LEARNING CONTENT
I. INTRODUCTION
A. COMMUNICATING
1. DEFINITION
The term communication has various meanings, depending on the context
in which it is used.
To some, communication is the interchange of information between two or
more people, in other words, the exchange of ideas or thoughts. This kind
of communication uses methods such as talking and listening or writing
and reading.
However, painting, dancing, and storytelling are also methods of
communication. In addition, thoughts are expressed to others not only by
spoken or written words but also by gestures or body actions.
Communication may have a more personal connotation than the
interchange of ideas or thoughts. It can be a transmission of feelings or a
more personal and social interaction between people.
Frequently, one member of a couple comments that the other is not
communicating. Some teenagers complain about a generation gap— being
unable to communicate with understanding or feeling to a parent or
authority figure.
Sometimes a client may say that a nurse is efficient but lacking in
something called bedside manner. For the purpose of this text,
communication is any means of exchanging information or feelings
between two or more people. It is a basic component of human
relationships, including nursing.
Any communication that intends to obtain a response. Thus,
communication is a process.
It has two main purposes: to influence others and to gain information.
Communication can be described as helpful or unhelpful. The former
encourages the sharing of information, thoughts, or feelings between two
or more people. The latter hinders or blocks the transfer of information and
feelings.
Nurses who communicate effectively are better able to collect assessment
data, initiate interventions, evaluate outcomes of interventions, initiate
change that promotes health, and prevent the safety and legal problems
associated with nursing practice.
The communication process is built on a trusting relationship with a client
and supports people. Effective communication is essential for the
establishment of a nurse-client relationship.
Communication can occur on an intrapersonal level within a single
individual as well as on interpersonal and group levels.
Intrapersonal communication is the communication that you have with
yourself; another name is self-talk. Both the sender and the receiver of a
message usually engage in self-talk. It involves thinking about the
message before it is sent, while it is being sent, and after it is sent, and it
occurs constantly. Consequently, intrapersonal communication can
interfere with a person’s ability to hear a message as the sender intended
2. The Communication Process
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 receiving of a message. Because communication intends to
elicit a response, the process is ongoing; the receiver of the message then
becomes the sender of a response, and the original sender then becomes
the receiver.
Face-to-face communication involves:
• a sender
• a message
• a receiver
• a response/feedback
Sender
The sender, an individual or group wishing to communicate a message to
another, can be considered the source-encoder. This term suggests that
the individual or group sending the message must have an idea or reason
for communicating (source) and must put the idea or feeling into a form
that can be transmitted.
Encoding involves the selection of specific signs or symbols (codes) to
transmit the message, such as which language and words to use, how to
arrange the words, and what tone of voice and gestures to use.
For example, if the receiver speaks English, the sender usually selects
English words. If the message is “Mr. Johnson, you have to wait another
hour for your pain medication,” the tone of voice selected, and a shake of
the head can reinforce it. The nurse must not only deal with dialects and
foreign languages but also cope with two language levels—the laypersons
and the health professionals.
Message
The second component of the communication process is the message
itself, what is said or written, the body language that accompanies the
words, and how the message is transmitted. The method used to convey
the message can target any of the receiver’s senses.
The method needs to be appropriate for the message, and it should help
make the content of the message clearer.
For example, talking face-to-face with an individual may be more effective
in some instances than telephoning, emailing, or texting a message.
Written communication is often appropriate for long explanations or for
communication that needs to be preserved.
Another form of communication has evolved with technology—electronic
communication. Common forms of electronic communication are email
and texting, in which an individual can send a message, by computer or
smartphone, to another individual or group of people.
The use of email and texting has become prevalent as a primary form of
personal communication. It is important to know the rules of etiquette for
each. For example, emails should be short and to the point, and
punctuation matters.
Acronyms should be used sparingly, and do not write in all caps because it
implies you are shouting.
Texting is even more concise, and if the information is complex, consider
using email or telephone or speaking with the individual in person.
Communicating by email and text does not provide the sender with
relevant information, such as if the receiver is confused, upset, or needs
clarification. Therefore, it is important to reread what you email or text
before pressing the send button. Nurses need to know when it is and when
it is not appropriate to use email for communicating with clients.
The nonverbal channel of touch is often highly effective. Nurses use
touch in two key circumstances.
For example, touch is used frequently when completing a physical task
while providing nursing care to a client (e.g., taking blood pressure,
administering medications, changing a dressing). The other circumstance
is driven by an emotional response to a client’s distress (e.g., holding a
hand, stroking a shoulder, providing a comforting embrace).
Receiver
The receiver, the third component of the communication process, is the
listener, who must listen, observe, and attend.
This individual is the decoder, who must perceive what the sender
intended (interpretation). Perception uses all senses to receive verbal and
nonverbal messages.
To decode means to translate the message sent via the receiver’s
knowledge and experiences to sort out the meaning of the message.
Whether the message is decoded accurately by the receiver, according to
the sender’s intent, depends largely on their similarities in knowledge and
experience and sociocultural background. If the meaning of the decoded
message matches the intent of the sender, then the communication has
been effective. Ineffective communication occurs when the receiver
misinterprets the sent message.
For example, Mr. Johnson may perceive the message accurately, “No pain
medication for another hour.” However, if experience has taught him that
he can receive the pain medication early if a certain nurse is on duty, he
will interpret the intent of the message differently.
Response
The fourth component of the communication process, the response, is the
message that the receiver returns to the sender. It is also called feedback.
Feedback can be either verbal, nonverbal, or both.
Nonverbal examples are a nod of the head or a yawn. Either way, feedback
allows the sender to correct or reword a message.
In the case of Mr. Johnson, the receiver may appear irritated or say, “Well,
the nurse on the other shift gives me my pain medication early if I need it.”
The sender then knows the message was interpreted accurately. However,
now the original sender becomes the receiver, who is required to decode
and respond.
3. Modes of Communication
Although both kinds of communication occur concurrently, most
communication is nonverbal. Learning about nonverbal communication is
important for nurses in developing effective communication patterns and
relationships with clients.
a. Verbal Communication
Verbal communication 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 exchanged. An
abundance of words can be used to form messages. In addition, a wide
variety of feelings can be transmitted when people talk. Nurses need to
consider the following when choosing words to say or write pace and
intonation, simplicity, clarity and brevity, timing and relevance,
adaptability, credibility, and humor.
Nurses need to consider the following when choosing words to say or
write:
a) Pace and Intonation
The manner of speech, as in the rate or rhythm and tone, will modify the
feeling and impact of a message. The tone of words can express
enthusiasm, sadness, anger, or amusement. The rate of speech may
indicate interest, anxiety, boredom, or fear. For example, speaking slowly
and softly to an excited client may help calm the client.
b) Simplicity
Simplicity includes the use of commonly understood words, brevity, and
completeness. The use of complex technical terms becomes natural to
nurses. However, clients often misunderstand these terms. Words such as
vasoconstriction or cholecystectomy are meaningful to the nurse and easy
to use but not advised when communicating with clients. Nurses need to
select appropriate, understandable, and simple terms based on the client’s
age, knowledge, culture, and education.
