Understanding Therapeutic Communication in Nursing

Learning Objectives After completing this class, the learner will be able to Define the concept and purpose of therapeutic communication. Provide examples of techniques that promote therapeutic communication. Identify barriers to effective communication. And distinguish between effective and ineffective communication techniques. Therapeutic communication is the method of communication to develop a therapeutic nurse-patient relationship. So what does it involve? The nurse must demonstrate compassion, empathy, and respect in relating to clients, professional colleagues, and self. demonstrate the therapeutic use of self, demonstrate presence, attending, listening, respect, genuineness, and empathy, and recognize the potential for conflict and develop skills in conflict resolution. When it comes to therapeutic communication and the therapeutic nurse-patient relationship, knowing isn't doing. Only doing is doing. And that means that you have to practice your skills. One method of practicing and evaluating your progress in the development of therapeutic communication is to do process recordings. For those interested in doing process recordings, come and see me. The therapeutic nurse patient relationship is a mutual learning experience. From a more advanced perspective, the nurse patient relationship can actually be viewed through the lens of an almost developmental model. When you and your patient first meet, you're essentially both strangers to each other. you We often work with patients who are sick and they don't know how to navigate that relationship well in the beginning. Nurses do a lot of scaffolding and there are phases to this relationship where we help guide our patient in their actions. We help them to learn what behaviors are appropriate and inappropriate within this professional relationship where we are the nurse and they are the patient. And you can actually view the patient now. navigate the relationship better as they get better. And so it's also informative. It's not just a mutual learning experience. It is a corrective emotional experience for the patient. It is based on the humanity and dignity of both the nurse and the patient. It includes mutual respect and acceptance of sociocultural differences. And the nurses use their personal and professional attributes. and clinical techniques in the formation of this nurse-patient relationship, ultimately with a guide to promote insight and behavior change in the patient. Self-realization, self-acceptance, and self-respect. A clear sense of personal identity and integration. We have a goal for our patients that they be able to form intimate, interpersonal relationships with others. capacity to give and receive support, improved functioning and ability to satisfy needs, and achieve realistic personal goals. These are all long-term goals for our patients and we achieve these goals by using therapeutic communication. and forming a therapeutic nurse-patient relationship. Achieving therapeutic goals. When achieving goals with your patients, and in order to do that, we have to explore various aspects of the patient's life experiences, allow the patient to express their thoughts, feelings, and emotions, observe and relate behaviors to thoughts, clarify areas of conflict and anxiety, identify and maximize the patient's ego strengths and encourage socialization and family relatedness. For help in doing this please refer to the handouts that are provided to you. There are pages that describe strengths and weaknesses, specifically ego strengths, and also there is a section that describes cognitive distortions and being aware of what kind of cognitive distortions you're seeing in your patient is going to help you help the patient relate their thoughts to their behavior. Therapeutic communication. Know yourself. In order to be therapeutic with the patient, you first and foremost have to know and be aware of your own personal biases. And to do this, you can perform some self-awareness exercises. There are some questions you can ask yourself, like what are your personal expectations about yourself and your own nursing practice? How does your family view mental illness? How does your family treat people? with mental illness? Are there any members of your family who are mentally ill? How is this discussed and dealt with in your family? We also have to be aware of our everyday language. How often do we say words like crazy, psycho, insane, loco? These are things to be aware of. Do friends, family members, or even have you yourself received mental health care? These are things to think about and be aware of. With therapeutic communication and knowing yourself, know that the most important tool in psychiatric nursing is the self. And we'll discuss later a little bit more about the therapeutic use of self and what that means. Personal qualities of the nurse. We have to take a look and clarify our own values when it comes to nursing. Also, we can explore our feelings and spend some time in introspection. We have to think about serving as a role model. being altruistic and also reflect on ethics and responsibility. The American Association of Colleges of Nursing have a list of core values and I think it's valuable if you're going to be clarifying your own values. that you hold as a nurse. These are a valuable list, and they include human dignity, integrity, autonomy, altruism, and social justice. What does it mean to provide care? care to a patient. What do we offer? What is a therapeutic milieu? In the therapeutic milieu, in the environment where we provide care, there are certain things that we offer to our patients. One of them is containment, where we're keeping them physically safe. We're providing structure, food, shelter, limit setting, minimization of harm. We also offer support. We help people feel better. We offer enhancement of self-esteem, patient comfort. we recognize needs, we give limited advice, we offer education and praise. There's also the concept of involvement, where we encourage the patient to participate in their care, we frame involvement from the beginning of their admission, we offer community groups, other forms of groups. There's also the concept of validation, affirm the patient's feelings and emotions and allow expression of sadness. Now, not every therapeutic milieu can offer every single kind of these concepts well. Some milieus are better at focusing at one. For example, a state hospital is going to focus most on containment. But here at Harbor, you know, we are not a state hospital. We offer more than just containment and limit setting. We can offer support and involvement and validation. Maybe not every single thing all at the same time. But I think... to do it well. We've got to be self-aware and we have to be aware of our own concept of caring, what we think it means to be a nurse, what we think it means to provide care to our patients. And it all goes back to what our thoughts are about human dignity, integrity, autonomy, altruism, social justice, respect for self, respect for others. Being a role model. Nurses have an