Therapeutic Communication

Communication stems from the Latin word communicare, “to impart, participate, convey, and share information about” (Webster’s New Collegiate Dictionary, 1974, p. 228). It is the act or reciprocal process of imparting or interchanging thoughts, attitudes, emotions, opinions, or information by speech, writing, or signs. Nurses can use this dynamic and interactive process to motivate, influence, educate, facilitate mutual support, and acquire essential information necessary for survival, growth, and an overall sense of well-being (Howells, 1975; Kleinman, 2004) Communication is essential for nurses to develop and maintain competent communication and interpersonal skills. Effective communication skills are required to facilitate therapeutic interactions, assess client need, and implement interventions that promote an optimal level of functioning. Early forms of communication and interactions with primary caregivers are the origin of trust, security and safety, and lifelong interpersonal relationships and communication patterns (Antai-Otong & Wasserman, 2003). Research findings indicate that effective communication between the nurse and physician enhances problem solving and decision making and improves treatment outcomes (Boyle & Kochinda, 2004; Schmidt & Svarstad, 2002). In contrast, negative or poor communication between the nurse and physician has a deleterious impact on staff morale, staff and client satisfaction, treatment outcomes, and quality of care (Larson, 1999; Rosenstein, 2002; Rosenstein & O’ Daniel, 2005). Thus in the communication process, communication is define as the exchange of thoughts, feeling, and other information. It is the interchange of information between two or more people; in other words the exchange of ideas or thoughts. It is where thoughts are conveyed to others not only by spoken or written words but also by gestures or body

actions. It can be transmission of feelings or a more personal and social interaction between people. It is a basic component of human relationships. The intent of any communication is to elicit a response. It includes all the techniques by which an individual affects another. The two main purpose of communication are to influence others and to obtain information. Face-to-face communication involves a sender a message a receiver and a response or feedback. In its simplest form, communication is a two way process involving the sending and the receiving of a message. The sender a person or groups who wish to convey a message to another can be considered the source-encoder. This term suggest that the person or group sending a message must have an idea or reason communicating (source) and must put the idea or feeling into a form that can be transmitted. Encoding involves the selection or specific signs or symbol (codes) to transmit the message such as which language and words to use how to arrange the words to use how to arrange the words and what tone of voice and gestures to use. The second component of the communication process is the message itself-what is actually said or written the body language that accompanies the words and how the message is transmitted. The medium used to convey the message is the channel and it can target any of the receiver’s senses. It is important for them to be appropriate for the message and it should help make the intent of the message clearer. The receivers the third component of the communication process is the listener who must listen observe and attend. This person is the decoder who must perceive what the intended (interpretation). Perception uses all of the senses receive verbal and nonverbal messages. The fourth component of the communication process the response is the message that the receiver returns to the sender is also called feedback. Feedback can be either verbal or

non verbal or both. Nonverbal examples are a nod of the head or a yawn. Either way feedback allows the sender to correct or record message. There are two major modes of communication. One is verbal communication which is largely conscious because people choose the words they use. The words used vary among individuals according to culture socioeconomic background, age, and education. As a result countless possibilities exist for the way ideas are exchange. An abundance of word can be used to form messages. In addition, a wide variety of feelings can be conveyed when people talk. When choosing words to say or write, nurses need to consider. Two is nonverbal communication which is sometimes called body language. It includes gestures body movements use of touch and physical appearance including adornment. Nonverbal communication often tells other more about what a person is felling than what is actually said because nonverbal behavior is controlled less consciously than verbal behavior. Nonverbal communication either reinforces or contradicts what is said verbally. Communication also varies in different level of deployment. Infants communicate through their senses. Teach parents about the importance of touch. They respond best to high-pitched soft or gentle tone of voice and eye contact .While in toddlers and preschoolers; allow time for them to complete verbalizing their thoughts without interruption. Provide them a simple response to question because they have short attention spans. For them, drawing a picture can provide another way for the child communicates. In school-age children talking to them at his or her eye level is important to increase their self- esteem. Include the children in the conservation when communicating with the parents. For adolescent, it is important to take time to build

rapport, use active listening skills and project nonjudgmental attitude and non reactive behavior even when the adolescent says disturbing remarks. There are several factors which influences the communication process; the development, role and relationship, environment, therapeutic communication and alike. In development as a factor which influences communication process, language psychosocial and intellectual development moves through the stages across the life span. Knowledge of a client’s development stage will allow the nurse to modify the message accordingly. The use of dolls and games with simple language may help explain a procedure to an 8-years-old. With adolescent who have developed more abstract thinking skill a more detailed explanation can be given where as a well educated middle-age business executive may wish to have detailed technical information provided. Older clients are apt to have a wider range of experiences with the health care system which may influence their response and understanding. With aging also come changes in vision and hearing acuity that can affect nurse-client interactions. The