For example, instead of saying to a client, “I will be catheterizing you for a
urine analysis,” it may be more appropriate and understandable to say, “I
need to get a sample of your urine, so I will collect it by putting a small
tube into your bladder.” The latter statement is more likely to elicit a
response from the client asking why it is needed and whether it will be
uncomfortable because the client understands the message being
conveyed by the nurse.
c) Clarity and Brevity
A message that is direct and simple will be effective. Clarity is saying
precisely what is meant, and brevity is using the fewest words necessary.
The result is a message that is simple and clear. An aspect of this is
congruence, or consistency, where the nurse’s behavior or nonverbal
communication matches the words spoken.
When the nurse tells the client, “I am interested in hearing what you have
to say,” the nonverbal behavior would include the nurse facing the client,
making eye contact, and leaning forward. The goal is to communicate
clearly so that all aspects of a situation or circumstance are understood. To
ensure clarity in communication, nurses also need to enunciate
(pronounce) words carefully.
d) Timing and Relevance
Nurses need to be aware of both relevance and timing when
communicating with clients. No matter how clearly or simply words are
stated or written, the timing needs to be appropriate to ensure that words
are heard. Furthermore, the messages need to relate to the client or to the
client’s interests and concerns.
This involves sensitivity to the client’s needs and concerns. For example, a
client who is fearful of the possibility of cancer may not hear the nurse’s
explanations about the expected procedures before and after gallbladder
surgery. In this situation, it is better for the nurse first to encourage the
client to express concerns and then to deal with those concerns. The
necessary explanations can be provided at another time when the client is
better able to listen.
Another problem in timing is asking several questions at once. For
example, a nurse enters a client’s room and says in one breath, “Good
morning, Mrs. Brody. How are you this morning? Did you sleep well last
night? Your husband is coming to see you before your surgery, isn’t he?”
The client no doubt wonders which question to answer first, if any.
A related pattern of poor timing is to ask a question and then not wait for
an answer before making another comment. Conversely, by allowing the
client to respond to the social talk or chat, the nurse develops a rapport
with the client that can help facilitate effective therapeutic communication.
e) Adaptability
The nurse needs to alter spoken messages following behavioral cues from
the client. This adjustment is referred to as adaptability. What the nurse
says and how it is said must be individualized and carefully considered.
This requires smart assessment and sensitivity on the part of the nurse.
For example, a nurse who usually smiles appears cheerful and greets the
client with an enthusiastic “Hi, Mrs. Brown!” notices that the client is not
smiling and appears distressed. It is important for the nurse to then modify
his or her tone of speech and express concern by facial expression while
moving toward the client.
f) Credibility
Credibility means worthiness of belief, trustworthiness, and reliability.
Credibility may be the most important criterion for effective
communication. Nurses foster credibility by being consistent, dependable,
and honest. The nurse needs to be knowledgeable about what is being
discussed and to have accurate information. Nurses should convey
confidence and certainty in what they are saying while being able to
acknowledge their limitations (e.g., “I don’t know the answer to that, but I
will find someone who does”).
g) Humor
The use of humor can be a positive and powerful tool in the nurse–client
relationship, but it must be used with care. Humor can be used to help
clients adjust to difficult and painful situations. The physical act of laughter
can be an emotional and physical release, reducing tension by providing a
different perspective and promoting a sense of well-being.
When using humor, it is important to consider the client’s perception of
what is considered humorous. Timing is also important to consider.
Although humor and laughter can help reduce stress and anxiety, the
feelings of the client need to be considered.
VERBAL COMMUNICATION SKILLS USING CONCRETE MESSAGES
o When speaking to the client, the nurse should use words that are as clear as possible so
the client can understand the message. Anxious people lose cognitive processing skills,
the higher anxiety, the less the ability to process concepts—so concrete messages are
important for accurate information exchange.
o In a concrete message, the words are explicit and need no interpretation; the speaker uses
nouns instead of pronouns—for example, “What health symptoms caused you to come to
the hospital today?” or “When was the last time you took your antidepressant
medications?” Concrete questions are clear, direct, and easy to understand. They elicit
more accurate responses and avoid the need to go back and rephrase unclear questions,
which interrupts the flow of a therapeutic interaction.
o Abstract messages, in contrast, are unclear patterns of words that often contain figures of
speech that are difficult to interpret. They require the listener to interpret what the
speaker is asking. For example, a nurse who wants to know why a client was admitted to
the unit asks, “How did you get here?”
o This is an abstract message: the terms how and here are vague. An anxious client might
not be aware of where he or she is and might reply, “Where am I?” or might interpret this
as a question about how he or she was conveyed to the hospital and respond, “The
ambulance brought me.” Clients who are anxious, experiencing language barriers,
cognitively impaired, or suffering from some mental disorders often function at a
concrete level of comprehension and have difficulty answering abstract questions. The
nurse must be sure that statements and questions are clear and concrete
b. NONVERBAL COMMUNICATION
Nonverbal communication, sometimes called body language, includes
gestures, body movements, use of touch, and physical appearance,
including adornment. Nonverbal communication often tells others more
about what a person is feeling than what is format, said, because
nonverbal behavior is controlled less consciously than verbal behavior
(Figure 26–4 •).
Nonverbal communication either reinforces or contradicts what is said
verbally. For example, if a nurse says to a client, “I’d be happy to sit here
and talk to you for a while,” yet glances nervously at a watch every few
seconds, the actions contradict the verbal message. The client is more
likely to believe the nonverbal behavior, which conveys “I am very busy
and need to leave.”
Observing and interpreting the client’s nonverbal behavior is an essential
skill for nurses to develop. Observing nonverbal behavior efficiently
requires a systematic assessment of the person’s overall physical
appearance, posture, gait, facial expressions, and gestures. The nurse,
however, needs to exercise caution in interpretation, always clarifying any
observation with the client.
Clients who have altered thought processes, such as with schizophrenia or
dementia, may experience times when expressing themselves verbally is
difficult or impossible. During these times, the nurse needs to be able to
interpret the feeling or emotion that the client is expressing nonverbally.
An attentive nurse who clarifies observations very often portrays caring
and acceptance to the client. This can be the beginning for establishing a
trusting relationship between the nurse and the client, even for clients who
have difficulty communicating appropriately.
Transculturally, nonverbal communication varies widely (Seiler, Beall, &
Mazer, 2017). Even for behaviors such as smiling and handshaking,
cultures differ. For example, to some individuals, smiling and handshaking
are an integral part of an interaction and essential to establishing trust.
The same behavior might be perceived by others as insolent and frivolous.
The nurse cannot always be sure of the correct interpretation of feelings
that are expressed nonverbally. The same feeling can be expressed
nonverbally in more than one way, even within the same cultural group.
For example, anger may be communicated by aggressive or excessive
body motion, or it may be communicated by frozen stillness. In some
cultures, a smile may be used to conceal anger. Therefore, the
interpretation of such observations requires validation with the client. For
example, the nurse might say, “You look like you have been crying. Is
something upsetting you?”
a) Personal Appearance
Clothing and adornments can be sources of information about an
individual. Although the choice of apparel is highly personal, it may convey
social and financial status, culture, religion, group association, and self-
concept. Charms and amulets may be worn for decorative or for health
protection purposes. When the symbolic meaning of an object is unfamiliar,
the nurse can inquire about its significance, which may foster rapport with
the client.
