Communication and Therapeutic Communication

Communication

  • The interaction between two or more people involving the exchange of information between sender and receiver.
    • Verbal:
      • Content: literal words spoken.
      • Context: environment, circumstances, situation in which communication occurs.
    • Nonverbal:
      • Process: all messages used to give meaning, context to message.
      • Congruent or incongruent message.

Therapeutic Communication

  • Interpersonal interactions focusing on the patient’s needs.
  • Requires a need for privacy.
  • Encompasses goals that facilitate the nursing process.
  • Needed to effectively meet the standards of client care.
  • Goals:
    • Establish therapeutic nurse-client relationship.
    • Identify client’s most important concerns; assess patient’s perceptions.
    • Facilitate client’s expression of emotions.
    • Teach client, family necessary self-care skills.
    • Recognize client’s needs.
    • Implement interventions to address client’s needs.
    • Guide client toward acceptable solutions.

Proxemics (Distance Zones)

  • Intimate: 0 to 18 inches.
  • Personal: 18 to 36 inches.
  • Social: 4 to 12 feet.
  • Public: 12 to 25 feet.
  • Therapeutic communication is most comfortable when the nurse and patient are 3 to 6 feet apart.

Social and Physical Distancing

  • Recommended to prevent the spread of COVID-19 virus.
  • Social distancing: Staying home and away from others.
  • Physical distancing: Staying at least 6 ft away from others.
  • Affect distance zones and use of touch.

Touch

  • Five types: functional/professional; social–polite; friendship–warmth; love–intimacy; sexual-arousal.
  • Can be comforting and supportive, but also a possible invasion of intimate and personal space.
  • The nurse must evaluate the use of touch based on the client’s preferences, history, and needs (e.g., clients with a history of abuse).

Active Listening and Observation

  • Active listening: Concentrating exclusively on what the patient says.
  • Active observation: Watching nonverbal actions as the speaker communicates.
  • These help the nurse:
    • Recognize the most important issue.
    • Know what questions to ask.
    • Use therapeutic communication techniques.
    • Prevent jumping to conclusions.
    • Objectively respond to the message.

Verbal Communication Skills

  • Need for concrete, not abstract, messages.
  • Therapeutic Techniques (see Table 6.1):
    • Exploring, focusing, restating, reflecting promote discussion of feelings or concerns in more depth.
    • Other techniques useful in focusing or clarifying what is being said.
    • Feedback by making an observation or presenting reality.

Nontherapeutic Techniques

  • Avoidance of nontherapeutic techniques (see Table 6.2):
    • Advising, belittling, challenging, probing, and false reassuring.

Interpretation of Signals or Cues

  • Overt: Clear, direct statements.
  • Covert: Vague, indirect messages.

Nonverbal Communication Skills

  • Facial expression: Expressive or confusing.
  • Body language: Open or closed body position.
  • Vocal cues.
  • Eye contact.
  • Silence.

Understanding Meaning and Context of Communication

  • Meaning: Usually more meaning than just spoken word.
  • The nurse must try to discover all the meaning in the client’s communication, not only the literal meaning of words.
  • Context:
    • Validation of the client findings from verbal and nonverbal information.
    • Assessment focuses on who, what, when, how, why.

Understanding Spirituality

  • Spirituality: Belief about life, health, illness, death, and one’s relationship to the universe.
  • Nurses must:
    • Assess their own spiritual and religious beliefs.
    • Remain objective and nonjudgmental.
    • Assess client’s spiritual and religious needs.
    • Be aware of and respect client’s beliefs.

Interpretation of Communication Environmental Context

  • Patient:
    • Culture/Values/Beliefs
    • Spoken Language
    • Developmental level
    • Experience
    • Coping ability/Emotional state
    • Psychopathology
    • Psychopharmacology
  • Nurse:
    • Culture/Values/Beliefs
    • Experience
    • Knowledge of psychopathology
    • Skills to guide

Cultural Considerations

  • Cultural assessment.
  • Use of a translator who can retain original intent without inserting biases.
  • Nurse must understand differences in how various cultures communicate.
  • Need for awareness of cultural differences in:
    • Speech patterns and habits
    • Styles of speech and expression
    • Eye contact
    • Touch
    • Concept of time
    • Health and health care

Therapeutic Communication Session

  • Goals:
    • Establish rapport
    • Actively listening
    • Gaining in-depth understanding of client’s perception of issue
    • Be empathetic
    • Exploring client’s thoughts and feeling
    • Facilitating client’s expression of thoughts and feeling
    • Guiding client in developing problem-solving skills
    • Promoting client’s evaluation of solutions

Initiation of Session

  • Introduction
  • Establishment of contract for relationship
  • Learning how client prefers to be addressed
  • Identification of major concern
  • Nondirective role (broad-opening, open-ended questions)
  • Directive role (direct yes/no questions; usually for patients with suicidal thoughts, in crisis, or who are out of touch with reality)

Questioning Techniques

  • Open-ended versus yes-or-no questions
  • Proper phrasing of questions
  • Using “think” versus “feel”
  • Active listening skills, asking many open-ended questions, building on client’s responses
  • Techniques include clarification and placing an event in time or sequence.

Key Aspects of Guiding the Client

  • Asking for clarification
  • Addressing client’s avoidance of anxiety-producing topic
  • Guiding the client in problem-solving and change
  • Help the client explore possibilities
  • Client’s participation is key
  • Avoid inserting own beliefs

Assertive Communication

  • Expression of positive and negative feelings/ideas in open, honest, direct way
  • Calm, specific factual statements
  • Focus on “I” statements
  • Possible responses
    • Aggressive
    • Passive–aggressive
    • Passive
    • Assertive
  • Broken record technique
  • Rehearsing responses

Therapeutic Communication Techniques

  • Accepting
  • Acknowledgement
  • Broad Openings
  • Empathy
  • Exploring
  • Focusing
  • Paraphrasing- Example: "I am too tired to even think" with, "Did you mean that you are too tired now to continue with this education?"
  • Reflecting/Reflection
  • Restating
  • Summarizing

Environment tips

  • Environment: What type of environment would enhance therapeutic communication?

Ineffective Communication Techniques

  • Advising
  • Arguing
  • Belittling Feelings
  • Being judgmental
  • Challenging
  • False Assurance
  • Probing
  • Stereotyping
  • Parroting
  • Changing the Subject

Community-Based Care

  • Nurses increasingly caring for high-risk patients in homes; families becoming more responsible for primary prevention
  • Therapeutic communication techniques and skills are essential for caring for patients in the community.
  • Increased self-awareness, knowledge needed about cultural differences; sensitivity to beliefs, behaviors, feelings of others
  • Collaboration with patient and family as well as other health-care providers

Self-Awareness Issues

  • Nonverbal communication: as important as verbal
  • Therapeutic communication influential in effectiveness of interventions
  • Awareness of own communication is first step in improving communication
  • Ask for feedback from colleagues
  • Examine own communication skills