Therapeutic Communication Techniques 1. Accepting indicating reception Ex. Yes. I follow what you said.

. nodding Rationale: An accepting response indicates the nurse has heard and followed the train of thought. It does not indicate agreement but is non judgmental. Facial expression, tone of voice, and so forth also must convey acceptance or the words lose their meaning. 2. Broad opening allowing the client to take the initiative in introducing the topic. Ex. Is there something youd like to talk about? Where would you like to begin? Rationale: Broad openings make explicit that the client has the lead in the interaction. For the client who is hesitant about talking, broad openings may stimulate him or her to take the initiative 3. Consensual validation searching for mutua l understanding, for accord in the meaning of the words. Ex. Tell me whether my understanding of it aggress with your. Are you using this word to convey that.? Rationale: For the verbal communication to be meaningful, it is essential that the words being used have the same meaning for both (all) participants. Sometimes, words, phrases or slang terms have different meaning and can be easily misunderstood. 4. Encouraging comparison asking that similarities and differences be noted. Ex. Was it something like..? Have you had similar experiences? Rationale: Comparing ideas, experiences, or relationships brings out many recurring themes. The client benefits from making these comparison because he or she might recall past coping strategies that were effective or remember that he or she has survived a similar situation 5. Encouraging description of perception asking the client to verbalize what or she perceives

Ex.

Tell me when you feel anxious. What is happening. What does the voice seem to be saying.

Rationale: to understand the client the nurse must see things from his or her perspective. Encouraging the client to describe ideas fully may relieve the tension the client is feeling and he or she might be less likely to take action on ideas that are harmful or frightening. 6. Encouraging expression asking the client to appraise the quality of his or her experiences. Ex. What are your feelings in regards to? Does this contribute to your distress? Rationale: The nurse asks the client to consider people and events in light of his or her own values. Doing so encourages the client to make his or her own appraisal rather than to accept the opinion of other. 7. Exploring delving further into a subject or idea Tell me more about that. Would you describe it more fully? what kind of work? Rationale: When clients deal with the topics superficially, exploring can help them examined the issue more fully. Any problem or concern can be better understood if explored in depth. If the

Ex.

client expresses an unwillingness to explore a subject, however, the nurse must respect his or her wishes. 8. Focusing concentrating on a single point Ex. this point seems worth looking at more closely. Of all the concerns youve mentioned, which is most troublesome? Rationale: The nurse encourages the client to concentrate his or her energies on a single point which may prevent a multitude of factors or problems from overwhelming the client. It is also useful technique when a client jumps from one topic to another.

9. Formulating a plan of action asking the client to consider kinds of behavior likely to be appropriate in future situations. Ex. What could you do to let your anger out harmlessly?might you do to handle Next time this comes up, what might you do to handle it?

Rationale: It may be helpful for the client to plan in advance what he or she might do in future similar situations. Making definite plans increases the likelihood that the client will cope more effectively in similar situation. 10. General Leads giving encouragement to continue Ex. Go on. And then? Tell me about it. Rationale: General leads indicate that the nurse is listening and following what the client is saying without taking away the initiative for the interaction. They also encourage the client to continue if he or she is hesitant or uncomfortable about the topic. 11. Giving information making available the facts that the client needs. Ex. My name is. Visiting hours are My purpose in being here is. Rationale: Informing the client of facts increases his or her knowledge about a topic or lets the client know what to expect. The nurse is functioning as a resource person. Giving information also builds trust with the client. 12. Giving recognition acknowledging, indicating awareness. Ex. Good morning Mr Youve finished your list of things to do. I notice that youve combed your hair. Rationale:

Greeting client by name, indicating awareness of change or noting efforts the client has made all show that the nurse recognizes the client as a person, as an individual. Such recognition does not carry the of value, that is, of being good or bad. 13. Making observation verbalizing what the nurse perceive. Ex. You appear tense. Are you uncomfortable when.? I notice that youve biting your lip. Rationale: Sometimes clients cannot verbalize or make themselves understood. Or the client may not be ready to talk. 14. Offering self making oneself available Ex. Ill sit with you awhile. Ill stay here with you. Im interested in what you think. Rationale: The nurse can offer his or her presence, interest and desired to understand. It is important that this offer is unconditional, that is, the client does not have to respond verbally to get the nurses attention. 15. Placing event in time or sequence clarifying the relationship of events in time. Ex. What seemed to lead up to ..? was this before or after.? When did this happen? Rationale: Putting events in proper sequence helps both the nurse and client to see them in perspective. The client may gain insight into cause-and-effect behavior and consequences, or the client may be able to see that perhaps something are not related. 16. Presenting reality offering for consideration that which is real. Ex. I see no one else in the room. that sound was a car backfiring. Your mother is not here. I am a nurse.

