THE THERAPEUTIC COMMUNICATION SESSION
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Goals The nurse uses all the therapeutic communication techniques and skills previously described to help achieve the following goals:
• Establish rapport with the client by being empathetic, genuine, caring, and unconditionally accepting of the client regardless of his or her behavior or beliefs.
• Actively listen to the client to identify the issues of concern and to formulate a client-centered goal for the interaction.
• Gain an in-depth understanding of the client’s perception of the issue, and foster empathy in the nurse–client relationship.
• Explore the client’s thoughts and feelings. • Facilitate the client’s expression of thoughts and feelings. • Guide the client to develop new skills in problem solving. • Promote the client’s evaluation of solutions.
Often the nurse can plan the time and setting for therapeutic communication, such as having an in-depth, one-on-one interaction with an assigned client. The nurse has time to think about where to meet and what to say and will have a general idea of the topic, such as finding out what the client sees as his or her major concern or following up on interaction from a previous encounter. At times, however, a client may approach the nurse saying, “Can I talk to you right now?” Or the nurse may see a client sitting alone, crying, and decide to approach the client for an interaction. In these situations, the nurse may know that he or she will be trying to find out what is happening with the client at that moment in time.
When meeting the client for the first time, introducing oneself and establishing a contract for the relationship is an appropriate start for therapeutic communication. The nurse can ask the client how he or she prefers to be addressed. A contract for the relationship includes outlining the care the nurse will give, the times the nurse will be with the client, and acceptance of these conditions by the client.
Nurse: “Hello, Mr. Kirk. My name is Joan, and I’ll be your nurse today. I’m here from 7 AM to 3:30 PM. Right now I have a few minutes, and I see you are dressed and ready for the day. I would
like to spend some time talking with you if this is convenient.” (giving recognition and introducing self, setting limits of contract)
After making the introduction and establishing the contract, the nurse can engage in small talk to break the ice and to help get acquainted with the client if they have not met before. Then the nurse can use a broad
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opening question to guide the client toward identifying the major topic of concern. Broad opening questions are helpful to begin the therapeutic communication session because they allow the client to focus on what he or she considers important. The following is a good example of how to begin the therapeutic communication:
Nurse: “Hello, Mrs. Nagy. My name is Donna, and I am your nurse today and tomorrow from 7 AM to 3:30 PM. What do you like to be called?” (introducing self, establishing limits of relationship)
Client: “Hi, Donna. You can call me Peggy.” Nurse: “The rain today has been a welcome relief from the heat of the
past few days.” Client: “Really? It’s hard to tell what it’s doing outside. Still seems hot
in here to me.” Nurse: “It does get stuffy here sometimes. So tell me, how are you
doing today?” (broad opening)
Nondirective Role When beginning therapeutic interaction with a client, it is often the client (not the nurse) who identifies the problem he or she wants to discuss. The nurse uses active listening skills to identify the topic of concern. The client identifies the goal, and information gathering about this topic focuses on the client. The nurse acts as a guide in this conversation. The therapeutic communication centers on achieving the goal within the time limits of the conversation.
The following are examples of client-centered goals:
• The client will discuss her concerns about her 16-year-old daughter who is having trouble in school.
• The client will describe difficulty she has with side effects of her medication.
• The client will share his distress about son’s drug abuse. • The client will identify the greatest concerns he has about being a single
parent.
The nurse is assuming a nondirective role in this type of therapeutic communication, using broad openings and open-ended questions to collect information and to help the client identify and discuss the topic of concern. The client does most of the talking. The nurse guides the client through the interaction, facilitating the client’s expression of feelings and identification of issues. The following is an example of the nurse’s nondirective role:
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Client: “I’m so upset about my family.” Nurse: “You’re so upset?” (reflecting) Client: “Yes, I am. I can’t sleep. My appetite is poor. I just don’t
know what to do.” Nurse: “Go on.” (using a general lead) Client: “Well, my husband works long hours and is very tired when he
gets home. He barely sees the children before their bedtime.” Nurse: “I see.” (accepting) Client: “I’m busy trying to fix dinner, trying to keep an eye on the
children, but I also want to talk to my husband.” Nurse: “How do you feel when all this is happening?” (encouraging
expression) Client: “Like I’m torn in several directions at once. Nothing seems to go
right, and I can’t straighten everything out.” Nurse: “It sounds like you’re feeling overwhelmed.” (translating into
feelings) Client: “Yes, I am. I can’t do everything at once all by myself. I think we
have to make some changes.” Nurse: “Perhaps you and I can discuss some potential changes you’d
like to make.” (suggesting collaboration)
In some therapeutic interactions, the client wants only to talk to an interested listener and feel like he or she has been heard. Often, just sharing a distressing event can allow the client to express thoughts and emotions that he or she has been holding back. It serves as a way to lighten the emotional load and release feelings without a need to alter the situation. Other times, the client may need to reminisce and share pleasant memories of past events. Older adults often find great solace in reminiscing about events in their lives such as what was happening in the world when they were growing up, how they met and when they married their spouses, and so forth. Reminiscence is discussed further in Chapter 24.
