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This article focuses on the concept of "Therapeutic communication". it also tries to highlight the
importance of this concept, which through verbal or nonverbal communication makes the nurse
consciously influence a client or help the client. it involves the use of specific strategies that
encourage the patient to express feelings and ideas. There are different reactions to "therapeutic
communication" as all patients differ in their characters, background, social status, culture, etc.
This article will also compare the role of the nurse as compared to that of the doctor. They must
both master efficient therapeutic techniques of communication in order to establish empathy
towards the experience that the patient reveals. it is of great importance for them to have
communicative therapeutic skills in order to successfully apply the communicative process as well
as to fulfil the standards of healthcare for the patients. Through therapeutic communication they
should establish a relationship, identify the patients worries and needs, estimate the perceptions
of the patient including detailed actions (behaviour, messages) etc. Results and recommendations
will include a comparison between different techniques of therapeutic communication based on
different experts such as Knapp and Hall, de vito etc.

introduction to therapeutic communication The concept of "therapeutic communication" refers to

the process in which the nurse consciously influences a client or helps the client to a better
understanding through verbal or nonverbal communication. Therapeutic communication involves

the use of specific strategies that encourage the patient to express feelings and ideas and that
convey acceptance and respect.1 However the concept has been defined furthermore by different
scholars analyzing the terms separately, in terms of word structure and meaning. Therapeutic and
communication are two complex words each of which containing different meanings. However
the term gains quite another meaning when referring to medical terminology and when considered
as a compound noun. Therapeutic refers to the science and art of healing (Miller and Keane,
1972); of or pertaining to a treatment or beneficial act (Potter and Perry, 1989). This can be further
extended to include what Rogers (1961) calls the helping relationship, which is one that promotes
growth and development and improved coping with life for the other person. Communication
has a number of definitions that tend to emphasize either the message or the meaning. Mohan,
Mcgregor and Strano (1992) provide the following: the ordered transfer of meaning: social
interaction through messages: reciprocal creation of meaning: sharing of information, ideas or
attitudes between or among people. de vito (1991) suggests that communication is an act by one
or more persons of sending and receiving messages that are disturbed by noise, occur within a
context, have some effect and provide some opportunity. Therapeutic communication involves the
exchange of information on two levels verbal or nonverbal. Messages are sent and received
simultaneously. verbal communication includes the arrangement of words into sentences, the
content as well as context the area where the conversation takes place which might include the
time and the physical, social, emotional and cultural environment. (weaver,1996). nonverbal
communication includes the behavior accompanying the verbal content such as body language,
eye content, facial expression, the tone of the voice etc. nonverbal communication mainly indicates
the thoughts, needs or feelings of the client, mainly subconsciously.

Different theories and viewpoints of therapeutic communication Therapeutic communication

techniques have been studied and elaborated by different scholars3. Hildegard E. Peplau was a
primary contributor to mental health law reform, thus leading the way towards humane treatment
of patients with behavior and personality disorders. She introduced the theories of developmental
stages of the nurse- patient relationship. The stages included: the orientation phase, the
identification phase, the exploitation phase and the resolution phase. Her theories led the path to
later nurse theorists and clinicians in developing more sophisticated techniques.

j. A. De Vitos involved three context dimensions to consider during the communication process.
They were: physical, social/psychological and temporal. The three content dimensions interact,
they are not applied separately. The factors in each dimension influence the formality, seriousness
and intimacy of the communication. de vito (1989) also implies that this is a very linear process
where the communication starts with one person and proceeds via a series of steps to another
person. northouse & northouse (1992) suggests using a form of touch so that the patients will
perceive touch in a positive way. it has to be appropriate to the particular situation, not to use a
touch gesture that imposes more intimacy on a patient than he or she desires, and to observe the
clients response to the touch. Potter & Perry (1999) studied and analyzed different aspects of
verbal communication resulting in six of them as the most important ones. They were: vocabulary,
denotative and connotative meaning, intonation, pacing, clarity and brevity, timing and relevance.
knapp and Hall (2002) arranged the way in which nonverbal messages can interact with verbal
messages. according to Knapp and Hall the categories are as follows: repeating, conflicting,
complementing, substituting, regulating and accenting/moderating. in case of mixed messages it
is the mental health professionals duty to pay attention to nonverbal communication techniques
used by the patient to attain additional information. Body movements and positioning are to be
noticed when people perceive mixed messages during interactions. Arnold & Boggs (2003)
concentrated on nonverbal communication which includes messages that are created through body
motions, facial expressions, use of space and sounds and the use of touch. They distinguished four
areas in which nonverbal behaviors are used: proxemics, cultural variations, kinesics which
includes body language and facial expression, and appearance.

