Download Guidelines for Therapeutic Communication: Be congruent in what

Guidelines for Therapeutic Communication:
 Be congruent in what you are saying and what your body language is conveying.
 Use clear, concise words that are adapted to the individual’s intelligence and
experience.
 Do not say, “I’ll understand” or “You’ll be okay”. Nonverbally or verbally say, “I care
about you” or “I want to help you”.
 Use appropriate silence to give the patient time to organize his thoughts and
respond.
 Let the patient set the pace of the interaction- do not hurry him.
 Accept the patient as he is, without making judgments.
 Offer a collaborative relationship in which you are willing to work with the patient
in resolving problems and making change.
 Use open-ended questions to encourage expression of feelings and thoughts.
 Explore ideas completely. Do not drop a subject that the patient has introduced
without some resolution.
 Clarify statements and relationships when necessary. Do not try to read the
patient’s mind or interpret what he says.
 Give positive feedback every chance you get.
 Paraphrase statements and feelings to facilitate ventilation.
 Translate feelings into words so that hidden meanings can be discovered.
 Focus on reality, especially if the patient misinterprets facts or if he is
misrepresenting the truth.
 Offer teaching and information, but avoid giving advice.
 Search for mutual intuitive understanding.
 Encourage an appropriate plan of action, such as problem-solving or self-care.
 Summarize at the end of conversation to focus on the important points of the
communication and validate the patient’s understanding.
 Remember, the more personal and intense a feeling or thought is, the more difficult
it is to communicate. Give the patient time to express his deepest feelings. The
key word is listen.
Common Communication Strategies/Techniques:
TECHNIQUES
1.Using silence
2.Attentive listening
DESCRIPTIONS
EXAMPLES
quietly
(or
 Accepting
pauses
or  Sitting
walking with the client)
silences that may extend for
and waiting attentively
several seconds or minutes
until the client is able
without interjecting any
to put thoughts and
verbal response
feelings into words.
 Promotes
observations
about the client and allows
time for the client to
organize thoughts.
 Facilitates eye contact with
the
client
and
communicates interest in
the
client's
needs,
concerns, and problems
 Making statements that
are specific rather than
general, and tentative
rather than absolute
3.Being specific and
tentative
4.Providing general 
leads
5.Using Touch

6.Using
open- 
ended questions
7.Paraphrasing
restating
or 

Using
statements
or
questions
that
(a)
encourage the client to
verbalize (b) choose a topic
of conversation, (c) facilitate
continued verbalization
Providing appropriate forms
of touch to reinforce caring
feelings. Because tactile
contacts vary considerably
among individuals, families
and cultures, the nurse must
be
sensitive
to
the
differences in attitudes and
practices of clients and self
Asking broad questions that
lead or invite the client to
explore thoughts or feelings
Actively listening for the
client's basic message and
then
repeating
those
thoughts and/or feelings in
similar words.
Provides an opportunity for
the interviewer to validate
information by asking the
client to restate information
or provide an example.







“Rate your pain on
a scale of 0-10”
(specific)
 “Are you in pain?”
(general)
 “You
seem
unconcerned
about
your
diabetes”
(tentative)
 “You don’t care
about
your
diabetes and you
never
will”
(absolute)
"Perhaps you would
like to talk about…"
"Where would you like
to begin?"
"And then… what?"
Putting an arm over
the client’s shoulder.
Placing your hand
over the client’s hands
“I’d like to hear more
about that”
 “Tell me about…”
 Client:
"I
couldn't
manage to eat any
dinner last night.
HCP:
"You
had
difficulty
eating
yesterday."
 Client: "I have trouble
talking to strangers."
HCP: "You find it
difficult talking to
8.Perception

checking or seeking
consensual
validation
A
method
similar
to 
clarifying that verifies the
meaning of specific words
rather than the overall
meaning of a message
9.Clarifying/

Seeking clarification
method of making the 
client's
broad
overall
meaning of the message 
more understandable.
Used when paraphrasing is
difficult
or
when
the
communication is rambling
or garbled.
Facilitates
correct
communication
of
information by asking the
client to restate information
or provide an example
 Suggesting
one’s
presence, interest or
wish to understand the
client without making
any
demands
or
attaching conditions that
the client must comply
with to receive the
nurse’s attention
Helping the client expand on 
and develop a topic of
importance. It is important
for the nurse to wait until the
clients think they have
talked about the main
concerns before attempting
to focus.
Eliminates vagueness in
communication, limits the
area of discussion for the
client, and helps the
interviewer to direct atten-


10.Offering self
11.Focusing


people you do not
know?"
Client: “My husband
never gives me any
presents”
HCP: “You mean he
has never given you a
present
for
your
birthday
or
christmas?”
"I'm
not
sure
I
understand that."
"Would you please
say that again?"

