Introduction

A therapeutic nurse–patient relationship is the foundation of nursing care and involves patient-centred therapeutic communication skills. Well-developed interpersonal and communication skills are considered essential for all nurses, regardless of where they work (Sharples 2013).

The primary goal of therapeutic communication for the nurse is to promote wellness and personal growth in patients. Therapeutic communication empowers patients to make decisions but differs from social communication in that it is patient centred and goal directed with limited personal disclosure from the professional, whereas social communication involves equal opportunity for personal disclosure. Nurses should not share intimate details of their personal lives with patients. However, nurses should use personal self-disclosure cautiously and only in selected situations. Personal self-disclosure by the nurse may be useful for the following goals:

• to educate the patient
• to build the therapeutic alliance with the patient
• to encourage the patient’s independence (Kibble et al. 2014). For example, the nurse may share thoughts and life experiences with a patient to show understanding of their situation.

Skills essential to therapeutic communication include active listening, broad openings, humour, sharing perceptions, clarifying, focusing, informing, paraphrasing, reflecting, restating, summarising, suggesting, therapeutic silence, and using open-ended statements and questions (Box 1). Paraphrasing involves restating a patient’s original message by transforming the message into the nurse’s own words without losing the meaning. Empathy in communication is achieved through the use of all the aforementioned skills. Empathy is being sensitive and understanding of a patient’s feelings and communicating this understanding to the patient. It differs from sympathy in that sympathy is nonobjective and noncritical. The nurse should be careful to not be judgmental, authoritative, or argumentative. To preserve confidentiality, nurses should not communicate about sensitive topics in front of the patient’s family or friends.

 

Box 1 Therapeutic communication techniques. (From Keltner N, Steele D 2015 Psychiatric Nursing, 7th edn. Mosby, St Louis.) Technique: Listening Definition: An active process of receiving information and examining one's reaction to messages received Example: Consider the cultural practice of your patient, maintain appropriate eye contact, and be receptive to nonverbal communications Therapeutic Value: Nonverbally communicates nurse’s interest and acceptance to patient Nontherapeutic Threat: Failure to listen, interrupting patient Technique: Broad openings Definition: Encouraging patient to select topics for discussion Example: ‘What are you thinking about?’ Therapeutic Value: Indicates acceptance by nurse and value of patient’s initiative Nontherapeutic Threat: Domination of interaction by nurse, rejecting responses Technique: Restating Definition: Repeating main thought patient has expressed Example: ‘You say that your mother left you when you were five years old’ Therapeutic Value: Indicates that nurse is listening and validates, reinforces, or calls attention to something that has been said Nontherapeutic Threat: Lack of validation of nurse’s interpretation of message, being judgmental, reassuring, offending Technique: Clarification Definition: Attempting to improve the nurse’s understanding of words, vague idea, or unclear thoughts of the patient or asking the patient to explain what they mean Example: ‘I’m not sure what you mean. Could you tell me again?’ Therapeutic Value: Helps to clarify the patient’s feelings, ideas, and perceptions and to provide an explicit connection between them and the patient’s actions Nontherapeutic Threat: Failure to probe, assumed understanding Technique: Reflection Definition: Directing back to the patient ideas, feelings, questions, or content Example: ‘You’re feeling tense and anxious and it’s related to a conversation you had with your father last night?’ Therapeutic Value: Validates nurse’s understanding of what patient is saying and signifies empathy, interest, and respect for patient Nontherapeutic Threat: Stereotyping patient’s responses, inappropriate timing of reflections, inappropriate depth of feeling of reflections, inappropriate to the culture and experience and educational level of the patient Technique: Humour Definition: Discharging of energy though comic enjoyment of the imperfect Example: ‘This gives a whole new meaning to “Just relax”’ Therapeutic Value: Can promote insight by making conscious repressed material, resolving paradoxes, tempering aggression, and revealing new options and is a socially acceptable form of sublimation Nontherapeutic Threat: Indiscriminate use, belittling patient, screen to avoid therapeutic intimacy Technique: Informing Definition: Demonstrating skills or giving information Example: ‘I think it would be helpful for you to know more about how your medication works’ Therapeutic Value: Helpful in patient education about relevant aspects of patient’s well-being and self-care Nontherapeutic Threat: Giving advice Technique: Focusing Definition: Asking questions or making statements that help patients expand on a topic of importance Example: ‘I think it would be helpful if we talk more about your relationship with your father’ Therapeutic Value: Allows patient to discuss central issues related to problem and keeps communication process goal directed Nontherapeutic Threat: Allowing abstractions and generalisations, changing topics Technique: Sharing perceptions Definition: Asking patient to verify nurse’s understanding of what patient is thinking or feeling Example: ‘You’re smiling, but I sense that you are really very angry with me’ Therapeutic Value: Conveys nurse’s understanding to patient and has potential for clearing up confusing communication Nontherapeutic Threat: Challenging patient, accepting literal responses, reassuring, taunting, offending Technique: Theme identification Definition: Clarifying underlying issues or problems experienced by patient that emerge repeatedly during nurse–patient relationship Example: ‘I’ve noticed that in all the relationships that you have described, you’ve been hurt or rejected by the man/woman.  Do you think this is an underlying issue?’ Therapeutic Value: Allows nurse to best promote patient’s exploration and understanding of important problems Nontherapeutic Threat: Giving advice, reassuring, disapproving Technique: Silence Definition: Using silence or nonverbal communication for a therapeutic reason Example: Sitting with patient and nonverbally communicating interest and involvement Therapeutic Value: Allows patient time to think and gain insights, slows the pace of the interaction, and encourages patient to initiate conversation, while conveying nurse support, understanding, and acceptance Nontherapeutic Threat: Questioning patient, asking for ‘why’ responses, failure to break a nontherapeutic silence Technique: Suggesting Definition: presenting of alternative ideas for patient’s consideration relative to problem solving Example: ‘Have you thought about responding to your boss in a different way when he raises that issue with you? For example, you could ask him whether a specific problem has occurred’ Therapeutic Value: Increases patient’s perceived options or choices Nontherapeutic Threat: Giving advice, inappropriate timing, being judgmental

