Therapeutic Communication: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of therapeutic communication in order to:
- Assess verbal and nonverbal client communication needs
- Respect the client's personal values and beliefs
- Allow time to communicate with the client
- Use therapeutic communication techniques to provide client support
- Encourage the client to verbalize feelings (e.g., fear, discomfort)
- Evaluate the effectiveness of communications with the client
Communication is a human, interactive process that sends some meaning, information, message, emotions, and/or beliefs from one human being to another person or to a group of people. Connectedness and interrelationships between and among human beings occur because communication occurs.
There are several forms of communication. Communication can occur with the spoken word, with the written word, and with body language and gestures, which are oral communication, written communication and nonverbal communication, respectively.
It is essential that the components of all types of communication are effective in order for the communication to occur and be effective. The sender of the message must be able to formulate and then express the message and the receiver of the message must be able to process the message and then effectively respond back to the message. The expressions of the message and the responding to the message can be done orally, in writing and with body language cues like shaking one's head up and down for yes and side to side for no, for example.
The sender transmits and conveys the message to others; the receiver is the person who gets the message from the sender; the message is the information or emotion that is being conveyed or sent to another; and the feedback is the response of the receiver to the message.
Many factors impact on and adversely affect communication. For example, nurses must overcome barriers to communication such as:
Level of Development and Age
Infants can only communicate and send messages to others with behavioral cues such as crying and smiling. They are also not able to process messages from others unless they consist of message cues like cooing, a gentle touch and a facial expression such as a smile.
Young children, like toddlers and preschool children, typically have a limited vocabulary so they are not able to understand verbal messages unless they are simple and at their level of understanding. They are also now able to receive and process nonverbal communication cues as well as to send messages with the same cues. For example, they will interpret the angry face of a parent as one that expresses the dissatisfaction of the parent in terms of their poor behavior.
The nurse will assess the client's communication needs in respect to their specific age and developmental status and modify care accordingly to these age related needs.
Level of Consciousness
Depending on the client's level of consciousness along the continuum some clients are fully able to effectively formulate and send a message, process and respond to the message; others may be only able to send a message OR receive a message effectively; and still more may not be able to do either.
The nurse will also assess the client's communication needs in terms of their level of consciousness and, then, plan care accordingly. For example, the nurse may communicate with a nonresponsive client with touch to communicate caring and the presence of the nurse, and they may use pictures to communicate messages to a client who is not able to receive and process verbal communication.
Emotional State and Level of Stress
Communication can be greatly impaired when the client is adversely affected with stress and other emotional states such as anxiety, fear, distress, and confusion. For this reason, the nurse will attempt to alleviate these symptoms in order to be able to overcome this barrier to effective communication.
As previously discussed, foreign language interpreters are often needed to facilitate communication with clients who communicate in a language other than English; American Sign Language interpreters may possibly be needed to effectively communicate with those who have a profound hearing deficit; and nurses and others may also need to utilize Braille reading materials for those affected with blindness.
Nature of the Relationships Between and Among People Involved in the Communication Process
Communication can be impeded when the client views the health care professional as the one that is in the position of power and control rather than a person who is mutually exchanging a message with the client who is the center of care and the person who is actually in the position of power and decision making, rather than the nurse or another health care professional.
In order to eliminate this barrier, the nurse must establish trust with the patient, they must face the person when they are communicating with them, and at the same eye level of the patient in order to convey equality and mutuality rather than a position of power and authority over the client.
Individual Values, Beliefs, Perspectives, and Perceptions
Individual values, perspectives, perceptions and beliefs bias communication. At times people will only hear or see what they hear or see as based on their own, rather than an objective, view and perspective. For example, a client may only hear the nonthreatening rather than the threatening and stressful aspects of their plan of care because they are biased against the negative aspects of care. Similarly, gestures and other forms of body language are interpreted very differently as based on the client's preconceived notions, as well as their values, beliefs, perspectives, and perceptions.