“I’ll stay with you
until your daughter
arrives”
Client: "My wife says
she will look after me,
but I don't think she
can, what with the
children to take care
of, and they're always
after
her
about
something - clothes,
homework, what's for
dinner that night."
HCP: "You are worried
about how well she
can manage."
12.Clarifying time or 
sequence
13.Presenting
reality

14.Offering
information/giving
information/
Educating
15.Reflecting

16.Acknowledging

17.Summarizing
and Planning




tion to the pertinent aspects
of a client's message.
Helping the client clarify an
event,
situation,
or
happening in relationship to
time
Helping the client to
differentiate the real from
the unreal
Providing, in a simple and
direct manner, specific
factual information the client
may or may not request.
Directing ideas, feelings,
questions, or content back
to clients to enable them to
explore their own ideas and
feelings about a situation
Giving recognition, in a
nonjudgmental way, of a
change in behavior, an
effort that client has made,
or a contribution to a
communication.






Stating the main points of a 
discussion to clarify the
relevant points discussed.
Useful at the end of an 
interview or to review a
health-teaching session.
Condenses data to further
validate information and to
end a component of the
interview or the interview
itself
Client: “I vomited this
morning”
HCP: “Was that after
breakfast?”
“Your magazine is
here in the drawer. It
has not been stolen”
"Your
next
consultation in the
health center is on…"
Client: "What can I
do?"
HCP: "What do you
think
would
be
helpful?"
"You walked twice as
far today with your
walker."
"It's good that you
have decided to…"
"During the past half
hour, we have talked
about…"
“tomorrow afternoon
we may explore this
further”
General Guidelines for Transcultural Therapeutic Communication:
Communication and culture are closely interconnected. Through communication,
the culture is transmitted from one generation to the next, and knowledge about the
culture is transmitted within the group and to those outside the group. Communicating
effectively with clients of various ethnic and cultural backgrounds is critical to providing
culturally competent nursing care. There are cultural variations in both verbal and
nonverbal communication.
Verbal Communication:
The most obvious cultural difference is in verbal communication; vocabulary,
grammatical structure, voice qualities, intonation, rhythm, speed, pronunciation, and
silence. Initiating verbal communication may be influenced by cultural values. Verbal
communication becomes even more difficult when an interaction involves people who
speak different languages. Both clients and health professionals experience frustrations
when they are unable to communicate verbally with each other.
Verbal Communication with Clients who have Limited Knowledge of English
 Avoid slang words, medical terminology and abbreviations
 Augment spoken conversation with gestures or pictures to increase the client’s
understanding.
 Speak slowly, in a respectful manner, and at a normal volume. Speaking loudly
does not help the client understand and may be offensive.
 Frequently validate the client’s understanding of what is being communicated. Do
not automatically interpret a client’s smiling and nodding to mean that the client
understands; the client may only be trying to please the nurse and not understand
what is being said.
Nonverbal Communication:
Even nonverbal communication can lead to misunderstandings. Gestures, facial
expressions, and body language may carry certain meanings commonly understood in
one culture, but they would be misunderstood in another. Also, clients from different
cultures may misinterpret gestures that Western nurses use to convey empathy and
caring. For examples, actions such as gentle touch on the hand, maintaining eye contact,
or smiling and nodding may seem intrusive, disrespectful, or dismissive to clients of
certain cultures.
Developmental Considerations in Communication:
Failure to communicate at the client’s individual developmental level can represent a
significant roadblock to effective communication. Young children for example are
generally incapable of abstract thought. Knowing this, the nurse will communicate with
the child in relatively concrete terms. It is important that the nurse consider not only the
age but also the developmental stage of the client, which may be affected by preexisting
diseases.
Useful Communication Skills for Older Persons