obligation to model adaptive and growth-producing behavior. Effective nurses approach life with a sense of growing, hopefulness, and being adaptive. Chaos, conflict, distress, or denial in the nurse's personal life will decrease the effectiveness of the care they provide to patients. Facilitative communication. All behavior is communication. We have verbal communication, spoken or written words, but much of our communication is nonverbal, maybe upwards of 70%. This includes vocal cues, actions, facial gestures, body position, use of space and touch. We also need to be aware of the communication process, whether the communication is moving from the person communicating to the person receiving. Also, whether communication is congruent or incongruent with body language. For example, if a patient says, I'm fine, that's a lot different than a patient like this saying, I'm fine. So you can write in your charting, patient said, I'm fine, but without describing the body language, other people are not going to get the full picture of what occurred. There are two basic requirements for therapeutic communication. communication. One, preserve the dignity of each individual, both yourself and the patient. And two, offer acceptance before suggestions. There are many different therapeutic communication techniques. Please see the handout that we've given you. It provides very good and specific examples of each kind. But here I'll label them. Active listening, broad openings, restating, clarification, reflection, validation, focusing, and sharing perceptions, theme identification, silence, humor, informing, suggesting. Also avoid why and closed-ended questions. When you ask a patient why, it's almost accusatory. Kind of implies that the patient has done something wrong. Instead of asking why, try to use how. Say something like, how did that come about? Instead of, why did you do X, Y, Z? Closing the question, try to use how. Closed-ended questions shut down a conversation, where an open-ended question gives the patient the opportunity to really speak and express themselves and give you lots of data. There may be times when you use a closed-ended question, for example, if you need to talk need to shut down the conversation. Maybe a patient is hyperverbal or is very tangential or circumstantial and they're not getting to the point. But most of the time, we're going to use open-ended questions. When using therapeutic communication techniques in the clinical arena, listening is the foundation of what we do. Sometimes, you know, we don't know exactly what to say or we're afraid that we're going to say the wrong thing. Whenever you're in doubt, the go-to is listening. Also, one really good technique is restating a part of what the patient just said to you. It gives an opportunity for the patient to clarify whether or not you really understood what they said. It also gives you the opportunity to clarify vague ideas or thoughts. And we can also reflect and validate the patient's behavior and feelings. One question that frequently pops up from clinicians is, what do I do if I have a problem with my body? if I have a patient who's hallucinating or who is delusional. Certainly I don't validate a hallucination or a delusion. And the answer here is to look past the content and go to the feeling of the hallucination or delusion. We can always validate feelings. I'll give you an example. If the patient is seeing something that's really frightening to them, a question we should ask is, are you scared by what you see? If the patient is scared, that's when we step into it. help them. We can talk to them about how we're going to keep them safe. We can ask if they want to move to a different area or a quieter room or a darker room. So we're not validating the hallucination or a delusion. We're going right to the feeling. Is the feeling scary? Is the feeling distressing? Maybe the feeling isn't distressing. Maybe the feeling is comforting. That's data that we need to get. When we're working with our patients and when we're using these techniques, we need to use the appropriate techniques. appropriate depth of feeling. What does that mean? It means if you're having really big feelings when working with your patient, that's data that you need to look at and be aware of. If you're really angry or upset with the patient, maybe this is projective identification. Maybe you're feeling a small iota of what the patient is feeling to a much larger extent, something to be aware of. Also, use focusing and refocusing to help your patient come back to the point. of what they were saying. Again, check in with your patient, share your perceptions of what they said, and ask the patient to verify that your perceptions are correct. This is meaningful for a number of ways. Number one, it's helping you get more accurate data, but it's also showing the patient that you really care, that what they say matters, and that you care enough to try to be as accurate as possible in understanding them. Also, help your patient to identify themes by noting underlying issues or problems. Use silence. Silence is meaningful and it can be a really useful technique for nurses. I'll give you an example. For patients who demonstrate catatonia, people who are selectively mute, What underlies catatonia is often something called pathological ambivalence. They are so anxious that they can't make a decision. They can't even make the decision to talk, to speak to you. So what are your interventions? What kind of therapeutic communication can you use? with someone who's having trouble talking? The answer is silence. Just sitting with your patient for five minutes a day can do a lot for that person. Number one, it can take the anxiety and pressure off their shoulders. shoulders because they know that you're going to sit with them and they don't have to talk. But it also shows that you care, that they mean something to you, and that you're willing to work with them and sit with them and be with them even if they're not able to talk to you. It's a very effective intervention. Use humor. Humor is a constructive coping behavior. A lot of times we use humor towards the end of the therapeutic nurse-patient relationship when patients are better. I would be careful in using humor because you need to know that the patient knows that you're laughing with them and not at them. And that's something that you can know as you progress through the therapeutic nurse-patient relationship. Be consistent with your social and cultural values. Help the patient to develop insight. and you want to use these techniques to help decrease tension and anxiety. You don't want to mask your feelings, but you do want to be aware of the feelings that you are having. And don't succumb to the feelings that you are having. to patient behaviors that are designed to push you away. You don't want to increase social distance. You don't want to allow avoidance or ridicule of the patient. And note when you see behaviors that are designed to push you away, you have to fight those. You have to try to break through those behaviors and connect with that patient in some