Therapeutic Therapeutic CommunicationCommunication

Learning ObjectivesLearning Objectives

1.1. Describe the goals of therapeutic Describe the goals of therapeutic communication.communication.

2.2. Identify therapeutic and nontherapeutic verbal Identify therapeutic and nontherapeutic verbal communication skills.communication skills.

3.3. Discuss nonverbal communication skills such as Discuss nonverbal communication skills such as facial expression, body language, vocal cues, facial expression, body language, vocal cues, eye contact and understanding of levels of eye contact and understanding of levels of meaning and context.meaning and context.

4.4. Discuss boundaries in therapeutic Discuss boundaries in therapeutic communication with respect to distance and communication with respect to distance and touch.touch.

5.5. Given a hypothetical situation, select an Given a hypothetical situation, select an effective therapeutic response to the client.effective therapeutic response to the client.

ProxemicsProxemics

Public zonePublic zone

ReligionReligion

Social zoneSocial zone

SpiritualitySpirituality

Therapeutic communicationTherapeutic communication

Verbal communicationVerbal communication

CommunicationCommunication

Process that people use to exchange Process that people use to exchange communication.communication.

Sent and received on two levels:Sent and received on two levels:

Verbally - use of wordsVerbally - use of words

Nonverbally – by behaviors that Nonverbally – by behaviors that accompany the wordsaccompany the words

Verbal communicationVerbal communication

consists of the words a person uses to speak consists of the words a person uses to speak to one or more listeners.to one or more listeners.

Content – the literal words the person speaks.Content – the literal words the person speaks.

Context – environment in which Context – environment in which communication occurs. Can include the time, communication occurs. Can include the time, physical, social, emotional, and cultural physical, social, emotional, and cultural environments. Includes the circumstances or environments. Includes the circumstances or parts that clarify the meaning of the content parts that clarify the meaning of the content of the message.of the message.

Nonverbal communicationNonverbal communication

behavior that accompanies verbal content behavior that accompanies verbal content (i.e. body language, eye contact, facial (i.e. body language, eye contact, facial expression, tone of voice, speed and expression, tone of voice, speed and hesitations in speech, grunts and groans, hesitations in speech, grunts and groans, and distance from the listener(s).and distance from the listener(s).

indicates speaker’s thoughts, feelings, indicates speaker’s thoughts, feelings, needs, and values – acted unconsciouslyneeds, and values – acted unconsciously

ProcessProcess

denotes all non verbal messages that denotes all non verbal messages that the speaker uses to give meaning and the speaker uses to give meaning and context to the message.context to the message.requires the listener(s) to observe the requires the listener(s) to observe the behaviors and sounds that accent the behaviors and sounds that accent the words.words.to interpret the speaker’s nonverbal to interpret the speaker’s nonverbal behaviors to assess whether they agree behaviors to assess whether they agree or disagree with the verbal content.or disagree with the verbal content.

Congruent messageCongruent message

when content and process agreewhen content and process agree

i.e. “ Alam ko wala ako sa i.e. “ Alam ko wala ako sa sarili….kailangan ko ng tulong” (with sad sarili….kailangan ko ng tulong” (with sad facial expression + genuine, sincere tone facial expression + genuine, sincere tone of voice)of voice)

Incongruent messageIncongruent message

when content and process disagreewhen content and process disagree

i.e. “Naghahanap ako ng tulong” i.e. “Naghahanap ako ng tulong” (with clenched fists, rigid posture, (with clenched fists, rigid posture, agitated, frowning facial expression)agitated, frowning facial expression)

Nonverbal process represents a more Nonverbal process represents a more accurate message than does verbal accurate message than does verbal content.content.

What is therapeutic communication?What is therapeutic communication?

an interpersonal interaction between the nurse an interpersonal interaction between the nurse and client during which the nurse focuses on the and client during which the nurse focuses on the client’s specific needs to promote an effective client’s specific needs to promote an effective exchange of information.exchange of information.

Skilled use of therapeutic communication Skilled use of therapeutic communication techniques helps the nurse understand and techniques helps the nurse understand and empathize with the client’s experience.empathize with the client’s experience.

All nurses need skills in therapeutic All nurses need skills in therapeutic communication to effectively apply the nursing communication to effectively apply the nursing process and to meet standards of care for their process and to meet standards of care for their clients.clients.

Goals of Therapeutic communicationGoals of Therapeutic communicationEstablish a therapeutic nurse-client relationship.Establish a therapeutic nurse-client relationship.

Identify the most important client concern at that moment Identify the most important client concern at that moment (client-centered goal)(client-centered goal)

Asses the client’s perception of the problem as it unfolds. Asses the client’s perception of the problem as it unfolds. Includes detailed actions (behaviors and messages) of the Includes detailed actions (behaviors and messages) of the people involved and the client’s thoughts and feelings people involved and the client’s thoughts and feelings about the situation, others, and self.about the situation, others, and self.

Facilitate the clients expression of emotions.Facilitate the clients expression of emotions.

Teach the client and family necessary self-care skills.Teach the client and family necessary self-care skills.

Recognize the client’s needs.Recognize the client’s needs.

Implement interventions designed to address the client’s Implement interventions designed to address the client’s needs.needs.

Guide the client toward identifying a plan of action to a Guide the client toward identifying a plan of action to a satisfying and socially acceptable resolution.satisfying and socially acceptable resolution.

CommunicationCommunication

InitiateInitiate

MaintainMaintain

TerminateTerminate

Privacy and Respecting Privacy and Respecting BoundariesBoundaries

Desirable but not always possible.Desirable but not always possible.Ideal settings:Ideal settings:conference room conference room interview roominterview room

end of the hallend of the hallquiet corner of the day room or lobbyquiet corner of the day room or lobby need of formal setting if the setting need of formal setting if the setting is nontherapeutic to maintain is nontherapeutic to maintain boundaries.boundaries.

