Therapeutic communication techniques.
Nurses are critical in the delivery of essential health services and are core in strengthening the health system. They bring people-centred care closer to the communities where they are needed most, thereby helping improve health outcomes and the overall cost-effectiveness of services. Nurses usually act as first responders to complex humanitarian crises and disasters; protectors and advocates for the community and communicators and co-ordinators within teams. Communication is a core component of sound relationships, collaboration and co-operation, which in turn are essential aspects of professional practice. The quality of communication in interactions between nurses and patients has a major influence on patient outcomes. Increases in nursing communication can lessen medical errors and make a difference in positive patient outcomes. This chapter explores how effective communication and interpersonal skills can enhance professional nursing practice and nursing relationships with various stakeholders. It explains principles of communication, communication process, purpose of communication, types of communication, barriers to effective communication, models of communication and strategies of improving communication and guidelines for successful therapeutic interactions.
- communication skills
- non-verbal communication
- nurse–patient relationship
- nursing verbal communication
Nurses are critical in the delivery of essential health services and are core in strengthening the health system [1, 2]. They bring people-centred care closer to the communities where they are needed most, thereby helping improve health outcomes and the overall cost-effectiveness of services . Nurses usually act as first responders to complex humanitarian crises and disasters; protectors and advocates for the community and communicators and co-ordinators within teams. Communication skills for nurses are essential but may be difficult to master. Communication is the exchange of information between people by sending and receiving it through speaking, writing or by using any other medium. Clear communication means that information is conveyed effectively between people. To be a successful nurse, excellent communication skills are required . Nurses speak to people of varying educational, cultural and social backgrounds and must do so in an effective, caring and professional manner, especially when communicating with patients and their families . The quality of communication in interactions between nurses and patients has a major influence on patient outcomes. This influence can play a very important role in areas such as patient health, education and adherence . Good communication plays an important role in the organization’s effective functioning [7, 8, 9]. A nurse must therefore, continuously try to improve his/her communication skills as poor communication can be dangerous and lead to confusion.
2. Principles of communication
Principles of communication can be summarized as follows:
Communication is a process;
Communication is not linear, but circular;
Communication is complex;
Communication is irreversible; and
Communication involves the total personality .
3. Communication process
Interaction between people is cyclic, which means that what one person says and does evokes a reaction from the other person, and this reaction again stimulates another reaction from the first person [10, 11]. Three things are needed for successful communication. They are:
A clear message; and
A receiver .
4. Purpose of communication
The purpose of communication is to inquire, inform, persuade, entertain, request and investigate. A single message can have one or more of the following purposes:
To convey information/opinion, for example, “I have headache” or “I am here to give you medication”.
To request information/opinion/behavior, for example, “Are you allergic to penicillin?” or “Tell me more about the injury”.
To give social acknowledgement, for example, “Hello” or “Good morning”.
These three primary types of messages can be combined in many ways so that they form an interaction (conversation). The goals of the interaction can be comprehensive. Nurses strive to make all their communication with patients therapeutic, that is, their communication is purposefully and consciously planned to promote the patient’s health and wellbeing.
5. Types of communication
Verbal and non-verbal communications are the two main types of communication used by human beings.
5.1. Verbal communication
Verbal communication is associated with spoken words and is vitally important in the healthcare context. Members of the multi-disciplinary healthcare team communicate verbally with one another and with patients as well as family members.
5.2. Verbal communication
Non-verbal communication is not reliant on words. It is sent through the use of one’s body rather than through speech or writing. This kind of communication, called body language, can tell a great deal or can totally the wrong impression. It is worth noting that body language may indicate a different meaning to what is spoken. As approximately 60% of communication is non-verbal, non-verbal skills are essential for effective communication . Often non-verbal messages send stronger signals than verbal messages. Non-verbal communication is made up of:
6. Communication process
The communication process may be explained by means of a linear model of communication, interactive model of communication or transactional model of communication .
6.1. Linear model of communication
Linear model of communication entails a sender, a message, a receiver and noise (Figure 1).
6.2. Interactive model of communication
Interactive model of communication gives a slightly more complex explanation of the communication process. Communication is seen as a process in which the listener gives feedback or responds to a message after a process of interpretation. A communicator creates and interprets a message with a personal field of expertise and/or a frame of reference Figure 2).