How an individual dresses is often an indicator of how the individual feels.
People who are tired or ill may not have the energy or the desire to
maintain their normal grooming. When a client known for immaculate
grooming becomes careless about appearance, the nurse may suspect a
loss of self-esteem or a physical illness. The nurse must validate these
observed nonverbal data by asking the client. For acutely ill clients in
hospital or home care settings, a change in grooming habits may signal
that the client is feeling better. For example, a man may request a shave,
or a woman may request shampoo and some makeup.
b) Posture and Gait
The ways people walk and carry themselves are often reliable indicators of
self-concept, current mood, and health. Erect posture and an active,
purposeful stride suggest a feeling of well-being. A slouched posture and a
slow, shuffling gait suggest depression or physical discomfort. Tense
posture and a rapid, determined gait suggest anxiety or anger. The posture
of people when they are sitting or lying down can also indicate feelings or
mood. Again, the nurse clarifies the meaning of the observed behavior by
describing to the client what the nurse sees and then asking what it means
or whether the nurse’s interpretation is correct.
For example, “You look like it really hurts you to move. I’m wondering how
your pain is and if you might need something to make you more
comfortable?”
c) Facial Expression
No part of the body is as expressive as the face (Figure 16.5). Feelings of
surprise, fear, anger, disgust, happiness, and sadness can be conveyed by
facial expressions. Although the face may express the individual’s genuine
emotions, it is also possible to control these muscles so that the emotion
expressed does not reflect what the individual is feeling. When the
message is not clear, it is important to get feedback to be sure of the
intent of the expression.
Many facial expressions convey a universal meaning. The smile expresses
happiness. Disapproval is conveyed by the mouth turned down, the head
tilted back, and the eyes directed down the nose. No single expression can
be interpreted accurately, however, without considering other reinforcing
physical cues, the setting in which it occurs, the expression of others in the
same setting, and the background of the client.
Nurses need to be aware of their expressions and what they are
communicating to others. Clients are quick to notice the nurse’s facial
expression, particularly when they feel unsure or uncomfortable.
The client who questions the nurse about a feared diagnostic result will
watch whether the nurse maintains eye contact or looks away when
answering. The client who has had disfiguring surgery will examine the
nurse’s face for signs of disgust. It is impossible to control all facial
expressions, but the nurse must learn to control expressions of feelings
such as fear or disgust in some circumstances.
Eye contact is another essential element of facial communication. In many
cultures, mutual eye contact acknowledges recognition of the other
individual and a willingness to maintain communication.
Often, an individual initiates contact with another individual with a glance,
capturing the individual’s attention prior to communicating. An individual
who feels weak or defenseless often averts the eyes or avoids eye contact;
the communication received may be too embarrassing or too dominating.
FACIAL EXPRESSIONS CAN BE CATEGORIZED INTO:
An expressive face portrays the person’s moment-by-moment thoughts, feelings, and needs.
These expressions may be evident even when the person does not want to reveal his or her
emotions.
An impassive face is frozen into an emotionless deadpan expression similar to a mask.
A confusing facial expression is one that is the opposite of what the person wants to convey.
A person who is verbally expressing sad or angry feelings while smiling is exhibiting a
confusing facial expression.
Facial expressions often can affect the listener’s response. Strong and emotional facial
expressions can persuade the listener to believe the message. For example, by appearing
perplexed and confused, a client can manipulate the nurse into staying longer than scheduled.
Facial expressions such as happy, sad, embarrassed, or angry usually have the same meaning
across cultures, but the nurse should identify the facial expression and ask the client to validate
the nurse’s interpretation of it—for instance, “You’re smiling, but I sense you are angry”
(Wasajja, 2018).
Frowns, smiles, puzzlement, relief, fear, surprise, and anger are common facial
communication signals. Looking away, not meeting the speaker’s eyes, and yawning indicate
that the listener is disinterested, lying, or bored. To ensure the accuracy of the information, the
nurse identifies nonverbal communication and checks its congruency with the content
(Wasajja, 2018). An example is “Mr. Jones, you said everything is fine today, yet you frowned
as you spoke. I sense that everything is not really fine” (verbalizing the implied).
Body language
This open posture demonstrates unconditional positive regard, trust, care, and acceptance. The
nurse indicates interest in and acceptance of the client by facing and slightly leaning toward
him or her while maintaining non-threatening eye contact.
Closed body positions, such as crossed legs or arms folded across the chest, indicate that the
interaction might threaten the listener who is defensive or not accepting
Hand gestures add meaning to the content. A slight lift of the hand from the arm of a chair
can punctuate or strengthen the meaning of words. Holding both hands with palms up while
shrugging the shoulders often means “I don’t know.” Some people use many hand gestures to
demonstrate or act out what they are saying, while others use very few gestures. The
positioning of the nurse and client in relation to each other is also important.
Sitting beside or across from the client can put the client at ease while sitting behind a desk
(creating a physical barrier) can increase the formality of the setting and may decrease the
client’s willingness to open up and communicate freely. The nurse may wish to create a more
formal setting with some clients, however, such as those who have difficulty maintaining
boundaries.
d) Gestures
Hand and body gestures may emphasize and clarify the spoken word, or
they may occur without words to indicate a feeling or to give a sign. A
father awaiting information about his daughter in surgery may wring his
hands, tap his foot, pick at his nails, or pace back and forth. A gesture may
more clearly indicate the size or shape of an object. A wave goodbye and
the motion of a visitor toward a chair are gestures that have relatively
universal meanings. Some gestures, however, are culture-specific. The
gesture meaning “shoo” or “go away” in some cultures means “come
here” or “come back” in other cultures.
B. Therapeutic Communication
1. DEFINITION
Skilled use of therapeutic communication techniques helps the nurse
understand and empathize with the client’s experience. All nurses need
skills in therapeutic communication to effectively apply the nursing process
and to meet standards of care for their clients.
Therapeutic communication promotes understanding and can help establish a
constructive relationship between the nurse and the client. Unlike a social
relationship, which may not have a specific purpose or direction, the therapeutic
helping relationship is client- and goal-directed.
Nurses need to respond to the content of a client’s verbal message and the feelings
expressed. It is important to understand how the client views the situation and feels
about it before responding. The content of the client’s communication is the words or
thoughts, as distinct from the feelings. Sometimes people can convey a thought in
words while their emotions contradict the words; that is, words and feelings are
incongruent.
For example, a client says, “I am glad he has left me; he was very cruel.” However,
the nurse observes that the client has tears in her eyes as she says this. To respond
to the client’s words, the nurse might simply rephrase, saying, “You are pleased that
he has left you.” To respond to the client’s feelings, the nurse would need to
acknowledge the tears in the client’s eyes, saying, for example, “You seem saddened
by all this.” Such a response helps the client to focus on her feelings. In some
instances, the nurse may need to know more about the client and her resources for
coping with these feelings.
