic communication begins as soon as nurses introduce themselves. Throughout the course of providing care, the nurse will evaluate and adjust their communication strategy to ensure that it is effective for the patient. One of the most basic examples, and also one of the easiest for a well-educated and experienced nurse to forget, is avoiding medical terminology (Afrieye, 2020). All information and teaching provided to the patient must align with their health literacy level. This means not using medical jargon, including acronyms, that may confuse or intimidate a patient. If a patient cannot understand the nurse’s language, they won’t be able to comprehend why the information the nurse is providing is important to their care. Effective, therapeutic communication also allows the nurse to gather data for clinical decision-making. For example, using open-ended rather than closed questioning helps the nurse gain valuable information from the patient and transition the assessment to the next phase of nursing care. (Table 6.1). In the nursing process, the next step would be to identify the nursing diagnosis and formulate a plan of care. In the CJMM, the nurse would next analyze cues and prioritize hypotheses.
| Therapeutic Communication | Nontherapeutic Communication | |
|---|---|---|
| Offering self | Friendly, approachable, and inviting. When appropriate, use “we” and “us” instead of “you” or “I” to show unity and inclusivity. | Formal, guarded, and distant. May use “I” and “you” to emphasize individual roles. |
| Communicating nonverbally | Relaxed body language, open posture, consistent but comfortable eye contact, and active listening. | Tense body language, crossed arms, avoidance of eye contact, and minimal nonverbal feedback. |
| Encouraging elaboration, seeking clarification | Encourages questions and listens to different viewpoints. Asks open-ended questions to promote deeper discussion and help patients feel more at ease expressing their thoughts, concerns, and preferences. | Discourages or dismisses questions. Asks closed-ended questions (“yes” or “no”) that limit responses or make patients feel cut-off and hesitant to share more about what they are thinking or feeling. |
| Giving information | Proactive in sharing information, values transparency, and explains the reasoning (or “why”) behind decisions. | Reluctant to share information, prefers to keep things private, and may be secretive about decisions. |
| Restating, reflecting, summarizing | Actively listens to others, “teaches back” what they have heard to confirm understanding, and values feedback. | Appears disinterested in what others have to say, interrupts frequently, and dismisses feedback. |
| Encouraging collaboration | “What are your thoughts on this?” “How can we work together to achieve this goal?” “I’d like to hear what you have to say.” |
“You just need to do what we tell you to do.” “Did you take your medication like you were supposed to or not?” “I don’t have time to listen to your concerns.” |
Imagine that a patient presents with a weeping (fluid-oozing) rash on his leg. The nurse can ask an open-ended question like, “What can you tell me about that rash I see on your leg?” or phrase it as a statement such as, “Please tell me about the rash I see on your leg,” to open the door for further exploration into the patient’s health. On the other hand, a question such as, “I see your left leg has a weeping rash. Did you tell your doctor?” is closed-ended. Here, the patient can only answer yes or no; they have either told the doctor about their rash or they have not. This question does not give the patient a natural opportunity to tell the nurse more about the rash and provide the crucial details necessary for a comprehensive assessment. In this example, the closed-ended question, “Did you tell your doctor?” could also make the patient feel judged or even guilty. If they have not told their doctor about the rash, they may feel that they’ve “been bad” and worry about what the nurse will think of them.
To communicate nonjudgmentally and without bias, the nurse constantly needs to reflect on both their verbal and nonverbal communication with patients. Nurses need to be self-aware and willing to correct their behavior if it’s not contributing to open, effective, and compassionate communication. This requires a critical appraisal of their actions and words and an honest look at their beliefs and perceptions.
Effective communication in health care is not just verbal; it also includes nonverbal, written, and visual communication. The spoken word, in whatever language the patient can best communicate and understand is verbal communication. Physical movements or motions, including body language, that convey thoughts, attitudes, and sentiments to a patient are methods of nonverbal communication. A type of nonverbal communication based on physical movement and expression is body language. Reinforcement of verbal information given to the patient in a format they can read is considered written communication. Strategies like return demonstration can confirm a patient’s understanding and is considered visual communication.
