Additional Considerations

As a nurse, you will encounter other populations and situations that will require you to thoughtfully consider how to best communicate in a way that is respectful, effective, and therapeutic. You might not even know when you are caring for certain populations, because it may not be obvious, so it is always best to ground your communication in best practices (e.g., College of Nurses of Ontario practice standard concerning therapeutic nurse-client relationship). For example, it is not necessarily readily apparent when a language discordance exists, or when a person is experiencing intense emotions, or when a person has a disability.

Language discordance

There will be times when you and the client and/or family do not speak the same language. In this case, you need to carefully assess and evaluate their understanding.

Here are some strategies to address language discordance:

• Speak directly to the client using simple language (no jargon, no medical language).
• Be aware of your non-verbal language and consider how gestures may help the client understand what you are trying to communicate.
• Use pictures and/or have a paper and pen for them to write down notes and questions.
• Consider how best to incorporate the care partner into conversations if they speak the same language as you, but the client does not. Care partners can be an integral part of the care processes and may be constantly translating what is going on for their loved one. Thus, in everyday communication, you may consider engaging the care partner in interpreting for you and the client. For example, it may be appropriate to ask them to interpret when introducing yourself and asking the client about benign and less sensitive topics (e.g., “Are you hungry?” “Can you sit up?”).
• However, sometimes the use of an interpreter is needed. Many healthcare institutions have access to interpretation services, but these can be expensive. You may also have professional colleagues who are trained in the ethics of interpretation and can help.
• Consider using a translating app such as Google Translate that can help you translate one language into another. Although you may not speak the other language, you can show the written translation to the client so that they can read it. Additionally, the client can also type concerns, responses to your questions, and their own questions into the translating app.

Emotions

Clients commonly experience sadness, anger, fear, anxiety, embarrassment, and other emotional responses in the context of health and illness. It is important that you cultivate a therapeutic environment where clients feel comfortable to open up about their emotions. Open-ended questions like “Tell me about how you are feeling” can facilitate discussions about a client’s emotional response. Additionally, you might consider using permission statements to help normalize how the client is feeling and provide an opening for them to speak about emotions. For example, “Clients often experience sadness or anger when they are diagnosed, how are you feeling?”

It is important that you acknowledge the client’s emotions and provide space for them to experience the emotions. Avoid changing topics. Give the client time to voice their emotions or even cry. Using silence and active listening are effective communication strategies during these circumstances.

Violence and trauma

Many clients will have experienced violence and trauma in their lives such as abuse, bullying, grief or loss of a loved one, or natural disasters or war. You will often not even be aware that they have experienced violence or trauma, so it’s best to use a trauma-informed approach with all clients, as discussed in Chapter 1. Approach all clients with the assumption that they may have experienced violence and trauma at some point in their lives. Reflect on how best to help them feel safe and provide them as much choice and control in the clinical encounter as possible.

Some communication strategies that are consistent with a trauma-informed approach include:

• Introducing who you are and why you are there.
• Explaining each step of what you are doing.
• Asking permission to touch.
• Giving the client options on what topic to discuss first.

Communicating with clients about violence and trauma requires knowledge, skill, and experience. This field of study is vast and deep. As you develop foundational communication skills, you will have opportunities to build knowledge about trauma-informed communication. For now, recognize that there is much more to know about trauma-informed approaches and that an in-depth understanding is needed to best care for these clients.

Hearing and visual impairment

You can inquire about the presence of any hearing or visual impairment and what is best for the client in terms of communication. For people with hearing and visual impairment, begin by minimizing any background noises or distractions. You should speak in a clear, slightly louder voice, steady tone with a deeper pitch. Avoid shouting and using a high pitch as this can distort sounds and make your words more difficult to hear. You should face the client directly and clearly articulate your words so that they can read your lips and attend to non-verbal cues as necessary. If the client has an assistive device (e.g., glasses or a hearing aid), make sure that they have access to the device.

Intellectual impairment

Some of your clients will have intellectual or cognitive impairments that may result in disabilities affecting their ability to learn and reason (e.g., Down syndrome, fetal alcohol syndrome). You should consider how each client can best participate in communication (e.g., listening, talking, understanding and processing information). You should engage in active listening and determine what is important to the client. Speak clearly and ask simple questions. Speak in a positive tone with a steady pace and avoid speaking slower as this can come across as patronizing. You may encourage them to bring someone with them that they trust, such as a care partner; you should still focus your attention on the client but also create an inclusive space for the care partner to be involved.

Substance impairment

A client under the influence of drugs and substances (alcohol, cannabis, prescribed medications, and/or illegal street drugs) can have altered capacity to think, reason, and communicate. Although some of these substances may be illegal and non-prescribed, it is important to maintain a non-judgmental attitude and convey unconditional positive regard. As a nurse, it is not your job to judge a client. Rather, you should use a relational inquiry approach to understand the circumstances that have influenced their choices and respect that each client has agency and self-determination.

While the client is under the influence of a substance, use communication strategies that facilitate their capacity to understand what you are saying and communicate with you while maintaining safety. Thus, you should speak clearly and in short simple sentences. Focus on the reason for seeking care or the priority issue. There will be time for a collaborative discussion and health promotion after the effects of the substances have dissipated.

Escalation

Communication is a particularly important strategy to use when your purpose is to de-escalate a situation. Escalation can occur in any healthcare situation when clients are encountering intense emotions and experiences entangled with stress, fear, anger, uncertainty, pain, and lack of control. This can lead to the client spiraling out of control, agitation, aggression, and even violence. Contextual factors may include clients who have received bad news such as a diagnosis, clients who are under the influence, and/or clients who are having a mental health crisis. Attend to your own safety and be aware of the potential risk factors. It is important to notify a colleague(s) when interviewing a client who is at risk of, or has a history of, escalating.

De-escalation includes ways to reduce and/or prevent escalation. De-escalating communication strategies include:

• Acknowledge and value how the client feels and be non-judgmental.
• Avoid downplaying or judging how the client feels.
• Engage in active listening to understand the situation and explore the reason for the escalation.
• Offer genuine interest, concern, and empathy.
• Remain calm and do not allow your voice or non-verbal communications to demonstrate rising emotions.
• Recognize the client’s self-determination and collaborate with them on how to address the issue.
• Maintain your safety, but do not act afraid.
• Maintain your professionalism and do not take the situation personally.

Inappropriate communication from the client

There will be times when clients engage in inappropriate communication. This kind of communication may include verbal and non-verbal language such as inappropriate physical touch, violent or aggressive behaviour, harassing language (e.g., name-calling, threats), and sexualized language. As a nurse, you should rely on the CNO (2019a) practice standard about the therapeutic nurse-client relationship. Keep in mind that there is meaning associated with all client behaviour and that you should attempt to understand it (CNO, 2019a).

Consider these strategies when responding to inappropriate client language:

• If applicable, ensure your personal safety. Depending on the situation, this may involve moving toward the doorway or having it in your sight, leaving the room, or calling for help.
• Acknowledge the language/behaviour and clearly let the client know that it is inappropriate, do so in a professional and non-judgmental manner.
• Remind the client that as a nurse you only engage in professional relationships with clients and families.
• Ask the client if their language has something to do with the effects of their health or illness.

Activity: Check Your Understanding