ProxemicsProxemics

Study of the distance zones between people Study of the distance zones between people during communication.during communication. communicating with familiar people is communicating with familiar people is

more comfortable with smaller distances more comfortable with smaller distances (Devito, 2004)(Devito, 2004)

Four distance zones observed in the US, Four distance zones observed in the US, Canada, and Eastern European nations:Canada, and Eastern European nations:

Intimate zone Intimate zone • (0 to 18 inches between people)(0 to 18 inches between people)• For parents with young childrenFor parents with young children• Mutually desire personal contactMutually desire personal contact• People whisperingPeople whispering• Threatening and produces anxiety when not observed.Threatening and produces anxiety when not observed.

Personal zonePersonal zone• (18 to 36 inches)(18 to 36 inches)• For family and friends who are talking.For family and friends who are talking.

Social zoneSocial zone• (4 to 12 feet)(4 to 12 feet)• Acceptable for communication in social, work, and Acceptable for communication in social, work, and

business settings.business settings.

Public zonePublic zone• (12 to 25 feet)(12 to 25 feet)• Acceptable between a speaker and an Acceptable between a speaker and an

audience, small groups, and other informal audience, small groups, and other informal functions.functions.

when the nurse must invade the when the nurse must invade the intimate or personal zone of the intimate or personal zone of the client, the nurse should always ask client, the nurse should always ask for the client’s permission. for the client’s permission.

Answerable in a yes or no format. Answerable in a yes or no format. (acceptable at this time only)(acceptable at this time only)

The therapeutic communication The therapeutic communication interaction is most comfortable when the interaction is most comfortable when the nurse and client are 3 to 6 feet apart.nurse and client are 3 to 6 feet apart.

Set limits gradually once the patient Set limits gradually once the patient invades the nurse’s intimate space.invades the nurse’s intimate space.

TouchTouch↑ ↑ intimacy ↓ need for distanceintimacy ↓ need for distance 5 types:5 types:

• Functional professional touch – for Functional professional touch – for examination or proceduresexamination or procedures

• Social-polite touch – for greeting or Social-polite touch – for greeting or guiding someone to the correct directionguiding someone to the correct direction

• Friendship warmth touch – hug in greeting Friendship warmth touch – hug in greeting with arm around shoulder; back slappingwith arm around shoulder; back slapping

• Love-intimacy touch – tight hugs and Love-intimacy touch – tight hugs and kisses between lovers and relativeskisses between lovers and relatives

• Sexual-arousal touch – used by loversSexual-arousal touch – used by lovers

Knapp (1980)Knapp (1980)

Touching is comforting and supportive Touching is comforting and supportive when it is welcome and permitted.when it is welcome and permitted.

Observe for cues if touch is desired or Observe for cues if touch is desired or indicated.indicated.

Touch can be comforting and therapeutic Touch can be comforting and therapeutic but can be invading the intimate and but can be invading the intimate and personal space.personal space.

A client with paranoia may interpret being A client with paranoia may interpret being touched as a threat and may attempt to touched as a threat and may attempt to protect himself by striking the staff protect himself by striking the staff person.person.

Active Listening and Active Listening and ObservationObservation

Active listening – refraining from Active listening – refraining from other internal mental activities and other internal mental activities and concentrating exclusively on what concentrating exclusively on what the client says.the client says.

Active observation – watching the Active observation – watching the speaker’s nonverbal actions as he or speaker’s nonverbal actions as he or she communicates.she communicates.

Recognize the issue that is most important Recognize the issue that is most important to the client at this time.to the client at this time.

Know what further questions to ask the Know what further questions to ask the client.client.

Use additional therapeutic communication Use additional therapeutic communication techniques to guide the client to describe techniques to guide the client to describe his or her perceptions fully.his or her perceptions fully.

Understand the client’s perceptions of the Understand the client’s perceptions of the issue instead of jumping to conclusions.issue instead of jumping to conclusions.

Interpret and respond to the message Interpret and respond to the message objectively.objectively.

Think ahead – be ready with Think ahead – be ready with questionsquestions

Ask specific questions.Ask specific questions.

Develop empathy with the client Develop empathy with the client (ability to place oneself into the (ability to place oneself into the experience of another for a moment experience of another for a moment in time).in time).

Gather as much issue as possibleGather as much issue as possible

Verbal Communication SkillsVerbal Communication Skills

Using concrete messages Using concrete messages – – use clear, direct, and easy to understand use clear, direct, and easy to understand words especially when communicating to words especially when communicating to anxious people to prevent loss of cognitive anxious people to prevent loss of cognitive processing skills (↑ anxiety = ↓ ability to processing skills (↑ anxiety = ↓ ability to process) process) - avoid rephrasing- avoid rephrasing““When was the last time you took you When was the last time you took you antidepressant medications?”antidepressant medications?”

Abstract messagesAbstract messages• unclear pattern of wordsunclear pattern of words• Contains figures of speechContains figures of speech• Requires listener to interpret what the Requires listener to interpret what the

speaker is askingspeaker is asking

““How did you get here?”How did you get here?”

Abstract (unclear)Abstract (unclear)

““Your clinical performance has to Your clinical performance has to improve.”improve.”

““Get the stuff from him.”Get the stuff from him.”

Concrete (clear)Concrete (clear)

““John will be home today at 5pm, and you John will be home today at 5pm, and you can pick up your clothes at that time.”can pick up your clothes at that time.”

““To administer medications tomorrow, To administer medications tomorrow, you’ll have to be able to calculate dosages you’ll have to be able to calculate dosages correctly by the end of today’s class.”correctly by the end of today’s class.”

Using Therapeutic Communication Using Therapeutic Communication TechniquesTechniques

Choice of technique depends on the intent Choice of technique depends on the intent of the interaction and client’s ability to of the interaction and client’s ability to communicate verbally.communicate verbally.Techniques such as exploring, focusing, Techniques such as exploring, focusing, restating, and reflecting encourage the restating, and reflecting encourage the client to discuss one’s feelings or concerns client to discuss one’s feelings or concerns in more depth. in more depth. Nontherapeutic techniques cut off Nontherapeutic techniques cut off communication (i.e. agreeing, advising, communication (i.e. agreeing, advising, reassuring).reassuring).