6.3. Transactional model of communication
Transactional model of communication acknowledges and gives emphasis to the dynamic nature of interpersonal communication and the multiple roles of the communicators. Features such as time, messages, noise, fields of experience, frames of reference, meanings, shared systems of communicators and personal systems all pay a role in the process of communication. Communicators often participate simultaneously (sending, receiving and interpreting). The unique interpretive and perceptual processes of individuals thus play an essential role in the communication process.
7. Barriers to effective communication
Effective communication skills and strategies are important for nurses. Clear communication means that information is conveyed effectively between the nurse, patients, family members and colleagues. However, it is recognized that such skills are not always evident and nurses do not always communicate well with patients, family members and colleagues. The message sent may not be the message received. The meaning of a message depends on its literal meaning, the non-verbal indicators accompanying it and the context in which it is delivered. It is therefore, easy to misinterpret the message, or to interpret it correctly, but to decide not to pursue its hidden meaning this leads to obstruction to communication. Continuous barriers to effective communication brings about a gradual breakdown in relationships. The barriers to effective communication outlined below will help nurses to understand the challenges .
7.1. Language barrier
Language differences between the patient and the nurse are another preventive factor in effective communication. When the nurse and the patient do not share a common language, interaction between them is strained and very limited [9, 10, 11]. Consequently, a patient may fail to understand the instructions from a nurse regarding the frequency of taking medication at home.
7.2. Cultural differences
Culture is another hindrance. The patient’s culture may block effective nurse–patient interactions because perceptions on health and death are different between patients [12, 13, 14]. The nurse needs to be sensitive when dealing with a patient from a different culture [9, 15, 16]. What is acceptable for one patient may not be acceptable for another. Given the complexity of culture, no one can possibly know the health beliefs and practices of every culture. The nurse needs check with the patient whether he/she prefers to be addressed by first name or surname. The use of eye contact, touching and personal space is different in various cultures and rules about eye contact are usually complex, varying according to race, social status and gender. Physical contact between sexes is strictly forbidden in some cultures and can include handshakes, hugging or placing a hand on the arm or shoulder. A ‘yes’ does not always mean ‘yes’. A smile does not indicate happiness, recognition or agreement. Whenever people communicate, there is a tendency to make value judgements regarding those perceived as being different. Past experiences can change the meaning of the message. Culture, background and bias can be good if they allow one to use past experiences to understand something new; it is when they change meaning of the message that they interfere with the communication process . It is important for nurses to think about their own experiences when considering cultural differences in communication and how these can challenge health professionals and service users.
Conflict is a common effect of two or more parties not sharing common ground. Conflict can be healthy in that it offers alternative views and values. However, it becomes a barrier to communication when the emotional ‘noise’ detracts from the task or purpose. Nurses aim for collaborative relationships with patients, families and colleagues.
7.4. Setting in which care is provided
The factors in care setting may lead to reduction in quality of nurse–patient communication. Increased workload and time constraints restrict nurses from discussing their patients concerns effectively . Nurses work in busy environments where they are expected to complete a specific amount of work in a day and work with a variety of other professionals, patients and their families. The roles are hard, challenging and tiring. There is a culture to get the work done. Some nurses may consider colleagues who spend time talking with patients to be avowing the ‘real’ work and lazy. Nurses who might have been confident in spending time with patients in an area where this was valued, when faced with a task-orientated culture have the dilemma of fitting into the group or being outside the group and spending time engaging with patients. Lack of collaboration between the nurses and the doctors in information sharing also hinder effective communication. This leads to inconsistencies in the information given to patients making comprehension difficult for the patient and their families.
7.5. Internal noise, mental/emotional distress
Internal noise has an impact on the communication process. Fear and anxiety can affect the person’s ability to listen to what the nurse is saying. People with feelings of fear and anger can find it difficult to hear. Illness and distress can alter a person’s thought processes. Reducing the cause of anxiety, distress, and anger would be the first step to improving communication.
If a healthcare professional feels that the person is talking too fast, not fluently, or does not articulate clearly etc., he/she may dismiss the person. Our preconceived attitudes affect our ability to listen. People tend to listen uncritically to people of high status and dismiss those of low status.