roles

and

the

relationship

between

sender

and

receiver

affect

communication process. Roles such as nursing student and instructor client and physician or parent and child affect the content and responses in the communication process. Choice of words sentence structure and tone of voice vary considerably from the role to the role in addition the specific relationship between the communicators is significant. The nurse who meets with a client for the first time communicates differently from the nurse, who has previously developed a relationship with that client, People usually communicate most effectively in a comfortable environment. Temperature extremes excessive noise and a poorly ventilated environment can all interfere with communication Also lack of privacy may interfere with a clients

communication about matter that clients considers private. Environmental distraction can impair and distort communication. Therapeutic communication promotes understanding and can help establish a constructive relationship between the nurse and the client. Unlike the social relationship where there may not be a specific purpose of direction the therapeutic helping relationship is client and goal directed. Nurses needed to respond not only the content of client’s verbal message but also the felling expressed. It is important to understand how the clients view the situation and feels about it before responding. There is a helping relationship between the nurse and the client. Nurse client relationship are referred to by some as interpersonal relationship by other as therapeutic relationships and by still others as helping relationship Helping is a growth facilitating process that strives to achieve two basic goals (Egan 1998). It may be a way which helps client manage their problems more effectively and develop unused or underused opportunities more fully. And also, it helps client become better at helping themselves in their everyday lives. The helping relationship process can be described in terms of four sequential phases, each characterized by identifiable tasks and skills. The relationship must progress through the stages in succession because each builds on the one before. Nurses can identify the progress of a relationship by understanding these phases. The pre-interaction phase is similar to the planning stage before an interview. In most situations, the nurse has information about the client before the first face-to-face meeting. Planning for the initial visit may generate some anxious and feeling specific information to be read positive outcomes can evolve.

Introductory phase, also referred to as the orientation phase, is important because it sets the tone for the rest of the relationship. During this initial encounter, the client and the nurse closely observe each other and form judgments about the others’ behavior. The tree stages of this introductory phase are opening the relationship, clarifying the problem, and structuring and formulating the contact. Other important tasks of the introductory phase include getting to know each other and developing a degree of trust. During the working phase of a helping relationship, the nurse and the client begin to each other as unique individuals. They begin to appreciate this uniqueness and care about each other. Caring is sharing deep and genuine concern about the welfare of another person. Once caring develops the potential for empathy increases. The working phase has two major stages: exploring and understanding thought and feelings, and facilitating and talking action. The nurse helps the client to explore thought, feelings, and actions and helps the client plan a program of action to meet reestablished goals. In exploring and understanding thoughts and feelings, the nurse requires the empathetic listening skills, respect, genuineness, concreteness, and confrontation for this phase of the helping relationship. During the first stage of the working phase, the intensity of interaction increases, and feelings such as anger, shame, and self-consciousness may be expressed. The termination phase of the relationship is often expected to be difficult and filled with ambivalence. However, if the previous phases have evolved effectively, the client generally has a positive outlook and feels able to handle problems independently. On the other hand, because caring attitudes have developed, it is natural to expect some feeling loss, and each person needs to develop a way of saying good-bye.

Therapeutic communication refers to a healing or curative dialogue between people. This is particularly significant to the nurse because it is the basis of therapeutic relationships. Therapeutic communication fosters an active collaborative process that facilitates problem solving, change, learning, and growth. The nurse-client relationship is a dynamic partnership that defines, directs, and evaluates treatment outcomes. (Antai-Otong and Wasserman 2003) Communication is conveyed through feelings, attitude or thoughts. This reciprocal process enables the nurse to effect adaptive changes in the client. (Travelbee, 1971) The foundation of therapeutic communication is rapport. Rapport refers to the harmony or accord between people. This initial alliance is vital to the formation of trust. As the therapeutic relationship evolves, so does the client’s willingness to trust and share information. (Antai-Otong and Wasserman 2003) The nature of communication patterns is complex and involves several components. The major components of communication patterns relate to an array of neurobiological, psychosocial, and developmental issues. People are social beings. Emotional ties foster a sense of identity, comfort, security, and support. From birth to death, relationships with others are central to human existence. Communication

is

critical

to

healthy

human

interactions.