Sometimes clients need time to deal with their feelings. Strong emotions are often
draining. People usually need to deal with feelings before they can cope with other
matters, such as learning new skills or planning for the future.
This is most evident in hospitals when clients learn that they have a terminal illness.
Some require hours, days, or even weeks before they are ready to start other tasks.
Some need only time to themselves, others need someone to listen, others need
assistance identifying and verbalizing feelings, and others need assistance making
decisions about future courses of action.
Establishing a therapeutic relationship is one of the most important
responsibilities of the nurse when working with clients. Communication is
the means by which a therapeutic relationship is initiated, maintained, and
terminated.
2. Consideration in Effective Therapeutic Communication
a) Privacy and respect for boundaries
Privacy is desirable but not always possible in therapeutic communication.
An interview in a conference room is optimal if the nurse believes this
setting is not too isolative for the interaction. The nurse can also talk with
the client at the end of the hall or in a quiet corner of the day room or
lobby, depending on the physical layout of the setting. The nurse needs to
evaluate whether interacting in the client’s room is therapeutic. For
example, if the client has difficulty maintaining boundaries or has been
making sexual comments, then the client’s room is not the best setting. A
more formal setting would be desirable.
Proxemics is the study of distance zones between people during
communication. People feel more comfortable with smaller distances
when communicating with someone they know rather than with strangers
(McCall, 2017). People from the United States, Canada, and many Eastern
European nations generally observe four distance zones:
o Intimate zone (0–18 in between people): This amount of
space is comfortable for parents with young children, people
who mutually desire personal contact, or people whispering.
Invasion of this intimate zone by anyone else is threatening
and produces anxiety.
o Personal zone (18–36 in): This distance is comfortable
between family and friends who are talking.
o Social zone (4–12 ft): This distance is acceptable for
communication in social, work, and business settings.
Some people from different cultures (e.g., Hispanic, Mediterranean, East
Indian, Asian, and Middle Eastern) are more comfortable with less than 4 to
12 ft of space between them while talking. The nurse of European
American or African American heritage may feel uncomfortable if clients
from these cultures stand close when talking. Conversely, clients from
these backgrounds may perceive the nurse as remote and indifferent
(Andrews & Boyle, 2015).
Both the client and the nurse can feel threatened if one invades the other’s
personal or intimate zone, which can result in tension, irritability, fidgeting,
or even flight. When the nurse must invade the intimate or personal zone,
he or she should always ask the client’s permission.
For example, if a nurse performing an assessment in a community setting
needs to take the client’s blood pressure, he or she should say, “Mr. Smith,
to take your blood pressure I will wrap this cuff around your arm and listen
with my stethoscope. Is this acceptable to you?” He or she should ask
permission in a yes-or-no format, so the client’s response is clear. This is
one of the times when yes-or-no questions are appropriate.
b) use of touch
As intimacy increases, the need for distance decreases. Knapp (1980)
identified five types of touch:
Functional–professional touch is used in examinations or
procedures such as when the nurse touches a client to assess
skin turgor or a massage therapist performs a massage.
Social–polite touch is used in greeting, such as a handshake
and the “air kisses” some people use to greet acquaintances,
or when a gentle hand guides someone in the correct
direction.
Friendship–warmth touch involves a hug in greeting, an arm
thrown around the shoulder of a good friend, or the
backslapping some people use to greet friends and relatives.
Love–intimacy touch involves tight hugs and kisses between
lovers or close relatives.
Sexual–arousal touch is used by lovers.
Touching a client can be comforting and supportive when it is welcome and
permitted. The nurse should observe the client for cues that show whether
touch is desired or indicated.
For example, holding the hand of a sobbing mother whose child is ill is
appropriate and therapeutic. If the mother pulls her hand away, however,
she signals to the nurse that she feels uncomfortable being touched.
The nurse can also ask the client about touching (e.g., “Would it help you
to squeeze my hand?”). The nurse must evaluate the use of touch based
on the client’s preferences, history, and needs.
The nurse may find touch supportive, but the client may not. Likewise, a
client may use touch too much, and again the nurse must set appropriate
boundaries. Although touch can be comforting and therapeutic, it is an
invasion of intimate and personal space.
Some clients with mental illness have difficulty understanding the concept
of personal boundaries or knowing when touch is or is not appropriate.
Clients with a history of abuse have had others touch them in harmful,
hurtful ways, usually without their consent. They may be hesitant or even
unable to tell others when touch is uncomfortable.
Consequently, most psychiatric inpatient, outpatient, and ambulatory care
units have policies against clients touching one another or staff. Unless
they need to get close to a client to perform some nursing care, staff
members should serve as role models and refrain from invading clients’
personal and intimate space.
When a staff member is going to touch a client while performing nursing
care, he or she must verbally prepare the client before starting the
procedure. A client with paranoia may interpret being touched as a threat
and may attempt to protect him or herself by striking the staff person.
c) active listening and observation.
Peplau (1952) used observation as the first step in the therapeutic
interaction. The nurse observes the client’s behavior and guides him or her
in giving detailed descriptions of that behavior. The nurse also documents
these details. To help the client develop insight into his or her interpersonal
skills, the nurse analyzes the information obtained, determines the
underlying needs that relate to the behavior, and connects pieces of
information (makes links between various sections of the conversation).
A common misconception by students learning the art of therapeutic
communication is that they must always be ready with questions the
instant the client has finished speaking. Hence, they are constantly
thinking ahead regarding the next question rather than actively listening to
what the client is saying. The result can be that the nurse does not
understand the client’s concerns, and the conversation is vague,
superficial, and frustrating to both participants.
When a superficial conversation occurs, the nurse may complain that the
client is not cooperating, is repeating things, or is not taking responsibility
for getting better. Superficiality, however, can be the result of the nurse’s
failure to listen to cues in the client’s responses and repeatedly asking the
same question. The nurse does not get details and work from his or her
assumptions rather than from the client’s true situation.
While listening to a client’s story, it is almost impossible for the nurse not
to make assumptions. A person’s life experiences, knowledge base, values,
and prejudices often color the interpretation of a message.
In therapeutic communication, the nurse must ask specific questions to get
the entire story from the client’s perspective, clarify assumptions, and
develop empathy with the client. Empathy is the ability to place oneself
into the experience of another for a moment in time. Nurses develop
empathy by gathering as much information about an issue as possible
directly from the client to avoid interjecting their personal experiences and
interpretations of the situation. The nurse asks as many questions as
needed to gain a clear understanding of the client’s perceptions of an
event or issue.