Therapeutic Communication Therapeutic Communication TechniquesTechniques

Accepting - indicating reception “Yes”Accepting - indicating reception “Yes”

“ “I follow what you said”I follow what you said”

NoddingNodding

Broad openings “Is there something you’d like to Broad openings “Is there something you’d like to - Allowing the client to take talk about?”Allowing the client to take talk about?”

the initiative in introducing the “Where would you like to begin?” the initiative in introducing the “Where would you like to begin?”

topictopic

Consensual Validation “Tell me whether my understanding Consensual Validation “Tell me whether my understanding

- Searching for mutual of it agrees with yours.”- Searching for mutual of it agrees with yours.”

understanding, for accord “Are you using this word to convey understanding, for accord “Are you using this word to convey

in the meaning of the words that…?” in the meaning of the words that…?”

Encouraging Comparison “ Was it something like….?”Encouraging Comparison “ Was it something like….?”- Asking that similarities and “Have you had similar - Asking that similarities and “Have you had similar

experiences?”experiences?”differences be noted differences be noted

Encouraging description of “Tell me when you feel anxious.Encouraging description of “Tell me when you feel anxious.perceptions - asking the client “What is happening?”perceptions - asking the client “What is happening?”to verbalize what he or she perceives “What does the voice seem to to verbalize what he or she perceives “What does the voice seem to

be be saying?”saying?”

Encouraging expression “What are your feelings in Encouraging expression “What are your feelings in regard regard

- Asking the client to appraise his to….?”- Asking the client to appraise his to….?”or her experiences “Does this contribute to your or her experiences “Does this contribute to your distress?”distress?”

Exploring – delving further into a “Tell me more about that.”Exploring – delving further into a “Tell me more about that.”subject or idea “Would you describe it more subject or idea “Would you describe it more

fully.”fully.” “ “What kind of work?”What kind of work?”

Focusing – concentrating on a single “This point seems worth looking at Focusing – concentrating on a single “This point seems worth looking at

point more closely.”point more closely.”

“ “Of all the concerns you’ve Of all the concerns you’ve

mentioned which is the most mentioned which is the most

troublesome?”troublesome?”

Formulating a plan of action “What could you do to let your anger Formulating a plan of action “What could you do to let your anger

- Asking the client to consider out harmlessly?”- Asking the client to consider out harmlessly?”

kinds of behavior likely to be “Next time this comes up, whatkinds of behavior likely to be “Next time this comes up, what

appropriate in future situations might you do to handle it?”appropriate in future situations might you do to handle it?”

General leads – giving encouragement “Go on.General leads – giving encouragement “Go on.

to continue” “And then?”to continue” “And then?”

“ “Tell me about it.”Tell me about it.”

Giving information – making available “My name is…”Giving information – making available “My name is…”

the facts that the client needs “Visiting hours are…”the facts that the client needs “Visiting hours are…”

“ “My purpose in being here is…”My purpose in being here is…”

Giving recognition – acknowledging, “Good morning, Mr. …”Giving recognition – acknowledging, “Good morning, Mr. …”

indicating awareness “You’ve finished your list of indicating awareness “You’ve finished your list of things to things to

do.”do.”

“ “I notice that you’ve combed your I notice that you’ve combed your

hair.”hair.”

Making observations – verbalizing what “You appear tense.”Making observations – verbalizing what “You appear tense.”

the nurse perceives “Are you uncomfortable when…?”the nurse perceives “Are you uncomfortable when…?”

“ “I notice you are biting you lip.”I notice you are biting you lip.”

Offering self – making oneself available “I’ll sit with you awhile.”Offering self – making oneself available “I’ll sit with you awhile.”

“ “I’ll stay here with you.”I’ll stay here with you.”

“ “I’m interested in what you think.”I’m interested in what you think.”

Placing event in time or sequence “What seemed to lad up to…?”Placing event in time or sequence “What seemed to lad up to…?”- Clarifying the relationship events in “Was this before or after?”- Clarifying the relationship events in “Was this before or after?”time “When did this happen?”time “When did this happen?”

Presenting reality – offering for “I see no one else in the room.”Presenting reality – offering for “I see no one else in the room.”consideration that which is real “That sound was a car backfiring.”consideration that which is real “That sound was a car backfiring.” “ “Your mother is not here, I am a Your mother is not here, I am a nurse.”nurse.”

Reflecting – directing client actions, Patient: “Do you think I should tellReflecting – directing client actions, Patient: “Do you think I should tellthoughts and feelings back to the client the doctor?”thoughts and feelings back to the client the doctor?” Nurse: “Do you think you should?’Nurse: “Do you think you should?’ Patient: “My brother spends all my Patient: “My brother spends all my money and then has the money and then has the nerve to ask for more.”nerve to ask for more.” Nurse: “this causes you to feel Nurse: “this causes you to feel angry?”angry?”

Restating – repeating the main idea Pt.: “I can’t sleep. I stay awake allRestating – repeating the main idea Pt.: “I can’t sleep. I stay awake all

expressed night.”expressed night.”

Nurse: “You have difficulty sleeping.”Nurse: “You have difficulty sleeping.”

Client: I’m really mad, I’m really Client: I’m really mad, I’m really

upset.”upset.”

Nurse: “You’re really mad and upset.”Nurse: “You’re really mad and upset.”