Rationale: When it is obvious that the client is misinterpreting reality, the nurse can indicate what is real. The nurse does this by calmly and quietly expressing the nurses perceptions or facts, not by way of arguing with the client or belittling his or her experience. The intent is to indicate an alternative line of thought for the client to consider, not to convince the he or she is wrong. 17. Reflecting directing client actions, thought, and feelings back to client Ex. Client: Do you think should tell the doctor.? Nurse: Do you think you should? Client: My brother spends all my money and then more. Nurse: this causes you to feel angry? Rationale: Reflection encourages the client to recognize and accept his or her own feelings. The nurse indicates that the clients point of view has value, and that the client has the right to have opinions, make decisions, and think independently. 18. Restating repeating the main idea expressed Ex. Client: I cant sleep. I stay awake all night. Nurse: You have difficulty sleeping. Client: Im really mad, Im really upset. Nurse:Youre really mad and upset. Rationale: The nurse repeats what the client has said in approximately or nearly the same words the client has used. This restatement lets the client know that he or she communicated the idea effectively. This encourages the client to continue. Or if the client has been misunderstood, he or she can clarify his or her thought. 19. Seeking information seeking to make clear that which is not meaningful or that which is vague. Ex. Im not sure that I follow. have I heard you correctly? Rationale: has nerve to ask for

the nurse should seek clarification throughout interactions with clients. Doing so can help the nurse to avoid making assumptions that understanding has occurred when it has not. It helps the clients to articulate thoughts, feelings, and ideas more clearly. 20. Silence absence of verbal communication, which provides time for the client to put thoughts or feeling into words, to regain composure or to continue talking. Ex. Nurse say nothing but continue to maintain eye contact and conveys interest.

Rationale: Silence often encourages the client to verbalize, provided that it is interested and expectant. Silence gives the client time to organize thought, direct the topic of interaction, or focus on issues that are most important. Much nonverbal behavior takes place during silence, and the nurse needs to be aware of the client and his or her nonverbal behavior. 21. Suggesting collaboration offering to share, to strive, to work with the client for his or her benefit. O your room, and I Ex. Perhaps you and I can discuss and discover the triggers for your anxiety. Lets go to your room, and Ill help you find what youre looking for. Rationale: the nurse seeks to offer a relationship in which the client can identify problems in living with others, grow emotionally, and improve the ability to form satisfactory relationships. The nurse offers to do things with, rather than for, the client. 22. Summarizing organizing and summing up that which has gone before. Ex. have I got this straight? Youve said that During the past hour, you and I have discussed Rationale: Summarization seeks to bring out the important points of the discussion and too increase the awareness and understanding of both participants. It client and omits the irrelevant and organizes the pertinent aspects of the interaction. It allows both the client and the nurse to depart with the same ideas and provides a sense of closure at the completion of each discussion. 23. Translating into feelings- Seeking to verbalize clients feelings that he or she expresses only indirectly.

Ex. Client: Im dead. Nurse: Are you suggesting that you feel lifeless? Client: Im way out in the ocean. Nurse: You seem to feel lonely or deserted. Rationale: Putting into words what the client has implied or said indirectly tends to make the discussion less obscure. 24. Verbalizing the implied Voicing what the client has hinted at or suggested. Ex. Client: I cant talk to you or anyone. Its a waste of time. Nurse: Do you feel that no one understands? Rationale: Putting into words what the client has implied or said indirectly tends to make the discussion less obscure. The nurse should be as direct as possible without being unfeelingly blunt or obtuse. The client may have difficulty communicating directly. 25. Voicing doubt expressing uncertainty about the reality of the clients perceptions. Ex. Isnt that unusual? Really? Thats hard to believe. Rationale: Such expression permits the client to become aware that others do not necessarily perceive events in the same way or draw the same conclusion. Nontherapeutic communication Technique 1. Advising telling the client what to do Ex. I think you should why dont you. Rationale: Giving advice implies that only the nurse knows what is best for the client. 2. Agreeing indicating accord with client. Ex. Thats right. I agree. Rationale:

approval indicates the client is right rather than wrong. this gives the client the impression that he or she is right because of agreement with the nurse. Opinions and conclusions should be exclusively the clients. When the nurse agrees with the client, theres no opportunity for the client to change his or her mind without being wrong. 3. Belittling feelings expressed - misjudging the degree of the clients discomfort. Ex. client: I have nothing to live for I wish I was dead. Nurse: Everybody gets down in the dumps, or Ive felt that way myself. Rationale: When the nurse tries to equate the intense and overwhelming feelings the client has expressed to everybody or to the nurses own feelings, the nurse implies that the discomfort is temporary, mild, self-limiting, or not very important. The client is focus on his or her own worries and feelings; hearing the problems or feeling of others is not helpful. 4. Challenging demanding proof from the client Ex. But how can you be president of the United states? If youre dead, why is your heart beating? Rationale: Often the nurse believes that if he or she can the challenge the client to prove unrealistic ideas, the client will realize there is no proof and then will recognize reality. Actually, challenging causes the client to defend the delusion or misperceptions than before. 5. Defending attempting to protect someone or something from verbal attack. Ex. this hospital has a fine reputation. Im sure your doctor has your best interests in mind. 6. Disagreeing opposing the clients or ideas Ex. thats wrong. I definitely disagree with I dont believe that. Rationale: disagreeing implies the client is wrong. consequently the client feels defensive about his or her point of view of ideas. 7. Disapproving denouncing the clients behavior o r ideas. Ex. Thats bad.

Id rather you wouldnt Rationale: disapproval implies that the nurse has the right to pass judgment on the clients thoughts or actions. It further implies that the client is expected to please the nurse. 8. Giving approval sanctioning the client behavior or ideas. Ex. thats good. Im glad that 9. Giving literal responses responding to a figurative comment as though it were a statement of fact Ex. Client: theyre looking in my head with the television camera. Nurse: try not to watch television, or What channel. 10. Interpreting asking to make conscious that which is unconscious, telling the client the meaning of his or her experience Ex. what you really mean is. Unconsciously youre saying. 11. Introducing an unrelated topic changing the topic Ex. Client: Id like to die. Nurse: did you have visitors last evening? 12. Making stereotype comments offering meaningless cliches or trite comments Ex. Its for your own good. Keep your chin up. Just have a positive attitude and youll be better in no time. 13. Probing persistent questioning of the client Ex. Now tell me about this problem. You know I have to find out. Tell me your psychiatric history. 14. Reassuring - indicating there is no reason for anxiety or other feelings of discomfort. Ex. I wouldnt worry about that. Everything will be all right. youre coming along just fine. 15. Rejecting refusing to consider or showing contempt for the clients ideas or behaviors. Ex. Lets not discuss. I dont want to hear about.

16. Requesting an explanation asking three clients to provide reasons for thoughts, feelings, behaviors, events. Ex. Why do you think that? Why do you feel that way? 17. Testing appraising the clients degree of insight Ex. Do you know what kind of hospital this is? Do you still have the idea that..? 18. Using denial refusing to admit that a problem exists Ex. Client: Im nothing. Nurse: Of course youre something-everybodys something. client: Im dead. Nurse: Dont be silly. USE OF APPROPRIATE COMMUNICATION TECHNIQUES COMMUNICATION Reciprocal exchange of ideas between or among persons Is the process that people use to exchange information.

Modes: Verbal written/spoken Non-Verbal posture, tone of voice, facial expression, body language, eye contact, speed and hesitations in speech Meta Communication based on role expectations/hidden meaning of words Types of Non-Verbal Communication 1. Kinesis body movement, eye contact, gestures, facial expression 2. Paralanguage Voice quality, non-language vocalization such as crying, sobbing, moaning 3. Proxemics law of space relationship 4. Touch physical act 5. Cultural Artifacts eye glasses, uniform, beard ELEMENTS OF COMMUNICATION Sender

 Message Receiver Channel Feedback Context Therapeutic Communication o A way of interacting in a purposeful manner to promote the clients ability to express his thoughts and feelings openly. o Is an interpersonal interaction between the nurse and client during which the nurse focuses on the clients specific needs to promote an effective exchange of information. o Skilled use of therapeutic communication techniques helps the nurse understand and empathize with the clients experience Purposes of therapeutic communication: Establish a therapeutic nurse-client relationship Identify the most important client concern at that moment Assess the clients perception of the problem as it unfolds 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 identifying a plan of action to a satisfying and a socially acceptable resolution. To have an effective therapeutic communication, the nurse must consider: a. b. c. Privacy and respecting boundaries Use of touch Active listening and observation