7.7. Difficulty with speech and hearing
People can experience difficulty in speech and hearing following conditions like stroke or brain injury. Stroke or trauma may affect brain areas that normally enable the individual to comprehend and produce speech, or the physiology that produces sound. These will present barriers to effective communication.
Medication can have a significant effect on communication for example it may cause dry mouth or excess salivation, nausea and indigestion, all of which influence the person’s ability and motivation to engage in conversation. If patients are embarrassed or concerned that they will not be able to speak properly or control their mouth, they could be reluctant to speak.
Equipment or environmental noise impedes clear communication. The sender and the receiver must both be able to concentrate on the messages they send to each other without any distraction.
8. Improving communication
Some ways of improving communication are as follows:
Listen without interrupting the sender.
Show empathy at all times and try to understand.
Try to stay focused on the conversation. Do not however, force the patient to continue if he/she becomes anxious or seems to wish to change the subject.
Use the body language that indicates your interest and concern. Touch the patient if it seems appropriate. Lean forward, listen intently and maintain eye contact if it culturally acceptable.
Offer factual information. This relieves anxiety. Do not offer your personal opinion. Assure the patient that you have professional discretion.
Try to reflect the feelings and thoughts the patient is expressing by rephrasing questions and comments using their own words.
Avoid unclear or misleading messages.
Avoid giving long explanations.
Give your co-workers your full attention when communicating with them.
Ask questions to clarify unclear messages.
Do not interrupt until the sender has completed the message.
Provide a quiet environment without distractions.
Be convincing wen communicating .
9. Communicating with patients
There are several points to be kept in mind when communicating with patients. The first point is that you are there to provide care and support to the patient.
Be open, respectful and gracious in all your interactions with the patient and keep his/her cultural preferences in mind.
Answer nurses’ bells promptly.
Make sure you have the patients’ attention when communicating.
Use words that are non-threatening – explain what you would like to do and do not give orders to the patient.
Use simple, understandable phrases, not medical terms as most patients do not understand these terms.
Speak clearly and courteously.
Use a pleasant and normal tone of voice to the hard of hearing.
Always stand so that the patient can see the nurse’s face when communicating, as lip reading is part of all normal hearing.
Use body language that is appropriate.
Explain facts and procedures before donning a mask that covers the wearer’s mouth and lower face.
Be alert to the patient’s needs. Allow time for answers to your requests and to answer patient’s questions .
10. Communicating by phone
Nurses often communicate over the phone with patients, family members and colleagues and this can lead to misunderstandings. The way in which the pone is answered and a message is interpreted needs special skills because the body language of the person at the other end of the phone line cannot be seen. When answering the phone or making a call:
Always speak clearly into the mouthpiece of the phone.
Offer a greeting for example, good morning or good afternoon.
Identify the unit or place of work.
Identify yourself by indicating who you are and where you are phoning from.
Identify the person to whom you are speaking.
Politely listen to the message and make notes if you think you may not remember all the information.
If you are asked to call another person, note the date, time, caller’s name and telephone number together with the message.
Date and sign the message .
11. Assertive communication
The skill of assertiveness is important to nurses. Nurses are expected to be the patients’ advocates. So, they need to have the assertive communication skills in order to be able to be patients’ advocates. Assertiveness enables a person to be honest with him/herself and in relationships with others. Assertiveness helps to enhance relationships, avoid power games and is a vehicle for clear outcomes. Hargis as cited by van Niekerk identifies four elements of assertive communication :
Content – where the rights of the people involved are embedded gently in the statement. This could be done by using an explanation, empathy for the listener, and praise for the listener, an apology for the consequence for the listener or a compromise that is favorable to both people.
Covert elements – where the speaker is able to recognize their rights and the rights of the listener in the communication process. These include respect, expressing feelings, having your own priorities, being able to say ‘no’, being able to make mistakes and choosing to say nothing.
Process – concerned with how people express themselves assertively. Is their body language, intonation and choice of language reflective of a confident assertive person? Are the processes that make up communication congruent, in keeping with what is being said? The process also involves managing the setting so that people are not embarrassed, or the noise levels are kept to a minimum. Increasing the likelihood of assertive communication happening again involves feedback to the listener to show that their accomplishment is appreciated.