Seeking information – seeking to “I’m not sure that I follow.”Seeking information – seeking to “I’m not sure that I follow.”

make clear that which is not “Have I heard you correctly?’make clear that which is not “Have I heard you correctly?’

meaningful or that which is vaguemeaningful or that which is vague

Silence – absence of verbal Nurse says nothing but continues toSilence – absence of verbal Nurse says nothing but continues to

communication, which provides maintain eye contact and conveys communication, which provides maintain eye contact and conveys

time for the client to put thoughts interest.time for the client to put thoughts interest.

or feelings into words, to regain or feelings into words, to regain

composure, or to continue talkingcomposure, or to continue talking

Suggesting collaboration – offering to “Perhaps you and I can discuss andSuggesting collaboration – offering to “Perhaps you and I can discuss and

share, to strive, to work with the discover the triggers for your clientshare, to strive, to work with the discover the triggers for your client

for his or her own benefit. anxiety.”for his or her own benefit. anxiety.”

Summarizing – organizing and summing “Have I got this straight?”Summarizing – organizing and summing “Have I got this straight?”

up that which has gone before “You’ve said that..?”up that which has gone before “You’ve said that..?”

“ “During the pat hour, you and I have During the pat hour, you and I have

discussed…”discussed…”

Translating into feelings – seeking Client: ”I’m dead.”Translating into feelings – seeking Client: ”I’m dead.”

To verbalize client’s feelings that Nurse: “Are you suggesting that youTo verbalize client’s feelings that Nurse: “Are you suggesting that you

he or she expresses only indirectly feel lifeless?”he or she expresses only indirectly feel lifeless?”

Client: “I’m way out in the ocean.”Client: “I’m way out in the ocean.”

Nurse: “You seem to feel lonely and Nurse: “You seem to feel lonely and

deserted.”deserted.”

Verbalizing the implied – voicing what Pt.: “I can’t talk to you or Verbalizing the implied – voicing what Pt.: “I can’t talk to you or anyone. It’sanyone. It’s

the client has hinted at or suggested. a waste of time.”the client has hinted at or suggested. a waste of time.”

Nurse: Do you feel that no Nurse: Do you feel that no one one

understands?” understands?”

Voicing doubt – expressing uncertainty “Isn’t that unusual?”Voicing doubt – expressing uncertainty “Isn’t that unusual?”

about the reality of the client’s “Really? about the reality of the client’s “Really?

perception “That’s hard to believe.”perception “That’s hard to believe.”

Non-therapeutic Communication Non-therapeutic Communication

TechniquesTechniques Advising – telling the client what to do “I think you should…”Advising – telling the client what to do “I think you should…” “ “Why don’t you…”Why don’t you…”

Agreeing – indicating accord with the “That’s right.”Agreeing – indicating accord with the “That’s right.”client “I agree.”client “I agree.”

Belittling feelings expressed Pt.: “I have nothing to live for…I Belittling feelings expressed Pt.: “I have nothing to live for…I - Misjudging the degree of the client’s wish I was dead.”- Misjudging the degree of the client’s wish I was dead.”discomfort Nurse: “Everybody gets down in discomfort Nurse: “Everybody gets down in

the the dumps.” or “I’ve felt that way dumps.” or “I’ve felt that way myself.”myself.”Challenging – demanding proof from “But how can you be president Challenging – demanding proof from “But how can you be president

of theof thethe client United states?”the client United states?” “ “if you’re dead, why is your heart if you’re dead, why is your heart beating?”beating?”

Defending – attempting to protect “This hospital has a fine reputation.Defending – attempting to protect “This hospital has a fine reputation.someone or something from verbal “ “I’m sure your doctor has your bestsomeone or something from verbal “ “I’m sure your doctor has your bestattack interests in mind.”attack interests in mind.”

Disagreeing – opposing the client’s “That’s wrong.”Disagreeing – opposing the client’s “That’s wrong.”Ideas “I definitely disagree with…”Ideas “I definitely disagree with…” “ “ I don’t believe that.”I don’t believe that.”

Disapproving – denouncing the client’s “That’s bad.” Disapproving – denouncing the client’s “That’s bad.” behavior or ideas “I’d rather you wouldn’t…”behavior or ideas “I’d rather you wouldn’t…”

Giving approval – sanctioning the pt.’s “That’s good.”Giving approval – sanctioning the pt.’s “That’s good.”behavior or ideas “I’m glad that…”behavior or ideas “I’m glad that…”

Giving literal responses – responding Pt. : “They are looking in my head to aGiving literal responses – responding Pt. : “They are looking in my head to afigurative comment as though it a television camera.”figurative comment as though it a television camera.”were a statement of fact Nurse: “Try not to watch television” were a statement of fact Nurse: “Try not to watch television” or “What channel?”or “What channel?”

Indicating the existence of an external “what makes you say that?”Indicating the existence of an external “what makes you say that?”source – attributing the source of “What made you do that?”source – attributing the source of “What made you do that?”thoughts, feelings, and behavior to “Who told you that you were a thoughts, feelings, and behavior to “Who told you that you were a others or to outside influences prophet?”others or to outside influences prophet?”

Interpreting – asking to make “What you really mean is?”Interpreting – asking to make “What you really mean is?”conscious that which is unconscious; “Unconsciously you’re saying…”conscious that which is unconscious; “Unconsciously you’re saying…”telling the client the meaning of his or telling the client the meaning of his or her experienceher experience

Introducing an unrelated topic Pt.: “I’d like to die.”Introducing an unrelated topic Pt.: “I’d like to die.”– – changing the subject Nurse: “Did you have visitors last changing the subject Nurse: “Did you have visitors last evening?”evening?”

Making stereotyped comments “Its for your own good.”Making stereotyped comments “Its for your own good.”- Offering meaningless cliches or “Keep your chin up.”- Offering meaningless cliches or “Keep your chin up.”trite comments “Just have a positive attitude trite comments “Just have a positive attitude

and you’ll and you’ll be better in no time.”be better in no time.”

Probing – persistent questioning of the “Now tell me about this Probing – persistent questioning of the “Now tell me about this problem.problem.

client You know I have to find out.”client You know I have to find out.”

“ “Tell me your psychiatric Tell me your psychiatric history.”history.”