Therapeutic communication in Albania The political transformations after the 1990s in albania
had their influence in all the fields of science thus giving way to new progress. The present day
albanian society is transforming itself in a dazzling manner. There is a wide variety of
transformations embracing all walks of life, science, technology or significant fields such as,
medicine and its related fields that are vitally critical to sustaining human health and well-being.
Medicine is a tremendous science that has undergone great development. as with all the other
specialties with social interactions, psychiatry and mental health field suffered totalitarian control
during the communist regime encoun tering difficulties in the way patients were treated as well as
in the manners that were used to treat the patients. as in all the fields even in medicine, the
psychological and psychiatric orientation were heavily influenced by the soviet methods and
school filled with political interventions. after the collapse of the communist regime all fields of
science underwent thorough transformations and changes to adapt to the contemporary methods
used worldwide. These methods of therapeutic communication started being used even in albania
and made progress in all the fields of mental health step by step. nowadays not only have they been
mastered by the mental health care professionals, but also by the nurses as the whole educational
system has undergone complete transformation, thus graduating university level professional
nurses at the Faculty of nursing. However a lot is yet to be done on a professional level as well as
in infrastructure. Therapeutic communication used by health care professionals is only offered by
the most important mental health care centers in the country for the time being. This needs to be
extended all over the system of healthcare. intensive care must be paid to apply and offer
professional assistance all over the country through multidisciplinary highly qualified teams.
Therapeutic nurse patient relationship Therapeutic communication involves the interpersonal
communication between the patient and the nurse. This communication is intended to help the
patient. The skills required in therapeutic communication are delicate and far numerous than those
required in general interpersonal interaction, and mastering of therapeutic techniques helps the
nurse understand the patient better. Sound interpersonal interaction skills for the nurse are of great
importance and necessary for effective therapeutic communication. However therapeutic
communication is aimed at establishing several objectives for the nurse as a mental health
professional. communication is the means which initiates, elaborates and ends the nurse- patient
relationship. in order to achieve an efficient therapeutic communication the nurse must follow the
rule of privacy and confidentiality-safeguard the patients rights to privacy, allow the patient to
express themselves freely, respect the patient by taking into consideration the background, age,
religion, socioeconomic status and race in respecting personal space. The nurse must be ready to
distinguish between the patients needs and intentions; he might need to set the limits in case he
feels that they are going to be violated. Professional communication is very important for the
relationship between the nurse and the patient. They both need to follow rules, use courtesy forms:
say hello, goodbye, knock on doors, introduce themselves, make eye contact, smile etc.

Therapeutic communication includes five levels: 1. interpersonal communication - Face to face

interaction between the nurse and another person. 2. transpersonal communication- interaction that
occurs within a persons spiritual domain. 3. Small-group communication- interaction that occurs
when a small number of people meet and share a common goal. (The latter not widespread in
albania) 4. intrapersonal communication- Powerful form of communication that occurs within an
individual. 5. Public communication- interaction with an audience (nurses are required to use eye
contact, gestures, etc). The nurse and the patient need to collaborate actively following different
types of communication: active listening- attentive to what the patient is saying verbally and
non-verbally. Share observations- make comments on how the individual looks, sounds or acts.
Share empathy: be sensitive to the patient. Share hope- conveys a sense of possibility.
Share humor- has a positive effect on an individual. Make sure the patient understands
what is being said. Sharing feelings- help patients to share feelings by observing and
encouraging communication. Use touch- brings the sense of caring by holding a patients
hand. Use silence it is useful in allowing the patient to think and gain some insight into the
situation. listening is crucial.
Therapeutic versus non therapeutic communication techniques The nurse might employ different
techniques to establish a relationship with the patient. The selection of the technique depends
heavily on the purpose of collaboration and the ability of the patient to communicate verbally. The
nurse needs to master each technique in order to be able to select the right techniques which would
facilitate the interaction and strengthen the nurse- patient relation. Therapeutic communication
helps patients to trust and relax, while non-therapeutic communi cation causes patients to feel
uncomfortable and untrusting and builds walls barring communication between caregiver and
patient.