Directive Role When the client is suicidal, experiencing a crisis, or out of touch with reality, the nurse uses a directive role, asking direct yes/no questions and using problem solving to help the client develop new coping mechanisms to deal with present here-and-now issues. The following is an example of therapeutic communication using a more directive role:
Nurse: “I see you sitting here in the corner of the room away from
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everyone else.” (making observation) Client: “Yeah, what’s the point?” Nurse: “What’s the point of what?” (seeking clarification)
Client: “Of anything.” Nurse: “You sound hopeless.” (verbalizing the implied) “Are you
thinking about suicide?” (seeking information) Client: “I have been thinking I’d be better off dead.”
The nurse uses a very directive role in this example because the client’s safety is at issue.
As the nurse–client relationship progresses, the nurse uses therapeutic communication to implement many interventions in the client’s plan of care. In Unit 4, specific mental illnesses and disorders are discussed, as are specific therapeutic communication interventions and examples of how to use the techniques effectively.
How to Phrase Questions The manner in which the nurse phrases questions is important. Open- ended questions elicit more descriptive information; yes/no questions yield just an answer. The nurse asks different types of questions based on the information the nurse wishes to obtain. The nurse uses active listening to build questions based on the cues the client has given in his or her responses.
In English, people frequently substitute the word feel for the word think. Emotions differ from the cognitive process of thinking, so using the appropriate term is important. For example, “What do you feel about that test?” is a vague question that could elicit several types of answers. A more specific question is, “How well do you think you did on the test?” The nurse should ask, “What did you think about. . .?” when discussing cognitive issues, and “How did you feel about. . .?” when trying to elicit the client’s emotions and feelings. Box 6.1 lists “feeling” words that are commonly used to express or describe emotions. The following are examples of different responses that clients could give to questions using “think” and “feel”:
Nurse: “What did you think about your daughter’s role in her automobile accident?”
Client: “I believe she is just not a careful driver. She drives too fast.”
Nurse: “How did you feel when you heard about your daughter’s automobile accident?”
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Client: “Relieved that neither she nor anyone else was injured.”
Using active listening skills, asking many open-ended questions, and building on the client’s responses help the nurse obtain a complete description of an issue or an event and understand the client’s experience. Some clients do not have the skill or patience to describe how an event unfolded over time without assistance from the nurse. Clients tend to recount the beginning and the end of a story, leaving out crucial information about their own behavior. The nurse can help the client by using techniques such as clarification and placing an event in time or sequence.
BOX 6.1 “FEELING” WORDS
Afraid Alarmed Angry Anxious Ashamed Bewildered Calm Carefree Confused Depressed Ecstatic Embarrassed Enraged Envious Excited Fearful Frustrated Guilty Happy Hopeful Hopeless Horrified Impatient Irritated Jealous Joyful Lonely Pleased Powerless
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Relaxed Resentful Sad Scared Surprised Tense Terrified Threatened Thrilled Uptight
Asking for Clarification Nurses often believe they always should be able to understand what the client is saying. This is not always the case: the client’s thoughts and communications may be unclear. The nurse never should assume that he or she understands; rather, the nurse should ask for clarification if there is doubt. Asking for clarification to confirm the nurse’s understanding of what the client intends to convey is paramount to accurate data collection.
