4.3 Therapeutic Communication
The importance of good communication between the nurse and patient/family cannot be overstated. Communication has been found to be a central part of the nurse-patient relationship and is based on the formation of trust and personal attitudes. [1]. Most students, and even novice nurses, think that if they are not performing an actual skill for a patient, they are not performing effective and important nursing care. However, there is much good that nurses can do by simply communicating with patients. Communication does not refer to the general pleasantries that people engage in as a formality. Casual conversation might be useful to get to know a person; however, is not what denotes effective nurse-patient communication. There are several ways that that nurses can engage in more effective communication with patients and families. Some of these will be described in this chapter, as well as some basic tools that can be used by nursing students and novice nurses as ways to help train them to engage in more effective communication with patients and families. Since communication is one of the skills that nursing students feel the least comfortable with, we will explore some possible follow-up responses that can used with patients.
Students and novice nurses may wonder how to start. How can I be myself and still maintain a professional demeanor and boundary? It is something that takes trial and error and also some comfort with oneself and with the profession. If a patient asks you a personal question such as “Do you have any children?” or “Have you lived around town all your life?” There is no adverse reason for not answering, unless the nurse is uncomfortable in the situation. While the same response may not be appropriate for every patient, there are some effective responses nurses can use to clarify meaning or elicit further information from patients. This is particularly important because patient communication can often be unclear. Sometimes, the more subtle statements that patients make require active listening and good communication on the part of the nurse in order to really understand the needs or concerns of the patient.
Therapeutic communication has roots going back to Florence Nightingale, who insisted on the importance of building trusting relationships with patients. She taught that therapeutic healing resulted from nurses’ presence with patients.[2] Since then, several professional nursing associations have highlighted therapeutic communication as one of the most vital elements in nursing. Therapeutic communication is a type of professional communication defined as the purposeful, interpersonal, information-transmitting process that leads to patient understanding and participation.[3]
Nonverbal communication is an important component of active listening. SOLER is a mnemonic for establishing good nonverbal communication with patients. SOLER stands for the following[4]:
- S: Sitting and squarely facing the client
- O: Using open posture (i.e., avoid crossing arms)
- L: Leaning towards the client to indicate interest in listening
- E: Maintaining good eye contact
- R: Maintaining a relaxed posture
Touch
Professional touch is a powerful way to communicate caring and empathy if done respectfully while also being aware of the patient’s preferences, cultural beliefs, and personal boundaries. Nurses use professional touch when assessing, expressing concern, or comforting patients. For example, simply holding a patient’s hand during a painful procedure can effectively provide comfort.
For individuals with a history of trauma, touch can be negatively perceived, so it is important to ask permission before touching. Inform the person before engaging in medical procedures requiring touch such as, “I need to hold down your arm so I can draw blood.”
Nurses should avoid using touch with individuals who are becoming agitated or experiencing a manic or psychotic episode because it can cause escalation. It is also helpful to maintain a larger interpersonal distance when interacting with an individual who is experiencing paranoia or psychosis.
Therapeutic Communication Techniques
There are a variety of therapeutic techniques that nurses use to engage patients in verbalizing emotions, establishing goals, and discussing coping strategies. See Table 4.1 for definitions of various therapeutic communication techniques discussed in the American Nurse, the official journal of the American Nurses Association.
Table 4.1 Therapeutic Communication Techniques[5]
| Therapeutic Techniques | Definition | Examples |
|---|---|---|
| Acceptance | Acceptance acknowledges a patient’s emotions or message and affirms they have been heard. Acceptance isn’t necessarily the same thing as agreement; it can be enough to simply make eye contact and say, “I hear what you are saying.” Patients who feel their nurses are listening to them and taking them seriously are more likely to be receptive to care. | Patient: “I hate taking all this medicine. It makes me feel numb.”
Nurse (making eye contact): “Yes, I understand.” |
| Clarification | Clarification asks the patient to further define what they are communicating. Similar to active listening, asking for clarification when a patient says something confusing or ambiguous is important. It helps nurses ensure they understand what is actually being said and can help clients process their ideas more thoroughly. | Paient: “I feel useless to everyone and everything.”
Nurse: “I’m not sure I understand what you mean by useless. Can you give an example of a time you felt useless?” |
| Focusing | Focusing on a specific statement made by a patient that seems particularly important prompts them to discuss it further. Clients don’t always have an objective perspective on their situation or past experiences, but as impartial observers, nurses can more easily pick out important topics on which to focus. | Patient: “I grew up with five brothers and sisters. We didn’t have much money, so my mom was always working and never home. We had to fend for ourselves, and there was never any food in the house.”
Nurse: “It sounds as if you experienced some stressful conditions growing up.” |
| Exploring | Exploring gathers more information about what the patient is communicating. | Patient: “I had to lie when I found out a dark secret about my sister.”