3. Therapeutic Communication Goals
a) Establish a therapeutic nurse-client relationship
Purpose: To create a foundation of trust, respect, and professional caring
Example: A nurse meets a new patient admitted for depression and says,
"Hello Mrs. Johnson, I'm Sarah, and I'll be your nurse today. I'm here to help
support you during your stay. Would you like to tell me a bit about what
brought you here?"
b) Identify the most important client concern
Purpose: To focus care on what matters most to the client at that moment
Example: Rather than assuming a cancer patient's main concern is pain, the
nurse asks "What's troubling you the most right now?" and discovers the
patient is actually most worried about their children's wellbeing.
c) Assess client's perception of the problem
Purpose: To understand how the client views and interprets their situation
Example: When working with a client struggling with alcohol use, the nurse
asks, "Can you help me understand what typically happens before you feel the
urge to drink? What thoughts and feelings come up for you?"
d) Facilitate expression of emotions
Purpose: To help clients process and understand their feelings in a safe
environment
Example: When a client becomes tearful while discussing a recent loss, the
nurse says, "I see this is really painful for you. It's okay to cry here. Would
you like to talk about what you're feeling?"
e) Teach necessary self-care skills
Purpose: To empower clients and families with tools for managing health
Example: Working with a diabetic patient, the nurse demonstrates insulin
injection technique, watches the patient practice, and provides gentle
feedback: "You're doing great. Let's practice one more time so you feel
confident doing this at home."
f) Recognize client's needs
Purpose: To identify both expressed and unexpressed needs for
comprehensive care
Example: While treating a elderly patient's wound, the nurse notices signs of
poor nutrition and gently explores food security issues: "I notice you've lost
some weight. Can we talk about how meals are going at home?"
g) Implement needs-based interventions
Purpose: To provide personalized care that addresses specific client
requirements
Example: For an anxious client, the nurse teaches breathing exercises and
establishes a daily check-in routine to monitor anxiety levels and coping
strategy effectiveness.
h) Guide toward action planning
Purpose: To help clients develop realistic and achievable solutions
Example: Working with a client managing chronic pain, the nurse helps break
down goals: "Let's identify three small activities you'd like to accomplish this
week, and plan how to pace them with your energy levels."
4. Using Therapeutic Communication Techniques
a) Variety of Therapeutic Communication Techniques in Psychiatric Settings
Purpose: To build trust and facilitate mental health assessment and treatment
Examples:
Active Listening with a paranoid patient: "I notice you're feeling unsafe. Can you
tell me more about these feelings?"
Strategic Silence: Allowing a depressed patient time to process emotions and
respond
Open-ended Questions with anxiety patients: "How do your anxiety symptoms
affect your daily activities?"
Reflection with PTSD clients: "You mentioned feeling triggered when hearing
loud noises. That must be very challenging."
b) Matching Technique to Psychiatric Presentations
Purpose: To adapt communication based on specific mental health conditions
Examples:
For Manic Patients: Using clear, direct statements to help focus scattered thoughts
"Let's focus on one thing at a time. What's most important to discuss right now?"
For Depressed Patients: Encouraging expression while validating feelings "I hear
how difficult getting out of bed has been. What support would be helpful?"
For Psychotic Patients: Using reality-based, concrete communication "I understand
you're hearing voices. I'm not hearing them, but I believe they feel real to you."
For Anxious Patients: Providing reassurance while teaching coping skills "Let's
practice some grounding techniques together when you feel overwhelmed."
c) Adapting to Psychiatric Client's State
Purpose: To ensure effective communication regardless of mental status Examples:
During Crisis: Short, clear directions "You're safe here. Take a deep breath with
me."
During Dissociation: Grounding techniques "Can you tell me five things you can
see in this room right now?"
During Emotional Flooding: Calming presence "I'm here with you. We can take
this at your pace."
d) Facilitating Therapeutic Relationships in Psychiatric Care
Purpose: To create safe, trusting environments for mental health treatment Examples:
Setting Boundaries: "I care about your progress, and our professional relationship
helps me support you best"
Maintaining Consistency: Regular check-ins at scheduled times
Supporting Autonomy: "What coping strategies have worked for you in the past?"
Crisis Planning: "Let's develop a plan together for when you feel overwhelmed"
e) Specific Psychiatric Nursing Interventions
Purpose: To implement therapeutic communication within mental health treatment
Examples:
Medication Education: "Can you tell me what you understand about how this
medication helps with depression?"
Group Therapy Facilitation: "Would anyone like to share their experience with
using mindfulness techniques?"
Safety Assessment: "Sometimes when people feel this way, they think about
hurting themselves. Have you had thoughts like this?"
Family Education: "Let's discuss ways your family can support your recovery
while maintaining healthy boundaries."
Practical Application Example with a Schizophrenic Patient:
Initial Contact:
Introduce self clearly and establish a presence
"I'm Sarah, your nurse for today. I'll be checking in with you regularly."
Assess current mental status through observation and gentle questioning
During Acute Phase:
Use simple, concrete statements
Avoid arguing with delusions while acknowledging the patient's experience
"I understand you believe the TV is sending you messages. That must be
distressing."
Focus on here-and-now reality
"Let's focus on what's happening right now in this room."
Stabilization Phase:
Begin teaching reality testing
Help identify early warning signs
Develop coping strategies
"What helps you feel most grounded when the voices start?"
Recovery Planning:
Collaborate on medication management
Discuss triggers and warning signs
Create relapse prevention plan
"Let's write down your early warning signs and what helps during those times."
5. THERAPEUTIC COMMUNICATION TECHNIQUES
a) Accepting In psychiatric nursing, acceptance is crucial when working with patients
experiencing mental health challenges. For example, when a patient with depression
expresses feelings of worthlessness, the nurse might respond with "I see that these
feelings are very real for you" while maintaining supportive eye contact. This
technique is particularly valuable when working with patients experiencing delusions
or hallucinations - while nurses don't validate the delusion itself, they accept that the
patient's experience is genuine for them.
b) Broad Openings Psychiatric nurses use this during initial assessments and daily
interactions. Instead of asking "Are you feeling anxious today?" (which is leading),
they might say "How are you feeling this morning?" This is especially effective when
working with patients who are guarded or have trust issues. For example, with a
newly admitted patient experiencing paranoia, starting with "What would you like to
tell me about what brought you here?" allows them to share at their own comfort
level.
c) Consensual Validation This is essential in psychiatric nursing when working with
patients who might have altered thought processes or communication difficulties. For
instance, when working with a patient with schizophrenia who uses unique words or
phrases, the nurse might say "When you say the 'shadow people,' do you mean the
figures you see when you're alone?" This ensures accurate understanding for both
care planning and building therapeutic rapport.
d) Encouraging Comparison In psychiatric nursing, this helps patients recognize
changes in their mental state and coping abilities. For example, with a bipolar patient,
the nurse might ask "How do your energy levels now compare to last week?" This
helps patients develop insight into their illness patterns and recognize early warning
signs of decompensation. It's also valuable in tracking treatment progress.
e) Encouraging Description of Perceptions Psychiatric nurses use this to assess
thought processes and reality testing. For example, when a patient reports anxiety,
instead of accepting this at face value, the nurse might ask "Can you describe what
you're experiencing in your body right now?" This provides valuable clinical
information about the nature and severity of symptoms while helping patients become
more self-aware of their psychological and physiological states.
f) Encouraging Expression In psychiatric nursing, this technique helps patients who
might have difficulty identifying or expressing emotions. For instance, after a group
therapy session, a nurse might ask a patient with social anxiety "How did it feel for
you to share in the group today?" This helps patients develop emotional vocabulary
and insight while providing the nurse with important information about the patient's
progress and emotional state.
g) Exploring In psychiatric nursing, exploring involves asking questions that help
patients expand on their thoughts, feelings, or experiences in greater detail. For
example, if a patient mentions feeling anxious, instead of moving on, the nurse might
say "Tell me more about that anxiety - what situations trigger it most?" This
technique is particularly valuable when:
Assessing suicide risk ("Can you tell me more about these thoughts of not
wanting to live?")