Reassuring – indicating there is no “I wouldn’t worry about that.”Reassuring – indicating there is no “I wouldn’t worry about that.”

reason for anxiety or other feelings of “Everything will be alright.”reason for anxiety or other feelings of “Everything will be alright.”

discomfort “You’re coming along just discomfort “You’re coming along just fine.”fine.”

Rejecting – refusing to consider or “Let’s not discuss…”Rejecting – refusing to consider or “Let’s not discuss…”

Showing contempt for the client’s “I don’t want to hear about.”Showing contempt for the client’s “I don’t want to hear about.”

Ideas or behaviorsIdeas or behaviors

Requesting an explanation – asking “Why do you think that?”Requesting an explanation – asking “Why do you think that?”

the client to provide reasons for “Why do you feel that way?”the client to provide reasons for “Why do you feel that way?”

thoughts, feelings, behaviors, eventsthoughts, feelings, behaviors, events

Testing – appraising the client’s “Do you know what kind Testing – appraising the client’s “Do you know what kind hospitalhospital

degree of insight this is.”degree of insight this is.”

“ “Do you still have the idea Do you still have the idea that…?”that…?”

Using denial – refusing to admit that a Pt.: “I’m nothing.”Using denial – refusing to admit that a Pt.: “I’m nothing.”

problem exists Nurse: “Of course you’re problem exists Nurse: “Of course you’re something something

---everbody’s ---everbody’s something.” something.”

Pt. “I’m dead.”Pt. “I’m dead.”

Nurse: “Don’t be silly.”Nurse: “Don’t be silly.”

Interpreting Signals or CuesInterpreting Signals or Cues

Cues are verbal or nonverbal messages Cues are verbal or nonverbal messages that signal key words or issues for the that signal key words or issues for the client.client.

Nurse watches and listens carefully.Nurse watches and listens carefully.

Client: “I had a boyfriend when I was Client: “I had a boyfriend when I was

younger.”younger.”

Nurse:Nurse:ReflectingReflecting

““You had a boyfriend?You had a boyfriend?

Encouraging descriptionEncouraging description““Tell me about you and your boyfriend.”Tell me about you and your boyfriend.”

Placing events in time or sequencePlacing events in time or sequence““How old were you when you had this How old were you when you had this boyfriend?”boyfriend?”

Theme of sadnessTheme of sadness

Client: “Oh, hi nurse.” (face is sad; eyes look Client: “Oh, hi nurse.” (face is sad; eyes look teary; voice is low, with little inflection)teary; voice is low, with little inflection)

Nurse:Nurse:

““You seem sad today, Mr. Goodbar.”You seem sad today, Mr. Goodbar.”

Client:Client:

““Yes, it is the Yes, it is the anniversaryanniversary of my of my husband’s husband’s deathdeath.”.”

Nurse: Nurse:

““How long ago did your husband die?”How long ago did your husband die?”

““Tell me about your husband’s death, Mr. Tell me about your husband’s death, Mr. Goodbar.”Goodbar.”

Client:Client:

““Life is so hard. I want it to be done. There Life is so hard. I want it to be done. There is no rest. Sleep, sleep is good…..forever.”is no rest. Sleep, sleep is good…..forever.”

Nurse: “I hear you saying things seem Nurse: “I hear you saying things seem hopeless. I wonder if you are planning to hopeless. I wonder if you are planning to kill yourself.”kill yourself.”

Use of figures of speechUse of figures of speech

Client: Client:

““My son’s bedroom looks like a bomb went off.”My son’s bedroom looks like a bomb went off.”

Nurse:Nurse:

““You’re saying your son is not very neat.”You’re saying your son is not very neat.”

Client:Client:

““My mind is like mashed potatoes.”My mind is like mashed potatoes.”

Nurse: Nurse:

““I sense you find it difficult to put thoughts I sense you find it difficult to put thoughts together.”together.”

Client:Client:

““She has more guts than brains.”She has more guts than brains.”

Nurse:Nurse:

““Give me one example of how you see Give me one example of how you see Mary as having more guts than brains.” Mary as having more guts than brains.” (focusing)(focusing)

Nonverbal Communication SkillsNonverbal Communication Skills

A behavior that a person exhibits while A behavior that a person exhibits while delivering verbal content.delivering verbal content.• facial expressionfacial expression• Eye contactEye contact• Space Space • TimeTime• BoundariesBoundaries• Body movementsBody movements

One third is transmitted by words and two One third is transmitted by words and two thirds is communicated nonverbally.thirds is communicated nonverbally.

Conveys the speaker’s actual meaning.Conveys the speaker’s actual meaning.

Involves the unconscious mind acting out Involves the unconscious mind acting out emotions related to the verbal content, the emotions related to the verbal content, the situation, the environment, and the situation, the environment, and the relationship between the speaker and the relationship between the speaker and the listener.listener.

Ways in which nonverbal messages accompany verbal Ways in which nonverbal messages accompany verbal messages:messages:• Accent: using flashing eyes or hand movementsAccent: using flashing eyes or hand movements• Complement: giving quizzical looks, noddingComplement: giving quizzical looks, nodding• Contradict: rolling eyes to demonstrate that the Contradict: rolling eyes to demonstrate that the

meaning is the opposite of what one is saying.meaning is the opposite of what one is saying.• Regulate: taking a deep breath to demonstrate Regulate: taking a deep breath to demonstrate

readiness to speak, using “and uh” to signal the readiness to speak, using “and uh” to signal the wish to continue speakingwish to continue speaking

• Repeat: using nonverbal behaviors to augment the Repeat: using nonverbal behaviors to augment the verbal message such as shrugging after saying verbal message such as shrugging after saying “Who knows?”“Who knows?”

• Substitute: using culturally determined body Substitute: using culturally determined body movements that stand in for words such as pumping movements that stand in for words such as pumping the arm up and down with a closed fist to indicate the arm up and down with a closed fist to indicate success.success.