Nurse: “If you feel comfortable doing so, tell me more about the situation.” |
| Giving Recognition | Giving recognition acknowledges and validates the patient’s positive health behaviors. Recognition acknowledges a patient’s behavior and highlights it without giving an overt compliment. A compliment can sometimes be taken as condescending, especially when it concerns a routine task like making the bed. | Nurse: “I noticed you took all of your medications.” |
| Open-Ended Questions/ Offering General Leads | Using open questions or offering general leads provides keywords to “open” the discussion while also seeking more information. Therapeutic communication is most effective when patients direct the flow of conversation and decide what to talk about. Giving patients a broad opening such as “What’s on your mind today?” or “What would you like to talk about?” is a good way to encourage clients to discuss what’s on their mind. | Patient: “I’m unsure of what to do next.”
Nurse: “Tell me more about your concerns.” |
| Paraphrasing | Paraphrasing rephrases the patient’s words and key ideas to clarify their message and encourage additional communication. | Patient: “I’ve been way too busy today.”
Nurse: “Participating in the support groups today has kept you busy.” |
| Presenting Reality | Presenting reality restructures the patient’s distorted thoughts with valid information. | Patient: “I can’t go in that room; there are spiders on the walls.”
Nurse: “You may feel frightened, but I see no evidence of spiders on the walls.” |
| Restating | Restating uses different word choices for the same content stated by the patient to encourage elaboration. | Client: “The nurses hate me here.”
Nurse: “You feel as though the nurses dislike you?” |
| Reflecting | Reflecting asks clients what they think they should do, encourages them to be accountable for their own actions, and helps them come up with solutions. | Patient: “Do you think I should do this new treatment or not?”
Nurse: “What do you think the pros and cons are for the new treatment plan?” |
| Providing Silence | Providing silence allows quiet time for self-reflection by the patient. | The nurse does not verbally respond after a patient makes a statement, although they may nod or use other nonverbal communication to demonstrate active listening and validation of the patient’s message. |
| Making Observations | Observations about the appearance, demeanor, or behavior of patients can help draw attention to areas that might pose a problem for them. | Nurse: “You look tired today.”
Patient: “I haven’t been getting much sleep lately because of so many racing thoughts in my head at night.” |
| Offering Self/Providing Presence | Offering self provides support by being present. Inpatient care can be lonely and stressful at times. When nurses provide presence and spend time with their patients, it shows clients they value them and are willing to give them time and attention. | Offering to simply sit with patients for a few minutes is a powerful way to create a caring connection. |
| Encouraging Descriptions of Perceptions | Asking about perceptions in an encouraging, nonjudgmental way is important for patients experiencing sensory issues or hallucinations. It gives clients a prompt to explain what they’re perceiving without casting their perceptions in a negative light. It is also important to establish safety by ensuring the hallucinations are not encouraging the patient to harm themselves or others. | The patient looks distracted and frightened as if they see or hear something.
Nurse: “It looks as though you might be hearing something. What do you hear now?” or “It looks as if you might be seeing something. What does it look like to you?” |
| Encouraging Comparisons | Encouraging comparisons helps patients reflect on previous situations in which they have coped effectively. In this manner, nurses can help patients discover solutions to their problems. | Nurse: “It must have been difficult when you went through a divorce. How did you cope with that?”
Patient: “I walked my dog outside a lot.” Nurse: “It sounds as though walking your dog outside helps you cope with stress and feel better?” |
| Offering Hope | Offering hope encourages a patient to persevere and be resilient. | Nurse: “I remember you shared with me how well you coped with difficult situations in the past.” |
| Offering Humor | Humor can lighten the mood and contribute to feelings of togetherness, closeness, and friendliness. However, it is vital for the nurse to tailor humor to the patient’s sense of humor. | Nurse: “Knock, knock.”
Patient: “Who’s there?” Nurse: “Orange.” Patient: “Orange who?” Nurse: “Orange you glad to see me?” (Laughs with the patient) |
| Confronting | Confronting presents reality or challenges a patient’s assumptions. Nurses should only apply this technique during the working phase after they have established trust. Confrontation, when used correctly, can help patients break destructive routines or understand the state of their current situation. | Patient: “I haven’t drunk much this year.”
Nurse: “Yesterday you told me that every weekend you go out and drink so much you don’t know where you are when you wake up.” |
| Summarizing | Summarizing demonstrates active listening to patients and allows the nurse to verify information. Ending a discussion with a phrase such as “Does that sound correct?” gives patients explicit permission to make corrections if they’re necessary.
|
Patient: “I don’t like to take my medications because they make me tired, and I gain a lot of weight.”