Non-verbal cues – gesture, touch, proxemics and posture – also need to reflect confidence, regard and respect for self and others.
12. Therapeutic interactions
Therapeutic interactions are purposeful as opposed to social. Social interaction entertains the participants, but in a professional situation, the nurse usually has a clinical objective that he/she wants to achieve with communication. The nurses therefore, decides on the purpose of the interaction before or shortly after it begins. The following purposes are common in nursing:
Assess a patient: The nurse wants to know more about a patient to identify his/her problems. This type of conversation can be a structured interview using an interview schedule. The purpose of this conversation is always a better understanding of the patient.
Instruct a patient: Patient instruction may vary from an informal conversation during which few facts are conveyed to an elaborate instruction session.
Problem solving: If a patient discuss his/her problems with a nurse, the nurse helps the patient to analyze the problem, consider possible alternative ways of handling it and how to decide which way is the best. Problem solving is done with the patients and not for them.
Give emotional support: The presence of an empathetic nurse, that is, one who can enter into the patient’s shoes and understand the patient’s experience, is immensely supportive of the patient. Emotional support alleviates the loneliness of the patient’s experience of illness and increases his/her dignity .
13. Guidelines for successful therapeutic interactions
After the purpose of the therapeutic interaction has been established, the following guidelines assist in conducting a successful interaction:
13.1. Maintaining a low-authority profile
The nurse must strive to maintain a low-authority profile at the beginning of the conversation. As the conversation progresses, the nurse can use more directive techniques to find out specific information. There are usually differences in age, sex, occupation, cultural background, moral and religious convictions between the nurse and the patient. These differences make it impossible for the nurse to fully understand the patient’s behavior and reactions. It is therefore, important for the nurse to understand and accept differences in patients’ cultures and beliefs. When in doubt, check with the patient. If trust is established, patient will be willing to teach the nurse.
13.2. Use of understandable language
The nurse should determine the patient’s level of understanding and if necessary change the use of language, comments and questions. Using the terminology which the patient does not understand can also frighten the patient and make him/her think that he/she has a more serious problem than he/she originally wanted help for. At the same time, the patient could give incorrect information because due to confusion, he/she may give affirmative answers to questions about symptoms that he/she has not actually experienced . Nurses should share their aims with patients before expecting them to participate in the interaction. They should understand that there is a mutual understanding of each other’s point of departure. In an assessment interview, the nurse can, for instance, say: “Mr Jones, I would like to give you information on how to lose weight so as to bring down you high blood pressure, but I first need to find out what you already know about the condition”. It is not only important that the patients understand what nurses expect from the conversation; it is also essential that nurses understand the patients and convey this understanding before they participate in the conversation. When providing emotional support, this understanding is often all that is necessary. For nurses to understand patients, they must encourage them to talk – not just about facts, but also about their feelings. The nurse must listen more than speak, both to what the patient is saying verbally and what is being said non-verbally. Having listened carefully, the nurse then concentrates and responds empathetically to the patients’ feelings. Only when the nurse has a reasonably complete understanding of the patient’s situation and has communicated this understanding, can she proceed to interventions, such as giving information or solving a problem.
13.3. Tailor the message to the totality of the person
Saying something does not necessary mean that the message has been received and understood. It is the responsibility of the nurse to ensure that the person with whom he/she is conversing understands the message. To ensure this, the message has to be adapted to the language, culture and socio-economic status of the patient. The emotional or physical condition of patients may also make it difficult for them to receive long of complicated messages or even any message. There may also be other disturbances in the immediate environment for example, noise that can make the patient not to hear or understand the message. The message must also be adapted to the age of the patient .
13.4. Validate the interpretation with the patient
Validation means that you ask the patient whether your interpretation is correct or not. You therefore, ask him/her to confirm your understanding of what he/she said. Many misunderstandings arise because people interpret other people’s words without checking their interpretation. The nurse should try to eliminate misunderstandings in the conversations by checking meaning with the patient.
