Therapeutic Communication in Nursing

Introduction to Communication in Nursing

• Communication is profoundly important in nursing, making it a recurring topic in the curriculum and specialty areas, such as mental health.
• Therapeutic communication, specifically, is a challenging concept for many students and forms a significant part of the first mental health exam.

Purpose and Objectives of the Lecture

• Purpose: To introduce therapeutic communication, starting from the basics, assuming no prior knowledge.
• Specific Objectives:
  • Identify the nurse's role in advocating for the client, which is considered the most important role in nursing.
  • Apply therapeutic communication techniques.
  • Compare intra-professional with inter-professional communication.
  • Discuss two types of therapeutic communication: verbal and nonverbal.
  • Examine how healthcare professionals communicate among themselves.
  • Identify different levels of communication.

Types of Professional Communication

• Intra-professional Communication:
  • Refers to communication within the nursing profession.
  • Involves interactions between a director of nursing, nurse manager, charge nurse, Registered Nurses (RNs), Certified Nursing Assistants (CNAs)/aides, and Licensed Practical Nurses (LPNs).
  • The speaker clarifies that while CNAs are not nurses, their tasks are delegated by nurses, thus falling under intra-professional nursing care.
  • A doctor is not included in intra-professional communication because they are of a different profession (medical doctors).
• Inter-professional Communication:
  • Involves communication with all other healthcare professionals involved in patient care, beyond the nursing team.
  • Examples include:
    • Healthcare providers (physicians, nurse practitioners, physician assistants).
    • Physical therapists (for mobility issues).
    • Dietitians (for education on conditions like cardiac or diabetes).
    • Social workers (for community resources, transitional care facilities like assisted living or rehab centers).
  • The lecturer notes that communication with inter-professional teams differs slightly from intra-professional communication.
  • The patient themselves are not considered professional; they are the subject of care.
  • Inter-professionals are engaged only when their specific expertise meets the patient's needs for holistic care.

Assignments and Practical Information

• Assignments: Two assignments due this week, both in ATI:
  • Access via the "Nurses Touch" tile (not "Engage Fundamentals"), then "Professional Communication."
  • Topics: "Factors that affect communication with individuals and groups" and "Therapeutic Communication."
• Time Zone: All due dates and times are based on Mountain Time.

The Hospital Environment and Patient Experience

• Patient Vulnerability: People are typically in the hospital for negative, serious reasons and are often emotional or anxious.
• Student Nurse Perspective: Entering clinicals (e.g., NUR 125) can be a new and different environment, as hospitals are not places for fun.
• Confidentiality and Privacy:
  • Hospital cafeterias are quiet due to the serious nature of why people are there; respect the privacy of others.
  • Students are reminded not to discuss patients, units, or sensitive information loudly in public areas like cafeterias or hallways, as others may overhear and misinterpret information as pertaining to their loved ones.
  • Nurses' stations, often centrally located, act like "tunnels for sound," meaning conversations can easily be overheard by patients in their rooms who have little else to do but listen.
  • Assumption of relevance: Patients often assume overheard conversations are about them, leading to misinterpretations and distress.
  • Advice: Keep voices down, avoid specific patient discussions in hallways or at the nurses' station; use a nurse's lounge or empty patient lounge for sensitive conversations.
• Student Nurse Role with Patient Questions:
  • Patients often assume anyone in scrubs is a nurse.
  • Student nurses should prepare a scripted response: "I am a student nurse, so I'm not the best person to answer that for you. Let me go tell your nurse, and they can come back and answer your question."
  • It is acceptable and encouraged to say "I don't know" but always provide a plan to get the correct answer (e.g., asking the primary nurse).
  • Building and Maintaining Trust:
    • Avoid false reassurances (e.g., saying "I'll be back in five minutes" if unable to return promptly) as patients, with nothing else to do, will notice the time discrepancy, breaking trust.
    • Trust is vital for nurses to do their job effectively and is developed through therapeutic communication.