Facial ExpressionFacial ExpressionFacial movements connects with words to Facial movements connects with words to illustrate meaning; this connection demonstrates illustrate meaning; this connection demonstrates the speaker’s internal dialogue (Greene & the speaker’s internal dialogue (Greene & Burleson, 2003)Burleson, 2003)Categories of Facial Expression:Categories of Facial Expression:• An expressive face portrays the person’s An expressive face portrays the person’s

moment by moment thoughts, feelings, and moment by moment thoughts, feelings, and needs. needs.

• An impassive face is frozen into an emotionless An impassive face is frozen into an emotionless deadpan expression similar to a mask.deadpan expression similar to a mask.

• A confusing facial expression is one that is the A confusing facial expression is one that is the opposite of what the person wants to convey. opposite of what the person wants to convey.

Common facial communication signalsCommon facial communication signals• FrownsFrowns• SmilesSmiles• PuzzlementPuzzlement• ReliefRelief• FearFear• SurpriseSurprise• AngerAnger

Body LanguageBody Language

Gestures, postures, movements, and body Gestures, postures, movements, and body positionpositionNonverbal form of communicationNonverbal form of communicationClosed body positionsClosed body positionsdefensive = crossed legs, arms folded defensive = crossed legs, arms folded across the chestacross the chestOpen body position = both feet on the Open body position = both feet on the floor, knees parallel, hands at the side of floor, knees parallel, hands at the side of the body, legs uncrossed or crossed only the body, legs uncrossed or crossed only at anklesat anklesdemonstrates unconditional positive demonstrates unconditional positive regard, trust, care and acceptanceregard, trust, care and acceptance

Vocal CuesVocal CuesNonverbal sound signals which are transmited along with Nonverbal sound signals which are transmited along with the content.the content.Volume – loudness of the voiceVolume – loudness of the voice- can indicate anger, fear, happiness, or deafness- can indicate anger, fear, happiness, or deafnessTone – indicates when someone is relaxed agitated or Tone – indicates when someone is relaxed agitated or boredboredPitch – from shrill and high to low and threateningPitch – from shrill and high to low and threateningIntensity - power, severity and strength behind the words. Intensity - power, severity and strength behind the words. Indicates importance of the message.Indicates importance of the message.Emphasis – refers to accents on words or phrases that Emphasis – refers to accents on words or phrases that highlight the subject or give insight on the topic.highlight the subject or give insight on the topic.Speed – number of words spoken per minute.Speed – number of words spoken per minute.Pauses – adds emphasis or feeling.Pauses – adds emphasis or feeling.

High- pitched = anxietyHigh- pitched = anxiety

Circumstantiality – use of extraneous Circumstantiality – use of extraneous words with long tedious descriptions. words with long tedious descriptions. Indicates client is confused about what is Indicates client is confused about what is important or a poor historian.important or a poor historian.

Slow, hesitant responses = depressed, Slow, hesitant responses = depressed, confused and searching for correct words, confused and searching for correct words, having difficulty finding the right words to having difficulty finding the right words to describe an incident, or reminiscingdescribe an incident, or reminiscing

Eye contactEye contact

Mirror of the soul = Reflect our Mirror of the soul = Reflect our emotionsemotions

Used to assess the other person and Used to assess the other person and the environment and to indicate the environment and to indicate whose turn to speak.whose turn to speak.

Maintain good eye contact. Don’t Maintain good eye contact. Don’t stare at the client.stare at the client.

SilenceSilence

As long pauses.As long pauses.

Indicates lack of energy to talk, Indicates lack of energy to talk, depressed, lost in one’s thought, depressed, lost in one’s thought, inattentioninattention

Allow sufficient time to respondAllow sufficient time to respond

Don’t jump in or restate questionDon’t jump in or restate question

Understanding the meaning of Understanding the meaning of communicationcommunication

““I’m so tired that I just can’t go on.” I’m so tired that I just can’t go on.”

Client wishes to die.Client wishes to die.

Further assess the client’s statement Further assess the client’s statement whether the client is suicidal.whether the client is suicidal.

People who appear strong and dominating People who appear strong and dominating and often manipulate and criticize others = and often manipulate and criticize others = low self-esteem and feel insecurelow self-esteem and feel insecure

Insecurity and low self esteem translates Insecurity and low self esteem translates into jealousy and mistrust of others and into jealousy and mistrust of others and attempts to feel more important and strong attempts to feel more important and strong by dominating or criticizing other people.by dominating or criticizing other people.

Understanding contextUnderstanding context

Gather informationGather informationFocus on Focus on who was therewho was therewhat happenedwhat happenedwhen it occurredwhen it occurredhow the event progressedhow the event progressedwhy the client believes it happened as it why the client believes it happened as it diddid

Example:Example:

““I collapsed.”I collapsed.”

Seek clarification (What do you mean….)Seek clarification (What do you mean….)

Placing events in time and sequence Placing events in time and sequence (Describe where you were and what you (Describe where you were and what you were doing….)were doing….)

Understanding SpiritualityUnderstanding Spirituality

Client’s belief about life, health, illness, Client’s belief about life, health, illness, death, and one’s relationship to the universe.death, and one’s relationship to the universe.

The nurse must remain objective and The nurse must remain objective and nonjudgmental regarding the client’s beliefs nonjudgmental regarding the client’s beliefs and must not allow them to alter the nursing and must not allow them to alter the nursing care. care.

The nurse must not impose one’s belief on The nurse must not impose one’s belief on the client. the client.

Respect client’s religious and spiritual beliefs.Respect client’s religious and spiritual beliefs.

Cultural ConsiderationCultural Consideration

i.e. Greetings (handshake, “hello”, bowing)i.e. Greetings (handshake, “hello”, bowing)Assess clients emotional expressions, Assess clients emotional expressions, beliefs, values, and behaviors; modes of beliefs, values, and behaviors; modes of emotional expression; and views about emotional expression; and views about mental health and illness.mental health and illness.Language barrierLanguage barrierIndividualistic – self reliance and Individualistic – self reliance and independenceindependenceCollectivistic – valuing the group and Collectivistic – valuing the group and observing obligations that enhance the observing obligations that enhance the security of the group. More private and security of the group. More private and guarded whne speaking to non members of guarded whne speaking to non members of the group.the group.