way and form that nurse-patient relationship because that's how you get good outcomes. You want to limit repetitive, direct questions, especially the why, and also understand that these patients probably have had the same questions over and over again, and it's okay to validate that. We do inform. You want to give relevant information to your patient, especially information about navigating the county system, navigating an inpatient admission. But when it comes to personal information, that's where you want to be careful. So here's another question we get. What kind of personal information is it okay to share? share with a patient. For example, if a patient says, are you married? How long have you been working here? Or do you have children? Is it okay to answer those questions? I would say it depends. So one technique that you can use when sharing that kind of personal information, you got to know what it means to the patient before you give them the answer. And I'll tell you why. It could be used against you. If the patient says, are you married? you married? And you say no. What if the patient turns around and says, well, I am, and I don't think you'll ever understand my feelings or my position on this issue because you're not, right? So you got to know what the patient is going to do with your answer before you give it. So one thing you can say to the patient is, you know, I'll answer that question, but I'd like to know what it means to you if I'm married or have children or how long I've worked here, etc., etc. Ask them. Ask them what it means to them if you give them that information. This does a couple things. It sets a limit with the patient and it also kind of ensures that they won't be that intrusive in the future. They're not going to do it if they have to work for it. Suggestions. Suggestions can be therapeutic or non-therapeutic. It's probably best to get the patient to answer the question themselves. A lot of times they already know the answer to the hard questions. They just need permission to answer. themselves and you can give them that permission. Communicate your understanding and validate their feelings before giving suggestions or advice. And communication should preserve the self-respect and dignity of both individuals. If you're upset, you need to step back and wait until you can go on and have this conversation calmly. There's a difference between effective communication techniques and ineffective communication techniques. So, you know, we've spoken a little bit about the therapeutic communication techniques, like using a broad opening, et cetera, et cetera. But let's jump right into ineffective communication. Ineffective communication techniques include advising, agreeing, belittling, challenging, arguing, defending, disagreeing, disapproving, giving too much approval, changing the subject, reassuring, requesting an explanation. Thank you. There are some times when you might change a subject that's called a risky shift and we do it if patients are super hyperverbal and we need to direct them back. But most of the time these techniques are ineffective and they're going to result in not a great outcome. Phases of the relationship. In the nurse-patient relationship there are phases. You begin with the pre-interaction where you don't know each other and pre-interaction also involves the nurse's self-awareness and self-exploration. There are also fears that need to be addressed, fears of the patient, fears that it won't go well when you speak with them. This is all part of the pre-interaction phase. Then there's the introduction phase where you get to know the patient and you're orienting them to the unit and to the nurse-patient relationship. Now remember, this is a professional relationship where you are the nurse and they are the patient. And this needs to be made known right from the beginning because you don't want the relationship going into inappropriate territory. So we're going to do some limiting. setting in the introductory introductory phase. Then we have the working phase where we're exploring the patient's life events, what's going on with them, what they're feeling. During the working phase, we're helping them to express their thoughts, feelings, and emotions. We're helping them relate to their patients. their cognitive distortions to behaviors that have had poor outcomes in their life. And we're also helping them navigate our system from getting here to planning for discharge. there's the termination phase. This is also important and it's something that has to be talked about because this relationship is something that they can use as a springboard. They can use, if they successfully navigate the nurse-patient relationship, they can use that to springboard to other relationships, but they can't be coming back to you personally. They can't be, you know, knocking on our door and requesting to see you personally again. And so you have to talk about the termination phase. You have to talk about the nurse-patient relationship. And I would present it as a positive thing. And again, you know, if they can have a successful therapeutic relationship with you as a clinician, they can do it again. And they will if they have outpatient follow-up. So this is a good thing. Let's talk a little bit about the pre-interaction phase. So the initial tasks are self-exploration, self-analysis, challenges. of the psychiatric setting can cause stress and fear for both people. The patient may be afraid of a psychiatric admission. You may also be afraid. There can be fears of inadequacy related to inexperience, fears of saying the wrong thing, being afraid of unpredictable situations or aggressive behavior, questioning your own mental health status, analyzing strengths and limitations of both people. thoughts about gathering data about the patient, and also planning for your first interaction. And remember that your fears are often overblown. We have a fear that things are going to go worse than they actually do. In the introductory and orientation phase, we need to find out why the patient sought help. We're going to be exploring their feelings, identifying problems, and this is when we really establish trust, understanding, acceptance, and kind of open the doors to communication. We want to establish a goal with the patient. And I would recommend in this introductory phase, when you're first interviewing the patient during their admission, one of the first things you should say to them or ask them is, what do you hope to get out of this admission? What do you hope to get out of being here? And I would say this. Some other clinicians here say things like, what can we do for you? That's passive because it puts the onus on the professional and not on the patient. I think. think when you ask the patient what do you hope to get out of being here you're putting the ball in their court and you are helping them understand that they are expected to be active in their care planning from the very beginning you also want to formulate goals maybe you know a safety contract explain roles talk about confidentiality responsibilities of the patient