Understanding the context of symptoms ("When did you first notice these feelings
starting?")
Investigating medication effects ("Could you describe how the new medication is
affecting your sleep?")
h) Focusing This technique helps direct or redirect patients' attention to specific aspects
of their experience or behavior that need attention. In psychiatric nursing, focusing is
crucial when:
Working with patients who have racing thoughts or flight of ideas (common in
mania)
Helping patients with ADHD stay on track during therapeutic conversations
Addressing specific symptoms or behaviors
Example: If a patient with schizophrenia is speaking about multiple topics rapidly,
the nurse might say "Let's focus on what you mentioned about your medication
side effects first."
i) Formulating a Plan of Action In psychiatric nursing, this involves helping patients
develop concrete strategies for managing their mental health. This technique is
essential for:
Discharge planning ("What specific steps will you take if you start feeling
overwhelmed at home?")
Crisis prevention ("Let's create a plan for what to do when you notice warning
signs of depression")
Medication management ("How can we help you remember to take your evening
dose?")
Real-world application: Working with a patient with panic disorder to develop a
step-by-step action plan for managing panic attacks in public settings:
Identify early warning signs
List specific coping strategies
Define when to use PRN medication
Outline emergency contacts and resources
j) General Leads These are verbal and non-verbal encouragements that show patients
you're engaged and want them to continue sharing. In psychiatric nursing, this
includes:
Verbal cues: "Go on," "And then?" "Tell me more"
Non-verbal cues: Nodding, maintaining eye contact, leaning slightly forward
Brief acknowledgments: "Mm-hmm," "I see," "Yes"
This technique is particularly valuable when:
Building initial rapport with new patients
Working with patients who are hesitant to share or have trust issues
Conducting mental health assessments
Supporting patients during emotional disclosures
Clinical Example Applications:
With a Depressed Patient:
Exploring: "You mentioned feeling 'empty' - could you help me understand what
that emptiness feels like?"
Focusing: "Of all the symptoms you've described, which one impacts your daily
life the most?"
Action Planning: "What small activity could you try tomorrow morning to help
you get out of bed?"
General Leads: Nodding supportively as they describe their struggles
With an Anxious Patient:
Exploring: "What happens in your body when you start feeling anxious?"
Focusing: "Let's talk specifically about your panic attacks at work"
Action Planning: "What coping skills could you use when you feel anxiety
building?"
General Leads: "Mm-hmm" while they describe their anxiety triggers
These techniques should be used flexibly and in combination, depending on:
The patient's current mental state
The phase of treatment
The therapeutic goals
The patient's communication style and preferences
The immediate clinical situation
k. Placing Events in Time or Sequence: This involves helping people understand
how events relate to each other chronologically and causally. It includes:
Establishing clear timelines of events
Identifying patterns over time
Understanding cause and effect relationships
Connecting past experiences to present situations
Recognizing how sequences of events influence outcomes
Helping clients see their progress or journey over time
l) Presenting Reality: This means helping people see and understand what is
actually happening, rather than what they might imagine or fear. It involves:
Offering objective observations
Pointing out factual evidence
Helping distinguish between facts and interpretations
Presenting alternative perspectives based on reality
Challenging distorted thinking with concrete evidence
Supporting reality testing in a gentle, supportive way
Grounding discussions in verifiable experiences
m) Reflecting: This is a fundamental therapeutic technique that involves mirroring
back to clients their own experiences in a way that promotes deeper
understanding:
Content Reflection:
Restating or paraphrasing what the client has said
Summarizing key points of their narrative
Highlighting important themes in their story
Feeling Reflection:
Naming emotions the client is expressing
Acknowledging underlying feelings
Validating emotional experiences
Behavior Reflection:
Describing observed actions or patterns
Noting behavioral changes
Highlighting inconsistencies between actions and stated goals
Purpose of Reflection:
Helps clients hear their own thoughts and feelings
Demonstrates active listening and understanding
Allows clients to correct misunderstandings
Deepens self-awareness
Promotes insight and self-discovery
Creates opportunities for clarification
Builds therapeutic alliance through showing empathy
n. Restating In psychiatric nursing, restating helps confirm understanding and shows
active listening. For example, if a patient says "Everything feels like it's spinning out
of control," the nurse might respond "You're feeling like you've lost control of things
in your life." This is particularly useful:
With patients experiencing thought disorders to clarify communication
During assessment to ensure accurate documentation
When working with agitated patients to show you're listening
To help patients hear their own thoughts reflected back
o) Seeking Information This involves clarifying vague or unclear statements to ensure
proper assessment and care. In psychiatric settings, this is crucial when:
Assessing suicide risk ("When you say you 'want it to end,' what exactly do you
mean?")
Evaluating medication effects ("Could you be more specific about feeling
'weird'?")
Understanding psychotic symptoms ("What do the voices tell you?")
p) Silence Therapeutic silence is particularly valuable in psychiatric nursing as it:
Gives patients time to process emotional content
Allows patients experiencing racing thoughts to collect themselves
Creates space for patients who are guarded to open up
Shows respect during moments of intense emotion For example, after a patient
shares a traumatic experience, allowing silence rather than immediately
responding gives them space to process.
q) Suggesting Collaboration This technique builds therapeutic alliance in psychiatric
care through:
Treatment planning ("Let's work together to find coping strategies that work for
you")
Medication management ("We can figure out the best time for you to take your
medications")
Goal setting ("How can we work together to help you feel safe?")
r) Translating into Feelings This helps patients who struggle with emotional
expression or awareness. For example:
When a patient describes physical symptoms of anxiety without naming the
emotion
With patients who act out behaviorally rather than expressing feelings
During group therapy to model emotional awareness Example: "When you talk
about pacing all night and being unable to sit still, it sounds like you're feeling
really anxious."
s) Verbalizing the Implied In psychiatric nursing, this helps bring unstated concerns
into open discussion:
With suicidal patients who hint at self-harm
When patients indirectly express medication non-compliance
During family sessions when conflicts are implied but not directly stated
Example: "You've mentioned several times that you 'might as well not be here.'