Barriers to therapeutic communication include giving an opinion, offering false reassurance, being defensive, showing approval or disapproval, stereotyping, and asking ‘why?’ The use of ‘why’ questions causes increased defensiveness in a patient and hinders communication. The therapeutic nurse–patient relationship is goal directed, with the patient moving towards productive modes of interpersonal functioning.

Before communicating with the patient it is important for nurses to recognise their beliefs and values regarding the person and their family. This requires them to be mindful of the values and beliefs they hold. Understanding how their blueprint of behaviour may differ from the other person’s and how this may affect the therapeutic relationship is important. With this knowledge nurses can monitor their own behaviour, working towards better understanding and acceptance of others.

This stage (preorientation phase) allows nurses to discover information from the patient’s notes, the multidisciplinary team (MDT), and possibly family members. This information can enhance the communication between nurses and patients at the initial meetings. It may also enable nurses to make informed choices regarding the need to provide immediate care and to manage risk (Sharples 2013).

Three overlapping phases characterise the nurse–patient relationship: orientation, working, and termination:

1. The orientation phase involves learning about the patient and any initial concerns and needs. In the orientation phase, clarify your role and that of other healthcare personnel, establish rapport with the patient, collect information, establish goals, and clarify misunderstandings.
2. When the orientation phase is successful and the patient is ready, the nurse moves to the working phase to discuss, prioritise, and develop effective mutual goals.
3. The termination phase consists of evaluation and discussion of specific patient changes in thoughts and behaviours, summarising the progress towards prescribed goals. Prepare for termination generally at the beginning of the relationship. The nurse must communicate effectively with patients throughout all three phases of the nurse–patient relationship.