During the comprehensive physical assessment, the nurse will use verbal and nonverbal communication with patients. While verbal communication is the most effective, nonverbal communication can enhance the assessment by allowing the nurse to convey attentiveness and empathy. Nonverbal communication also has potential pitfalls, however, of which the nurse must be aware. Body language, facial expressions, eye contact, tone of voice, physical distance, and touch are all facets of nonverbal communication that can either enhance or hinder the nurse-patient relationship. Nurses have to be conscious of their own nonverbal cues, as even unintentional signals can convey messages contrary to their intended communication. An open, relaxed posture, appropriate eye contact, and a warm smile can foster trust and reassurance, and help build rapport with patients. On the other hand, closed-off body language like crossed arms, frowning, or excessive distance may send the message that the nurse is disinterested, disapproving, or unempathetic.
The nurse also needs to attentively observe—and interpret—a patient’s nonverbal cues. An averted gaze, fidgeting, or incongruent facial expressions can indicate discomfort, fear, or confusion—even if what the patient says to the nurse conveys the opposite. Nurses have to integrate a patient’s nonverbal cues with verbal communication to fully understand their needs.
There are many layers to understanding and interpreting nonverbal cues from patients, and it’s not always as simple as paying attention to what they do and say. Cultural competence is critical to understanding nonverbal communication because different cultures ascribe different meanings to the same gestures, expressions, or social norms and concepts. What may be perceived as respectful in one cultural context could be seen as offensive or inappropriate in another. Making eye contact during a conversation and maintaining “personal space” are just two examples of relatively common aspects of nonverbal communication that are very culturally dependent. Nurses need to continually educate themselves about the cultural backgrounds and customs of the communities they serve to ensure they are providing culturally sensitive care.
Active Listening
Communication is not just about how the nurse speaks but also about how they listen. The nurse should strive to be an active listener when the patient is talking (Tennant & Toney-Butler, 2022). This means that they don’t just hear but seek to understand what the patient is telling them.
To be an active listener, fully focus on the patient. One way to demonstrate openness to listening is simply looking at them or turning toward them. Taking a seat so that they can be at a similar level as the patient is also helpful, as standing over them can be intimidating. Avoid interrupting the patient as they are speaking. Use supportive statements and phrases to acknowledge what they have shared (“I understand that sharing these details is difficult for you. . .” and “It sounds like you are worried about. . .”) and encourage them to elaborate or clarify (“Tell me more about that. . .”).
When they are done sharing, the task of summarizing or explaining the message received gives patients a chance to correct any misunderstandings or offer more details. It also gives the nurse an opportunity to demonstrate empathy and understanding and develop trust further.
Communicating with Patients Who Speak a Different Languages
English may not be the first language of all patients. When nurses do not speak the patient’s preferred language, the communication barrier can make it challenging to develop the nurse-patient relationship and gather a comprehensive health history and physical assessment.
Cultural awareness and competency guide nurses working with patients who have a preferred language other than English. To begin, the nurse must determine a patient’s language preferences and decide what steps to take to ensure that the patient’s needs are understood and met. It is the legal responsibility of a facility to provide language services for patients that meet certain standards (U.S. Department of Health and Human Services, n.d.). The nurse must know what language resources are available to them. Each health care organization has assistive technology that staff can use to communicate with patients. One example is Martti, a translation technology solution that integrates with EHRs, as well as tablets and mobile devices (Cloudbreak, n.d.).
The nurse should not use patient family members or nonapproved translators to communicate medical information. While a patient’s family may be trying to help, medical translation is more complex than translating everyday conversation; it requires expertise (Villanueva, 2023). It is also not appropriate for a family member, such as a patient’s child, to translate for them, as it could allow for the transmission of personal medical information to someone who is not authorized to receive it or lead to a miscommunication if the family member is not well versed in medical terminology.
Using an approved translation service allows the patient to understand and answer the nurse’s questions, which ensures the comprehensive physical and psychological assessment will be accurate. While the nurse should generally avoid “yes” or “no” questions, the simple binary can be helpful when there are language barriers, and the patient needs to communicate basic—but important—information to the nurse.