If the nurse needs more information or clarification on a previously discussed issue, he or she may need to return to that issue. The nurse also may need to ask questions in some areas to clarify information. The nurse then can use the therapeutic technique of consensual validation, or repeating his or her understanding of the event that the client just described, to see whether their perceptions agree. It is important to go back and clarify rather than to work from assumptions.
The following is an example of clarifying and focusing techniques:
Client: “I saw it coming. No one else had a clue this would happen.”
Nurse: “What was it that you saw coming?” (seeking information)
Client: “We were doing well, and then the floor dropped out from under us. There was little anyone could do but hope for the best.”
Nurse: “Help me understand by describing what ‘doing well’ refers to.” (seeking information)
“Who are the ‘we’ you refer to?” (focusing) “How did the floor drop out from under you?” (encouraging description
of perceptions) “What did you hope would happen when you ‘hoped for the best’?”
(seeking information)
Client’s Avoidance of the Anxiety-Producing Topic
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Sometimes, clients begin discussing a topic of minimal importance because it is less threatening than the issue that is increasing the client’s anxiety. The client is discussing a topic but seems to be focused elsewhere. Active listening and observing changes in the intensity of the nonverbal process help to give the nurse a sense of what is going on. Many options can help the nurse to determine which topic is more important:
1. Ask the client which issue is more important at this time. 2. Go with the new topic because the client has given nonverbal messages
that this is the issue that needs to be discussed. 3. Reflect the client’s behavior, signaling there is a more important issue
to be discussed. 4. Mentally file the other topic away for later exploration. 5. Ignore the new topic because it seems that the client is trying to avoid
the original topic.
The following example shows how the nurse can try to identify which issue is most important to the client:
Client: “I don’t know whether it is better to tell or not tell my husband that I won’t be able to work anymore. He gets so upset whenever he hears bad news. He has an ulcer, and bad news seems
to set off a new bout of ulcer bleeding and pain.” Nurse: “Which issue is more difficult for you to confront right now:
your bad news or your husband’s ulcer?” (encouraging expression)
Guiding the Client in Problem Solving and Empowering the Client to Change Many therapeutic situations involve problem solving. The nurse is not expected to be an expert or to tell the client what to do to fix his or her problem. Rather, the nurse should help the client explore possibilities and find solutions to his or her problem. Often just helping the client to discuss and explore his or her perceptions of a problem stimulates potential solutions in the client’s mind. The nurse should introduce the concept of problem solving and offer himself or herself in this process.
Virginia Satir (1967) explained how important the client’s participation is to finding effective and meaningful solutions to problems. If someone else tells the client how to solve his or her problems and does not allow the client to participate and develop problem-solving skills and paths for change, the client may fear growth and change. The nurse who gives advice or directions about the way to fix a problem does not allow the
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client to play a role in the process and implies that the client is less than competent. This process makes the client feel helpless and not in control and lowers self-esteem. The client may even resist the directives in an attempt to regain a sense of control.
When a client is more involved in the problem-solving process, he or she is more likely to follow through on the solutions. The nurse who guides the client to solve his or her own problems helps the client to develop new coping strategies, maintains or increases the client’s self- esteem, and demonstrates the belief that the client is capable of change. These goals encourage the client to expand his or her repertoire of skills and to feel competent; feeling effective and in control is a comfortable state for any client.
Problem solving is frequently used in crisis intervention but is equally effective for general use. The problem-solving process is used when the client has difficulty finding ways to solve the problem or when working with a group of people whose divergent viewpoints hinder finding solutions. It involves several steps:
1. Identify the problem. 2. Brainstorm all possible solutions. 3. Select the best alternative. 4. Implement the selected alternative. 5. Evaluate the situation. 6. If dissatisfied with results, select another alternative and continue the
process.
Identifying the problem involves engaging the client in therapeutic communication. The client tells the nurse the problem and what he or she has tried to do to solve it:
Nurse: “I see you frowning. What is going on?” (making observation; broad opening)
Client: “I’ve tried to get my husband more involved with the children other than yelling at them when he comes in from work, but I’ve had little success.”
Nurse: “What have you tried that has not worked?” (encouraging expression)
Client: “Before my surgery, I tried to involve him in their homework. My husband is a math whiz. Then I tried TV time together, but the kids like cartoons and he wants to watch stuff about history, natural science, or travel.”