Nature of Therapeutic Communication

• Definition: A purposeful, interpersonal information-transmitting process that leads to client understanding and participation.
• Purposeful Interaction: Every conversation with a patient has a specific objective, often for gathering information or providing it.
• Distinction from Social Interaction: Unlike social interactions, therapeutic communication always has a goal or purpose.
• Importance:
  • Nurse-Client Relationship: Essential for establishing rapport and trust. Nursing has topped the Gallup poll for trustworthiness for 23 consecutive years because patients open up to nurses.
  • Patient Safety: Patients who communicate openly provide necessary information for safe care.
  • Client Satisfaction: Statistically, a client who likes their nurse is less likely to sue. Patient satisfaction surveys also influence hospital reimbursement rates from the government.
• Challenges: Not every nurse will "click" with every patient. It's acceptable to request a change in assignment if a therapeutic relationship cannot be established, especially in critical care settings where assignments might be long-term.

Key Therapeutic Communication Techniques (ATI perspective)

• Contextual Factors: Sound decisions require considering the client's communication ability, contextual factors, and developmental/sociocultural issues.
• Active Listening:
  • Being attentive to both verbal and non-verbal cues.
  • Involves being present for the patient, often by sitting down at eye level at the bedside.
• Asking Relevant Questions:
  • Open-ended Questions: Encourage expression of feelings and ideas, promote discussion, require more than a simple yes/no response.
    • Examples: "How do you cope with anxiety?", "What event in your life has been the most stressful?", "Can you please tell me more about what's happening to you that led you to be hospitalized here?"
    • NCLEX Tip #1: Ask and assess emotions to obtain important information (e.g., "Tell me what concerns you have," "What are you feeling right now?").
  • Closed-ended Questions: Can be used for ice-breaking or specific factual information (e.g., "Did you sleep well last night?") but should not be the sole communication method.
• Providing Information: Helpful for reducing a patient's fear of the unknown, particularly for anxious patients.
• Using Confrontation: Helps clients become aware of inconsistencies in feelings, attitudes, beliefs, or behaviors.
• Using Silence: Especially useful when clients need to process thoughts or make decisions; allows them time to think without feeling pressure to speak.
• Clarifying, Focusing, Paraphrasing, Summarizing:
  • Clarifying: Ensures mutual understanding, crucial in healthcare. Don't be afraid to ask for repetition, particularly with patients who mumble or have hearing difficulties.
  • Paraphrasing: Repeating what the client said in your own words to confirm understanding and show you've heard them.
• Controlling Tone and Pace of Voice: Avoids hidden messages; speaking too loudly can be perceived as yelling, while adjusting volume is necessary for hard-of-hearing patients.
• Empathy: Understanding the patient's feelings by putting yourself in their shoes.
• Reflecting: Asking clients what they think they should do, empowering them to take control.
• Unconditional Acceptance: Allowing the client to express feelings or thoughts without judgment; clarify misunderstandings without telling the patient they are wrong.
• Stating Facts to Build Trust: Part of NCLEX Tip #2: State facts and reflect on patient feelings (e.g., "We have the vital signs under control," "You must be very upset").

Non-Verbal Communication Considerations

• Touch: A tricky area. Generally, maintain private space and always ask permission before touching a patient (e.g., "Mr. Smith, is it okay if I put this cuff on your arm?").
  • Cultural Differences: Some cultures (e.g., Muslim patients) strictly limit touch, especially between genders. Nurses must be culturally sensitive and research patient beliefs if unknown.
• Eye Contact: Cultural variations exist; some cultures (e.g., certain Asian descents) may consider direct eye contact disrespectful.

Therapeutic Communication for Anxiety and Depression (ATI Fundamentals Exam Content)

• These conditions are prevalent, and nurses will encounter them frequently on med-surg units.
• General approach:
  • Create a safe, non-judgmental environment for clients to explore feelings.
  • Utilize active listening, empathy, open-ended questions, and reflective statements.
  • Provide accurate information to alleviate fear of the unknown, which often fuels anxiety.
  • Encourage positive coping strategies and focus on the future rather than dwelling on past negatives or "should haves."
  • Set realistic, short-term and slightly longer-term goals to build morale and reduce anxiety/depression.
  • Offer consistent reassurance and support, emphasizing that they are not alone.
  • Teach mindfulness and relaxation techniques (e.g., counting backwards from 100, reciting the alphabet backward for distraction).
  • Build a strong therapeutic alliance to foster trust and collaboration.

Non-Therapeutic Communication and Icebreakers

• While the focus is therapeutic, some non-therapeutic communication for ice-breaking is acceptable (e.g., weather). However, avoid personal or potentially sensitive topics like sports, which can be divisive.