Integrating

neurobiological and psychosocial factors into the communication process enhances the nurse-client relationship. The third major factor that influences communication is developmental stage. Four stages have been identified in language development and communication:

1. The first stage and initial communication begins with the birth cry, which evolves into gurgles and variations in sounds and sucking rates that convey different needs. 2. The second stage involves cry vocalizations and variations in sounds and pitches. 3. The third stage consists of babbling, which varies with culture and is influenced by the intonation patterns and language of the primary caregivers. 4. The evolution of “true speech” begins in the fourth stage, which ends the first

year, and is described as prelinguistic vocabulary. These stages parallel cognitive and neurobiological development, which influence refinement of schemata and systematic growth of logical operations or understanding of self and the world. In applying Piaget’s theory, nurses can interpret a child’s behaviors (both verbal and nonverbal), depending on the stage of cognitive functioning, that is, sensorymotor, preoperational, concrete operational, or formal operational stage of reasoning. Sociological factors also play a major role in language and communication development. Learning takes place in the context of reciprocating motor gestures between the infant and the primary caregivers (Condon & Sander, 1974; Piaget, 1970). Several theorists have defined communication. According to the dyadic interpersonal communication model described by Berlo in 1960, communication is a dynamic interaction that consists of a source, who has a purpose that is understandable to another person, and an encoder, who is able to understand the meaning of the message. The message is processed and decoded and

understood by the recipient, or decoder. In essence, people must convey clear messages if they expect the information to be understood. The value of communication lies in the ability to use various symbols or ideas to convey a common understanding of the messages. (Peplau, 1952). The goal of therapeutic interactions is congruence between nonverbal and verbal communication. Nonverbal communication has a greater impact than verbal communication and yet not enough attention in nursing is focused on this area in communication training programs (Krujiver, Kerkstra, Franke, Bensing, & Van de Wiel, 2000). The old adage, “action speaks louder than words,” is relevant to understanding communication in any society. A major limitation of nonverbal communication is the inability to validate the meaning of feelings. The effective use of verbal communication varies among individuals. It is influenced by developmental stage, neurobiological components such as stress, cognitive function, and psychosocial and cultural factors. Therapeutic communication is a complex process, and its effectiveness is influenced by various factors that direct the communication process, these includes attitude, trust, empathy, language, culture, perception and observation, self-concept and self-esteem, anxiety and stress, and personal space. The nurse’s interest, acceptance, and attitude toward the client play major roles in therapeutic interactions. The nurse’s attitude sets the mood of nurse-client relationship. Clients need to feel valued and respected. The nurse conveys trust and empathy through verbal and nonverbal communication. The client needs to be

approached in an unhurried manner; avoiding abrupt or indifferent responses. The client is more likely to be cooperative and participate in treatment when the nurse uses calm, concerned approach. The concerned and caring nurse generates trust. The client feels confident and safe in these environments. Four common themes of competence in nursing practice include trusting, caring, communication skills, and knowledge and adaptability (Locsin, 1998). Empathy communicates understanding and concern. Interestingly enough, a review of the literature reveals a lack of clarity and consensus on what exactly is meant by “empathy” (Reynolds, Scott, & Austin, 2000), yet it is always viewed as a critical aspect of therapeutic relationships. This powerful communication tool conveys “I am with you and I have a sense of what you are experiencing,” without totally losing one’s identity. More specifically though, empathy involves the sensitivity to current feelings and the ability to communicate this understanding in language attuned to the client’s feelings (Truax, 1961), thus promoting change, growth, and health restoration. Verbal cues consist of using words to communicate ideas, thoughts, and feelings. Language is a complex phenomenon and the tool we use to communicate with each other. It activates higher cognitive processes such as understanding, thinking, remembering, and reasoning. Through language we learn, educate, socialize, create, and validate perceptions of the world and ourselves by sharing feelings and thoughts. Effective communication through language is linked with health. Culturally sensitive care is crucial to therapeutic communication. Whereas it may not be possible to know all cultural nuances, being attentive to understanding various