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Nurse: “How have you involved your husband in this plan for him to get more involved with the children?” (seeking information)
Client: “Uh, I haven’t. I mean, he always says he wants to spend more quality time with the kids, but he doesn’t. Do you mean it would be better for him to decide how he wants to do this—I mean, spend quality time with the kids?”
Nurse: “That sounds like a place to start. Perhaps you and your husband could discuss this issue when he comes to visit and decide what would work for both of you.” (formulating a plan of action)
It is important to remember that the nurse is facilitating the client’s problem-solving abilities. The nurse may not believe the client is choosing the best or the most effective solution, but it is essential that the nurse supports the client’s choice and assists him or her to implement the chosen alternative. If the client makes a mistake or the selected alternative isn’t successful, the nurse can support the client’s efforts and assist the client to try again. Effective problem solving involves helping the client to resolve his or her own problems as independently as possible.
ASSERTIVE COMMUNICATION Assertive communication is the ability to express positive and negative ideas and feelings in an open, honest, and direct way. It recognizes the rights of both parties, and is useful in a variety of situations, such as resolving conflicts, solving problems, and expressing feelings or thoughts that are difficult for some people to express. Assertive communication can help a person deal with issues with coworkers, family, or friends. It is particularly helpful for people who have difficulty refusing another’s request, expressing emotions of anger or frustration, or dealing with persons of authority.
Nurses can assist clients to learn and practice assertive communication skills, as well as using assertive communication to communicate with other nurses and members of the health-care team. It can be used in both personal and professional situations.
Assertive communication works best when the speaker is calm; makes specific, factual statements; and focuses on “I” statements. For example, one of the nurses on your unit is always a few minutes late to work, arriving in a rush and disrupting change-of-shift report. There are four types of responses that coworkers can have to this situation:
• Aggressive: After saying nothing for several days, one nurse jumps up
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and yells, “You’re always late! That is so rude! Why can’t you be on time like everyone else?” Then the nurse stomps out of the room, leaving everyone uncomfortable.
• Passive–aggressive: A coworker says to another nurse, “So nice of her to join us! Aren’t we lucky.” Everyone sits in uncomfortable silence.
• Passive: One nurse doesn’t say anything at the time, but later tells coworkers, “She’s always late. I had to tell her what she missed. I have so much work of my own to do.” But this nurse doesn’t say anything to the nurse who was late.
• Assertive: After report, one nurse says, “When you are late, report is disrupted, and I don’t like having to repeat information that was already discussed.” This nurse has communicated feelings about the specific situation in a calm manner with no accusations or inflammatory comments.
Using assertive communication does not guarantee that the situation will change, but it does allow the speaker to express honest feelings in an open and direct way that is still respectful of the other person. This lets the speaker feel good about expressing the feelings, and may lead to a discussion about how to resolve this problem.
Sometimes, people have difficulty “saying no” or refusing requests from others. Later, the person may regret saying yes, and feel overburdened or even resentful. Using assertive communication can help the person say no politely, but firmly, even when the person making the request is persistent in the request.
Nurse 1: “Can you work for me next Saturday?” Nurse 2: “No, I can’t work for you next Saturday.” Nurse 1: “Oh please, can’t you help me? I have tickets for a
concert that I really want to see?” Nurse 2: “I can’t work for you next Saturday.” Nurse 1: “Why not? I heard you say you weren’t doing anything special
this weekend. Please, I’ll never ask again. Please? I’ll do something special for you.”
Nurse 2: “I can’t work for you next Saturday.”
This is called the “broken record technique.” Instead of responding to additional information, such as concert tickets, not having plans, or emotional pleas, the speaker simply repeats the response without justifying or explaining the response. In time, the person can become quite comfortable refusing a request without feeling guilty or compelled to
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explain the refusal. In time, this can allow the person to avoid stress from being overcommitted or resentful from agreeing to a request that is later resented.
Assertive communication takes practice. It is often helpful to “rehearse” statements or responses in advance, especially if expressing feelings or discussing conflict is difficult. Using assertive communication doesn’t always produce a positive result, and others may not like the assertive communication style, especially if it is a change from a previous style. But the speaker can feel confident that he or she communicated thoughts and feelings openly and honestly while respecting the rights of both parties.