The Therapeutic Communication The Therapeutic Communication SessionSession

GoalsGoalsEstablish rapport with the client by being Establish rapport with the client by being emphathetic, genuine, caring, and unconditionally emphathetic, genuine, caring, and unconditionally accepting of the client regardless of his or her accepting of the client regardless of his or her behavior or beliefs.behavior or beliefs.Actively listen to the client to identify the issues of Actively listen to the client to identify the issues of concern and to formulate a client-centered goal for concern and to formulate a client-centered goal for the interaction.the interaction.Gain an in-depth understanding of the client’s Gain an in-depth understanding of the client’s perception of the issue, and foster empathy in the perception of the issue, and foster empathy in the nurse-client relationship.nurse-client relationship.Explore the client’s thought’s and feelings.Explore the client’s thought’s and feelings.Facilitate the client’s expression of thoughts and Facilitate the client’s expression of thoughts and feelings.feelings.Guide the client to develop new skills in problem Guide the client to develop new skills in problem solving.solving.Promote the client’s evaluation of solutions.Promote the client’s evaluation of solutions.

Beginning Therapeutic Beginning Therapeutic CommunicationCommunication

Plan the time and setting for therapeutic Plan the time and setting for therapeutic communication.communication.Introduce oneself when meeting for the Introduce oneself when meeting for the first time.first time.Establish a contract (outlining the care the Establish a contract (outlining the care the nurse will give, the times the nurse will be nurse will give, the times the nurse will be with the client, and acceptance of these by with the client, and acceptance of these by the client).the client).Ask how client can be addressedAsk how client can be addressed..

Nurse: Nurse:

““Hello, Mr. Doolittle. My name is Florence, Hello, Mr. Doolittle. My name is Florence, and I’ll be your nurse today. I’m here from and I’ll be your nurse today. I’m here from 7 am to 3:30 pm. Right now I have a few 7 am to 3:30 pm. Right now I have a few minutes, and I see you are dressed and minutes, and I see you are dressed and ready for the day. I would like to spend ready for the day. I would like to spend some time talking with you if this is some time talking with you if this is convenient.”convenient.”

Use small talk and get acquainted.Use small talk and get acquainted.

Use broad opening questionsUse broad opening questions

Nurse: “Hello, Mrs. Pitt. My name is Brod. I am your nurse Nurse: “Hello, Mrs. Pitt. My name is Brod. I am your nurse today and tomorrow from 7 am to 3 pm. What do you like today and tomorrow from 7 am to 3 pm. What do you like to be called?”to be called?”

Client: “Hi, Brod. You can call me Shaina.”Client: “Hi, Brod. You can call me Shaina.”

Nurse: The rain today has been a welcome relief from the Nurse: The rain today has been a welcome relief from the heat of the past few days.”heat of the past few days.”

Client: “Really? Its hard to tell what its doing outside. Still Client: “Really? Its hard to tell what its doing outside. Still seems hot in here to me.”seems hot in here to me.”

Nurse: “It does get stuffy here sometimes. So tell me, how Nurse: “It does get stuffy here sometimes. So tell me, how are you doing today?” (broad opening)are you doing today?” (broad opening)

Non-directive RoleNon-directive RoleUse active listening skills to identify Use active listening skills to identify the topic of concern.the topic of concern.

Use non-directive role by using broad Use non-directive role by using broad openings and open ended questions.openings and open ended questions.

Guide client throughout the Guide client throughout the interaction.interaction.

Be an interested listener.Be an interested listener.

Allow client to express feelings and Allow client to express feelings and thoughts.thoughts.

Directive RoleDirective RoleIndicated for suicidal, experiencing a Indicated for suicidal, experiencing a crisis, or is out of touch with reality.crisis, or is out of touch with reality.

Asking direct yes/no questions.Asking direct yes/no questions.

Using problem solving – to develop Using problem solving – to develop coping mechanismscoping mechanisms

How to Phrase QuestionsHow to Phrase Questions

The manner in which the nurse phrases The manner in which the nurse phrases questions is important. questions is important. Open ended questions elicit more Open ended questions elicit more descriptive information; yes/no questions descriptive information; yes/no questions yield just an answer. yield just an answer. The nurse asks different types of questions The nurse asks different types of questions based on the information the nurse wishes based on the information the nurse wishes to obtain. to obtain. The nurse uses active listening to build The nurse uses active listening to build questions based on the cues the client has questions based on the cues the client has given in his or her response. given in his or her response.

““What did you think about……?” (when What did you think about……?” (when discussing cognitive issues)discussing cognitive issues)

““How did you feel about………?” (when How did you feel about………?” (when trying to elicit the client’s emotions trying to elicit the client’s emotions and feelings)and feelings)

Feeling WordsFeeling WordsAfraid HopelessAfraid HopelessAlarmed HorrifiedAlarmed HorrifiedAngry ImpatientAngry ImpatientAnxious IrritatedAnxious IrritatedAshamed JealousAshamed JealousBewildered JoyfulBewildered JoyfulCalm LonelyCalm LonelyCarefree PleasedCarefree PleasedConfused PowerlessConfused PowerlessDepressed RelaxedDepressed RelaxedEcstatic ResentfulEcstatic ResentfulEmbarrassed SadEmbarrassed SadEnraged ScaredEnraged ScaredEnvious SurprisedEnvious SurprisedExcited TenseExcited TenseFearful TerrifiedFearful TerrifiedFrustrated ThreatenedFrustrated ThreatenedGuilty ThrilledGuilty ThrilledHappy UptightHappy UptightHopefulHopeful

Asking for ClarificationAsking for Clarification

Accurate data collection is evident when Accurate data collection is evident when asking for clarification to confirm the asking for clarification to confirm the nurse’s understanding of what the client nurse’s understanding of what the client intends to convey.intends to convey.