Space between the nurse and the patient is important and varies among different cultures a) Intimate zone 0 to 18inches Visual distortion occurs Best for assessing breath and other body odors

b) c) d)

Personal distance(zone) 18 to 36inches Perceived as extension of self, voice is moderate, body odors are not apparent, no visual distortion Much of the physical assessment occurs at this distance Social distance 4 to 12 feet Used for impersonal business transactions, perceptual information much less detailed Much of a patient interview will occur at this distance Public distance 12+ feet Interaction with others is impersonal, speakers voice must be projected, subtle facial expressions imperceptible

Five types of touch 1. 2. 3. 4. 5. functional-professional touch Social-polite touch Friendship-warmth touch Love-intimacy touch Sexual-arousal touch

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 ESSENTIAL COMPONENTS OF A THERAPEUTIC RELATIONSHIP Genuiness Respect Empathy Acceptance Trust (rapport)

Self awareness and therapeutic use of self

Self-awareness is the process of developing an understanding of ones own values, belief, thoughts, feelings, attitudes, motivations, prejudices, strengths and limitations and how these qualities affects others. therapeutic use of self By developing self-awareness and beginning to understand his or her attitudes, the nurse can begin to use aspects of his or her personality, experiences, values, feelings, intelligence, needs, coping skills and perceptions to establish relationships with client. Johari Window Types of Relationships 1. Social relationship is primarily initiated for the purpose of friendship, socialization, companionship or accomplishment of task. 2. Intimate relationship involves two people who are emotionally committed to each other. 3. Therapeutic relationship focuses on the needs, experiences, feelings, and ideas of the client only. NURSE PATIENT RELATIONSHIP PHASES Pre-Interaction Phase: Begins when the nurse is assigned/chooses a patient Patient is excluded as an active participant Nurse feels certain degree of anxiety Includes all what the nurse thinks and does before interacting with the patient Major Task of the Nurse: to develop self-awareness Other Tasks: data gathering, planning for first interaction Orientation Phase begins when the nurse and client meet and ends when the client begins to identify problem to examine The nurse establishes roles, the purpose of meeting, and the parameters of the subsequent meetings identifies the clients problem and clarify expectation. Major tasks: to develop a mutually acceptable contract Other tasks: establish rapport, develop trust, assessment

Working / Therapeutic Phase It is highly individualized More structured than the orientation phase The longest and most productive phase of the nurse patient relationship limit setting is employed Major Task: identification and resolution of the patients problems Other Tasks: planning and implementation Termination Phase: It is a gradual weaning process It is a mutual agreement It involves feelings of anxiety, fear and loss It should be recognized in the orientation phase Major Task: to assist the patient to review what he has learned and transfer his learning to his relationship with others Other Tasks: evaluation Terminate when Goals have bee met Patient is emotionally stable The patient exhibits greater independence The patient is able to cope with anxiety, separation, fear and loss How to terminate? Gradually decrease interaction time Focus on future orientated topics Encourage expression of feelings Make the necessary referrals Never leave the patient unprepared!!! Common Problems Affecting NPR: Transference the development of an emotional attitude of the patient either positive or negative towards the nurse Resistance development of ambivalent feelings towards self-exploration Counter Transference transference as experienced by the nurse

Transcultural considerations in communicating with patients 1. Introduce yourself and the way in which you want to be called 2. By first name, last name or title 3. Ask the patient to do the same 4. Both the nurse and the patient will bring cultural stereotypes to a professional relationship. The role of a family member in providing care must be understood and explained. 5. Ethnocentrism viewing your own life as the most desirable, acceptable or best and to act in a superior manner to another cultures way of life 6. Cultural imposition tendency to impose your beliefs, values, and patterns of behavior on individuals from another culture 7. Some cultures are more comfortable at a variety of spaces when communicating 8. Some cultures expect health care workers to have all the answers their illness 9. Some cultures during illness or injury accept the sick role in different ways 10. Non verbal communication such as handshaking and touching may be perceived differently in different cultures 11. Asian, Native Americans, Indochinise, and Arabs may consider direct eye contact impolite or aggressive and they may avert their eyes during an interview 12. Touch, especially between members of different culture groups may be of concern 13. Language- nurses may encounter patients who do not speak the same language Traps/Barriers of interviewing/Non-therapeutic a. Providing false assurance or reassurance b. Giving advice or show approval or disapproval c. Authority d. Using avoidance language e. Distancing f. Professional jargon g. Leading or biased questions h. Talking too much/Overloading i. j. Interrupting Using why questions

k. Probing l. Rejecting; belittling