Cultural considerations

• Cultural sensitivity is critical to establishing a therapeutic relationship with patients:
  • for example, in some cultures, direct eye contact is disrespectful and therefore should be avoided
  • in some cultures, older people may not participate in their care decisions, believing that their children will make these decisions
  • nurses may face challenges when communicating with culturally and linguistically diverse patients. Effective communication is essential to improving health outcomes (Al Abed et. al 2014)
  • research shows that providing both general and disease-specific information to patients in a culturally sensitive manner improves chronic illness self-management
  • conversely, a language barrier prevents the delivery of timely health care, thereby worsening existing health problems and causing new health issues.
• The following factors are essential to effective care of culturally and linguistically diverse patients: 
  • appropriate linguistic services (e.g., interpreter or bilingual healthcare workers) and/or other communication strategies
  • a display of empathy and respect
  • an accurate health history for diagnostic and treatment purposes and health promotion and teaching
  • patient-centred communication behaviour, including the patient's part in all decision making about their care.
• It is also helpful to:
  • speak plainly
  • understand that members of certain cultures use cultural phrases or slang common to their culture and this is not an indication they do not understand English.
• When nurses communicate with patients of diverse cultures, an interpreter is sometimes necessary:
  • when using an interpreter, address the patient and family directly; do not direct questions or comments to the interpreter
  • take care to determine if the patient has understood
  • speak slowly in normal tones, and avoid overly technical jargon or terms unique to a culture (see Box 2).
• Adopt a flexible, respectful attitude that also communicates interest in the patient, bridging any communication barriers that exist because of cultural differences between patient and caregiver.
• When interacting with a community, culturally competent communication strategies use the language and the dialect of the community and use communication vehicles (e.g., preferred media outlets and familiar distribution sites) that are significant to the community served.
• Not all cultures express anxiety, anger, and depression in the same way as they are expressed in Western culture. Sometimes people present with somatic complaints, such as loss of appetite or poor sleep. In addition, some patients internalise anger and express it in somatic complaints of heat, indigestion, or tachycardia.

Communicating with children

• Communicating with children requires an understanding of feelings and thought processes from the child’s perspective (Hockenberry & Wilson 2015).
• Use vocabulary that is familiar to the child, based on the child’s level of understanding and appropriate to the child’s age and development. Try to be at eye level with the child.
• Understand the child’s cognitive, developmental, and functional level to select the most appropriate communication techniques. Some developmentally appropriate communication techniques include storytelling and drawing (Hockenberry & Wilson 2015).

Communicating with older people

• Be aware of any cognitive or sensory impairment. Assess each patient individually, and avoid stereotyping older people who have cognitive or sensory impairments.
• It is important to understand the value of good communication skills and the importance of the history and personality of older people in terms of providing both human and therapeutic responses. Regression to earlier defences is normal and adaptive in some of this group, particularly when facing illness.
• Make sure older patients with visual impairments use assistive devices such as eyeglasses and large-print reading material to aid in communication.

Care in a person's home

• Identify the primary caregiver for the patient, and adapt techniques to assess the level of understanding regarding the patient’s condition.
• Incorporate communication into the patient’s daily activities (e.g., bathing and dressing).

Preparation and safety

• Are you competent to provide this care? Should you summon an experienced colleague to help?
• Provide a quiet environment, maintain privacy, reduce distractions or interruptions, and meet the patient’s physical needs (e.g., comfort, pain relief, using the toilet as required) before beginning discussion.
• Assess the patient’s knowledge, needs, coping strategies, defences, and adaptation styles.
• Determine the patient’s need to communicate. Observe for nonverbal cues from the patient that they may want to communicate (e.g., frequent use of call bell, the patient appears overwhelmed).
• Assess personal barriers to communication with the patient (e.g., bias toward patient’s condition, nurse’s anxiety).
• Assess factors about self and patient that normally influence communication (Figure 1) (e.g., perceptions, values, and beliefs, socioeconomic background, age).
• Assess the patient’s hearing. Make sure their hearing aid is functional if worn and that the patient hears and understands words.
• Assess the patient’s language, ability to speak, and level of literacy:
  • Does the patient have difficulty finding words or associating ideas with accurate word symbols?
  • Does the patient have difficulty with expressions of language and/or reception of messages?
  • What is the patient’s primary language?
  • Does the patient skip over uncommon or hard words?
  • Does the patient avoid asking questions or have difficulty discussing concepts about illness?
  • Observe the patient’s communication – verbal or nonverbal behaviour (e.g., gestures, tone of voice, eye contact).

Procedure

Introduce yourself and check the patient’s identity, using the patient’s name-band and/or asking the patient's name, according to local policy.