13.5. Active listening
Active listening means concentrating all your senses and thoughts on the speaker. One can usually deduce whether a person is listening actively by looking at the following non-verbal indicators:
Is the eye contact maintained with the person who is speaking?
Are the body and face turned towards the speaker?
It is, of course, also clear from the verbal responses:
Are there regular verbal responses, even if these consist only of encouraging sounds?
Does the response indicate understanding, not only of the facts, but also of the feelings and the implications of the facts?
It is much easier to speak than to listen. Nurses are, in general, very active people, who want help b acting quickly. To ‘just listen’ without expressing opinions or offering advice is therefore, often not in their nature. Active listening is a valuable skill to acquire [10, 17, 18].
13.6. Evaluate own communication
In the interest of nurse–patient relationship, it is essential that they ascertain whether their communication has been successful. The following criteria can be used:
Simplicity: Say what you want to say concisely and without using difficult or unfamiliar terms.
Clarity: Say precisely what you want to say without digressing, and support your verbal message with non-verbal indicators.
Relevance: Make sure that your message suits the situation, the time and the person you are speaking to.
Adaptability: Adapt your response to the clues the patient that the patient gives you.
Respect: Always show respect for the individuality and dignity of the person you are speaking to .
14. Therapeutic communication techniques
|General area of issue||Therapeutic communication techniques||Rationale||Examples|
|To obtain information||Make broad opening remarks||This gives the patient the freedom to choose what he/she wishes to talk about||“Please tell me more about yourself”|
|Use open-ended questions||This type of question allows the patient to talk about his/her views about the subject. In this way, what the patient sees as important, what his/her intellectual capacity is and how well-orientated he/she is, becomes clear. This encourages the patient to say more and does not limit answers to a ‘yes’ or ‘no’||“How did you experience the pain?”|
“You say you felt dizzy, and then…”
“Tell me more about that”
|Share observations and thoughts||This shows that you are aware of what is happening to the patient and encourages him/her to talk about it||“You seem to be upset”|
|Confrontation||This entails confronting the patient with an observation you have made and assess his/her reaction to it. This technique is useful when verbal and non-verbal communication do not match||“You say that your ankle is very painful, but you do not react when I bend the ankle. How is it possible?”|
|Reflection||This means that you repeat what the patient said in the same or different words. This shows you are involved in what the patient is saying and that he/she should talk more about a specific point, or explain further||Patient: “It is sore”.|
Nurse: “Very painful?”
|Encourage description||This is used to obtain more information about patient’s views and feelings||“Tell me how it happened”|
|Validate what is being said||This is to make sure that you understand the patient correctly||“Do I understand you correctly when you say…”|
|Offer your presence||The nurse offers his/her attention and interest without making demands||“I will be with you until they come to fetch you for the operation in theater”|
|Summarizing||By organizing and checking what the patient has said, especially after a detailed discussion. This technique is used to indicate that a specific part of the discussion is coming to an end and that if the patient wishes to say any more, she should do so||“You went for a walk and then you felt the sharp chest pains, which radiated down your arm”|
|Use of interpretation||Draw a conclusion from the information you have gathered and discuss it with your patient to see whether it is true. The patient can then disagree with it, or confirm that your conclusions are true||“You must have been exhausted after walking a long distance from home to the hospital”|
|To give support||Supportive remarks||Make supportive remarks to encourage the patient to participate in the conversation. Show that you are listening||“Yes….”|
“Go on, I am listening”
|Appropriately touch the patient||Touch can assure the patient that the nurse cares and is present||Hold his/her hand. Consider the cultural belief and comfort of the patient before touching|
|Paraphrasing||This conveys understanding of the patient’s basic message||“It sounds as though the most important problem is the diet”|
|To assist in analysis and problem solving||Acknowledge the person||This promotes a sense of dignity||“Good morning Mr. Jones”|
|Sequencing||This helps the patient to see the connection between the parts of an occurrence. To effectively assess the patient’s needs, the nurse often needs to know the time frame within which symptom sand /or problems developed or occurred||“Did you experience this sharp pain before or after eating?”|
|Ask for clarification||This helps the nurse to understand and the patient to communicate more clearly||“What do you mean by everybody?”|
|Ask for alternatives||This stimulates creative thought and promotes finding solutions||“What else can you try?”|