Are you having thoughts of suicide?"
t) Voicing Doubt This technique is used carefully in psychiatric nursing to:
Challenge delusions gently ("I understand you believe this, but I'm seeing things
differently")
Address distorted thinking in eating disorders
Question self-defeating beliefs in depression Note: This must be done
therapeutically without invalidating the patient's experience.
u) Giving Information In psychiatric nursing, this involves:
Medication education (effects, side effects, importance of compliance)
Psychoeducation about mental health conditions
Information about coping strategies and resources
Treatment options and processes
v) Giving Recognition This reinforces positive behaviors and progress:
Acknowledging participation in group therapy
Recognizing when patients use healthy coping skills
Noting improvements in self-care or social interactions Example: "I notice you've
been joining the community meetings every morning this week."
w) Making Observations Psychiatric nurses use this to:
Provide feedback about behavioral changes ("I notice you seem more withdrawn
today")
Address concerning symptoms ("I see you're having trouble sitting still")
Document mental status changes
Support reality testing ("I observe that you're speaking very quickly")
x) Making oneself available is fundamentally about being present and accessible to
others in meaningful ways. This can manifest in several dimensions:
Physical Availability:
Being physically present when needed
Setting aside dedicated time for others
Creating space in one's schedule to respond to needs as they arise
Emotional Availability:
Being open to others' feelings and experiences
Maintaining an approachable demeanor
Demonstrating empathy and willingness to listen
Setting aside one's immediate concerns to focus on others
Mental Availability:
Giving full attention rather than being distracted
Being mentally present in conversations
Actively engaging with others' thoughts and ideas
Having the capacity to take on new responsibilities or challenges
Practical Implementation:
Communicating clearly about when and how you can be reached
Following through on commitments to be available
Creating boundaries that allow sustainable availability
Being responsive to communications within reasonable timeframes
The concept goes beyond simple physical presence - it's about creating an environment
where others feel comfortable approaching you and know they will receive genuine
attention and engagement. This might manifest in professional contexts (like
mentoring), personal relationships (being there for family and friends), or community
service.
Clinical Integration Example: With a patient experiencing paranoid thoughts:
Make Observation: "I notice you're staying in your room more."
Seek Information: "What are your concerns about leaving your room?"
Translate Feelings: "It sounds like you're feeling frightened."
Suggest Collaboration: "Let's work together to help you feel safer."
Give Information: "There are strategies we can use to help manage these fears."
6. NONTHERAPEUTIC COMMUNICATION TECHNIQUES
In psychiatric nursing, effective communication is a key component of therapeutic
relationships with patients. However, there are certain communication techniques
that are considered nontherapeutic, as they can hinder understanding, promote
defensiveness, and contribute to negative emotional responses. The following list
outlines various nontherapeutic communication techniques, explaining each in the
context of psychiatric nursing:
a. advising:
Explanation: Advising involves giving recommendations to the patient about
what they should do. In psychiatric nursing, it can be counterproductive
because it undermines the patient's autonomy and may convey a sense of
superiority from the nurse.
Example: "You should just leave your husband; that will make everything
better."
Impact: It prevents the patient from exploring their own feelings and decisions,
potentially causing them to feel invalidated or helpless.
b. Agreeing:
Explanation: Agreeing involves expressing agreement with the patient's
perspective or statement, which may unintentionally reinforce their irrational
thoughts or delusions.
Example: "I agree with you. The whole world is out to get you."
Impact: In psychiatric settings, agreeing with distorted thoughts or perceptions,
such as in cases of delusion, may reinforce those beliefs, further detaching the
patient from reality.
c. Belittling feelings expressed:
Explanation: Belittling occurs when the nurse trivializes or dismisses the
patient's emotions or concerns, making them seem unimportant.
Example: "That’s not a big deal. Don’t be so dramatic."
Impact: The patient may feel ashamed of their emotions or hesitant to share
further feelings, creating a barrier to communication.
d. Challenging:
Explanation: Challenging is when the nurse confronts the patient’s statements,
often with the intent of proving them wrong.
Example: "That’s not true. You’re just imagining things."
Impact: This can lead to defensiveness, confusion, or frustration, especially in
patients with conditions like psychosis, where their perceptions may already be
altered.
e. Defending:
Explanation: Defending occurs when the nurse attempts to protect or justify the
actions or statements of others, such as staff members or the healthcare system.
Example: "I’m sure the doctor knows what’s best for you."
Impact: The patient may feel dismissed or unheard, especially if they have
concerns or complaints about their care. It can create a power imbalance,
reducing trust in the nurse.
f. Disagreeing:
Explanation: Disagreeing involves directly stating that the patient’s thoughts or
perceptions are wrong.
Example: "That’s not what really happened."
Impact: It can create a defensive reaction, especially in patients with psychiatric
conditions such as depression or schizophrenia, where their thoughts may
already be distorted.
g. Disapproving:
Explanation: Disapproving involves expressing negative judgment or
condemnation of the patient's behavior or choices.
Example: "I can’t believe you would do something like that."
Impact: The patient may feel ashamed, guilty, or rejected, which can lead to
withdrawal and decreased self-esteem. It can be especially harmful in vulnerable
psychiatric patients.
h. Giving approval:
Explanation: Giving approval is when the nurse offers praise or validation in
response to something the patient says or does.
Example: "That’s great! I’m so proud of you!"
Impact: While positive reinforcement is important, over-approval may lead to
dependency or unrealistic expectations. It also places an unnecessary focus on
external validation instead of the patient’s internal growth.
i. Giving literal responses:
Explanation: Giving literal responses is when the nurse answers in a very direct,
straightforward manner without considering the emotional or symbolic meaning
behind what the patient is saying.
Example: Patient says, "I feel so empty," and the nurse responds, "You don’t
have any food in your stomach?"
Impact: It fails to address the emotional aspects of the patient's communication,
potentially causing them to feel misunderstood or neglected.
j. Indicating the existence of an external source:
Explanation: This technique refers to suggesting that the patient’s experiences
or feelings are due to external factors, which can minimize personal responsibility
or feelings.
Example: "It’s just the medication that’s making you feel this way."
Impact: The patient may feel disempowered or incapable of managing their own
emotions, leading to dependence on external factors for emotional regulation.
k. Interpreting:
Explanation: Interpreting involves the nurse assuming the meaning behind the
patient’s statements without fully understanding their perspective or asking for
clarification.
Example: "I think what you mean is that you’re angry at your mother."
Impact: This can feel invasive or presumptive, making the patient feel
misunderstood or invalidated, especially when they have not been able to
express their emotions clearly.
l. Introducing an unrelated topic:
Explanation: Introducing an unrelated topic involves shifting the conversation to
something entirely different, often in an effort to avoid the patient’s emotional
distress.
Example: "I know you’re upset, but let’s talk about the weather instead."
Impact: This can make the patient feel that their concerns are not important or
worth discussing, potentially leading to frustration or feelings of isolation.
m. Making stereotyped comments:
Explanation: Making stereotyped comments refers to using generalized phrases
that lack genuine understanding of the patient's individual experience.
Example: "Everything happens for a reason."
Impact: This can minimize the patient’s unique emotions or struggles, making
them feel that their experience is being dismissed or oversimplified.
n. Probing:
Explanation: Probing involves asking excessive or intrusive questions, which
can be perceived as an invasion of the patient’s privacy.
Example: "Why do you feel this way? When did you first feel this way? What
happened in your childhood?"
Impact: This can make the patient feel overwhelmed or pressured to reveal more
than they are comfortable with, potentially reducing trust and rapport.
o. Rejecting:
Explanation: Rejecting involves outright refusing to acknowledge or respond to
the patient’s requests or concerns.
Example: "I don’t want to hear about it."