I. The Work of the Nursing Student At the traditional pinning ceremony, LaGuardia nurses are
naturally excited about their entry into the world of healthcare. But the new nurse will enter a
profession of seemingly insurmountable pressures: increases in work hours, shortages in staff and
services, unrelenting emotional and physical strain, and close and constant confrontations with
suffering, disease, and death. Despite these familiar and unavoidable challenges, or perhaps
because of them, nursing remains a calling. Each semester at LaGuardia, over 200 students who
have completed a challenging set of prerequisites in the sciences, achieving GPAs of 3.7 to 4.0,
apply to an RN program that can accommodate a maximum of 70 applicants. LaGuardia also has
a Practical Nursing Program (PN), inaugurated in 2005. The program admits 60 students twice a
year; 3.4 was the minimum admission grade for fall 2008. Passing through LaGuardias nursing
programs is a demanding experience, but, having succeeded, our graduates have better than a 95%
chance of passing the Nursing Boards. Well received at nurse recruitment centers, LaGuardia
graduates place in specialty positions that include operating and emergency rooms, telemetry and
respiratory units as well as medical/surgical units. The hopeful LaGuardia nursing applicant is
often a newly arrived immigrant or single parent, drawn to the profession by the promise of
economic stability. If admitted, she or he sacri ces social and family life for a rigorous curriculum.
Most students are on scholarship or receive nancial aid; few, if any, are economically privileged.
Some shoulder nancial responsibility for personal and educational expenses by working full time
while preparing for nursing careers; others work weekends and evenings while attending day
classes. Students who are parents face unique demands on their time and energies: child care and
other domestic duties do not cease, and study time arrives only after the children are asleep. These
competing obligations of school, work, and home can drain the student nurses motivation. Yet
our nursing students survive and fare well, gaining the academic success that, in turn, will lead to
professional status and pursuit of degrees beyond the Associate in Applied Science. The ability to
make personal sacri ces and the determination to study hard, however, will not sustain a life of
service; the nurse must possess another exceptional quality: the skill to create a trusting
relationship that promotes growth and healing in the patients life. In the nursing profession, the
key to this relationship is therapeutic communication. As the nursing student in clinical training
soon learns, the most compassionate caregiver can be quickly exhausted by the work: patient
distress, scarcity of support, unavailability of supplies, malfunctioning machines, and the
competing demands of patients and families, supervisors, and doctors. If the nurse is to meet these
challenges, she must possess the capacity to communicate effectively with the patient in a limited
amount of time and in ways that conserve her psychological and physical energy. This article
explores therapeutic communication as a professional technique centered on empathy and
practiced for the purposes of reducing stress and increasing understanding in both the caregiver
and those cared for. Threaded throughout LaGuardias nursing program, introduced in the
classroom, and practiced in the clinical setting, the theory and practice of therapeutic
communication help the nursing student in a high-stress workplace learn to connect with and assess
her patient efficiently and empathically, thus making the enormous challenges encountered by the
healthcare worker more manageable.