Link to Learning
A nurse who is multilingual may want to consider becoming a certified medical interpreter. The National Board of Certification for Medical Interpreters is one organization that offers certification in Spanish, Russian, Mandarin, Cantonese, Korean, and Vietnamese.
Communicating with Patients Who Have Auditory Impairments
Communication barriers can also emerge for reasons other than language. For patients who have auditory impairments, the nurse will again need to be aware of the resources available to help them complete a comprehensive health assessment and physical exam and provide care for the patient. A patient with total or significant loss of hearing would need approved assistive technology or sign language interpretation to ensure that the questions the nurse needs to ask are heard and understood.
Considerations that the nurse should keep in mind when speaking to patients who are deaf or who have hearing impairments including:
- Assessing, identifying, and arranging for a patient’s needs to be met.
- Use a qualified sign language interpreter when needed. Do not rely on the nurse’s basic skills or interpretation provided by a family member.
- Confirming with the patient that their hearing aid (if applicable) is on and functioning in the setting.
- Making sure the room is adequately lit and there are no distractions.
- Facing the patient and maintaining eye contact while speaking to them.
- Speaking clearly and articulating each word (but do not overly exaggerate or speak too loudly).
- Being intentional about using body language and gesturing, as appropriate.
- Using visual aids, as appropriate (Centers for Medicare and Medicaid Services, 2023; HLAA, 2023; National Association for the Deaf, 2018).
The nurse will need to adjust their approach to suit the patient’s needs. For example, perhaps they planned to use a sign language interpreter for a deaf patient but discover that the patient is comfortable lip reading. In this case, they may not need the interpreter, and can adjust the plan so that they speak clearly and slowly to the patient and check for understanding frequently. In some health care settings, however, lip reading may be impossible, for example, because a provider is wearing a mask (Berry, 2021). The nurse also must consider that relying on writing to communicate with any patient can lead to misunderstandings, especially if the patient has low literacy or, more specifically, low health literacy. But for deaf patients who sign, the nurse should also keep in mind that American Sign Language (ASL) is not based on spoken English; there can be mistranslations just as there would be for other bilingual patients. In addition to being ineffective, writing can also be time-consuming and impractical for both the nurse and the patient, particularly in an emergency (National Association for the Deaf, 2018).
Life-Stage Context
Considerations for Older Patients with Hearing Loss
One factor to consider when adapting nurse-patient communication to various clients is age. If taking care of an 85-year-old patient, be aware of how the aging process can affect communication and care. When conducting the assessment, notice concerns that the patient expresses both verbally and nonverbally. While talking to the patient, notice, for instance, if the patient leans in closer to hear the questions. This observation will make clear that the patient may be having a hard time hearing the questions. It could be that the patient was brought into the hospital via ambulance, and the EMS crew did not retrieve the patient’s hearing aids from their home. Perhaps the patient is embarrassed about their hearing loss and does not want to express that they are struggling.
The nurse should adjust their assessment to put patients of all ages and abilities at ease and ensure they understand the assessment questions. By focusing on the patient’s needs and taking steps to address them, the nurse is fostering a trusting patient relationship, promoting effective communication, and ensuring that the data gathered are comprehensive and correct.
All patients, regardless of their communication needs, benefit from using the teach-back strategy to demonstrate their comprehension of the information the nurse has shared. The strategy, which involves having the patient explain the teaching provided to them in their own words, is an invaluable tool that helps the nurse assess for and quickly correct any gaps in knowledge or misunderstandings.
Models of Communication About Patient Care
Communication between the nurse and patient needs to focus on being effective and therapeutic. Communication with other health care professionals about patient care has a different goal completely. Communication about patient care is more direct, more streamlined, filled with jargon, and often requires one health care professional to convey the seriousness of a situation in as few words as possible so as not to delay care. Two models of communication health care professionals use with one another are Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) and ISBAR. These two models enhance teamwork, efficacy, and efficiency in communicating about patient care, and thus enhance quality of care.
Interdisciplinary Plan of Care
Admission to the Observational Unit Interdisciplinary Plan of Care
The interdisciplinary plan of care for a patient being admitted to the observational unit for diabetic venous ulcers and possible sepsis can involve several health-care disciplines working collaboratively. Members of the team may include physical therapists, respiratory therapists, case managers, dietitians, and a wound care nurse, each with their own role.