General
 Identify yourself by name. Repeat as needed.
 Call the client by his or her preferred name.
 Keep yourself in the client’s view so that he/she can see your face.
 Use direct eye contact. Sit or stand at the same level as the client.
 Use a calm, clear, slightly slower, or low-pitched voice.
 Eliminate background noise. Provide the client with a hearing amplification device
if needed.
 Ask one question at a time and wait for a response.
 Do not interrupt the person.
 Listen attentively.
Written
 Wear a name tag with large type.
 Leave a personal card or note with your name and phone number.
 Use written notes as reminders.
 Label names of people on pictures.
 Provide large-type reading materials.
 Prepare all teaching materials with large black type on a yellow background.
Body Language
 Use an open, gentle approach and genuine smile.
 Use gentle touch.
 Evaluate acceptability of hugs.
 A simple nod of the head is appropriate.
 Sit if the person is sitting or in bed.
Communicating with people who are:
a. Physically Challenged
Patients who are visually impaired:
 Acknowledge your presence in the patient’s room.
 Identify yourself by name
 Remember that the visually impaired patient will be unable to pick up most nonverbal
cues during communication. Speak in a normal tone of voice.
 Explain the reason for touching the patient before doing so.
 Indicate to the patient when the conversation has ended and when you are leaving
the room.
 Keep a call light or bell within easy reach of the patient.
 Orient the patient to the sounds in the environment and to the arrangement of the
room and its furnishings.
 Be sure eyeglasses are clean and intact or that contacts are in place.
Patients who are hearing impaired:
 Orient the patient to your presence before initiating conversation. This may be done
by gently touching the patient or moving so you can be seen.
 Talk directly to the patient while facing him or her. If the patient is able to lip read, use
simple sentences and speak in a quiet, natural manner and pace. Be aware of
nonverbal communication.
 Do not chew gum or cover your mouth when talking with the patient.
 Demonstrate or pantomime ideas that you cannot convey to the patient in another
manner.
 Be sure that hearing aids are clean, functioning and inserted properly.
b. Patients who are cognitively impaired:
 Establish and maintain eye contact with the patient to hold attention.
 Communicate important information in a quiet environment where there is little to
distract the patient’s attention.
 Keep communication simple and concrete. Break down instructions into simple tasks
and avoid lengthy explanations. Use pictures or drawings when appropriate.
 Whenever possible, avoid open-ended questions.
 Be patient and give the patient time to respond. If the patient does not respond after
2 minutes, repeat what you said. If there is still no response, take a break before
continuing the conversation so that neither you nor the patient becomes frustrated.
An unconscious patient:
 Be careful of what is said in the patient’s presence. Hearing is believed to be the last
sense lost, and therefore the unconscious patient is often likely to hear even though
there is no apparent response.
 Assume the patient can hear you. Talk in a normal tone of voice about things you
would ordinarily discuss.
 Speak with the patient before touching. Remember that touch can be an effective
means of communication with the unconscious patient.
 Keep environment noises at as low level as possible.
c. Aggressive/Angry clients:
 Use caution when communicating with a client who has a history of violent behavior
or poor impulse control.
 Do not turn your back on the client. Arrange the setting so that the client is not between
you and the door to the room.
 Focus on the client’s body language.
 Be alert for physical indicators of impending aggression: narrowed eyes, clenched
jaw, clenched fist, or a loud tone of voice.
 Model the expected behavior by lowering your tone of voice.
 Stay within the client’s line of vision.
 Do not use touch.
References:
 Taylor, C. et al, Fundamentals of Nursing The Art and Science of Nursing Care 5th ed. 2005,
Lippincott Williams & Wilkins
 Harkreader, H & Hogan, M. Fundamentals of Nursing, Caring and Clinical Judgment, 2nd ed.
2005, Saunders
 Daniels, Rick, Nursing Fundamentals, Caring and Clinical Decision Making, 2004, Thomson Asian
Edition
 Kozier & Erb’s Fundamentals of Nursing, 8th ed. 2007, Pearson