As a result of these factors, nurses must assess these individual values, beliefs, perspectives, and perceptions as they impact on the sending and receiving of messages. For example, the nurse will clarify and validate the client's nonverbal grimacing which could be a sign of pain or it could be a sign of disgust during the interaction.
Culture, in addition to many other things, also influences the person's use of terms and terminology as well as their perceptions of nonverbal messages. Some cultures view eye contact, touch and proxemics in a manner that is not shared by the nurse and clients of different cultures. Some cultures view eye contact, touch and close proximity as culturally acceptable and therapeutic, but other cultures may perceive and believe that eye contact, touch and close proximity are offensive.
Some medical treatments including sedation and intubation, for example, can be a barrier to effective communication. For example, an alert and oriented client who is intubated will not be able to send a verbal message but they can interpret and process verbal messages sent to them. They may only be able to send written and nonverbal messages to others; and a sedated client may have limited communication abilities in terms of sending and receiving messages secondary to their altered level of awareness and consciousness secondary to the sedating medication, for example.
Further information and details about the communication process, the elements of the communication process and barriers to effective communication was provided at the beginning of this NCLEX-RN review under the topic entitled "Integrated Process: Communication".
Respecting the Client's Personal Values and Beliefs Cultural Awareness/Cultural Influences on Health
As fully discussed under the sections entitled "Client Rights" , "Religious and Spiritual Influences on Health", and "Cultural Awareness/Cultural Influences on Health" as well as intermittently in this NCLEX-RN review course, nurses and all other health care providers must respect, uphold and integrate into the plan of care all of the client's personal values and beliefs without exception and despite any and all of the biases, values, beliefs and opinions of the nurse. Again, the client is the center of care, not the nurse or another health care provider.
Nurses have a daunting job. They care for a number of clients at one time and these clients have multiple needs with rapidly changing priorities. Nurses are often in a hurry to get this patient care done and complete in the proper manner but they often fail to take the time that is necessary to communicate with their clients.
A failure on the part of the nurse to allow enough time to communicate with the client is a frequently encountered barrier to communication in the health care setting.
Enough time must be allotted so that the client has the time that they need to fully tell you about all of their feelings and concerns and to ask you questions. They also need time during oral conversations and exchanges to process incoming messages, reflect on the message, and to formulate and express their feedback message to the nurse. For example, if you are discussing the client's plan of care for the day and you begin by telling them that they will be having a stress test, you must allow the client the time to process your incoming message about the stress test and to formulate their questions and responses to you.
More than the usual amount of time is needed to effectively communicate with the client when the meat of the conversation is complex and when the client is affected with:
- A decreased level of consciousness
- Expressive aphasia
- Receptive aphasia
- A language barrier
Therapeutic communication techniques such as active listening, silence, focusing, using open ended questions, clarification, exploring, paraphrasing, reflecting, restating, providing leads, summarizing, acknowledgment, and the offering of self, will be described below.
Attentive, Active Listening
Active listening is an essential part of communication. Attentive listening is far more than hearing and attentive listening is far more than simply remaining silent while listening to words. Active attentive listening is not a passive activity; it entails the nurse's hearing, processing and purposefully comprehending the client's words, as well as processing these words in the context of the client's situation and the nonverbal communication that is sent by the client as they are verbally expressing some message to the nurse.
Similar to listening, silence is a purposeful active process rather than a passive process. Senders and receivers of the message take advantage of brief pauses of silence to think about and reflect on the full meaning of received message and to contemplate and reflect on how to respond to the sent message with feedback. Silence is a therapeutic communication technique that is also very helpful when the nurse wants to give the client ample time to fully and openly discuss their feelings, opinions and beliefs, however, prolonged silence may be interpreted by the client as a lack of interest on the part of the nurse so silence, in order to remain therapeutic, must be of an appropriate duration so that it does not adversely affect the client and the therapeutic nurse-client relationship.
