Vocal Cues
Vocal cues are nonverbal sound signals transmitted
along with the content. The voice volume, tone, pitch,
intensity, emphasis, speed, and pauses augment the
sender’s message. Volume, the loudness of the voice,
can indicate anger, fear, happiness, or deafness. Tone
can indicate if someone is relaxed, agitated, or bored.
Pitch varies from shrill and high to low and threat-
ening. Intensity is the power, severity, and strength
behind the words, indicating the importance of the
message. Emphasis refers to accents on words or
phrases that highlight the subject or give insight on
the topic. Speed is number of words spoken per minute.
Pauses also contribute to the message, often adding
emphasis or feeling.
The high-pitched, rapid delivery of a message
often indicates anxiety. The use of extraneous words
with long, tedious descriptions is called circumstan-
tiality.Circumstantiality can indicate the client is
confused about what is important or is spinning an
untrue story (Morley et al., 1967). Slow, hesitant
responses can indicate that the person is depressed,
confused and searching for the correct words, having
difficulty finding the right words to describe an inci-
dent, or reminiscing. It is important for the nurse to
validate these nonverbal indicators rather than to as-
sume that he or she knows what the client is thinking
or feeling (e.g., “Mr. Smith, you sound anxious. Is that
how you’re feeling?”).Eye Contact
The eyes have been called the mirror of the soul be-
cause they often reflect our emotions. Messages that
the eyes give include humor, interest, puzzlement,
hatred, happiness, sadness, horror, warning, and
pleading. Eye contact,looking into the other person’s
eyes during communication, is used to assess the other
person and the environment and to indicate whose
turn it is to speak; it increases during listening but
decreases while speaking (Northouse & Northouse,
1998). While maintaining good eye contact is usually
desirable, it is important that the nurse doesn’t “stare”
at the client.
Silence
Silence or long pauses in communication may indicate
many different things. The client may be depressed
and struggling to find the energy to talk. Sometimes
pauses indicate the client is thoughtfully considering
the question before responding. At times, the client
may seem to be “lost in his or her own thoughts” and
not paying attention to the nurse. It is important to
allow the client sufficient time to respond, even if itseems like a long time. It may confuse the client if the
nurse “jumps in” with another question or tries to re-
state the question differently. Also, in some cultures,
verbal communication is slow with many pauses, and
the client may believe the nurse is impatient or dis-
respectful if he or she does not wait for the client’s
response.UNDERSTANDING THE MEANING
OF COMMUNICATION
Few messages in social and therapeutic communica-
tion have only one level of meaning; messages often
contain more meaning than just the spoken words
(deVito, 2002). The nurse must try to discover all the
meaning in the client’s communication. For example,
the client with depression might say, “I’m so tired
that I just can’t go on.” If the nurse considers only the
literal meaning of the words, he or she might assume
the client is experiencing the fatigue that often ac-
companies depression. However, statements such as
the previous example often mean the client wishes to
die. The nurse would need to further assess the client’s
statement to determine whether or not the client is
suicidal.
It is sometimes easier for clients to act out their
emotions than to organize their thoughts and feelings
into words to describe feelings and needs. For exam-
ple, people who outwardly appear dominating and
strong and often manipulate and criticize others in
reality may have low self-esteem and feel insecure.
They do not verbalize their true feelings but act them
out in behavior toward others. Insecurity and low
self-esteem often translate into jealousy and mistrust
of others and attempts to feel more important and
strong by dominating or criticizing them.UNDERSTANDING CONTEXT
Understanding the context of communication is ex-
tremely important in accurately identifying the mean-
ing of a message. Think of the difference in the mean-
ing of “I’m going to kill you!” when stated in two
different contexts: anger during an argument, and
when one friend discovers another is planning a sur-
prise party for him or her. Understanding the context
of a situation gives the nurse more information and
reduces the risk of assumptions.
To clarify context, the nurse must gather infor-
mation from verbal and nonverbal sources and vali-
date findings with the client. For example, if a client
says, “I collapsed,” she may mean she fainted or felt
weak and had to sit down. Or she could mean she was
tired and went to bed. To clarify these terms and
view them in the context of the action, the nurse could
say, “What do you mean collapsed?”(seeking clarifi-6 THERAPEUTICCOMMUNICATION 123