influences may facilitate the delivery and quality of health care. Communication is difficult at best, but when the sender and receiver are from different cultures, the difficulty becomes even more pronounced. Perception is the way events are interpreted through sensory stimulation. Past and present experiences and innate traits that validate or correct the receiver’s interpretation determine perception. Thoughts are stimulated by perceptions, and feelings respond to thoughts. In the following example, the nurse’s perception interferes with objective client care. Self-concept refers to one’s beliefs and feelings about self. It serves as a frame of reference for life experiences and perceptions of the world. It evolves over time and arises from interactions with others. Self-concept plays a major role in adaptation and the maturational process. Successful resolution of development tasks or stressors shapes a positive self-concept. Client interactions normally produce anxiety in both the client and the nurse. Anxiety is described as a vague, uncomfortable feeling and manifests itself psychologically and biologically. Response to anxiety varies among people and can be both motivating and distressful. Lower levels of anxiety increase alertness and enhance problem-solving abilities. However, heightened levels of anxiety decrease cognitive processing, causing disruption and distress. Sullivan (1954) described anxiety as the chief barrier to effective communication because it threatens self-esteem and self-respect. As a natural part of human experiences, nurses need to take steps to help clients handle anxiety. Reducing anxiety and redirecting it into useful channels enhances communication.

Hall (1966) introduced the concept personal space in interpersonal relationships. He believed that human beings are constantly changing positions and that social interactions are affected by space. He defined space or zone norms from a Western cultural perspective as the following: Intimate distance: 6 to 18 inches (between people touching). Personal distance: 1 ½ to 4 feet (arms length). Social distance: 4 to 12 feet (most frequently used in business activities). Public distance: 12 to 25 feet (entertainer, public speaker). It is important for the nurse to respect comfort zones and be aware of any boundary violations that may threaten one’s safety. A question often posed by students and nurses is, “What are therapeutic communication techniques?” A simple definition is that a therapeutic communication technique is one that facilitates therapeutic communication. In reality, the ability to communicate effectively is an art that uses basic listening and communication skills. The nurse can use this collaborative interaction to assess the client’s needs, formulate client outcomes, and evaluate the effectiveness of interventions. Therapeutic technique includes active listening, questioning, clarifying technique There are Principles of Communication. Acceptance is one of the principles needed by the nurse to bear in mind, favorable reception of another person by implying a client has the right to exist, to live and to have somebody to care about. Second is interest, nurses communicate when they are genuinely curious and express a desire to know another person. Interest is conveyed by asking about those aspects of a client’s life that others often reject. Another is show consideration for another by communicating their willingness to work with the client and accept the client’s ideas, feelings, and rights. This is all conveyed with respect. Next is honesty, nurses must show consistency, open and frank. Nurses do not take refuge behind a professional mask but instead

communicate with the client as an authentic person. Nurses must be honest and nondefensive about their thoughts and feelings that they discover through selfassessment. Also concreteness is one of the principles of therapeutic communication, being specific, to the point and clear when they communicate with the client should be practiced. Client’s who speak in vague, general, unfocused ways are helped to be more specific and focused. And the sixth is assistance, nurses assist clients by committing time and energy to therapeutic relationships. They convey that they are present and available and have tangible aid to offer that will help the client to choose and develop more functional ways of living. Permission also is a principle; nurses communicate permission by conveying the massage that it is acceptable to try new ways of behaving. Often client’s are afraid to choose freely and autonomously. They are bound by misconceived archaic rules and magical thinking and need to be given permission and encouragement to see and to things in new ways. Lastly the principle of protection, nurses protect clients by ensuring client’s safety, and assumes responsibility of working with the client to anticipate trouble spots with new behavior and develop effective ways of dealing with anticipated or actual problems, thus maximizing the possibility of success. (Haber et al., 2007) There are barriers of therapeutic communication. Giving advice is a barrier to good therapeutic communication. The nurse offers solutions and advices the client about what course of action to take. This approach denies the client’s ability to formulate solutions to problems and assume responsibility for direction of his/her life. Second is giving assurance, nurses offer information to the client that it is not based on fact and truth and differs from conveying information or giving realistic feedbacks. Reassurance denies the client’s right to the feelings being experienced and closes off communication

