Therapeutic

Communication

Therapeutic Communication
Interpersonal interactions between the nurse and the client
It focuses on the clients specific needs and is used to:
Establish the therapeutic relationship
Identify the clients most important concerns
Assess the clients perceptions
Facilitate the clients expression of emotions
Teach the client and family necessary self-care skills
Recognize the clients needs
Implement interventions designed to address the clients
needs
Guide the client toward satisfactory and acceptable
solutions

Communication
The process people use to exchange information:
Verbal (what is said, or content)
Context (environment or situation, including
culture)
Nonverbal (behavior such as facial expression,
tone of voice, hesitancy, distance from speaker,
or process)
Congruency (when content and process agree)
Incongruency (when content and process do not
agree; nonverbal is more accurate)

Essential Components of
Therapeutic Communication

Essential Components of
Therapeutic Communication
Privacy and respect for boundaries
Therapeutic communication is most comfortable
at 3 to 6 feet; should not be less than 18 inches

Proxemics:
1. Intimate Zone 0-8 inches between
people
2. Personal Zone 18-36 inches between
people
3. Social Zone - 4- 6 feet
4. Public Zone 12-25 feet

Essential Components of
Therapeutic Communication
Touching
Touch may be comforting and supportive
Touch also is an invasion of intimate and personal space
Nurse must evaluate whether the client
perceives touch as positive or threatening and
unwanted; never assume that touching a client
is acceptable

Types of Touch
Functional-professional touch is used in procedures or
examinations
Social-polite touch used in greeting such as handshake
Friendship warmth touch involves hugs in greeting
Love-intimacy touch involves tight hugs and kisses
between lovers or close relatives
Sexual Arousal used by lovers

Essential Components of
Therapeutic Communication
(contd)
Active listening means refraining from
other internal mental activities and
concentrating exclusively on what the
client says
Active observation means watching the
speakers nonverbal actions as he or
she communicates

Verbal Communication Skills

Use concrete messages
Concrete messages are specific and
clear; abstract messages are unclear and
vague and require interpretation
Concrete messages elicit more accurate
responses and avoid the need to go back
and rephrase unclear questions, which
interrupts the flow of a therapeutic
interaction

Verbal Communication Skills (contd)

Therapeutic communication techniques facilitate
interaction and enhance communication between
client and nurse
Techniques that encourage the client to
discuss his or her feelings or concerns in more
depth include:
o Exploring
o Focusing
o Restating
o Reflecting

Communication Techniques
Acceptance
Non-judgmental attitude
Convey respect

Offering Self
Sense of presence
Being available

Open-ended Questions
Broad openings allow Pt to select the topics

Validation
Confirming what the patient has said

Communication Techniques
Reflection
Content & feeling is referred back to Pt
Pt recognition & acceptance

Restatement
Paraphrase main content or emotion

Focus
Direct conversation to a single concept

Clarification
Enhance understanding vague or confused
message

Communication Techniques
Convey Information
Supply data via statement

Provide Feedback
Specific constructive information

State Observations
Verbalize what is witnessed or perceived

Connect Information
Identify relationships, similarities or differences
to clarify behavior/ thoughts

Communication Techniques
Confrontation
Identify discrepancies between what the
Pt says & does

Summarize
Highlight the main themes of content &
feelings discussed

Present Reality
Orient to the present
Clarify misperceptions

Silence
Interaction without words

Verbal Communication Skills (contd)

Avoid nontherapeutic communication, which are
responses that cut off communication and make
it more difficult for the interaction to continue
Responses that are common in social interaction
are:
Advising
Agreeing
Reassuring

Blocks to Communication
False Reassurance

May discourage Pt from disclosing

feelings

Rejecting
Refusing to consider the Pts ideas or
behaviors

Giving Approval
Passing judgment or Pt right or wrong

Giving Advice
Implies RN knows what is best for the Pt.