responsibilities of the nurse and clarify the expectations of the nurse and the patient The working phase. The working phase of the nurse-patient relationship is where the nurse and patient explore stressors. You're providing a lot of guidance and kind of scaffolding for the patient. What I mean by scaffolding is that you are helping the patient, but you're not completely containing and directing all of their behavior, but you're assisting them. The working phase is where you promote the development of... insight by helping the patient link perceptions, thoughts, feelings, and emotions to their actions, and this is really important. We want to translate the insight that they have into action and behavior change. We want to help the patient be aware of and work on their anxieties, increase the amount of responsibility on the patient, and help them develop constructive coping mechanisms. And you do that by talking to the patient about the adaptive coping mechanisms that they use. We want to list their strengths and weaknesses in our charting because we want to help other clinicians who care for them also understand what works for them and what doesn't work for them. A standoff, impasse, or plateau may develop if the patient resists moving forward. During the termination phase, learning is maximized because there are higher levels of trust and intimacy between the nurse and the patient and also the patient's ability to move forward. And also, the patient fits in. physically and mentally is better by this point. They're getting well. They're almost ready for discharge. There is an exchange of feelings and memories to evaluate the patient progress, whether they've met their goals. You want to establish the reality. of separation and explore feelings of rejection, loss, sadness, or anger. If they've done well with you, this may be the first really successful interchange and relationship they've had with someone for a while. A lot of our patients... burn bridges with people. And this is something that it's okay to talk about. At this time, you know, referrals need to be made for continued care or treatment. We want to be aware of the discharge plan. We want to make sure that we talk about the patient following up in the community and how that's important and how they can use the relationship they've had with you, again, as a jumping off point to do it again with follow-up care. Recognizing therapeutic communication techniques. Say the patient says, on admission, I don't know where to start. The nurse says, tell me about what's been on your mind recently. Which technique is this? A broad opening, reflection, sharing a perception, a suggestion. The answer is A, number one, broad opening. Addressing conflict. In order to address conflict in your setting or with your patient, you You have to assess your own personal responses to conflict. Be aware of what you feel. Anger, humiliation, annoyance, antagonism, bitterness, defensiveness. How do you react to these feelings? Embarrassment, frustration, feelings of inferiority, intimidation, resentment, devaluation. This is where you spend some time in introspection and step back and take a look. So how do you address conflict? How do you address these big feelings when you have them. How do you manage your own anxiety and fear? Cool off. Wait until you can speak calmly and in a friendly tone. Take deep breaths. Make positive statements before you continue. Remember that anticipation is often worse than the outcome. And diffuse your own anger before confronting the patient. And also, you don't have to do this alone. Go to your team. Talk to your team about how you're feeling. Ask for help from your team if you need it. Put the situation into perspective. Don't play the blame game and pick your battles. Use your therapeutic communication skills and techniques. Remember that a lot of what you're feeling is really good data. It tells you a lot about what's going on with the patient. Remember to use clear and congruent communication. If you have your arms crossed and you have an angry look on your face, but you're trying to communicate professionally, you're going to be sending a mixed signal to your patient. Take one issue at a time. Generate options for resolution. In conclusion, always listen to learn. Clinical vignette. MJ is a 40-year-old Caucasian male who was admitted to the inpatient psychiatric unit after a brief but serious depressive episode. The patient had recently lost his job and was experiencing intrusive thoughts, rumination, and suicidal ideation with plan. The patient denied intent to harm himself. on the unit. The patient was eager for follow-up care as an outpatient. Role play. I noticed you seem to be apprehensive today. Is something on your mind you'd like to talk about? Dr. Smith said I could go home today and, well, I'm not sure that's such a good idea. The thought of being discharged is making you uneasy. Could you tell me a little bit more about that? It's difficult to talk about, but since I've had this bout with depression, I don't feel like I feel like a failure at home. The idea of returning to your home roles, being a husband and father, seems a little overwhelming? A little, I guess. I'll need to take it slow and need to have people to talk to. Clinical vignette two. CT is a 21-year-old Asian-American male who presented to an outpatient behavioral health center for debilitating panic attacks. The patient repeatedly had panic attacks in public places, and his anxiety was impacting both his personal and professional life. I'm really confused. The doctor says that medication, therapy, or a combination of the two can help me with my anxiety. I can't decide whether to try the medicine or just do the therapy. Medications have side effects, and therapy is a huge time commitment. You're uneasy about taking medications and afraid you won't have time to devote to therapy sessions. Yeah, I guess, but my anxiety is really bad. I can't even function. You have to choose between some alternatives. all of which have pros and cons. It's not an easy situation, but that seems to be the reality right now. You're right. There's no getting around it. I might as well stop feeling sorry for myself and get some more information. Can you tell me more about the anxiety medication the doctor mentioned? Let's evaluate the technique. And I'd even encourage you to try these role play scenarios with your colleagues. If you do that, and when you do this, look at your body language. Try to identify the tone. Look at the techniques. Active listening, broad openings, restating, clarification, reflection, etc. Were there any techniques that seemed effective, ineffective? and ask for constructive criticism from your colleagues. I hope you found the information in this video helpful. Therapeutic communication can help you give better care to your patients and can give you some insight into yourself. For more information on therapeutic communication or process recording, contact Stephanie Arnold or Debbie Rhodes or myself are more than happy to provide any educational material to you. You just need to ask. Thank you.