II. Therapeutic Communication De ned Imagine the newly admitted patient surrounded by
strange technology and intimidated by a threatening environment, anxious and uncomfortable.
Dressed in a apping hospital gown, pricked by a phlebotomist, unaware when the doctor will
arrive, left to wait on a gurney in the cold hallway until a room is assigned, or the test results are
ready, or the radiologist is available: too many of us know these all too frequent and unfortunate
experiences. Now, when the patient is most vulnerable, the nurses work begins. The root cause of
the patients medical problem must be identi ed, personal information gathered, and options
explained to a person who is frightened or passive. At this critical moment, the nurses key goal is
to gain the patients cooperation. To succeed, the nurse must earn the patients trust in a limited
amount of time, eliciting the required data, yet communicating in a manner that conveys empathy,
saves energy but encourages the patient to reveal fears or frustrations, bridges cultural differences,
and recognizes individuality. Given the frequently short length of hospital stay and the absence of
familiarity between patient and nurse, how are these objectives to be met? In our everyday lives,
we often speak or act casually, without re ecting on the effects of our words or deeds.
Consequently, we unwittingly risk a relationship by asking personal questions, changing the
subject, giving personal opinions, or responding dismissively or automatically, all of which can
lead to defensive or negative reactions. Blunt why and how questions may seem aggressive;
advising and judging may appear to assume authority and belittle our partner in conversation. In a
hospital room, these forms of nontherapeutic communication will most likely elicit only
monosyllabic responses, yielding neither the re ection nor the information necessary for the
patients healthcare assessment and treatment plan. In this case, the relationship of the patient and
the nurse is in jeopardy; stress for both caregiver and cared for increase, and the nurses work
becomes more dif cult. In the world of healthcare, then, professional caregivers must be
especially sensitive to approaches that keep communication open. In the LaGuardia nursing
program, students learn that therapeutic communication can express care, interest, and respect in
several ways. Active listening may be signaled through body language. Sitting and facing the
patient in an open and forward-leaning posture with frequent eye contact, for example, sends a
message of interest and attentiveness. Careful observation and conversational prompts, such as
You look tired today, or I noticed you didnt want to eat this morning, can draw out the quiet
or withdrawn patient, leading the nurse to understand the underlying causes of the patients
discomfort. Asking openended questions invites the patient to lower his or her guard; and by
responding attentively, the nurse communicates commitment to staying focused and professional.
Conversely, moving around, avoiding the patients eyes, and doing most of the talking are
behaviors that indicate a lack of interest in the patients experience. Recognizing nonverbal
communication helps healthcare workers remain keenly aware that a patients cognition and
behaviors may not match. A diabetic, for example, may state an understanding of the need to
manage intake of carbohydrates, yet continue to stash chocolate bars in the bedside table. In this
case, a therapeutic approach recognizes the patients lack of readiness to commit to healthier
choices, and communicates support by modifying strategies and identifying alternative solutions.
Empathy is the calm understanding and acceptance of the thoughts and feelings of the patient.
When empathetic, one is nonjudgmental, sensitive, open, and capable of imagining another
persons experience. For example, an empathetic nurse responds to a patients need to smoke in
ways that neither promote the habit nor alienate the smoker. Finally, reminding a patient of her
strengths and previous successes in solving problems, the nurse conveys hope and the optimistic
belief that the patient is capable of participating in a plan of care. In summary, therapeutic
communication is holistic and patientcentered, and engages the totality of the patients condition
environmental, spiritual, psychological, as well as physiological elements. The practice of
therapeutic communication helps form a health-focused and stress-reducing collaborative
relationship; its primary goal is the establishment of trust in order to create a healing exchange
between nurse and patient. In a properly functioning relationship, the patient communicates his or
her experience, and shares necessary data, thoughts, and feelings with the nurse who listens
carefully to the patients expression of physical and holistic needs. Ideally, the result of this
reciprocal exchange is the formulation of a unique, mutually-designed but patientmanaged
treatment plan.

III. The First Semester: Introduction to Therapeutic Communication Having already completed
the required classes in science, English, and psychology, the newly admitted nursing student enters
the rst semester of the nursing program, which requires courses in Fundamentals of Nursing
(SCR110) and Perspectives of Nursing (SCR150). In Fundamentals, students attend approximately
ten hours of lecture/lab per week and six hours of weekly hospital/clinical experience; Perspectives
is a basic patient care course that requires a ten-page research paper, oral presentations, and class
discussions of assigned readings. On the rst day in the Fundamentals of Nursing course, new
students learn that, for the next twelve weeks, they must say goodbye to their social and family
lives. Fortunately, most nursing students possess the set of characteristics necessary to make these
sacri ces and to meet the demands of course work, labs, and exams that will consume the weeks
ahead. Focused, energetic, and driven, they are, in a word, typeA personalities. Instructors can
easily spot these students, as they are goal-oriented and obsessed with grades. But what instructors
may not see is that many also work long hours to cover their living expenses. Personal obligations,
combined with rigorous program requirements, call for ef cient organization of time and
resources.

