Learning Objectives
By the end of this section, you will be able to:
- Describe therapeutic communication techniques
- Recognize how to evaluate therapeutic communication
- Identify nontherapeutic communication techniques
The most used form of communication in health care is therapeutic communication, a specialized form of communication used by healthcare professionals, such as nurses, doctors, and therapists, to establish a therapeutic or healing relationship with patients (Martin & Chanda, 2016). Florence Nightingale discussed the importance of communication between patient and nurse in the 1800s. In the 1950s, the concept of therapeutic communication was developed to provide therapeutic benefit, especially with patients who were diagnosed with mental illness. The nursing theorist Hildegard Peplau developed the Theory of Interpersonal Relations that cemented the concept of therapeutic communication to advance the healing process in patients. Therapeutic communication has progressed to include verbal and nonverbal communication, helping patients overcome illnesses of the body and mind. Nurses should use therapeutic communication in all communication encounters with patients (Martin & Chanda, 2016).
Clinical Safety and Procedures (QSEN)
QSEN Competency: Patient-Centered Care
Definition: Recognize the patient or designee as the source of information and a full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs.
Skill: The nurse will do the following:
- Discuss principles of effective communication.
- Describe basic principles of consensus building and conflict resolution.
- Examine nursing roles in assuring coordination, integration, and continuity of care.
If the nurse and other members of the healthcare team do not provide therapeutic communication, the expected outcomes for the patient could be impacted negatively. If there is conflict between the patient and the healthcare team, negative health outcomes could occur.
Knowledge: The nurse must have an understanding of the key therapeutic communication delivery techniques so that they can use the most appropriate approach for the specific patient or designee and are able to evaluate its effectiveness.
Attitude: The nurse should engage in active listening, indicating an understanding of what the patient or designee is saying.
Therapeutic Communication Techniques
Therapeutic communication allows patients to express themselves. There are various therapeutic communication techniques in health care. Nurses should be very familiar with these different techniques, using them with each patient communication encounter. These techniques include providing information; sharing observations, feelings, empathy, hope, and humor; using touch and silence; focusing and clarifying; asking relevant questions; offering self, which is contributing support by being present or spending time with a patient; and active listening (Table 2.5). Using all these techniques as the situation warrants helps the nurse provide safe and effective care for the patient. The nurse should recognize that the use of open-ended questions supports therapeutic communication.
| Technique | Definition | Example |
|---|---|---|
| Providing information | Nurses are responsible for educating and informing patients and families. Patient education should be ongoing, with nurses using every encounter as an opportunity to educate. | As the nurse dispenses the morning medications, the nurse educates the patient about each medication, encouraging the patient to ask questions. |
| Sharing observations | Nurses should share their observations about the patient while providing care. Being mindful about the patient’s appearance and mood can give the nurse clues about the patient’s health. | The nurse states: I noticed you are crying; would you like to share with me what is making you sad? |
| Sharing feelings | Patients should be encouraged to share their feelings. Because patients are often frustrated with health care, nurses can create safe spaces where the patient feels comfortable sharing their feelings. | A nurse asks a patient to describe what they are feeling after the patient is given a particular diagnosis. |
| Sharing empathy | A nurse who expresses empathy may tell the patient that they hear and understand what the patient is saying, which helps the patient feel they are being cared for. | A nurse asks a patient about their cultural beliefs surrounding pregnancy. |
| Sharing hope | Nurses should be ready to share a sense of possibility for the patient, even when the news is bad. Sharing hope through active listening might be included for the patient who has just received a terminal diagnosis; however, information dispensed must remain factual. | A nurse should be present with the parent who has received bad news about their child, giving the parent time to talk. |
| Sharing humor | The nurse can use patient-driven humor as a gauge for deciding when and if to use humor with the patient. Recognize that there are many circumstances in which humor may not be appropriate as a therapeutic technique. | The nurse listens when a family member shares a funny story about the patient and then shares a related story. |
| Using touch | A nurse’s touch may be the only positive or healing touch the patient receives. However, a patient who is receiving many treatments may regard some touch as negative. An episode of handholding with the nurse after procedures can uplift their spirits. Some patients find touch to be unsettling, so the nurse must ask the patient before engaging. | The nurse asks the parent if it is okay to touch their infant before assessing them. |
| Using silence | Allowing a patient the time to think and process is important. Nurses should respectfully let the patient break the silence. | The nurse is quiet while the patient shares their rape experience from college. |
| Clarifying | Nurses should clarify communication received from patients. Often, patients use confusing and ambiguous communication when describing health issues. Nurses ask questions to help clarify the communication so that both parties better understand the issues. | The patient has described stomach pain. The nurse asks several follow-up questions about location, intensity, quality, radiation, onset, character, and exacerbating and relieving factors. |
| Asking relevant questions | Nurses should ask relevant questions about the healthcare issue before helping the patient make a decision about their care. The nurse uses the relevant question technique to gather information, while not overwhelming the patient with questions. | The patient discusses with the nurse their previous hospital experience. The nurse asks about the length of stay, the admitting diagnosis, and the outcome of treatment. |
| Offering self | Patients in any setting can be lonely, scared, and stressed. A nurse who offers themselves by sitting with the patient or spending time talking with the patient is offering self. Some patients report a boost in mood once a nurse has spent one-on-one time with them. | The nurse comforts the child when asked, before and during a vaccination. |
| Actively listening | Active listening includes using both verbal and nonverbal cues to convey interest in the patient’s communication. Simply saying “Go on” gives patients courage to continue a discussion of health issues. | The patient describes a previous medication reaction and the nurse clarifies some of the information the patient presents, encouraging the patient to share all aspects of their experience. |
Unfolding Case Study
Unfolding Case Study #1: Part 3
Refer back to Unfolding Case Study #1: Part 1 and Unfolding Case Study #1: Part 2 for a review of the patient data.