Focusing with the client is a therapeutic communication technique used by nurses, and other members of the health care team, that facilitates the client's abilities to focus on and pay attention to the matters at hand, which should reflect the client's priorities. At times, some clients may use the nurse's presence to talk about things not even related to their health care and their health care problems. For example, they may want to chat about their extended family and their accomplishments at the same time that the nurse has to educate the client about their plan of care. Focusing on the subject at hand decreases the risk of having these kinds of distractions impair the therapeutic communication process. For example, the nurse may say, "Mr. Burke, your family is very interesting and successful. Thank you for sharing this information with me. Now, let's discuss your diabetes and the insulin that you will be taking after you leave the hospital".
Using Open Ended Questions
Open ended question, as previously discussed, elicits more and fuller information than a closed ended question that requires more than a simple yes or no answer. This therapeutic communication technique is particularly useful when the nurse wants fuller and deeper information from the client and when the nurse is facilitating the client's full and free ventilation and expressions of their own feelings and beliefs. Closed ended questions are also useful particularly when the client is not able to, for one reason or another, formulate more complete feedback and communication to the nurse. For example, closed ended questions are useful when the client is cognitively impaired or they are on mechanical ventilation with intubation and not able to speak with the nurse and others.
Messages are often clarified and validated with clients in order for the nurse to insure that the nurse has received and interpreted the complete and correct message without any errors, without any bias and without any false assumptions. Specific clarification techniques include exploring, paraphrasing, reflecting and restating, which will be discussed below. A possible question that the nurse may ask the client to clarify a message could be "Am I correct that you told me that you plan on having home health care after your discharge?" or "You appear upset. Would you like to talk about it?' when the client appears upset with their nonverbal facial cues.
Exploring, in contrast to invasive and non therapeutic probing, is using techniques that encourage the client to provide more details and information about a particular topic or health care problem.
Paraphrasing, another technique that is used to clarify a client's message, is used by the nurse to rephrase a client's comment or question in a manner that is similar to what the nurse thinks that they have heard and understood. For example, a nurse may paraphrase a client statement such as "I am too tired to even think" with, "Did you mean that you are too tired now to continue with this education?"
Restating is done to clarify the client's message by repeating the same statement back to the client. For example, when a client says, "I am ready to do some walking" and the nurse says, "Did I hear you say that you are now ready to do some walking?"
This therapeutic communication technique reflects and mirrors what the nurse believes the client's feelings to be underneath the words. It mirrors, or reflects, the patient's feelings, not words, back to the client so that the client's feelings can be further explored and expressed by the patient. For example, when a client appears to be angry and upset, the nurse may state, "You seem a little angry today. Would you like to talk about it?".
Providing Leads to the Patient
Providing a lead to the client enables the client to continue discussing things with the nurse and it also facilitates the client's beginning a new discussion that is focused on a particular thing. For example, the nurse may say, "Tell me about your concerns relating to your new medications". Hopefully, the client will take this lead and begin a discussion about their new medications and their concerns relating to them with the nurse.
Summarizing is a highly useful therapeutic communication technique that sums up the primary and main points that were discussed as well as the conclusion of the discussion that was mutually decided up. For example, a nurse who is educating the client and family members about diabetes management and the interactions of diabetic medications, exercise, diet and other factors may summarize this discussion with a summarizing statement such as, "During our discussion today, we have discussed the roles of diabetic medications, exercise, diet and other factors as they interact with each other and how these interactions impact on the successful management of diabetes."
Recognition, Acknowledgment and Acceptance
Recognition, acknowledgment and acceptance of the client and their thoughts which are conveyed during communication are therapeutic communication techniques and strategies that give the nurse the opportunity to let the client know that you are interested in them and respectful of them and their thoughts It also allows the client to recognize that the nurse is open, honest and without any bias or judgements. The nurse accepts the client regardless of their thoughts and words.
Offering of Self
The therapeutic communication process and the therapeutic nurse-client relationship must be based on the nurse's willing and unconditional offering of self and their time to the client and their needs with only limited self disclosure by the nurse that directly assists the client with meeting their needs.
