Therapeutic Communication

Teresa S. Boyer EdD, RN, NNP, PMHNP

 • Joint Commission National
Patient Safety Goal #2

Standards • Quality and Safety

Education for Nurses
(QSEN)
3
It is impossible not to
communicate

4
5

• Verbal

• Non-verbal

FORMS of • Social
COMMUNICATION
• Therapeutic
6 • Vocabulary
• Denotative and
connotative
meaning
• Pacing
• Intonation
• Simplicity
• Clarity and
Verbal brevity
• Timing and
Communication relevance
• Credibility of
sender
• Humor
 • Denotation
• Exact and literal
meaning
Decoding • Connotation
of words • Emotional and
imaginative
association
• Positive and
negative
7
House vs Home vs Shack
 • Childish
Negative
connotation
Same denotative
meaning
• Childlike

• Youthful Positive
connotation

9
 • Politician
• Used car salesman
• Mom and Dad vs Mother
Words and Father
• Dinner

10
 • 93% of communication

Nonverbal • 55% facial expressions,

Communication posture, gestures

• 38% tone of voice

 • Body Language
– Facial Expression
– Posture And Gait
Nonverbal – Personal Appearance
Communication
– Gestures
– Eye Contact

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 Touch
• Very potent
• Comfort
• “I’m here”
• Cultural awareness
• Patient mentality
 A. The selection of words by
the sender.
During the B. The interpretation of the
communication message by the receiver.
process, C. The method by which the
“decoding” is message is given.
D. The way in which
feedback is interpreted.

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 A. The selection of words by
the sender.
During the B. The interpretation of the
communication message by the receiver.
process, C. The method by which the
“decoding” is message is given.
D. The way in which feedback
is interpreted.

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 What you do
READING speaks so loud
that I cannot
BODY hear what you
say.
LANGUAGE
~Ralph Waldo
Emerson

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Seven Universal Emotions
25
 • Posture
– Indicates
attentiveness,
Other respect, dominance
– Rigid—hostility
Body • Body orientation
Language – Face-to-face in most
situations
– Mental health
different
 • Eye contact
– Respect
– Disrespectful in
Other some cultures
• Gestures
Body – Hands, arms, fingers
Language – Folded arms
– Random, repetitive
movements
– Not universal
 Other Body Language
SOLER SURETY
• Sit squarely • Sit at an angle

• Open posture • Uncross legs & arms

• Lean toward the other • Relax

• Eye contact • Eye contact

• Relax • Touch

• Your intuition
29
Assess for Congruence
Incongruent Facial Expressions
 Personal
multicultural
Activity communication
assessment
Factors affecting • Environment • Culture &
Communication • Vocabulary ethnicity
• Timing • Behavior
• Relevance • Socioeconomics
• Developmental • Personality
variations • Behavior
• Gender • Literacy
• Physical,
mental, and
emotional state

3
3
PROXEMICS

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35
 • Intrapersonal
• Interpersonal
Levels of • Transpersonal
Communication • Small-group
• Public
communication
(includes public
speaking)

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 Intrapersonal
Communication

• Within the individual

• Self-talk, self-verbalization,
and inner thought
• Highly influential: positive
or negative
• Guided imagery, self-
instruction

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Guided Imagery

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 Interpersonal
Communication
One to one, usually face to face
Most frequent type of
communication in nursing
Social context: Symbols and
Cues
Opinions, experiences, values,
and belief systems vary, so use
validation and negotiation
Results in exchange of ideas,
problem solving, expression of
feelings, decision making, goal
accomplishment, team building,
and personal growth 39
 Transpersonal
Communication

• Occurs within a
person’s spiritual
domain
• Communicate
with Higher Power
• Prayer
• Meditation
• Guided reflection
• Religious rituals
 Small Group
Communication
Usually, goal directed
Requires understanding of
group dynamics
Respect and active listening
imperative
Types
◦ Committees
◦ Support groups
◦ Research teams
◦ Work-related social
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 Public
Communication
• Audience interaction
• Requires special
adaptations in eye
contact, gestures, voice
inflection, and use of
media materials
• When effective
increases audience
knowledge

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 • Number of
communicators
• Physical proximity
• Immediacy of the
exchange, taking place
Factors that
– live or in apparently
Influence Levels real time
of – on a delayed basis
Communication • Number of sensory
channels
• Context of the
communication (face-to-
face or mediated) 43
Therapeutic Relationships &
Therapeutic Communication
 Phases of a
Therapeutic Relationship