- The physical therapist (PT) aims to improve the patient’s mobility and strength, initiating ambulation within 24 hours, if medically capable, and conducting range-of-motion exercises to increase strength and endurance of all the extremities.
- The respiratory therapist (RT) focuses on promoting oxygenation and improved cardiovascular health with activities of daily living. The RT provides education on supplemental oxygen or any needed adaptive breathing equipment.
- The case manager (CM) assesses psychosocial needs, offers emotional support, and facilitates counseling for adjustment. The CM also arranges care across all disciplines, develops comprehensive care plans, and arranges any necessary post-discharge services.
- The registered dietitian (RD) optimizes nutrition for healing based on the patient’s compromised condition and advises the patient on dietary adjustments related to other comorbidities to prevent future decline.
- The wound care nurse (WCN) monitors the patient’s skin integrity, educating on proper risk factors, preventative measures, and infection control. The WCN intervenes promptly in case of complications.
Together, these interdisciplinary team members ensure a person-centered approach for providing support, as patients are admitted to a medical facility. Each health-care organization has a long list of specialty team members to meet the needs of the patient they serve.
TeamSTEPPS
Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) is a training resource from The Agency for Healthcare Research and Quality (AHRQ) and the U.S. Department of Defense (DOD). The tools were developed by applying military teamwork, operations, and communications concepts and strategies to health care (American Hospital Association, 2023).
The four core competencies of TeamSTEPPS will be familiar from nursing education:
- Team leadership: Delegating and coordinating tasks, motivating others, providing needed resources for optimal performance
- Communication: Effectively conveying information through different strategies
- Situation monitoring: Establishing and maintaining an agreed-upon way to monitor team performance
- Mutual support: Knowing team member needs and taking steps to meet them
Nurses can be trained in the approach and apply the teaching to their work to enhance teamwork and patient outcomes. Nurses may use the TeamSTEPPS framework in a variety of clinical situations, such as when they are providing reports at the start of shift, including a patient’s family in important treatment conversations, speaking up when they notice that a staff member is fatigued and may be unable to perform their duties, and participating in debriefs after procedures.
TeamSTEPPS has some similarities to another framework that nurses are familiar with—QSEN, which is often encountered early on in a nurse’s education. While TeamSTEPPS is more focused on strengthening health care teams and QSEN is more about the individual nurse, both frameworks consider teamwork and communication to be core competencies in health care quality and safety. One main difference is that in QSEN, there are six focused competencies, of which teamwork and safety are two. These concepts are more of an embedded thread and driving force behind the overall framework in TeamSTEPPS. Because there is significant overlap, nurses often use both frameworks when providing care.
Link to Learning
Review AHRQ’s TeamSTEPPS and think about how to use these tools and resources in nursing practice.
ISBAR
The nurse is the patient’s advocate. Effective communication with others in the interdisciplinary team is necessary to provide effective, coordinated, and patient-centered care. When communicating with other health professionals about patients, one evidence-based practice to use is ISBAR: identify, situation, background, assessment, and recommendation (see 1.2 Intercollaborative Care). The ISBAR format allows nurses to efficiently and effectively communicate the information gathered on a patient during the comprehensive physical history and assessment. For example, a nurse who is handing off a patient to a colleague at the end of their shift can use the ISBAR framework (Table 6.2).
| Component | Example |
|---|---|
| Identify the patient | “I’m Laurie Done, RN, and have been caring for Mrs. Martinez in room 204 today.” |
| Explain the situation | “Mrs. Martinez was admitted last night from the ER with a complicated UTI and started on IV ceftriaxone.” |
| Give background | “She has a history of UTIs. No known drug allergies. Her current medications are lisinopril and Zoloft.” |
| Provide most recent assessment data | “Her vitals are stable, and she voided cloudy, yellow urine at 1450.” |
| Offer recommendation | “I recommend encouraging oral hydration, monitoring her vitals, and continuing to administer medications as prescribed.” |
Once the receiving nurse has the information on the patient, the nurse can answer any questions or provide clarification before completing the hand-off.