So what does it involve? The nurse must demonstrate compassion, empathy, and respect in relating to clients, professional colleagues, and self. demonstrate the therapeutic use of self, demonstrate presence, attending, listening, respect, genuineness, and empathy, and recognize the potential for conflict and develop skills in conflict resolution.

When it comes to therapeutic communication and the therapeutic nurse-patient relationship, knowing isn't doing. Only doing is doing. And that means that you have to practice your skills. One method of practicing and evaluating your progress in the development of therapeutic communication is to do process recordings.

For those interested in doing process recordings, come and see me. The therapeutic nurse patient relationship is a mutual learning experience. From a more advanced perspective, the nurse patient relationship can actually be viewed through the lens of an almost developmental model.

When you and your patient first meet, you're essentially both strangers to each other. you We often work with patients who are sick and they don't know how to navigate that relationship well in the beginning. Nurses do a lot of scaffolding and there are phases to this relationship where we help guide our patient in their actions. We help them to learn what behaviors are appropriate and inappropriate within this professional relationship where we are the nurse and they are the patient.

And you can actually view the patient now. navigate the relationship better as they get better. And so it's also informative.

It's not just a mutual learning experience. It is a corrective emotional experience for the patient. It is based on the humanity and dignity of both the nurse and the patient. It includes mutual respect and acceptance of sociocultural differences.

And the nurses use their personal and professional attributes. and clinical techniques in the formation of this nurse-patient relationship, ultimately with a guide to promote insight and behavior change in the patient. Self-realization, self-acceptance, and self-respect. A clear sense of personal identity and integration. We have a goal for our patients that they be able to form intimate, interpersonal relationships with others.

capacity to give and receive support, improved functioning and ability to satisfy needs, and achieve realistic personal goals. These are all long-term goals for our patients and we achieve these goals by using therapeutic communication. and forming a therapeutic nurse-patient relationship.

Achieving therapeutic goals. When achieving goals with your patients, and in order to do that, we have to explore various aspects of the patient's life experiences, allow the patient to express their thoughts, feelings, and emotions, observe and relate behaviors to thoughts, clarify areas of conflict and anxiety, identify and maximize the patient's ego strengths and encourage socialization and family relatedness. For help in doing this please refer to the handouts that are provided to you. There are pages that describe strengths and weaknesses, specifically ego strengths, and also there is a section that describes cognitive distortions and being aware of what kind of cognitive distortions you're seeing in your patient is going to help you help the patient relate their thoughts to their behavior. Therapeutic communication.

Know yourself. In order to be therapeutic with the patient, you first and foremost have to know and be aware of your own personal biases. And to do this, you can perform some self-awareness exercises. There are some questions you can ask yourself, like what are your personal expectations about yourself and your own nursing practice?

How does your family view mental illness? How does your family treat people? with mental illness? Are there any members of your family who are mentally ill? How is this discussed and dealt with in your family?

We also have to be aware of our everyday language. How often do we say words like crazy, psycho, insane, loco? These are things to be aware of. Do friends, family members, or even have you yourself received mental health care? These are things to think about and be aware of.

With therapeutic communication and knowing yourself, know that the most important tool in psychiatric nursing is the self. And we'll discuss later a little bit more about the therapeutic use of self and what that means. Personal qualities of the nurse.

We have to take a look and clarify our own values when it comes to nursing. Also, we can explore our feelings and spend some time in introspection. We have to think about serving as a role model.

being altruistic and also reflect on ethics and responsibility. The American Association of Colleges of Nursing have a list of core values and I think it's valuable if you're going to be clarifying your own values. that you hold as a nurse. These are a valuable list, and they include human dignity, integrity, autonomy, altruism, and social justice. What does it mean to provide care?

care to a patient. What do we offer? What is a therapeutic milieu?

In the therapeutic milieu, in the environment where we provide care, there are certain things that we offer to our patients. One of them is containment, where we're keeping them physically safe. We're providing structure, food, shelter, limit setting, minimization of harm. We also offer support. We help people feel better.

We offer enhancement of self-esteem, patient comfort. we recognize needs, we give limited advice, we offer education and praise. There's also the concept of involvement, where we encourage the patient to participate in their care, we frame involvement from the beginning of their admission, we offer community groups, other forms of groups. There's also the concept of validation, affirm the patient's feelings and emotions and allow expression of sadness.

Now, not every therapeutic milieu can offer every single kind of these concepts well. Some milieus are better at focusing at one. For example, a state hospital is going to focus most on containment.

But here at Harbor, you know, we are not a state hospital. We offer more than just containment and limit setting. We can offer support and involvement and validation.

Maybe not every single thing all at the same time. But I think... to do it well.

We've got to be self-aware and we have to be aware of our own concept of caring, what we think it means to be a nurse, what we think it means to provide care to our patients. And it all goes back to what our thoughts are about human dignity, integrity, autonomy, altruism, social justice, respect for self, respect for others. Being a role model.

Nurses have an obligation to model adaptive and growth-producing behavior. Effective nurses approach life with a sense of growing, hopefulness, and being adaptive. Chaos, conflict, distress, or denial in the nurse's personal life will decrease the effectiveness of the care they provide to patients.