Probe
Pushing for answers the Pt does not want

Blocks to Communication
Defend
Implies Pt has no right to express his own
ideas

Belittle
Minimizing Pt. distress Pt. unimportant

Change the Subject

RN takes over the direction of the
conversation

Denial
Blocks further discussion
1/10

Samples
1. USING SILENCE...utilizing absence of verbal
communication.
2.ACCEPTING...givingindicationofreception.
"Yes."
"Uhhmm."
"Ifollowwhatyousaid."
Nodding.

3.GIVING RECOGNITION...acknowledging,indicatingawareness.

"Goodmorning,Mr.S."
"You'vetooledaleatherwallet."
"Inoticethatyou'vecombedyourhair.

4.OFFERING SELF...makingone'sselfavailable.

"I'llsitwithyouawhile."
"I'llstayherewithyou."
"I'minterestedinyourcomfort."

5.GIVING BROAD OPENINGS...allowingthepatienttotakethe

initiativeinintroducingthetopic.

"Istheresomethingyou'dliketotalkabout?"
"Whatareyouthinkingabout?"
"Wherewouldyouliketobegin?

6.OFFERING GENERAL LEADS....givingencouragementto

continue.

"Goon."
"Andthen?"
"Tellmeaboutit."

7.PLACING THE EVENT IN TIME OR IN SEQUENCE...

clarifyingtherelationshipofeventsintime.

"Whatseemedtoleadupto...?"
"Wasthisbeforeorafter...?"
"Whendidthishappen?

8.MAKING OBSERVATIONS...verbalizingwhatisperceived.

"Youappeartense."
"Areyouuncomfortablewhenyou...?"
"Inoticethatyou'rebitingyourlips."
"Itmakesmeuncomfortablewhenyou..."

9.ENCOURAGING DESCRIPTION OF PERCEPTIONS...asking

thepatienttoverbalizewhatheperceives.

"Tellmewhenyoufeelanxious."
"Whatishappening?"
"Whatdoesthevoiceseemtobesaying?

10.ENCOURAGING COMPARISON...askingthatsimilaritiesand
differencesbenoted.

"Wasthissomethinglike...?"
"Haveyouhadsimilarexperiences?"

11.RESTATING...repeatingthemainideaexpressed.

Patient."Ican'tsleep.Istayawakeallnight."
Nurse."Youhavedifficultysleeping."
Patient."Thefellowthatismymatediedatwarandispending

meyettomarry."
Nurse."Youweregoingtomarryhim,buthediedduringthe
war."

12.REFLECTING...directingbacktothepatientquestions,feelings,
andideas.
Patient:"DoyouthinkIshouldtellthedoctor...?"
Nurse:"Doyouthinkyoushould?"
Patient:"Mybrotherspendsallmymoneyandthenhasthenerve
toaskformore:
Nurse:"Thiscausesyoutofeelangry."

13.FOCUSING...concentratingonasinglepoint.
"Thispointseemsworthlookingatmoreclosely.
14. EXPLORING...delvingfurtherintoasubjectoridea.

"Tellmemoreaboutthat."
"Wouldyoudescribeitmorefully?"
"Whatkindofwork?"

15.GIVING INFORMATION...makingavailablethefactsthepatient

needs.

"Mynameis..."
"Visitinghoursare..."
"Mypurposeinbeinghereis..."
"I'mtakingyoutothe..."

16.SEEKING CLARIFICATION...seekingtomakeclearthat
whichisnotmeaningfulorthatwhichisvague.

"I'mnotsurethatIfollow."
"Whatwouldyousayisthemainpointofwhatyousaid?

17.PRESENTING REALITY...offeringforconsiderationthatwhich
isreal.
"Iseenooneelseintheroom."
"Thatsoundwasacarbackfiring."
"Yourmotherisnothere;I'manurse."

18. VOICING DOUBT...expressinguncertaintyastotherealityofthe

patient'sperceptions.

"Isn'tthatunusual?"
"Really?"
"That'shardtobelieve.

19.SEEKING VALIDATION...searchingformutualunderstanding,
foraccordinthemeaningofwords.

"Tellmewhethermyunderstandingofitagreeswithyours."
"Areyouusingthiswordtoconveytheidea...?"