When teaching Fundamentals, I introduce students to strategies that communicate empathy and
those that result in distancing and defensiveness. Through role plays and discussion, students
identify therapeutic and nontherapeutic responses, and learn the rationale behind effective
communication techniques. In one scenario, students assume the experience of patients, and
express the feelings and fears of individuals anxiously awaiting life-altering information in an
unfamiliar hospital; in a second role-play, students engage in therapeutic and nontherapeutic
communication with caregivers. By practicing both the facilitators of and the blocks to therapeutic
communication, students learn that the phrases that may be appropriate coming from family and
friends (Dont worry, youll feel better soon, How can you feel that way when your lab results
are normal? or Why didnt you go for a second opinion?) are alienating when spoken to a frail,
noncommunicative patient. After the role plays, students discuss the scenarios, and write
descriptive analyses of the participants communication skills, identifying barriers to and
facilitators of productive nurse-patient interaction, and emphasizing speci c areas for
improvement. Students then present a more positive therapeutic version using body language and
other facilitators to engage, interview, and assess the patient. Finally, we review strategies of
therapeutic communication to be used throughout nursing practice. After one or two weeks of
preparation in lecture and lab, students are ready to enter clinical training.

IV. The Application of Therapeutic Communication in the Clinical Setting Graduating nursing
students have often described patient interviews on the very rst day of their clinical practice as
among the most frightening aspects of their training. High achievers in the classroom, on the oor
they become robotic, tongue-tied and unable to apply their learning. More than once during the
transitional process from class to clinic, my students have described patients who wont let me
wash them, wont eat, or wont talk with me, implying that the problem is with the patient.
Claiming to legitimize the patients autonomy rights, the student nurse appears almost relieved to
forego clinical responsibilities. In these cases, students need guidance to become more assertive in
educating the patient to the bene ts of care. The student must learn that care refused or postponed
is nevertheless necessary; without it, optimum standards will not be achieved. After several weeks
of practice under the guidance of hospital personnel and course instructors, students become more
con dent of their bedside care; as their interaction becomes therapeutic, patients refusing care will
generally become more cooperative. Application of therapeutic communication in student-patient
interaction is best observed in the clinical hospital setting. Typically, student nurses begin each
preconference, which is the preparation time prior to the student-patient experience, with a focus
for the day. In the summer of 2008, as the instructor of 10 PN students at Elmhurst Hospital in
Queens, I observed nurse-patient interaction as the students performed tasks and engaged in
dialogue related to several gastrointestinal conditions. In their last semester before graduation,
these students rst reviewed the gastrointestinal material in lecture and preconference, and then
applied this knowledge to the determination of their patients health needs, prioritizing and
delivering the appropriate routine hygienic care. In the postconference hour at the end of each
clinical day, students discussed the ways therapeutic communication had enhanced their
caregiving. To complete the student evaluation, I asked patients to offer feedback about the level
of satisfaction with the students care. In postconference, students reported on their patients, often
recounting the personal stories, struggles, and successes that patients had shared. For example,
they reported that depressed patients had increased conversation, suggesting regained energy to
cope with their condition; described menus modi ed according to a patients cultural/palate
preference; or narrated life experiences that, when shared, fostered the nurse-patient relationship
and helped empower the patient. Students also reported positive practices of assertive
communication that clari ed misunderstanding, and helped to gather necessary information or
contribute reassurance. By exchanging information and feelings with patients, students used
therapeutic communication to aid patient care. By re ecting genuine interest and listening
attentively, they opened up a dialogue, allowing them to better understand their patients, as the
sample responses indicate:

using empathy, understanding, patience, I saw how TC enhanced my relationship with my

patient. He trusted me more and more, and shared with me his life before the surgery and told me
how much I helped him to understand his condition and to take care of himself after the discharge
I used the therapeutic technique of listening. When I just listen to what my patient is saying, I
am showing that I care about the patients feelings and problems. I used assertive communication
when I explained to Mrs. J. why I needed to take her pulse and respirations... I did this without
violating her rights. a good listener can provide reassurance, lighten another persons burden

It was hard to communicate verbally because of the language barrier but he and I communicated
using non verbal cues. He nodded and smiled; he responded to what I was saying. To his wife, I
taught her to communicate with her husband, to exercise his brain, and also for him to practice
starting to talk. In addition, cultural sensitivity enhanced the care...(he) prefers Indian food rather
than hospital food; therefore the patient eats more and prevents nutritional imbalance.