| Nursing Notes | 1700: Assessment Physical examination: Patient appears disheveled with clothes inappropriate for the cold weather, including short-sleeve shirt and shorts. While waiting for the interpreter, patient appears agitated with frequent coughing episodes. Begins to pace the room as son attempts to console her. HEENT: Pupils equal, reactive to light and accommodating, mucous membranes moist and intact, pharynx without lesions, palate intact. No thyroid enlargement noted. Lymphatic: Tonsillar and cervical lymph nodes slightly enlarged. Hard, palpable left axillary lymph nodes, tender to touch. No enlargement of right axillary or inguinal nodes, no pain or tenderness noted. Respiratory: Rales and rhonchi auscultated bilaterally. No stridor or murmur present. Cardiovascular: Sinus tachycardia on monitor, no edema, peripheral pulses 2+. Abdomen: Bowel sounds present in all four quadrants, no tenderness present. Musculoskeletal: Full range of motion, no issues noted. Skin: Pale and dry, no bruising. Mental assessment: Patient reports (per son) that she is stressed from coughing and anxious about her mother left alone at home. Patient requests the nurse “hurry and give me some medicine so I can go home.” Interpreter arrived to room at 2030. |
| Flow Chart | 2000: Assessment Blood pressure: 148/87 mmHg Heart rate: 110 beats/minute Respiratory rate: 26 breaths/minute Temperature: 102.2°F (39°C) Oxygen saturation: 97 percent on 2 L nasal cannula Pain: 8/10 (ear) |
| Provider’s Orders | 2030: New orders Sputum sample Wean from oxygen before discharge home Medications:
|
Evaluating the Effectiveness of Therapeutic Communication
Nurses should be adept at evaluating the effectiveness of therapeutic communication. Communication should go two ways, using the feedback loop, as feedback ensures the therapeutic communication has been effective. Nurses rely on the feedback loop to make this evaluation. If the communication has not been effective, the nurse should revise their approach, making sure they are providing effective communication for the patient.
Reflect on the Response
Nurses who use reflection on the response during therapeutic communication should restate what the patient has said. This allows the patient to hear their own words and encourages them to continue to communicate. Reflection helps the patient understand that the nurse is actively listening to them, further establishing the nurse-patient relationship.
Compare Response to the Desired Goals
After the nurse reflects on the patient’s response, they should compare the response to the desired goals of the communication. The nurse should consider various factors at play during communication. It is crucial to compare the patient’s response to the desired goal. If they align, it confirms effective therapeutic communication.
Revise Message if Communication Is Ineffective
If the nurse determines the therapeutic communication was not effective, revision of the message is needed. The nurse needs to revise the message and employ the feedback loop to again check if the intended message has been received. For instance, if a nurse was teaching a patient about their surgical care, the nurse would use a feedback loop to make sure the patient understood the instructions. If the patient is not able to repeat the instructions, the nurse should revise the message until the patient can repeat the instructions.
Patient Conversations
A Therapeutic Conversation with a Patient
Scenario: Linda has been a nurse in New Orleans, Louisiana, for four years. Her patient is Mr. Michael Boudreaux, a 62-year-old Army veteran who has lived in Louisiana his whole life. The nurse walks into the patient’s room to complete an assessment.
Nurse: Hi, my name is Linda, and I am going to be your nurse today. Do you mind verifying your name and date of birth for me?
Patient: Michael Boudreaux, date of birth 01/26/1961.
Nurse: Hi, Mr. Boudreaux, I would like to do an assessment of you, if that is okay?
Patient: Of course, I am just sitting here, worried about what is happening to me.
Nurse: Would you like to discuss with me some of the things that you are worried about?
Patient: Sure, I am worried that I have something really bad wrong with me and no one is telling me.
Nurse: Let me clarify, you feel like no one is talking to you and that makes you think that there is something bad happening?
Patient: Yes, do you know anything about my test results?
Nurse: None of the results are available at this time, but that doesn’t help you, does it? Would you like me to have the healthcare provider speak to you and explain why they are doing certain tests and what they might be looking for?
Patient: Yes, that would be helpful, and maybe make me less anxious. Thank you.
Nurse: You are very welcome, please don’t hesitate to ask me any other questions. I am here to help you feel better. I’ll need to touch you to do my assessment. Is that okay?