about them. Next is changing the subject. The nurse diverts the focus of the interaction at crucial times to something less threatening. Changing the subject usually occurs when the nurse is unwilling or unable to lessen the painful feelings being expressed by the client. Also being judgmental is a barrier to good therapeutic communication. The nurse respond to the client with value-laden judgments that come form the nurses value system. The fifth barrier is giving directions. The nurse approaches the client with specific directions to be followed and frequently lectures the client about advisability of following this course of action. Sixth is excessive questioning, on the part of the nurse it controls the nature of range of the client’s responses. The nurse can be perceived by the clients as an interrogator who is demanding information with out respect for the client’s ability or readiness to respond. Another one is using emotionally charged words. The nurse uses emotionally charged words with the client who cannot tolerate or accept such feelings. The client may withdraw physically and emotionally. Next is challenging, nurse sometimes feels that if the client is challenged to prove unrealistic ideas or perception, the client will realize that there is no proof to support such ideas and will be forced to acknowledge what is true. Making stereotypical comments is also a barrier. Offering trite expressions and meaningless clithes as responses diminishes the value of the nurse-client interaction. The tenth barrier is self focusing behavior. It is characterized by the nurse’s excessive interest in or preoccupation with his/her own thoughts, feelings, or actions. And lastly is double-bind message. The nurse delivers two conflicting messages, one verbal, the other is nonverbal. The nonverbal message contradicts the verbal message. It is unclear which message is to be obeyed. Public Distance: 12 to 25 feet. It is important for the nurse to respect comfort zone and be aware of any boundary violations that may threaten one’s safety.

A question often posed by student and nurses is, “What are therapeutic communication techniques?” A simple definition is that a therapeutic communication technique is one of that facilities therapeutic communications. In reality, the ability to communicate effectively is an art that uses basic listening and communication skills. The nurse can use this collaborative interaction to assess the client’s needs, formulate the client outcomes, and evaluate the effectiveness of interventions. Therapeutic techniques include: Active listening is the basis of all nurse client interactions. Listening is more than hearing. It is a dynamic and active process that requires enormous concentration and energy. It literally means using all the senses to assess verbal and non-verbal message. Active Listening conveys concern and respect for the client. It fosters a trusting relationship that encourages the client to express feelings and share thought. “Knowing the patient” and encouraging her to “tell their story” (Chamber Evans , Stelling & Goodwin, 1999) is essential in providing individualized and quality nursing care. Students and nurse clinicians can enhance their communication skill by identifying barriers to active listening. The art of active listening requires perseverance and patience. Questioning is a valuable tool that nurse use to encourage the expression and feelings and self-disclosure and to gain insight into the meaning of present stressors. The basis of the client response depends on her level of trust and security or in the comfort with questions. Nurse can put their clients at ease by introducing themselves and calling them by name, making eye contact and shaking hands at the same time helps nurses connect with clients both verbally and nonverbally. This establishes a safe

environment that promotes trust, care, and empathy. The nurse can use questioning as a tool to elicit pertinent information from the client. Clarifying techniques refers to the use of certain methods to clear up or make message understandable. Communication is complex, dynamic process that involves interaction between people. The likelihood of confusion exists in all human interactions. Specific clarifying techniques are paraphrasing or restatements. Paraphrasing involves listening to the client basic message and repeating themusing similar words. This technique focuses on the content of the message. It affords the nurse with a clearer understanding of the client distress. Touching

is

another

powerful,

sometimes

controversial

nonverbal

communication. It is critical aspect of human relationships throughout the lifespan. Touching is the key to survival, particularly during infancy, because it conveys trust, safety, and love, and it nurtures neurobiological and psychosocial development. Therapeutic touch enables the client to experience trust, reassurance, and acceptance. Silence is a natural phenomenon; it is deliberate restraint from verbal expression. Therapeutic useof silence is another effective communication technique, but it requires practice and skill to master. Silence can be use to help clients explore the meaning of feelings and thoughts. Humor is important but underutilized therapeutic communication techniques. It values

includes

physiological,

psychological,

social,

and

cognitive

benefits.

Physiologically, it stimulates the circulatory and respiratory system, relaxes the muscle and increase the productions of endorphins. Humor helps client express their feeling, thereby reducing anxiety and tension or stress (King, Novic, & Citrebaum, 1983, Lachman, 1983), particularly during intense situations.

Focusing refers to clarifying a perception or spotlighting certain aspects of communication. This technique is useful when clients are vague and need assistance with goal directed communication. Focusing is useful when clients don not express their feelings clearly, when they ramble, or when they discussed several issue at one time. Confrontation refers to an encounter or face-to-face meeting. Nurses often associate this term with conflict or angry discussion between opposing bodies. In reality, confrontation is necessary aspects of Nurse-clients interaction. Like other techniques, it is and art that involves pointing out contradictions or incongruities between feelings, thoughts, and behaviors. Summarizing is a communication tool that helps clients explores key points of a nurse-client interaction. This dynamic and collaborative process integrates perceptions from the nurse and client. Major points are reviewed and used to generate future client outcomes.