|Use of transition||This is used to guide the conversation to another subject, without losing the continuity of the conversation||“It seems to me that you have solved the problem of poor appetite, but I would like to hear more about your diabetes. How long have you been aware of this illness?”|
|Comparison||Use of examples and comparisons to concrete objects. In this way, a vague or abstract concept can be more easily explained||“Does the pain feel like a sharp or a blunt object that hits you?”|
|Use silence||This gives the patient the chance to think, and/or to his/her organize thoughts. Silence also give a nurse an opportunity to observe the patient. However, the nurse should avoid silences that last too long because they can make the patient anxious|
|To instruct the patient||Give information||This explains information and puts it at the patient’s disposal||“After the operation, you will have a drainage tube”|
|Orientate the patient towards reality||When the patient interprets something incorrectly, the nurse draws his/her attention to reality||“I am not your daughter, I am Nurse Jones”|
|Query what the patient says||The patient’s observation is called into question without belittling him/her, or arguing about it||Are you sure about that?”|
|Withhold social reward||Do not give social approval to wrong behavior so as not to encourage a repeat of the wrong behavior||Do not smile, nod or agree when the patient jeopardizes his/her recovery with wrong behavior|
|Give social reward||Reward behavior that promotes health to encourage a repeat of the correct behavior||Nod is approval at a patient with a weight problem who declines to eat a heavy meal|
15. Counter-productive communication techniques
There are certain counter-productive communication techniques that the nurse should avoid as they do not assist in the recovery of the patient and do not have any therapeutic value. Table 2 shows counter-productive communication techniques, explains why these should be avoided and gives examples [10, 18].
|Inappropriate reassurance||The nurse attempts to brush aside the patient’s aside the patient’s worry by acting as though it is unnecessary or inappropriate. Reassurance is not based on fact or real certainty. This helps the nurse more than it helps the patient||“Do not worry; everything will be fine”|
|Passing judgment||The nurse passes judgment on the patient’s behavior, thoughts or feelings and in doing so, places herself in the position of an adversary or a person who knows better and more||“As a Christian, I do not think you should terminate this pregnancy”|
|Giving advice||The nurse tells the patient how he/she ought to feel, think or act. This implies that she has the correct information and knows better than the patient. This is particularly problematic when the advice is based on limited assessment and knowledge of the patient and the situation||“I think you must…”|
|Closed questions||These questions require only a single word as an answer when specific information is needed. If this type of question is used often, the patient are less inclined to give the information and may be interpreted as an interrogation||“Do you feel any pain in your arm?”|
|‘Why’ questions||These questions demand that the patient explains behavior, feelings or thoughts that he/she often does not understand himself or herself. These questions are often asked early in a conversation when the nurse cannot even be certain that the patient wants to explain himself of herself to the nurse||“Why are you upset?”|
|Offering platitudes||This is stereotyped expression of something the patient is in any case aware of and which, therefore, helps little. This is similar to giving advice||“Everybody goes through this in life”|
|Defensiveness||The nurse tries to defend someone or something the patient criticized. This places the nurse and the patient on opposite sides and does not promote further openness on the part of the patient||“We are very short-staffed; so we cannot help everyone at the same time”|
Promoting effective communication in health care is demanding and challenging because of the nature of the work environment. Nurses who have received training in communication skills communicate effectively and show increased confidence in communicating with patients. Many nurses choose to work in other countries, providing an opportunity to broaden their experience and knowledge. However, it is important that nurses who have the opportunity to work in other countries develop communication skills, cultural awareness and sensitivity before arriving. For example, in China talking about death is taboo . In South Africa, maintaining eye during communication may be regarded as being disrespectful by Black people . This article provides a reflective account of the experiences of one of the authors of working overseas. This chapter provides the effective communication and interpersonal skills that enhance professional nursing practice and nursing relationships by explaining principles of communication, communication process, purpose of communication, types of communication, barriers to effective communication, models of communication and strategies of improving communication and guidelines for successful therapeutic interactions.
The author wishes to acknowledge the Durban University of Technology for funding this book chapter.
Conflict of interest
The author declares that there is no conflict of interest in this chapter.