01 02 03 04
Pre- Orientation Working Termination
Interaction phase phase: phase
phase ACTIVE

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 • Specific objectives
• Comfortable
environment
Building • Privacy
Rapport • Confidentiality
• Patient vs. Task
Focus

46
 Therapeutic
Communication

• Patient centered
• Goal directed
• Strengthens
therapeutic
relationships

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5 Key Characteristics of Therapeutic
Communication

Empathy Respect Genuineness

Concreteness Confrontation

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 Offering self
Sharing empathy
Sharing hope
Therapeutic Sharing humor
Communication Sharing feelings
Techniques
Using touch

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 Active listening

Establishing trust

Being assertive
Therapeutic
Interpreting body language and
Communication sharing observations
Techniques Exploring issues

Using silence

Summarizing the conversation

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 • Encouraging conversation
– Broad opening statements
– Using general leads
– Reflecting
• Helping client express thoughts
Using – Sharing observations
– Acknowledging feelings
Therapeutic – Selective reflecting
Communication – Using silence
Techniques – Giving information
• Ensuring mutual understanding
– Restating
– Clarifying
– Verbalizing thoughts/feelings
– Validating
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 Non-Therapeutic Communication
Techniques
• Challenging
• Probing
• Changing the subject
• Defensiveness
• False reassurance
• Disagreeing
• Judgment
• Rejection and minimization
• Stereotyping
53
 The nurse is teaching the client
about his upcoming procedure
and the client is very stressed.
Select the most important nursing
action.
A. Use humor first to decrease the
client’s stress level.
B. Determine if teaching can take
place at a different time.
C. Introduce himself as the RN to
give credibility to his message.
D. Speak to the client when family
members are there so they can
teach the client.
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Select the correct communication
technique that this statement
represents: “Can you tell me more
about that?”

A. Summarizing
B. Open-ended question
C. Focusing
D. Encouraging elaboration

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Which activities that take place during the
working phase of the nurse-client relationship?
Select all that apply.
a. The client and nurse identify goals of the relationship.
b. The client describes the role that the nurse plays in
the relationship.
c. The client participates actively in the relationship.
d. The client identifies the goals accomplished in the
relationship.
e. The client genuinely expresses his or her concerns to
the nurse.
A nurse who is preparing to administer an
injection to the patient states, “This injection
will not be painful.” Which communication
technique did the nurse use?
a. Seeking clarification
b.Giving information
c. Encouraging elaboration
d.Giving false reassurance
 Patient Satisfaction
AIDET
• A = Acknowledges the customer
• Smiles, makes eye contact & greets them in a
pleasant manner
• I = Introduce self
• States name, and role at ______________
• Highlights skills and expertise of self and other
healthcare team member
 AIDET (Continued)
• D = Duration
• Gives the customer a time expectation
• Keeps customer informed as to the amount of time a
procedure or process will take
• Includes letting them know if there is a wait time;
gives time expectation of that wait

• E = Explanation
• Keeps customers informed by explaining all
processes and procedures
• Assists customers to have clear expectations of what
will be occurring
 AIDET (Continued)
• T = Thanks the Customer
• Consistently thanks the Customer for their time and
if a patient , for choosing _____
• Expresses appreciation that they have chosen
_________as their health care facility
• Asks if there is anything else he/she can do for the
Customer before ending the interaction
 Respect is the culture to
use when we interact
R-E-S-P-E-C-T with our patients,
physicians, peers, and all
(Arizona of our customers.
Hospital and
Healthcare Everyone is expected to
Association) participate, regardless of
who you are and what
department you work in.
 Smile – A smile is a simple
gesture that often makes
R-E-S-P-E-C-T a big difference to those
we interact with.
(Arizona
Hospital and
Patients, physician, peers,
Healthcare and other people that we
Association) interact with deserve to
be treated in a respectful
manner.
 Every time you interact with a
patient, greet them by name
and ask if there is anything
else you can do for them
R-E-S-P-E-C-T before you leave.
(Arizona
Hospital and Communicate to the patient
what you are there to do for
Healthcare them (or to them).
Association)
Take the time to ask the
patient if they have any
questions or if there is
anything else you can do for
them before you leave.
 • Listen to me attentively
• Ask for my opinion
• Don’t minimize my concerns
• I am a real person, not just the gall
bladder in room 203
THINGS TO BE • Talk to me not at me
COMMUNICATED • Respect my privacy
WHEN YOU WALK • Remember my time is as important as
IN MY ROOM yours
• Tell me what I need to do not how to
do it
• Keep me updated
• Remember who I used to be
• Let me know you care about me