Nurse: “You haven’t been taking your medications this month because of the side effects of fatigue and weight gain. Is that correct?” |
Nontherapeutic Responses
Nurses must be aware of potential barriers to communication and avoid nontherapeutic responses. Nonverbal communication such as looking at one’s watch, crossing arms across one’s chest, or not actively listening may be perceived as barriers to communication. Nontherapeutic verbal responses often block the patient’s communication of feelings or ideas. See Table 4.2 for a description of nontherapeutic responses to avoid.
Table 4.2 Nontherapeutic Responses[6],[7]
| Nontherapeutic Response | Description | Examples |
|---|---|---|
| Asking Personal Questions | Asking personal questions that are not relevant to the situation is not professional or appropriate. Don’t ask questions just to satisfy your curiosity. | Nontherapeutic: “Why have you and Mary never gotten married?”
Therapeutic: “How would you describe your relationship with Mary?” |
| Giving Personal Opinions | Giving personal opinions takes away the decision-making from the patient. Effective problem-solving must be accomplished by the client and not provided by the nurse. | Nontherapeutic: “If I were you, I would put your father in a nursing home to reduce your stress.”
Therapeutic: “Let’s explore options for your father’s care.” |
| Changing the Subject | Changing the subject when someone is trying to communicate with you demonstrates lack of empathy and blocks further communication. It communicates that you don’t care about what they are sharing. | Nontherapeutic: “Let’s not talk about your insurance problems; it’s time for your walk now.”
Therapeutic: “After your walk, let’s look into what is going on with your insurance company.” |
| Stating Generalizations and Stereotypes | Generalizations and stereotypes can threaten nurse-patient relationships. | Nontherapeutic: “Older adults are always confused.”
Therapeutic: “Tell me more about your concerns about your father’s confusion.” |
| Providing False Reassurances | When a patient is seriously ill or distressed, the nurse may be tempted to offer false hope with statements that everything will be alright. These comments can discourage further expressions of a patient’s feelings. | Nontherapeutic: “You’ll be fine; don’t worry.”
Therapeutic: “It must be difficult not to know what will happen next. What can I do to help?” |
| Showing Sympathy | Sympathy focuses on the nurse’s feelings rather than the patient. It demonstrates pity rather than trying to help the patient cope with the situation. | Nontherapeutic: “I’m so sorry about your amputation; I can’t imagine losing my leg due to a car crash.”
Therapeutic: “The loss of your leg is a major change. How do you think this will affect your life?” |
| Asking “Why” Questions | A nurse may be tempted to ask the patient to explain “why” they believe, feel, or act in a certain way. However, patients and family members can interpret “why” questions as accusations and become defensive. It is best to rephrase a question to avoid using the word “why.” | Nontherapeutic: “Why are you so upset?”
Therapeutic: “You seem upset. Tell me more about that.” |
| Approving or Disapproving | Nurses should not impose their own attitudes, values, beliefs, and moral standards on others while in the professional nursing role. Judgmental messages contain terms such as “should,” “shouldn’t,” “ought to,” “good,” “bad,” “right,” or “wrong.” Agreeing or disagreeing sends the subtle message that a nurse has the right to make value judgments about the patient’s decisions. Approving implies that the behavior being praised is the only acceptable one, and disapproving implies that the patient must meet the nurse’s expectations or standards. Instead, the nurse should assist the patient to explore their own values, beliefs, goals, and decisions. | Nontherapeutic: “You shouldn’t consider elective surgery; there are too many risks involved.”
Therapeutic: “You are considering having elective surgery. Tell me more about the pros and cons of surgery.” |
| Giving Defensive Responses | When patients or family members express criticism, nurses should listen to the message. Listening does not imply agreement. To discover reasons for the patient’s anger or dissatisfaction, the nurse should listen without criticizing, avoid being defensive or accusatory, and attempt to defuse anger. | Patient: “Everyone is lying to me!”
Nontherapeutic: “No one here would intentionally lie to you.” Therapeutic: “You believe people have been dishonest with you. Tell me more about what happened.” (After obtaining additional information, the nurse may elect to follow the chain of command at the agency and report the patient’s concerns for follow-up.) |
| Providing Passive or Aggressive Responses | Passive responses serve to avoid conflict or sidestep issues, whereas aggressive responses provoke confrontation. Nurses should use assertive communication. | Nontherapeutic: “It’s your fault you are feeling ill because you didn’t take your medicine.”
Therapeutic: “Taking your medicine every day can prevent these symptoms from returning.” |
| Arguing | Arguing against patient perceptions denies that they are real and valid. They imply that the other person is lying, misinformed, or uneducated. The skillful nurse can provide information or present reality in a way that avoids argument. | Nontherapeutic: “How can you say you didn’t sleep last night when I heard you snoring!”