Impact: This can lead to feelings of rejection, isolation, and discouragement in
the patient, making them less likely to communicate their thoughts or emotions in
the future.
p. Requesting an explanation/asking:
Explanation: This technique involves asking the patient to explain or justify their
behavior or feelings in a way that may feel accusatory.
Example: "Why did you do that?"
Impact: It may cause the patient to feel defensive or self-conscious, rather than
fostering an open, supportive dialogue.
q. Testing:
Explanation: Testing is when the nurse tries to assess the patient's reactions or
challenge their behaviors in a way that may feel like an interrogation.
Example: "If I give you this medication, will you feel better?"
Impact: It can make the patient feel like they are being examined or judged,
leading to discomfort and reluctance to engage.
r. Using denial:
Explanation: Denial involves dismissing or refusing to acknowledge the patient’s
concerns or reality.
Example: "There’s nothing wrong with you, you’re just imagining things."
Impact: This can exacerbate feelings of invalidation or confusion, especially in
patients with conditions like depression or psychosis, who may already be
struggling to make sense of their experiences.
Conclusion:
Nontherapeutic communication techniques, if not recognized and managed, can
severely impair the relationship between a nurse and patient in psychiatric settings. They
can hinder the development of trust, promote defensiveness, and prevent patients from
exploring their emotions or gaining insight into their condition. Instead, nurses should
aim to use therapeutic communication techniques that are empathetic, nonjudgmental,
and supportive, encouraging open dialogue and fostering an environment of respect and
understanding.
A. PROCESS RECORDING
A. Definition, Feature, Purpose
DEFINITION
Recording the conversation during the interaction or the interview between the
nurse and the patient in the psychiatric setup with the nurse’s interference. ¢It is
the written account of the verbatim recording of all that transpires/emerged,
during and immediately following the nurse-patient interaction.
FEATURES
It may be written during or immediately following the interaction
It is a therapeutic tool in which the nurse uses her therapeutic communication
techniques to solve the patient’s problem.
It acts as an educational, teaching, therapeutic, and diagnostic tool.
PURPOSES
To improve the quality of nurse-patient interactions.
To assist the student nurse in planning, structuring, and evaluating the interaction
at a conscious level
To gain competency in interpreting and synthesizing raw data under supervision.
To develop awareness about own habitual, verbal, and nonverbal communication
pattern and the effects on others.
To identify the thoughts and feelings in relation to self and others.
To increase observational skills, and ability to identify the problems and gain
skills in solving them.
B. Pre-requisite for process recording and objectives
PRE-REQUISITE FOR PROCESS RECORDING
Physical setting - Calm and quiet environment (Interview rooms or bedside, if a
separate room is not available).
Obtaining consent for the patient to record the information.
Maintain confidentiality of information.
OBJECTIVES
Should be formulated prior to the meeting. ¢Should be specific and function as a
guide for interaction.
Short-term goals - to establish a therapeutic relationship with patients.
Long-term goals- to prepare the patient and family for follow-up and
rehabilitation
C. Application to nursing
It is a valuable tool in psychiatric nursing as it helps nurses to reflect on their
communication skills, identify areas for improvement, & strategies to enhance
their therapeutic communication with patients.
It provides the basic concept of interacting with patients.
This will help the student nurse to use various techniques so that he/she may
develop an effective therapeutic nurse-patient relationship.
It will also provide the method by which the nurse can interview the patient
skillfully.
It will provide nurses with a guideline to apply the knowledge in a clinical setting
while interacting with the patient.
D. Record of interaction between nurse and patient
Nurses should be truthful in recording what is said and done by themselves and
by the patient.
Observe for the nonverbal response ( eye contact, restlessness, pacing, biting
nails, changing position).
Nurses’ own thoughts and feelings should be recorded separately after writing
the interaction process
Patient overall response towards the interaction to be recorded
E. Analysis of the interaction
Analysis of the interaction should be done by interpreting the verbal and
nonverbal behavior and the patient’s thoughts and feelings evident from the
interaction.
Communication techniques used by the nurse are also to be recorded.
The nurse’s thoughts and feelings at the end of the interaction and plans made
for further interaction should be stated.
Time required to record is 30 min( 20 min for active interactions, 10 min for
conclusion and planning for next interview).
F. Advantages and disadvantages of process recording
ADVANTAGES OF PROCESS RECORDING
It helps in differentiating thoughts and feelings.
It helps to clarify the purpose of the interview or intervention.
It helps to improve written expression.
Helps to identify strengths and weaknesses.
It helps to improve self-awareness.
It helps to separate facts from judgment.
It helps to explore the interplay of values operating between the student and the
patient system through an analysis of the filtering process used in the session
DISADVANTAGES OF PROCESS RECORD
It is more time-consuming
Technical problems are frequent and become a source of frustration
The process is laborious because it requires actual observation and subsequent
participation by the clinical instructor during patient interviews
G. Importance of process recording
IMPORTANCE OF PROCESS RECORDING
Enhanced communication skills
Self-awareness and professional growth
Improved patient care
Identifying patterns
H. Steps involved in process recording in psychiatric nursing
STEPS INVOLVED IN PROCESS RECORDING IN PSYCHIATRIC NURSING
1. Preparation
The nurse should prepare for the therapeutic session by reviewing the
patient’s chart, identifying the patient’s goals and objectives, and planning
the therapeutic approach.
2. Recording
During the therapeutic session, the nurse should record the conversation
between themselves and the patient. The recording should capture the
verbal and nonverbal communication that occurs during the session.
3. Analysis
After the session, the nurse should listen to the recording and analyze the
communication that occurred. The analysis should focus on the nurse’s
communication style, the patient’s response, and areas for improvement.
4. Reflection
The nurse should reflect on the analysis and identify areas for
improvement in their communication style. They should develop
strategies to enhance their therapeutic communication with the patient.
5. Documentation
The process recording should be documented in the patient’s chart to
inform the patient’s care plan.
I.
How to write a process recording in psychiatric nursing
HOW TO WRITE A PROCESS RECORDING IN PSYCHIATRIC NURSING
There is no one right way to write a process recording, but there are some
general guidelines that can be followed. The following is a basic outline for a
process recording in psychiatric nursing:
1. Introduction: State the purpose of the interaction, the patient’s name, and any
other relevant information.
2. Verbatim Dialogue: Record the verbal communication that took place between
the nurse and the patient, as accurately as possible. This includes both the
words that were said and the tone of voice that was used.
3. Thoughts and Feelings: Record your thoughts and feelings as they occurred
during the interaction. This includes both your cognitive thoughts and your
emotional reactions.
4. Analysis: Reflect on the interaction and identify areas where you could have
improved your communication skills, interviewing skills, or patient assessment
skills. This is also a good time to identify any patterns of behavior or themes that
emerged during the interaction.
5. Evaluation: Evaluate your overall performance during the interaction and identify
areas where you need to improve. This is also a good time to set goals for future
interactions with patients.
VIDEO PRESENTATION OF PROCESS RECORDING:
A. https://youtu.be/6PO_NRvv7f0
B. https://youtu.be/DBZGHQXsNUs
C. https://youtu.be/yynoExAe5-E