64
Communication within
the Nursing Process 65
 Communication & Nursing Process

• Assessment • Nursing process

• Nursing Diagnosis – Reliable framework
for client care
• Planning – Must have effective
• Implementation interpersonal
• Evaluation communication to
work

66
 Assessment

• Does patient have

reasons to have inability
or impaired ability to
transmit, receive, or
process information
• Focused Assessment box
on page 487

67
 • Readiness for Enhanced
Communication
• Impaired Verbal
Communication
Analysis & • Impaired Communication
Identifying **Impaired communication
r/t lack of hearing due to
Nursing damage to the cochlea
Diagnoses from repeated ear
infections aeb not
answering when name was
called, not responding to
loud, sudden noises
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 • Anxiety
• Impaired social
Related interaction
Nursing • Social isolation
• Chronic low self-esteem
Diagnoses • Disturbed body image
• Risk for loneliness

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 Outcomes:
Ultimate End Result

Planning Outcomes
***These are not individualized***
• Effectively uses alternate means of communication
• Participates in therapeutic communication
• Demonstrates congruent verbal and nonverbal
communication
• Interprets messages accurately
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 • Depends on diagnosis
and the reason they
have the problem
Planning
• Enhance therapeutic
Interventions for
communication
Implementation • Barriers to therapeutic
communication

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 Communication impacts:
◦ Care effectiveness
◦ Therapeutic relationships
◦ Achievement of client goals

• Competent communication:
– Helps nurse maintain
IMPACT & effective relationships within
the entire sphere of
PURPOSE professional practice
– Helps meet
legal/ethical/clinical
standards of care
– Avoids the pitfalls of
misunderstandings,
increased liability, and
threats to professional
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credibility
 • Active listening
• Establish trust
• Use assertive
communication
• Restate, clarify, and
ENHANCING validate
THERAPEUTIC • Observe nonverbal
COMMUNICATION communication and
congruency and share
observation
• Explore issues
• Use silence
• Summarize
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 • Noise
• Inappropriate medium
• Emotions
Blocks &
• Language differences
Barriers
• Poor listening skills
to Effective
• Distractions
Communication
• Too many questions
• Closed ended questions

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 • Fire-hosing information
• Asking why
• Criticism
Blocks & • Inappropriately
changing subject
Barriers • Appearing disinterested
• Failing to probe
• Incomplete assessment

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 • Expressing approval or
disapproval
• Nurse judges patient
• Giving advice or opinion
• False reassurance
• Using reassuring clichés +/or
Blocks & automatic responses
• Stereotyping
Barriers • Patronizing or belittling
• Sympathy
• Defensive responses +/or
arguing
• Passive-aggressive responses
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 • Using medical jargon
• Assuming rather than
clarifying and
validating
• Leading the client
Blocks and • Letting family/friends
Barriers answer
• Not allowing adequate
time to respond
• Asking personal
questions
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 Why We
• Being Judgmental
Don’t • Rehearsing
Hear Each • Mind Reading
• Advising
Other
https://www.youtube.com/watch?v=-
4EDhdAHrOg&t=5s
 Why We
• Pleasing
Don’t • Filtering
Hear Each • Deflecting
Other
 • Be aware of own cultural biases
Communicating • Demonstrate empathy and respect
with Patients • Address the patient by title and name
From Other • Smile and be polite
Cultures • Do not be over friendly or casual
• Be sensitive and aware of patient’s feelings
• Ask patient about their culture 81
 Communicating with Patients
from Other Cultures
• Provide for translation services
• Use short words and sentences
• Provide written teaching materials in the patient’s
language of choice
– Health information in multiple languages
• Joint Commission National Health and Safety Goal #2
• QSEN

82
 Communicating with Patients from
Other Cultures
Consider the individual first and the cultural
Consider background second.
Assess language needs and, if required, arrange for
Assess an interpreter or family member to translate*.
Approach the client slowly and greet him/her respectfully,
Approach pronouncing his/her name correctly or asking how to
pronounce.
Do not Do not raise your voice to be understood.
raise
Allow Allow sufficient time and a quiet setting.
• (continued next slide)

83
 Sit at patient’s Listen to the
level at a client’s words and
comfortable watch nonverbal
distance language.

Communicating
Reassure client that
with Patients you are there to Try to mirror the
help and info client’s style of
from Other provided is communicating.
confidential.
Cultures
Provide written
material in client’s Allow time for
language, if questions.
available.