20.VERBALIZING THE IMPLIED...voicingwhatthepatienthas

hintedatorsuggested.

Patient.Ican'ttalktoyouortoanyone.It'sawasteoftime.
Nurse.Isityourfeelingthatnooneunderstands?
Patient.Mywifepushedmearoundjustlikemymotherandsister

did.
Nurse.Isityourimpressionthatwomenaredomineering?

21.ENCOURAGING EVALUATION...askingthepatienttoappraise
thequalityofhisexperiences.
"Whatareyourfeelingsinregardto...?"
"Doesthiscontributetoyourdiscomfort?
22.ATTEMPTING TO TRANSLATE INTO FEELINGS...seeking
toverbalizethefeelingsthatarebeingexpressedonlyindirectly.

Patient."I'mdead."
Nurse."Areyousuggestingthatyoufeellifeless?"or"Isitthat
lifeseemswithoutmeaning?"
Patient."I'mwayoutintheocean."
Nurse."Itmustbelonely."or"Youseemtofeeldeserted."

23.SUGGESTING COLLABORATION...offeringtoshare,tostrive,

toworktogetherwiththepatientforhisbenefit.
"PerhapsyouandIcandiscussanddiscoverwhatproducesyour
anxiety.
24.SUMMARIZING...organizingandsummingupthatwhichhas
gonebefore.

"HaveIgotthisstraight?"
"You'vesaidthat..."
"DuringthepasthouryouandIhavediscussed..."

Verbal Communication Skills (contd)

Interpreting signals or cues are verbal or
nonverbal messages that signal key words
or issues for the client
Finding cues is a function of active
listening
o Covert cues
o Metaphors
o Proverbs
o Clichs

Nonverbal Communication Skills

Facial expression
Body language
Vocal cues
Eye contact
Silence

Listening to the patient

S-sit squarely facing the client
O-observe an open posture
L-lean forward toward the client
E-establish eye contact
R-relax

Understanding the Meaning of

Communication
Messages often contain more
meaning than just the spoken
words
The nurse must try to discover all
the meaning in the clients
communication, not only the literal
meaning of the words

Understanding Context

Understanding the context of a

situation gives the nurse more
information and reduces the risk of
assumptions
To clarify context, the nurse must
gather information from verbal and
nonverbal sources and validate
findings with the client

Understanding Spirituality

Spirituality is a clients belief about life, health,

illness, death, and ones relationship to the universe
The nurse must first assess his or her own spiritual
beliefs
The nurse must remain objective and nonjudgmental
regarding the clients beliefs and must not allow
them to alter nursing care
The nurse must assess the clients spiritual needs
and guard against imposing his or her own on the
client

Cultural Considerations

The nurse must be aware of cultural

differences in:
Speech patterns and habits
Styles of speech and expression
Eye contact
Touch
Concept of time
Health and health care

Goals of a Therapeutic Communication

Session
Establishing rapport
Identifying issues of concern
Being empathetic, genuine, caring, and
unconditionally accepting of the person
Understanding the clients perception
Exploring the clients thoughts and feelings
Developing problem-solving skills
Promoting the clients evaluation of solutions

Beginning Therapeutic Communication

Introduce and establish a contract (to outline
the care being provided and the parameters
of the relationship)
Find client-centered goals (to maintain the
focus on the client and provide parameters
for evaluation of effectiveness)
Use directive or nondirective role
appropriately, based on client behaviors

Beginning Therapeutic Communication

(contd)
Phrase questions appropriately
Ask for clarification
Manage clients avoidance of the anxietyproducing topic
Guide the client in problem-solving and
empower the client to change

Community-Based Care

Nurses are increasingly caring for patients in

the family unit and in communities
Nurses need increased self-awareness and
knowledge about cultural differences
Nurses need self-awareness and sensitivity to
the beliefs, behaviors, and feelings of others
Nurses must collaborate with the client and
family as well as other healthcare providers

Self-Awareness Issues

Nonverbal communication is as
important as verbal
Ask colleagues for feedback
Examine your communication skills