During my time at Elmhurst Hospital, I used listening and touch as therapeutic techniques. When
I asked patients if they were doing ne, I touched them by rubbing their arm or back a little...
Listening and touch sends a message of care and trust...
Yesterday, my patient refused a.m. care. When I entered her room, I talked in a calm voice, asked
why she refused to take a shower. Through TC, I gathered information needed for my plan of care.
I learned she feels really cold, thats why she refuses to take a bath. My action was to teach the
importance of hygienic care. TC means a lot to a patient A simple gesture, a smile or hello has
a great importance.

Therapeutic Communication is one of the most valuable tools that nurses have to build rapport or
trust. This trust allows the nurse to provide reverse care. This means that the nurse allows the
patient to feel secure enough to share information, such as his/her feelings, frustration, pain,
happiness, or improvement. The information provided by therapeutic communication gives nurses
the clues or heads up of any exacerbation in the patients condition, as well as any developing
disease. TC is needed in nursing for both the progress of the patient, as well as the growth of the
nurse in her practice.

In the workplace, a nurses responsibilities and duties can be enormous. As these responses re
ect, using therapeutic communication helped students create a nurse-patient relationship that
allowed the nurse to better understand and provide nursing assistance.

Conclusion Usually by the end of the first year of clinical training, LaGuardia nursing students
know what to expect when they walk onto the hospital oor. They know that patients who must
make life-altering decisions will often lean on the nurse for support, and that the nurse who
expresses con dence is better able to motivate her patients to cooperate with the plans for that
day. After intensive clinical application, the ability to communicate therapeutically will become
almost second nature to the nurse who has learned to balance the stresses of demanding daily tasks
with the acquired skills of assessing a patients needs and determining an effective treatment plan.
The work of nursing in the 21st century is changing. With managed care, and the quest for
universal health coverage, there will be greater demands upon our system to provide high quality
care with a high rate of ef ciency. Using therapeutic communication effectively helps to create a
nurse-patient relationship that promotes choice and responsibility, gains patient input and
cooperation, maximizes positive care outcomes, and helps to avoid litigious confrontations. It is
only when the patient is able to partner in the management of his own healthcare that the nurses
work can be fully utilized and the patients success maximized. Integrating knowledge with
compassion, reducing stress and establishing rapport, the skill of therapeutic communication is the
nurses greatest asset.

TECHNIQUES OF THERAPEUTIC COMMUNICATION

1. Using Broad Opening Statements The use of a broad opening statement allows the patient
to set the direction of the conversation. Such questions as Is there something youd like to talk
about? Give the patient an opportunity to begin expressing himself. In using a broad opening
statement, the nurse focuses the conversation directly on the patient and communicates to him that
she is interested in him and his problems. Upon sensing that the patient may have a need, the nurse
can use a broad opening statement to initiate discussion, while at the same time allowing the patient
to determine what will be discussed. When the patient opens the conversation, the nurse can then
follow his lead to discover the meaning his opening remark had for him, encouraging him by
question or comment to express himself further. Whether what he has said is of an obviously
serious nature (Am I dying?), or less emotionally charged (Im going home tomorrow,) the
nurse should avoid making assumptions as to its meaning or the need he may be expressing.

2. Using General Leads During the conversation, general leads, such as yes or simply the uh
hum will usually encourage the patient to continue. General leads, like broad opening statements,
leave the direction of the conversation to the patient. They also convey to him that the nurse is
listening and that she is interested in what he will say next. This can be accomplished verbally or
non-verbally, but nodding or through facial expressions, which demonstrate attentiveness and
concern. The major purposes of general leads is to encourage the patient to continue, and to speak
spontaneously, so that the nurse can learn from him how he perceives his situation, and get some
idea of what his need may be. By becoming aware of and resisting any tendency she may have to
jump to conclusions regarding the nature of the patients problem, and instead of drawing him out,
the nurse can begin to obtain the information she needs to be of continuing assistance to the patient.
Some additional samples of general leads are: I see. And then., go on and incomplete or
open-minded sentences such as You were saying that

