4.2 Basic Concepts of Communication
Communication Standard of Professional Performance
The Standard of Professional Performance for Communication established by the American Nurses Association (ANA) is defined as, “The registered nurse communicates effectively in all areas of professional practice.”[1] See the following box for the competencies associated with the Communication standard.
ANA’s Communication Competencies
The registered nurse:
- Assesses one’s own communication skills and effectiveness.
- Demonstrates cultural humility, professionalism, and respect when communicating.
- Assesses communication ability, health literacy, resources, and preferences of health care consumers to inform the interprofessional team and others.
- Uses language translation resources to ensure effective communication.
- Incorporates appropriate alternative strategies to communicate effectively with health care consumers who have visual, speech, language, or communication difficulties.
- Uses communication styles and methods that demonstrate caring, respect, active listening, authenticity, and trust.
- Conveys accurate information to health care consumers, families, community stakeholders, and members of the interprofessional team.
- Advocates for the health care consumer and their preferences and choices when care processes and decisions do not appear to be in the best interest of the health care consumer.
- Maintains communication with interprofessional team members and others to facilitate safe transitions and continuity in care delivery.
- Confirms with the recipient if the communication was heard and if the recipient understands the message.
- Contributes the nursing perspective in interactions and discussions with the interprofessional team and other stakeholders.
- Promotes safety in the care or practice environment by disclosing and reporting concerns related to potential or actual hazards or deviations from the standard of care.
- Demonstrates continuous improvement of communication skills.
Nurse-Patient Relationship
Establishment of the therapeutic nurse-patient relationship is vital in nursing care. Nurses engage in compassionate, supportive, professional relationships with their patients as part of the “art of nursing.”[2] This is especially true in psychiatric care, where the therapeutic relationship is considered to be the foundation of patient care and healing.[3] The nurse-patient relationship establishes trust and rapport with a specific purpose; it facilitates therapeutic communication and engages the patient in decision-making regarding their plan of care.
Therapeutic nurse-patient relationships vary in depth, length, and focus. Brief therapeutic encounters might last only a few minutes and focus on the patient’s immediate needs, current feelings, or behaviors. For example, in the emergency department setting, a nurse may therapeutically communicate with a patient in crisis who recently experienced a situational trauma. During longer periods of time, such as inpatient care, nurses work with patients in setting short-term goals and outcomes that are documented in the nursing care plan and evaluated regularly. In long-term care settings, such as residential facilities, the therapeutic nurse-patient relationship may last several months and include frequent interactions focusing on behavior modification.
Phases of Development of a Therapeutic Relationship
The nurse-patient relationship goes through three phases. Hildegard Peplau, nursing theorist described these three phases as orientation, working, and termination.[4] The length of the phases will differ substantially based on the patient’s condition and location. In the emergency setting, the therapeutic relationship may last a few hours whereas in residential treatment facilities the relationship may evolve over weeks.
Orientation Phase
During the brief orientation phase, patients may realize they need assistance as they adjust to their current status. Simultaneously, nurses introduce themselves and begin to obtain essential information about patients as individuals with unique needs, values, beliefs, and priorities. During this brief phase, trust is established, and rapport begins to develop between the patient and the nurse. Nurses ensure privacy when talking with the patient and providing care, and respect the client’s values, beliefs, and personal boundaries.
A common framework used for introductions during patient care is AIDET, a mnemonic for Acknowledge, Introduce, Duration, Explanation, and Thank You.
- Acknowledge: Greet the patient by the name documented in their medical record. Make eye contact, smile, and acknowledge any family or friends in the room. Ask the patient their preferred way of being addressed (for example, “Mr. Doe,” “Jonathon,” or “Johnny”) and their preferred pronouns (e.g., he/him, she/her, or they/them).
- Introduce: Introduce yourself by your name and role. For example, “I’m John Doe, and I am a nursing student working with your nurse to take care of you today.”
- Duration: Estimate a timeline for how long it will take to complete the task you are doing. For example, “I am here to perform an admission assessment. This should take about 15 minutes.”
- Explanation: Explain step by step what to expect next and answer questions. For example, “I will be putting this blood pressure cuff on your arm and inflating it. It will feel as if it is squeezing your arm for a few moments.”
- Thank You: At the end of the encounter, thank the patient and ask if anything is needed before you leave. Ensure the patient knows how to reach you. If family members are present, thank them for being there to support the patient as appropriate. For example, “Thank you for taking time to talk with me today. Is there anything I can get for you before I leave?”
Working Phase
The majority of a nurse’s time with a patient is in the working phase. During this phase, nurses use active listening and begin by asking the reason the patient is seeking care to determine what is important to them. They use assessment findings to develop a nursing plan of care and plan patient education. If a care plan has already been established on admission, nurses use this time to implement interventions targeted to meet short-term outcomes and long-term goals. During the working phase, patients begin to accept nurses as health educators, counselors, and care providers. Nurses use therapeutic communication techniques to facilitate patients’ awareness of their thoughts and feelings and mutually develop goals and an individualized plan of care. Nurses provide reflective and nonjudgmental feedback to patients to help them clarify their thoughts, goals, and coping strategies.[5] Therapeutic communication techniques used during this phase, including motivational interviewing, are discussed later in this chapter.
Termination Phase
The final phase of a nurse-patient relationship is the termination phase. This phase typically occurs at the end of a shift or on discharge from care. If the previous working phase has been successful, the patient’s needs have been successfully met by collaboration among the patient, nurses, and interprofessional health care team members. The nurse should be aware the patient may try to return to the working phase to avoid termination of the relationship. During the termination phase, the nurse can encourage the patient to reflect on progress they have made and review post-discharge goals. The nurse also makes community referrals for follow-up and continuation of support in meeting goals.
- American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
- American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
- Ross, C. A., & Goldner, E. M. (2009). Stigma, negative attitudes and discrimination towards mental illness within the nursing profession: A review of the literature. Journal of Psychiatric and Mental Health Nursing, 16(6), 558-567. https://doi.org/10.1111/j.1365-2850.2009.01399.x ↵
- Hagerty, T. A., Samuels, W., Norcini-Pala, A., & Gigliotti, E. (2018). Peplau’s Theory of Interpersonal Relations: An alternate factor structure for patient experience data? Nursing Science Quarterly, 30(2), 160-167. https://dx.doi.org/10.1177%2F0894318417693286 ↵
- Hagerty, T. A., Samuels, W., Norcini-Pala, A., & Gigliotti, E. (2018). Peplau’s Theory of Interpersonal Relations: An alternate factor structure for patient experience data? Nursing Science Quarterly, 30(2), 160-167. https://dx.doi.org/10.1177%2F0894318417693286 ↵
A relationship that establishes trust and rapport with a specific purpose of facilitating therapeutic communication and engaging the client in decision-making regarding their plan of care.
Communicating both verbally and nonverbally that we are interested in what the other person is saying while also actively verifying our understanding with them.