84
 Use an interpreter. A translator
only restates the words; an
interpreter translates the words
with meaning.
Use dialect-specific interpreters
Allow time for interpreter and
client to become acquainted.
Allow extra time for the health
history.
Ideal Use of Know that some data may be lost
via interpretation.
Interpreters Avoid using relatives—they may
distort the interpretation.
Avoid using children, esp. for
sensitive topics.
Match interpreter with client by
age and gender.
Maintain eye contact with both
client and interpreter to read
nonverbal cues. 85

(continued next slide)

 Be aware of your body
language. Clients may
understand more than they can
express verbally.
Speak clearly & slowly, but do
not exaggerate or speak loudly.
Use active rather than passive
Ideal Use of tense and wait for feedback.
Interpreters Use as many words as possible
in the client’s language to
convey your message.
Use nonverbal communication
when you are unable to
understand the language.
Use a reference book with
common phrases.
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Ideal Use of https://www.youtube.com/wat
Interpreters ch?v=flB3DLEOsmg

87
Adapting Care for
Patients Who Are
Blind
• Always speak when
entering room
• Speak directly to patient; do
not turn your back
• Speak to the patient in a
normal tone of voice
• Speak to the patient before
touching him/her
• Offer to help with
arrangements for patient
who may enjoy hearing
tapes or reading Braille
literature
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 Adapting
Care for
Patients Who
are Deaf
◦ Look directly at the patient when speaking
◦ Do not cover mouth when speaking
- patient may read lips
◦ Charts with pictures
◦ Writing questions/comments on
paper or computer
◦ Charts with hand signs are available at the
local society for deafness and/or hearing
preservation 8
9
 Evaluation
Assessment to determine if
patient met the outcomes

If not, why?

If not, has progress toward

the outcome been made?

If not, what changes need to

be made to the plan of care?
90
THE GOOD, THE
BAD,
AND THE UGLY
Communication with Coworkers
 • How do you
communicate?

• Quiz to determine your

Activity communication style

• https://amycastro.com/
whats-your-communica
tion-style/
Lateral Violence/Bullying

93
 Collaborative Professional Communication

• Goal: Provide optimal, consistent care

• Ways to avoid amygdala hijack, where our midbrain

stress center overcomes the frontal lobe,
– and how taking just a few seconds to breathe, sip
some water, ask a question, or take a bio break
– can prevent an outburst that may be difficult to
apologize from and seek forgiveness

94
 • Speak clearly and positively.
• Maintain professional
composure.
• Use “I” statements.
• Focus on the issue.
Assertive • Use effective nonverbal
communication.
Communication
• Don’t invite negative
responses.
• Accept criticism.
• Use negative inquiry.
• Strive for a compromise.
SBAR
AKA
ISBAR
(with I =
Identify or

Introduce)
 • Shift report
• Physician report
Utilization • Transfer report
• Email
of SBAR
• Communication….
.

98
 Scenario
• Patient is admitted
• Diagnosis of atrial fibrillation
• Several prescriptions for Coumadin
(warfarin sodium) at home
• Unsure of the correct dosage

99
 •Situation: Clearly and briefly
define the situation.

•Background: Provide clear,

relevant background
information that relates to the
SBAR situation.

•Assessment: A statement of
your professional conclusion.
•
•Recommendation: What do
you need from the person?

100
• Introduction:

Hi Dr. Brown; this is Teresa Boyer from

the med/surg floor at Motlow Hospital.

• Situation Clearly and briefly define

the situation.

I’m taking care of Mr. Greene in Room

115. I’m calling regarding his pain
control.
 Mr. Greene is a 22-year-old
Background: who had appendectomy 1
Provide clear, day ago. He has required
relevant very minimal pain control
background since his surgery. He has
information that an order for Tylenol 650 mg
every 4 hours for minimal
relates
to moderate pain. He does
to the situation. not have any medication
allergies. This is his first
surgery.
 Mr. Greene ranks his pain
as a 9/10, sharp and
continuous. He is
reluctant to ambulate
Assessment: A and refusing to get into a
statement of chair at the bedside. His
your professional vital signs have been
assessment and stable, but are currently
conclusion elevated from baseline
with BP 160/84, HR 82,
RR 22. Temperature is
99⁰F, and the surgical
site is approximated and
unchanged with no
redness, edema,
drainage or ecchymosis.
 I believe that Mr.
Greene would benefit
Recommendation: from a stronger pain
What do you need medication. Once his
from the person? pain is under control,
he will be more likely
to get up and
ambulate. What
would you prefer to
order?