3. Reflecting In reflecting, all or part of the patients statement is repeated to encourage him to
go on. If he says, Everyone here ignores me the nurse might reply, ignores you? Letting him
hear all of what he has said, or part of what he has said may lead him to more fully consider and
expand upon his remark. Reflecting can be overused, and the patient is likely to become annoyed
if his own words or statements are continually repeated to him. Selective reflecting can be used
once the nurse has begun to understand what the patient is driving at. For example, if the patient
says, I feel so tired, I dont like it here, the nurse can either reflect, tired? or You dont like
it here, depending on which part of his statement she thinks is most important.

4. Sharing Observations Here, the nurse shares with the patient her observations regarding
behavior. The patient who has a need is often unaware of the source of this distress, or reluctant
to communicate it verbally. However, the tension or anxiety created by his need creates energy
which is transformed into some kind of behavior, nail biting, scratching, hand clenching, or general
restlessness. By sharing her observations of this behavior with him, the nurse is inviting the patient
to verify, correct or elaborate on her observations. In doing so, she is attempting to find out from
him the meaning of his behavior rather than assuming she knows. In her efforts to ascertain the
meaning of the observed behavior, the nurse may share with the patient what he has actually
perceived through her senses (You are trembling), or she may share her interpretation of what
she has perceived (You seem upset).

Generally, her perceptions tend to be correct; her interpretations of her perceptions, however, may
often be incorrect. When sharing her observations of the patients behavior, the nurse should
phrase her remarks tentatively, in such a manner that it is her observation, rather than the patients
behavior which is being questioned. This observation can be accomplished by afraid or angry
may evoke a response of denial from the emotional impact, e.g., tense, upset, or restless.

5. Acknowledging the patients Feelings The nurse helps the patient to know that his feelings
are understood and accepted and encouraged him to continue expressing them. If he were to say,
I hate it here. I wish I could go home, the nurse might respond, It must be difficult to stay in a
place you hate. When a patient talks about something that is upsetting to him or expresses a
complaint or criticism, the nurse can convey acceptance by acknowledging the feelings he is
expressing without agreeing or disagreeing with them. By sympathetically recognizing that it must
be difficult or embarrassing or frightening or frustrating, etc. to feel as the patient does, she does
not pass judgment on the thought or feeling itself. If communication is to be successful, it is
essential that the nurse accept the thoughts and feelings her patient is expressing, irrespective of
whether or not she, personally, thinks and feels the same way. For if the patient senses or is told
that the nurse does not approve of or does not agree with what he is expressing, it is extremely
unlikely that he will continue, or that a positive nursepatient relationship will ensue.

6. Using Silence In certain circumstances, an accepting, attentive silence may be preferable to

a verbal response. This allows the nurse to temporarily slow the pace of the conversation and
gives the patient an opportunity to reflect upon, then speak further about his feelings. Also, silence
allows the nurse to observe the patient for non-verbal clues and to assemble her own thoughts.
Due to the nature of conventional social conversation, in which pauses and lulls are generally
avoided, the nurse may instinctively become uneasy when the patient falls silent for any length of
time. However, periods of silence are often most beneficial to the communication process
allowing the patient to collect his thoughts and to reflect upon the topic being discussed.
Maintaining an attentive, expectant silence at this time lets him know that his silence, too, is
accepted. Because silence can convey much sadness, distress, anger, contemplation the nurse
can also attempt to assess the meaning of the silence within the context of the conversation and
with attention to accompanying nonverbal behavior. It is important to practice silence as the nurse
tends to exaggerate the period of time a silence lasts, due to her own anxiety. After several minutes
of silence, the nurse can help the patient to resume verbal activity with statements such as, You
were saying that or What were you thinking?

7. Giving Information Studies have shown that a major cause of anxiety or discomfort in
hospitalized patients is lack of information or misconceptions about their condition, treatment, or
hospital routines. When the patient is in need of information to relieve anxiety, form realistic
conclusions, or make decisions, this need will often be revealed during the interaction by
statements he makes. By providing such information as she prudently can, admitting and finding
out what she doesnt know, or referring the patient to someone who can assist him, the nurse can
do much to establish an atmosphere of helpfulness and trust in her relationship with the patient.