Nontherapeutic Communication Techniques
Unfortunately, nontherapeutic communication can also occur between the patient and nurse. Nontherapeutic communication can be defined as negative expressions, attitudes, and actions that make a patient feel uneasy. Both the patient and the nurse are subjected to many influences that can muddle communication. Nurses should try to avoid nontherapeutic communication and strive to revise the communication if nontherapeutic communication has occurred.
Link to Learning
Learn more about therapeutic and nontherapeutic communication techniques in this video.
Nontherapeutic communication can lead to miscommunication between the nurse and patient, and among healthcare providers, ultimately affecting the care the patient receives (Amoah et al., 2019). Nontherapeutic communication techniques include attacking and interrogating patients; changing the subject; giving automatic responses that are not helpful; giving false reassurance, which is comfort that is not based in facts, and advice; providing passive, aggressive, judgmental, or defensive responses; and arguing with the patient. Another nontherapeutic communication technique is not listening to the patient or not being actively present when with a patient, like scrolling on a phone during a patient encounter. All these nontherapeutic responses can negatively affect the nurse-patient relationship (Table 2.6).
| Techniques | Definition | Examples |
|---|---|---|
| Attacking | Verbal attacking is meant to criticize, dominate, or manipulate the patient. Attacking a patient will likely cause the patient to shut down and stop communicating or elicit an anger defense. Nurses must avoid verbally attacking patients. If the patient’s perception is that the nurse attacked them, the nurse should apologize and try to reestablish therapeutic communication. | The nurse tells the patient, “You came in here drunk and started hitting people.” |
| Interrogating | Interrogation of a patient is often described as asking “why” questions. When “why” questions are asked, the patient can become defensive or uncomfortable and stop communicating altogether. The nurse should avoid asking “why” questions, rephrasing questions to prevent the patient from becoming defensive. | The nurse asks the patient, “Why did you not take the medication like I instructed you to do?” |
| Changing the subject | When a nurse changes the subject while a patient is talking, the patient perceives that their communication is not important. Sometimes nurses rush patients through a communication encounter and can change the subject to meet the nurse’s goals for the encounter. The patient may see this as a form of disrespect or a way to silence them. The nurse needs to recognize factors influencing their own communication and allow the patient to speak uninterrupted to establish a positive nurse-patient relationship. | The patient tells the nurse about their chest pain, and the nurse asks, “What kind of insurance do you have?” |
| Automatic response | Automatic responses are ready-made sayings or statements that are used without any thought to the patient as an individual. Nurses should avoid these types of statements when communicating with patients because they can be interpreted as generalizations or stereotypes. Phrases like “I am sorry for your loss” seem automatic. Patients who receive automatic responses from the nurse may refrain from communicating at all. | The nurse tells the patient several times in the day that they will be right back and each time does not return to the room unless the patient specifically calls them. |
| False reassurance | Giving false reassurance that everything will be all right may do more harm than good. The nurse should allow the patient to voice their fears and concerns and then offer hope without devaluing the patient’s feelings. | The nurse tells the patient the medication they are given for nausea during chemotherapy will make all the nausea go away, and the patient will feel much better in a few minutes. |
| Giving advice | Nurses should not give advice when communicating with patients. Patients often ask for the nurse’s opinion, and the nurse should try to communicate therapeutically by giving factual information without personal experience and advice. Giving advice can prevent the patient from developing their own healthcare goals. | The nurse states, “You know, if it were me, I would not go to that healthcare provider.” |
| Defensive responses | Nurses should refrain from being defensive in all communication with patients. Patients sometimes express criticism about their health care, and nurses should not respond defensively. Nurses need to actively listen to the criticism as there is often a deeper meaning that the patient is attempting to convey. | The nurse states, “I didn’t do anything” when the patient states that the nurse took their belongings. |
| Passive or aggressive responses | Passive or aggressive responses should be avoided, if possible. Passive responses are those that try to avoid conflict or circumvent issues. Aggressive responses are responses that are meant to provoke confrontation. When the nurse attempts to avoid conflict or is angry with the patient, they should not let the patient know. Nurses should use assertive communication when they are tempted to use the passive or aggressive responses that can damage the nurse-patient relationship. | The patient soils themselves for the third time in the shift, and the nurse has to change the sacral dressing. The patient apologizes profusely to the nurse, and the nurse responds “yeah, yeah I know.” |
| Judgmental responses | Nurses should not make value judgments about the patients’ healthcare decision. Making judgments that the patient has done something right or wrong implies the nurse is the only person who has the ability to make those decisions. In a positive nurse-patient relationship, the nurse should not be seen as superior to the patient. | The nurse tells the patient, “You know the reason you have lung cancer is because you smoked for forty years.” |
| Arguing | Arguing with patients must be avoided at all costs. Arguing or challenging a patient implies that the nurse thinks the patient is lying or misinformed, damaging the nurse-patient relationship. Arguing usually prevents the patient from trusting the nurse. | The nurse argues with patient about their diet, the patient raises their voice, and the nurse does too. |