Therapeutic: “You don’t feel rested this morning? Let’s talk about ways to improve the quality of your rest.” |
See the following box for a summary of tips for using therapeutic communication and avoiding common barriers to therapeutic communication.
Tips for Effective Therapeutic Communication
- Establish a goal for the conversation.
- Be self-aware of one’s nonverbal messages.
- Observe the patient’s nonverbal behaviors and actions as ‘cues’ for assessments and planning interventions.
- Be aware of self-disclosure of personal information and use professional boundaries. (Review boundary setting in the “Boundaries” section of Chapter 1.)
- Be patient-centered and actively listen to what the patient is expressing (e.g., provide empathy, not sympathy; show respect; gain the client’s trust; and accept the person as who they are as an individual).
- Be sensitive to the values, cultural beliefs, attitudes, practices, and problem-solving strategies of the patient.
- Effectively use therapeutic communication techniques.
- Recognize themes in a conversation (e.g., Is there a theme emerging of poor self-esteem, guilt, shame, loneliness, helplessness, hopelessness, or suicidal thoughts?).
Common Barriers to Therapeutic Communication
- Using a tone of voice that is distant, condescending, or disapproving.
- Using medical jargon or too many technical terms.
- Asking yes/no questions instead of open-ended questions.
- Continually asking “why,” causing the patient to become defensive or feel challenged by your questions.
- Using too many probing questions, causing the patient to feel you are interrogating them, resulting in defensiveness or refusal to talk with the nurse.
- Lacking awareness of one’s biases, fears, feelings, or insecurities.
- Causing sensory overload in the patient with a high emotional level of the content.
- Giving advice.
- Blurring the nurse-patient relationship boundaries (e.g., assuming control of the conversation, disclosing personal information, practicing outside one’s scope of practice).
Recognizing and Addressing Escalation
When communicating therapeutically with a patient, it is important to recognize if the patient is escalating with increased agitation and becoming a danger to themselves, staff, or other patients. When escalation occurs, providing safety becomes the nurse’s top priority, and the focus is no longer on therapeutic communication. See the “Working with Anger and Aggression” section of Chapter 2 for more information on working with angry patients.
Cultural Considerations
Recall how cultural values and beliefs can impact a patient’s mental health in many ways. Every culture has a different perspective on mental health. For many cultures, there is stigma surrounding mental health. Mental health challenges may be considered a weakness and something to hide, which can make it harder for those struggling to talk openly and ask for help. Culture can also influence how people describe and feel about their symptoms. It can affect whether someone chooses to recognize and talk openly about physical symptoms, emotional symptoms, or both. Cultural factors can determine how much support someone gets from their family and community when it comes to mental health. Nurses can help patients understand the role culture plays in their mental health by encouraging therapeutic communication about their symptoms and treatment. For example, a nurse should ask, “What do you think is wrong? How would you treat your symptoms?” See the “Diversity and Culture” section of Chapter 1 for a larger discussion of cultural influences.
- Lowey, S.E. (2008) Communication between the Nurse and Family Caregiver in End-of-Life Care: A Review of the Literature. Journal of Hospice and Palliative Nursing, 10, 35-45. http://dx.doi.org/10.1097/01.NJH.0000306712.65786.ae ↵
- Karimi, H., & Masoudi Alavi, N. (2015). Florence Nightingale: The mother of nursing. Nursing and Midwifery Studies, 4(2), e29475. https://doi.org/10.17795/nmsjournal29475 ↵
- Abdolrahimi, M., Ghiyasvandian, S., Zakerimoghadam, M., & Ebadi, A. (2017). Therapeutic communication in nursing students: A Walker & Avant concept analysis. Electronic Physician, 9(8), 4968–4977. https://doi.org/10.19082/4968 ↵
- Stickley, T. (2011). From SOLER to SURETY for effective non-verbal communication. Nurse Education in Practice, 11(6), 395–398. https://doi.org/10.1016/j.nepr.2011.03.021 ↵
- American Nurse. (n.d.). Therapeutic communication techniques. https://www.myamericannurse.com/therapeutic-communication-techniques/ ↵
- Abdolrahimi, M., Ghiyasvandian, S., Zakerimoghadam, M., & Ebadi, A. (2017). Therapeutic communication in nursing students: A Walker & Avant concept analysis. Electronic Physician, 9(8), 4968–4977. https://doi.org/10.19082/4968 ↵
- Sharma, N. P. & Gupta, V. (2023) Therapeutic Communication. In StatPearls is licensed under CC BY 4.0 www.ncbi.nlm.nih.gov/books/NBK567775/ ↵
A type of professional communication defined as the purposeful, interpersonal, information-transmitting process that leads to client understanding and participation.
A mnemonic for effective nonverbal communication.