Establishing the nurse–patient relationship during the orientation phase

1. Perform hand hygiene. 
2. Introduce yourself and check the patient’s identity, using the patient’s name-band and/or asking the patient's name, according to local policy.
3. Provide a brief explanation of the purpose of the interaction, to obtain the patient’s consent and cooperation.
4. Create a climate of warmth and acceptance.
5. Be aware of nonverbal cues that are both sent and received.
6. Provide comfort and support to the patient.
7. Use appropriate nonverbal behaviours (e.g., good eye contact, open relaxed position, sitting at eye level with the patient).
   Rationale – Facilitates communication by showing interest in what the patient has to say.
8. Observe the patient’s nonverbal behaviours, including body language. If the patient’s verbal behaviours do not match their nonverbal behaviours, seek clarification.
   Rationale – Congruence between the patient’s verbal and nonverbal behaviours ensures the correct message is received.
9. Explain the purpose of the interaction when information is to be shared.
   Rationale – Information and explanation can decrease anxiety about the unknown.
10. Use active listening.
    Rationale – Conveys an interest in the patient’s needs, concerns, and problems; conveys empathy.
11. Identify the patient’s expectations in seeking health care.
    Rationale – Conveys a level of interest in the patient’s needs.
12. Sensitively ask the patient about their health status, lifestyle, support systems, patterns of health and illness, and strengths and limitations.
    Rationale – Facilitates a positive nurse–patient relationship and facilitates the development of trust, putting the patient at ease.
13. Encourage the patient to ask for clarification at any time during the communication.
    Rationale – Gives the patient a sense of control and keeps the channels of communication open.
14. Use therapeutic communication techniques when interacting with the patient (Box 1).
    Rationale – Techniques establish a greater understanding of messages sent and received.

Setting mutual goals during the working phase

1. Use therapeutic communication skills such as restating, reflecting, and paraphrasing to identify and clarify strategies for attainment of mutually agreed upon goals.
   Rationale – Effective communication ensures clear understanding by the patient and improves the patient’s ability to participate in care (Nørgaard et al. 2012).
2. Discuss and prioritise problem areas.
   Rationale – A patient, nonjudgmental, supportive approach minimises the patient’s anxiety.
3. Provide information to the patient and help the patient express needs and feelings.
   Rationale – The patient is able to respond to help, develop workable solutions based on goals, and fully participate in a realistic plan for their well-being.
4. Ask questions carefully and appropriately:

1. ask one question at a time, and allow sufficient time to answer
2. use direct questions
3. use open-ended statements as much as possible, such as ‘Tell me about how you are feeling today.’
   Rationale – Assists the patient in expressing themselves and allows the nurse to obtain thorough information about the patient’s needs and concerns.

Communicating with the patient during the termination phase

1. Use effective communication skills to discuss discharge and termination issues and to guide discussion related to specific changes in the patient’s thoughts and behaviours.
   Rationale – Communication skills reinforce behaviours and skills learned during the working phase of the relationship.
2. Summarise and restate with the patient what was discussed during interaction, including goal achievement.
   Rationale – Signals the close of the interaction and allows the nurse and patient to depart with the same idea. Provides a sense of closure and mutual understanding.

Ongoing care, monitoring and support

• Observe the patient’s verbal and nonverbal responses to the communication, and the patient’s willingness to share information and concerns during the orientation phase.
  Rationale – Both verbal and nonverbal feedback reveal the patient’s interest and willingness to communicate and reflect the patient’s ability to form a therapeutic relationship with the nurse.
• During the working phase, reflect on the nurse’s and patient’s responses that indicate the effectiveness of therapeutic techniques used in establishing rapport with the patient.
  Rationale – Sensitivity to your own therapeutic communication skills helps improve your ability to adjust techniques when necessary.
• During the working phase, evaluate the patient’s ability to work towards identified goals:
  • elicit feedback (verbal and nonverbal) to determine the success of goal attainment
  • evaluate the patient’s health status in relation to identified goals
  • re-evaluate and identify barriers if the patient’s goals are not met.  
    Rationale – Feedback is an essential step in evaluating new behaviours. Modifications are necessary if goals cannot be met.
• During the termination phase, use communication skills such as summarising and restating to reinforce the patient’s strengths, outline issues still requiring work, and develop an action plan. 
Rationale – This evaluates patient progress in terms of the attainment of mutually agreed upon goals.


Documentation and reporting

Document the communication pertinent to the patient’s health to include:
• Response to illness or therapies.
• Responses that demonstrate understanding or lack of understanding (include verbal and nonverbal cues).
• Any relevant information obtained through the patient’s verbal and nonverbal behaviours.