Facilitative communication. All behavior is communication. We have verbal communication, spoken or written words, but much of our communication is nonverbal, maybe upwards of 70%.

This includes vocal cues, actions, facial gestures, body position, use of space and touch. We also need to be aware of the communication process, whether the communication is moving from the person communicating to the person receiving. Also, whether communication is congruent or incongruent with body language.

For example, if a patient says, I'm fine, that's a lot different than a patient like this saying, I'm fine. So you can write in your charting, patient said, I'm fine, but without describing the body language, other people are not going to get the full picture of what occurred. There are two basic requirements for therapeutic communication. communication.

One, preserve the dignity of each individual, both yourself and the patient. And two, offer acceptance before suggestions. There are many different therapeutic communication techniques.

Please see the handout that we've given you. It provides very good and specific examples of each kind. But here I'll label them. Active listening, broad openings, restating, clarification, reflection, validation, focusing, and sharing perceptions, theme identification, silence, humor, informing, suggesting.

Also avoid why and closed-ended questions. When you ask a patient why, it's almost accusatory. Kind of implies that the patient has done something wrong.

Instead of asking why, try to use how. Say something like, how did that come about? Instead of, why did you do X, Y, Z? Closing the question, try to use how. Closed-ended questions shut down a conversation, where an open-ended question gives the patient the opportunity to really speak and express themselves and give you lots of data.

There may be times when you use a closed-ended question, for example, if you need to talk need to shut down the conversation. Maybe a patient is hyperverbal or is very tangential or circumstantial and they're not getting to the point. But most of the time, we're going to use open-ended questions. When using therapeutic communication techniques in the clinical arena, listening is the foundation of what we do. Sometimes, you know, we don't know exactly what to say or we're afraid that we're going to say the wrong thing.

Whenever you're in doubt, the go-to is listening. Also, one really good technique is restating a part of what the patient just said to you. It gives an opportunity for the patient to clarify whether or not you really understood what they said.

It also gives you the opportunity to clarify vague ideas or thoughts. And we can also reflect and validate the patient's behavior and feelings. One question that frequently pops up from clinicians is, what do I do if I have a problem with my body?

if I have a patient who's hallucinating or who is delusional. Certainly I don't validate a hallucination or a delusion. And the answer here is to look past the content and go to the feeling of the hallucination or delusion.

We can always validate feelings. I'll give you an example. If the patient is seeing something that's really frightening to them, a question we should ask is, are you scared by what you see? If the patient is scared, that's when we step into it. help them.

We can talk to them about how we're going to keep them safe. We can ask if they want to move to a different area or a quieter room or a darker room. So we're not validating the hallucination or a delusion. We're going right to the feeling. Is the feeling scary?

Is the feeling distressing? Maybe the feeling isn't distressing. Maybe the feeling is comforting.

That's data that we need to get. When we're working with our patients and when we're using these techniques, we need to use the appropriate techniques. appropriate depth of feeling.

What does that mean? It means if you're having really big feelings when working with your patient, that's data that you need to look at and be aware of. If you're really angry or upset with the patient, maybe this is projective identification.

Maybe you're feeling a small iota of what the patient is feeling to a much larger extent, something to be aware of. Also, use focusing and refocusing to help your patient come back to the point. of what they were saying.

Again, check in with your patient, share your perceptions of what they said, and ask the patient to verify that your perceptions are correct. This is meaningful for a number of ways. Number one, it's helping you get more accurate data, but it's also showing the patient that you really care, that what they say matters, and that you care enough to try to be as accurate as possible in understanding them. Also, help your patient to identify themes by noting underlying issues or problems.

Use silence. Silence is meaningful and it can be a really useful technique for nurses. I'll give you an example. For patients who demonstrate catatonia, people who are selectively mute, What underlies catatonia is often something called pathological ambivalence.

They are so anxious that they can't make a decision. They can't even make the decision to talk, to speak to you. So what are your interventions?

What kind of therapeutic communication can you use? with someone who's having trouble talking? The answer is silence.

Just sitting with your patient for five minutes a day can do a lot for that person. Number one, it can take the anxiety and pressure off their shoulders. shoulders because they know that you're going to sit with them and they don't have to talk. But it also shows that you care, that they mean something to you, and that you're willing to work with them and sit with them and be with them even if they're not able to talk to you.

It's a very effective intervention. Use humor. Humor is a constructive coping behavior.

A lot of times we use humor towards the end of the therapeutic nurse-patient relationship when patients are better. I would be careful in using humor because you need to know that the patient knows that you're laughing with them and not at them. And that's something that you can know as you progress through the therapeutic nurse-patient relationship. Be consistent with your social and cultural values. Help the patient to develop insight.

and you want to use these techniques to help decrease tension and anxiety. You don't want to mask your feelings, but you do want to be aware of the feelings that you are having. And don't succumb to the feelings that you are having. to patient behaviors that are designed to push you away.

You don't want to increase social distance. You don't want to allow avoidance or ridicule of the patient. And note when you see behaviors that are designed to push you away, you have to fight those. You have to try to break through those behaviors and connect with that patient in some way and form that nurse-patient relationship because that's how you get good outcomes.

You want to limit repetitive, direct questions, especially the why, and also understand that these patients probably have had the same questions over and over again, and it's okay to validate that. We do inform. You want to give relevant information to your patient, especially information about navigating the county system, navigating an inpatient admission.