8. Clarifying If the nurse has not understood the meaning of what the patient has said, she
clarifies immediately. She can use such phrases as Im not sure I follow or Are you using
this word to mean to request that the patient make his meaning clear to her. In seeking
immediate clarification when she is in doubt as to the patients meaning, the nurse can prevent
misunderstanding from hindering communication, also, because her efforts in clarifying will
demonstrate her continued interest in what the patient is saying, the use of this technique can help
motivate him to go on. Because meaningful communication depends greatly upon the extent to
which the persons involved understand clearly what each has said, the nurse should not hesitate to
interrupt the patient if there is any confusion in her mind about his meaning. She might say,
Before you go on, I want to understand what you meant by Also, the nurse should clarify
identities, such as ambiguous he or they. In addition, to enable the patient to best understand
her, the nurse should avoid the use of medical terminology or jargon whenever possible, and
attempt to express herself in such manner appropriate to the patients apparent level of
understanding.

9. Verbalizing Implied Thoughts and Feelings The nurse voices what the patient seems to have
fairly obviously implied, rather than what he has actually said. For example, if a patient has said,
Its a waste of time to do these exercises she might reply, You fell they arent benefiting you?
Besides, enabling the nurse to verify her impressions, verbalizing implied thoughts and feelings,
the nurse should be careful to verbalize only what the patient has fairly obviously suggested so
that she does not get into the area of offending interpretationsof making conscious that which is
unconscious.

10. Exploring or delving further into a subject or idea. Tell me more about that, Would you
describe it more fully? and What kind of work? are examples exploring topics which the patient
has brought up for discussion. The nurse should recognize when to delve further she should
refrain from probing or prying. If the patient chooses not to elaborate, the nurse should respect
the patients wishes. Probing usually occurs when the nurse introduces a topic because she is
anxious.

11. Presenting Reality Examples of presenting reality are: I see no one else in the room,
That sound was a car backfiring, and Your mother is not here; Im a nurse. When it is obvious
that the patient is misinterpreting reality, the nurse can indicate that which is real. She does this
not by way of arguing with the patient or belittling his own experiences, but rather by calmly and
quietly expressing her own perceptions or the facts in the situation. The intent here is merely to
indicate an alternate line of thought for the patient to consider, not to Convince the patient that
he is in error. This technique is highly useful with patients who are confused and geriatric patients
in nursing homes who show signs of confusion, psychiatric patients showing high anxiety and
patients who are confused due to alcohol or drugs such as LSD.
12. Voicing Doubt Statements like the following express uncertainty as to the reality of the
patients perceptions: Isnt that Unusual? Really? Thats hard to believe. Another means
of responding to distortions of reality is to express doubt. Such expression permits the patient to
become aware that others do not necessarily perceive events in the same way or draw the same
conclusions that he does. This does not mean that he will alter this point of view, but, at least he
will be encouraged to reconsider and re-evaluate what has occurred. And, the nurse has neither
agreed nor disagreed, yet, at the same time, she has not let misinterpretations and distortions pass
uncommented upon.

13. Suggesting Collaboration by offering to share, to strive, to work together with the patient for
his benefit. Perhaps you and I can discuss and discover what produces your anxiety (pain,
frustration, etc.). The nurse seeks to offer the patient a relationship in which he can identify his
problems in living with others, grow emotionally, and improve his ability to form satisfying
relationships with others. She offers to do things not For him or to him, but with him.

14. Validating When the nurse feels that the patients need has been met, she should validate
her impression with him. If his reply to such a question as Do you feel relaxed? or Are you
feeling better now? suggests his need has not been completely met, the nurse should renew her
efforts to assist him. The nurse should not assume that she has been successful in meeting a
patients need until this has been validated with him. Also, since the patient may have needs in
addition to that which the nurse has attempted to meet, validating gives him an opportunity to
make any such needs known. Also, the nurse observes his nonverbal behavior. A lessening of
tension or a positive change in behavior would support an affirmative verbal response; if tension
or behavior is not perceptibly altered, however, an affirmative reply would not be as meaningful.