Client’s avoidance of the Anxiety Client’s avoidance of the Anxiety Producing TopicProducing Topic

• Ask client which issue is more important at this Ask client which issue is more important at this time.time.

• Go with the new topic because the client has Go with the new topic because the client has given nonverbal messages that this is the issue given nonverbal messages that this is the issue that needs to be discussed.that needs to be discussed.

• Reflect the client’s behavior signaling there is a Reflect the client’s behavior signaling there is a more important issue to be discussed.more important issue to be discussed.

• Mentally file the other topic away for later Mentally file the other topic away for later exploration.exploration.

• Ignore the new topic, because it seems that Ignore the new topic, because it seems that the client is trying to avoid the original topic.the client is trying to avoid the original topic.

Guiding the Client in Problem Solving Guiding the Client in Problem Solving and Empowering the Client to Changeand Empowering the Client to Change

Explore possibilities to find solutions.Explore possibilities to find solutions.

Allow client to be in control, confident, Allow client to be in control, confident, competent, and aspires for growth and competent, and aspires for growth and change to develop new coping strategies change to develop new coping strategies as independently as possible.as independently as possible.

Frequently used in crisis intervention. (i.e. Frequently used in crisis intervention. (i.e. PTSD)PTSD)

Community Based CareCommunity Based Care

Self awarenessSelf awareness

KnowledgeKnowledge

Sensitivity to the beliefs, behaviors Sensitivity to the beliefs, behaviors and feelings of othersand feelings of others

AdaptationAdaptation

CollaborateCollaborate

Self-Awareness IssuesSelf-Awareness Issues

Awareness of how one communicates.Awareness of how one communicates.

Evaluate and improve therapeutic Evaluate and improve therapeutic communication.communication.

Be mindful of one’s facial expressions, Be mindful of one’s facial expressions, body posture, and other nonverbal skills. body posture, and other nonverbal skills.

Ask for feedback about style of Ask for feedback about style of communication. Examine communication.communication. Examine communication.

Key PointsKey Points

Communication is the process people use to Communication is the process people use to exchange information through verbal and non exchange information through verbal and non verbal messages. It is composed of both the verbal messages. It is composed of both the literal words or content and all the nonverbal literal words or content and all the nonverbal messages (process), including body language, messages (process), including body language, eye contact, facial expression, tone of voice, rate eye contact, facial expression, tone of voice, rate of speech, context, and hesitations that of speech, context, and hesitations that accompany the words. To communicate accompany the words. To communicate effectively, the nurse must be skilled in the effectively, the nurse must be skilled in the analysis of both context and process.analysis of both context and process.Therapeutic communication is an interpersonal Therapeutic communication is an interpersonal interaction between the nurse and client during interaction between the nurse and client during which the nurse focuses on the needs of the which the nurse focuses on the needs of the client to promote effective exchange of client to promote effective exchange of information between the nurse and client.information between the nurse and client.

Goals of therapeutic communication include establishing Goals of therapeutic communication include establishing rapport, actively listening, gaining the client’s perspective, rapport, actively listening, gaining the client’s perspective, exploring the client’s thoughts and feelings, and guiding the exploring the client’s thoughts and feelings, and guiding the client in problem solving.client in problem solving.The crucial components of therapeutic communication are The crucial components of therapeutic communication are confidentiality, privacy, respect for boundaries, self-disclosure, confidentiality, privacy, respect for boundaries, self-disclosure, use of touch, and active listening and observation skills.use of touch, and active listening and observation skills.Proxemics is concerned with the distance zones between Proxemics is concerned with the distance zones between people when they communicate: intimate, personal, social, and people when they communicate: intimate, personal, social, and public.public.Active listening involves refraining from other internal mental Active listening involves refraining from other internal mental activities and concentrating exclusively on what the client is activities and concentrating exclusively on what the client is saying.saying.Verbal messages need to be clear and concrete rather than Verbal messages need to be clear and concrete rather than vague and abstract. Abstract messages requiring the client to vague and abstract. Abstract messages requiring the client to make assumptions can be misleading and confusing. The nurse make assumptions can be misleading and confusing. The nurse needs to clarify any areas of confusion so that he or she does needs to clarify any areas of confusion so that he or she does not make assumptions based on his or her own experiences.not make assumptions based on his or her own experiences.

Nonverbal communication includes facial expressions, Nonverbal communication includes facial expressions, body language, eye contact, proxemics (environmental body language, eye contact, proxemics (environmental distance), touch, and vocal cues. All are important in distance), touch, and vocal cues. All are important in understanding the speaker’s message.understanding the speaker’s message.Understanding the context is important to the accuracy of Understanding the context is important to the accuracy of the message. Assessment of context focuses on the who, the message. Assessment of context focuses on the who, what, when, how, and why of an event.what, when, how, and why of an event.Spirituality and religion can greatly affect a client’s health Spirituality and religion can greatly affect a client’s health and health care. These beliefs vary widely and are highly and health care. These beliefs vary widely and are highly subjective. The nurse must be careful not to impose his or subjective. The nurse must be careful not to impose his or her beliefs on the client or to allow differences to erode her beliefs on the client or to allow differences to erode trust.trust.Cultural differences can greatly affect the therapeutic Cultural differences can greatly affect the therapeutic communication process.communication process.When guiding a client in the problem solving process, it is When guiding a client in the problem solving process, it is important that the client (not the nurse) chooses and important that the client (not the nurse) chooses and implements solutions.implements solutions.

Therapeutic communication techniques and skills Therapeutic communication techniques and skills are essential to successful management of clients are essential to successful management of clients in the community.in the community.

The greater the nurse’s understanding of his or The greater the nurse’s understanding of his or her own feelings and responses, the better the her own feelings and responses, the better the nurse can communicate nd understand others.nurse can communicate nd understand others.