But when it comes to personal information, that's where you want to be careful. So here's another question we get. What kind of personal information is it okay to share?

share with a patient. For example, if a patient says, are you married? How long have you been working here?

Or do you have children? Is it okay to answer those questions? I would say it depends. So one technique that you can use when sharing that kind of personal information, you got to know what it means to the patient before you give them the answer.

And I'll tell you why. It could be used against you. If the patient says, are you married? you married? And you say no.

What if the patient turns around and says, well, I am, and I don't think you'll ever understand my feelings or my position on this issue because you're not, right? So you got to know what the patient is going to do with your answer before you give it. So one thing you can say to the patient is, you know, I'll answer that question, but I'd like to know what it means to you if I'm married or have children or how long I've worked here, etc., etc.

Ask them. Ask them what it means to them if you give them that information. This does a couple things.

It sets a limit with the patient and it also kind of ensures that they won't be that intrusive in the future. They're not going to do it if they have to work for it. Suggestions.

Suggestions can be therapeutic or non-therapeutic. It's probably best to get the patient to answer the question themselves. A lot of times they already know the answer to the hard questions.

They just need permission to answer. themselves and you can give them that permission. Communicate your understanding and validate their feelings before giving suggestions or advice.

And communication should preserve the self-respect and dignity of both individuals. If you're upset, you need to step back and wait until you can go on and have this conversation calmly. There's a difference between effective communication techniques and ineffective communication techniques.

So, you know, we've spoken a little bit about the therapeutic communication techniques, like using a broad opening, et cetera, et cetera. But let's jump right into ineffective communication. Ineffective communication techniques include advising, agreeing, belittling, challenging, arguing, defending, disagreeing, disapproving, giving too much approval, changing the subject, reassuring, requesting an explanation.

Thank you. There are some times when you might change a subject that's called a risky shift and we do it if patients are super hyperverbal and we need to direct them back. But most of the time these techniques are ineffective and they're going to result in not a great outcome.

Phases of the relationship. In the nurse-patient relationship there are phases. You begin with the pre-interaction where you don't know each other and pre-interaction also involves the nurse's self-awareness and self-exploration.

There are also fears that need to be addressed, fears of the patient, fears that it won't go well when you speak with them. This is all part of the pre-interaction phase. Then there's the introduction phase where you get to know the patient and you're orienting them to the unit and to the nurse-patient relationship.

Now remember, this is a professional relationship where you are the nurse and they are the patient. And this needs to be made known right from the beginning because you don't want the relationship going into inappropriate territory. So we're going to do some limiting.

setting in the introductory introductory phase. Then we have the working phase where we're exploring the patient's life events, what's going on with them, what they're feeling. During the working phase, we're helping them to express their thoughts, feelings, and emotions.

We're helping them relate to their patients. their cognitive distortions to behaviors that have had poor outcomes in their life. And we're also helping them navigate our system from getting here to planning for discharge. there's the termination phase. This is also important and it's something that has to be talked about because this relationship is something that they can use as a springboard.

They can use, if they successfully navigate the nurse-patient relationship, they can use that to springboard to other relationships, but they can't be coming back to you personally. They can't be, you know, knocking on our door and requesting to see you personally again. And so you have to talk about the termination phase. You have to talk about the nurse-patient relationship. And I would present it as a positive thing.

And again, you know, if they can have a successful therapeutic relationship with you as a clinician, they can do it again. And they will if they have outpatient follow-up. So this is a good thing. Let's talk a little bit about the pre-interaction phase. So the initial tasks are self-exploration, self-analysis, challenges.

of the psychiatric setting can cause stress and fear for both people. The patient may be afraid of a psychiatric admission. You may also be afraid. There can be fears of inadequacy related to inexperience, fears of saying the wrong thing, being afraid of unpredictable situations or aggressive behavior, questioning your own mental health status, analyzing strengths and limitations of both people. thoughts about gathering data about the patient, and also planning for your first interaction.

And remember that your fears are often overblown. We have a fear that things are going to go worse than they actually do. In the introductory and orientation phase, we need to find out why the patient sought help. We're going to be exploring their feelings, identifying problems, and this is when we really establish trust, understanding, acceptance, and kind of open the doors to communication. We want to establish a goal with the patient.

And I would recommend in this introductory phase, when you're first interviewing the patient during their admission, one of the first things you should say to them or ask them is, what do you hope to get out of this admission? What do you hope to get out of being here? And I would say this.

Some other clinicians here say things like, what can we do for you? That's passive because it puts the onus on the professional and not on the patient. I think.

think when you ask the patient what do you hope to get out of being here you're putting the ball in their court and you are helping them understand that they are expected to be active in their care planning from the very beginning you also want to formulate goals maybe you know a safety contract explain roles talk about confidentiality responsibilities of the patient responsibilities of the nurse and clarify the expectations of the nurse and the patient The working phase. The working phase of the nurse-patient relationship is where the nurse and patient explore stressors. You're providing a lot of guidance and kind of scaffolding for the patient.