Barriers to therapeutic communication include challenging, probing, changing the subject, defensiveness, false reassurances, disagreeing, judgments, rejection and minimization, and stereotyping.
Challenging, simply defined in this context, is forcing the client to defend and justify their opinions, beliefs, and feelings. Challenging shows a lack of respect for the client and a lack of acceptance of the client as a unique being who has, and is entitled to, their own beliefs and opinions. The client has valid feelings that should never be challenged by the nurse.
Probing is also not therapeutic. It is invasive, uncomfortable for most clients, and a threat to the client's right to privacy and confidentiality. Probing the client with questions that are not relevant to their health care and health related concerns is never appropriate. It may satisfy the nurse's curiosity but it is NOT at all helpful to the client and addressing the client's needs.
Changing the Subject
Like probing, changing the subject serves only the needs of the nurse and not the client, therefore, it too is not acceptable in nursing practice. People, including nurses, change the subject when they are too uncomfortable and uneasy about continuing the conversation. The conversation has become too stressful for the nurse. This is not an option. Nurses must identify their own feelings and cope with them before they enter into therapeutic conversations and relationships with clients.
Defensiveness occurs when the nurse feels the need to defend themselves, their actions, their employers or others for their failures and shortcomings. Again, this technique fulfils the needs of the nurse rather than the client and, as such, it is not therapeutic.
False reassurances, like trite comments and giving clients every day advice, are not at all therapeutic. False assurances and reassurances such as "Don't worry, you are in good hands" and "Everything will be fine" are examples of false reassurances that will certainly be a conversation stopper that will lead to client anxiety and the client's unwillingness to share their true thoughts and fears to the nurse in the future. These effects are detrimental to the client and their wellbeing as well as the therapeutic nurse-client interactions at the present time and also in the future.
Disagreeing with clients is also not therapeutic or acceptable. The nurse can attempt to correct misinformation in a therapeutic manner but they should never disagree or argue with the client, their feelings and/or opinions.
Judgements place a positive or negative value on the client and their messages. The therapeutic nurse-client relationship must be, at all times, nonjudgmental, open and honest.
Rejection and Minimization
Rejection of the client and any minimization and rejection of their expressions of feelings and thoughts are also not at all acceptable in the therapeutic nurse-client relationship.
Stereotyping is a barrier to effective communication and, in fact, it is a barrier to all thought and interpersonal relationships. Stereotyping involves generalized thoughts and words that are not at all based on the individuality and uniqueness of the individual.
The therapeutic nurse-client relationship with a client begins with the establishment of trust. This trust is initiated within this relationship with honesty, openness, caring, compassion, and respect.
After this basic trust is established, it must be maintained and further developed throughout the working stage of this therapeutic relationship and the client is additionally encouraged to openly express and ventilate their feelings, fears, discomfort, and anxieties. Other elements of the therapeutic nurse-client relationship and therapeutic communication are open and honest communication, the encouragement of the patient's free expressions and ventilation of feelings, values, beliefs and views, the provision of an environment that is unconditionally accepting and respectful, and the nurse's maintaining a nonjudgmental, unbiased attitude relating to the patient's views, feelings, and ideas of client regardless of whether or not the nurse agrees with them.
Communication, a dynamic interpersonal process, is deemed as effective and therapeutic when all conveyed messages are fully comprehended by the receiver and when all feedback is conveyed by the receiver of the message to the sender of the message is also completely comprehended.
- Abuse and Neglect
- Behavioral Interventions
- Chemical and Other Dependencies/Substance Abuse Disorders
- Coping Mechanisms
- Crisis Intervention
- Cultural Awareness and Influences on Health
- End of Life Care
- Family Dynamics
- Grief and Loss
- Mental Health Concepts
- Religious and Spiritual Influences on Health
- Sensory/Perceptual Alterations
- Stress Management
- Support Systems
- Therapeutic Communication (Currently here)
- The Therapeutic Environment