What I mean by scaffolding is that you are helping the patient, but you're not completely containing and directing all of their behavior, but you're assisting them. The working phase is where you promote the development of... insight by helping the patient link perceptions, thoughts, feelings, and emotions to their actions, and this is really important. We want to translate the insight that they have into action and behavior change.

We want to help the patient be aware of and work on their anxieties, increase the amount of responsibility on the patient, and help them develop constructive coping mechanisms. And you do that by talking to the patient about the adaptive coping mechanisms that they use. We want to list their strengths and weaknesses in our charting because we want to help other clinicians who care for them also understand what works for them and what doesn't work for them. A standoff, impasse, or plateau may develop if the patient resists moving forward. During the termination phase, learning is maximized because there are higher levels of trust and intimacy between the nurse and the patient and also the patient's ability to move forward.

And also, the patient fits in. physically and mentally is better by this point. They're getting well. They're almost ready for discharge.

There is an exchange of feelings and memories to evaluate the patient progress, whether they've met their goals. You want to establish the reality. of separation and explore feelings of rejection, loss, sadness, or anger. If they've done well with you, this may be the first really successful interchange and relationship they've had with someone for a while.

A lot of our patients... burn bridges with people. And this is something that it's okay to talk about. At this time, you know, referrals need to be made for continued care or treatment.

We want to be aware of the discharge plan. We want to make sure that we talk about the patient following up in the community and how that's important and how they can use the relationship they've had with you, again, as a jumping off point to do it again with follow-up care. Recognizing therapeutic communication techniques. Say the patient says, on admission, I don't know where to start.

The nurse says, tell me about what's been on your mind recently. Which technique is this? A broad opening, reflection, sharing a perception, a suggestion. The answer is A, number one, broad opening. Addressing conflict.

In order to address conflict in your setting or with your patient, you You have to assess your own personal responses to conflict. Be aware of what you feel. Anger, humiliation, annoyance, antagonism, bitterness, defensiveness. How do you react to these feelings?

Embarrassment, frustration, feelings of inferiority, intimidation, resentment, devaluation. This is where you spend some time in introspection and step back and take a look. So how do you address conflict?

How do you address these big feelings when you have them. How do you manage your own anxiety and fear? Cool off.

Wait until you can speak calmly and in a friendly tone. Take deep breaths. Make positive statements before you continue.

Remember that anticipation is often worse than the outcome. And diffuse your own anger before confronting the patient. And also, you don't have to do this alone.

Go to your team. Talk to your team about how you're feeling. Ask for help from your team if you need it.

Put the situation into perspective. Don't play the blame game and pick your battles. Use your therapeutic communication skills and techniques.

Remember that a lot of what you're feeling is really good data. It tells you a lot about what's going on with the patient. Remember to use clear and congruent communication. If you have your arms crossed and you have an angry look on your face, but you're trying to communicate professionally, you're going to be sending a mixed signal to your patient.

Take one issue at a time. Generate options for resolution. In conclusion, always listen to learn.

Clinical vignette. MJ is a 40-year-old Caucasian male who was admitted to the inpatient psychiatric unit after a brief but serious depressive episode. The patient had recently lost his job and was experiencing intrusive thoughts, rumination, and suicidal ideation with plan.

The patient denied intent to harm himself. on the unit. The patient was eager for follow-up care as an outpatient. Role play. I noticed you seem to be apprehensive today.

Is something on your mind you'd like to talk about? Dr. Smith said I could go home today and, well, I'm not sure that's such a good idea. The thought of being discharged is making you uneasy. Could you tell me a little bit more about that?

It's difficult to talk about, but since I've had this bout with depression, I don't feel like I feel like a failure at home. The idea of returning to your home roles, being a husband and father, seems a little overwhelming? A little, I guess. I'll need to take it slow and need to have people to talk to. Clinical vignette two.

CT is a 21-year-old Asian-American male who presented to an outpatient behavioral health center for debilitating panic attacks. The patient repeatedly had panic attacks in public places, and his anxiety was impacting both his personal and professional life. I'm really confused.

The doctor says that medication, therapy, or a combination of the two can help me with my anxiety. I can't decide whether to try the medicine or just do the therapy. Medications have side effects, and therapy is a huge time commitment. You're uneasy about taking medications and afraid you won't have time to devote to therapy sessions. Yeah, I guess, but my anxiety is really bad.

I can't even function. You have to choose between some alternatives. all of which have pros and cons. It's not an easy situation, but that seems to be the reality right now. You're right.

There's no getting around it. I might as well stop feeling sorry for myself and get some more information. Can you tell me more about the anxiety medication the doctor mentioned?

Let's evaluate the technique. And I'd even encourage you to try these role play scenarios with your colleagues. If you do that, and when you do this, look at your body language.

Try to identify the tone. Look at the techniques. Active listening, broad openings, restating, clarification, reflection, etc. Were there any techniques that seemed effective, ineffective? and ask for constructive criticism from your colleagues.

I hope you found the information in this video helpful. Therapeutic communication can help you give better care to your patients and can give you some insight into yourself. For more information on therapeutic communication or process recording, contact Stephanie Arnold or Debbie Rhodes or myself are more than happy to provide any educational material to you.

You just need to ask. Thank you.

Transcript for:Understanding Therapeutic Communication in Nursing

Transcript for:
Understanding Therapeutic Communication in Nursing