Communication Techniques

Communication in nursing has the potential to be therapeutic or nontherapeutic. Therapeutic communication is the ideal. It consists of an exchange of information that facilitates the formation of a positive nurse-patient relationship and actively involves the patient in all areas of care. In contrast, nontherapeutic communication usually blocks the development of a trusting and therapeutic relationship.

Specific communication techniques are used to facilitate the development of therapeutic interaction. Some techniques are verbal, and others are nonverbal. Individual nurses are more or less comfortable with the various techniques, and the LPN/LVN should choose a communication technique that fits both the nurse’s style and the patient’s, and a given situation. The use of therapeutic communication techniques does not guarantee that therapeutic communication will occur. Therapeutic communication requires the nurse to have an awareness of the patient’s feelings and the ability to respond to the patient’s needs through the use of verbal and nonverbal communication skills (see Coordinated Care box).

 

Coordinated Care: Supervision

Communication Skills

•Nurses who have many years of education and experience continue to develop and improve effective communication skills, particularly cross-cultural communication.
•New and inexperienced unlicensed assistive personnel (UAP) often need guidance to make their communication skills more effective.
•It is a responsibility of the nurse to monitor how effective the UAP are when communicating with patients, and ancillary personnel from other departments such as x-ray, laboratory, and dietary departments.
•Two methods to help UAP become better communicators are role modeling effective communication techniques and in-service education programs.

 

Nonverbal Therapeutic Communication Techniques

Listening

Listening is an acquired skill that is vitally important to the nurse-patient relationship. Characteristics that aid the nurse in being a good listener include empathy, silence, and mindfulness of the patient’s verbal and nonverbal communication. In addition, the nurse must be nonjudgmental and accepting of the patient’s thoughts, feelings, and beliefs (Shipley, 2010). One of the most effective methods of therapeutic communication, listening can also be one of the most difficult to master (Table 4-2). It often feels awkward and uncomfortable at first. This nonverbal communication technique is a behavior that conveys interest and caring toward the patient. It is not always the result that counts the most: it is possible to hear without listening.

Listening is sometimes active and sometimes passive. Active listening requires full attention to what the patient is saying. The nurse hears the message, interprets its meaning, and gives the patient feedback indicating understanding of the message. The patient has an opportunity to validate that the message was received or not received as intended.

In passive listening, listening to the speaker is indicated either nonverbally through eye contact and nodding, or verbally through encouraging phrases such as “Uh-huh” and “I see” (Balzer Riley, 2012). Although it is not possible for the patient to be sure that the nurse has accurately received or understood the message, passive listening lets the patient know that the nurse is interested and being attentive to what is being said by the patient. The nurse’s level of confidence affects the ability to listen attentively. Novice nurses are often “thinking ahead” to the most appropriate response to the patient and, by so doing, miss what the patient is really trying to communicate. As experience and confidence is attained, the LPN/LVN gains the capacity to give full attention to the patient’s message, thus allowing for more appropriate intervention.

Silence

Maintaining silence is an extremely effective, yet sometimes difficult, therapeutic communication technique. In the American society, silence often feels awkward, which leads to the desire to interrupt silence by making conversation. This impulse does not always allow the

people involved in an interaction time to organize their thoughts sufficiently to communicate their needs or response. A person commonly needs several seconds after hearing a verbal message to interpret what has been stated and to formulate the most appropriate response. Unfortunately, the receiver often does not get this amount of time before a response is necessary. In many cases, the sender becomes uncomfortable with the silence and begins speaking again before the receiver has had an opportunity to formulate a response.

The ability to use silence effectively requires skill and timing. Prolonged silence is often difficult to maintain but is vitally important to an interaction. Silence conveys support, compassion, and caring. Holding the patient’s hand or placing one’s hand on the shoulder of a patient or loved one when combined with silence conveys caring and concern. An example of effective use of silence is when a patient dies. The nurse can communicate support and compassion by remaining with the family after relaying the news to them. Allowing family members time to express their feelings while remaining silent and using therapeutic touch communicates that the nurse cares about the family without trying to talk away the situation.

In some cases, it is helpful for nurses to let patients know that they do not have to speak and to convey that they are willing to just sit and wait until patients feel ready to respond. However, the nurse’s nonverbal cues must be congruent with this willingness to wait. Actions such as fidgeting, writing, and looking at one’s watch communicate the opposite message. Therapeutic silence requires practice to master the skill in a way that it becomes easy and natural.

Touch

Touch is another form of nonverbal communication that is inherent in the practice of nursing. Nearly every nursing intervention for the purpose of providing physical care calls for touch. When providing nursing care, touch is often highly personal or intimate in nature (e.g., giving a bed bath, assisting a patient on or off a bedpan, inserting a urinary catheter). Because of the intimate nature of touch in the nursing context, it must be used with great discretion to fit into sociocultural norms and guidelines. Some nurses are uncomfortable with touch because of a fear of its seeming inappropriate or being misinterpreted. When the nurse is comfortable with physical contact with a patient, touch has great potential for conveying warmth, caring, support, and understanding (Figure 4-2). For the nurse to convey warmth, the nature of touch must be sincere and genuine. However, if the nurse is not comfortable with touch, or the nurse touches the patient in a manner that communicates hesitancy or reluctance, a very strong negative message, such as rejection, is sent to the patient.

Interpretation of touch is dependent on several factors, such as the duration and intensity of the contact; the body part touched; the culture, gender, and age of both the patient and the nurse; the environment; and the stage of development of the relationship. Depending on the patient’s culture, holding the hand of a patient who does not speak English during a difficult procedure may be more effective and comforting than efforts to communicate verbally. A small child who is frightened by the hospital environment often responds better to being cuddled than to a verbal explanation of what is taking place. Older adult patients frequently reach out to touch the person caring for them. Many patients who are sad find a warm embrace to be very comforting. A back rub for the patient who is in pain often promotes relaxation and eases the pain. However, because of sociocultural differences, the nurse must always be alert to and aware of the possible variations in interpretation of touch. When used appropriately, touch has powerful potential as a communication technique.

Verbal Therapeutic Communication Techniques

Conveying Acceptance

Many issues in the nurse-patient relationship are of a highly personal nature. Some patients are hesitant to give the nurse complete information, particularly as it relates to values, beliefs, lifestyles, and practices. Often this reluctance has to do with a fear of disapproval from the nurse in regard to the patient’s values, beliefs, or practices, or even rejection of the individual as a person.

The nurse’s acceptance and willingness to listen and respond to what a patient is saying without passing judgment on the patient is key to the development of a therapeutic nurse-patient relationship. It is likely that, given variances in sociocultural influences (e.g., economic status, religion, upbringing, cultural background, and age), a patient’s values, beliefs, and practices will differ from that of the nurse. The nurse must be cognizant of conveying disapproval or communicating disapproval nonverbally through gestures or facial expressions.

Minimal encouragement is a subtle therapeutic technique that communicates to the patient that the nurse is interested and wants to hear more. It indicates acceptance of the patient as a person. It usually involves nonverbal cues, such as maintaining appropriate eye contact and nodding occasionally, and verbal comments such as “Yes, go on” to encourage the patient to continue.

The nurse may be confronted with a patient whose practices are harmful to a healthy lifestyle. Acceptance of the patient and the lifestyle are not synonymous with approving of the lifestyle choices. The challenge for the nurse is to facilitate changes in the patient’s health behaviors while helping the patient to maintain personal integrity. The LPN/LVN must keep in mind that both the nurse and the patient have the right to their own beliefs. The nurse can demonstrate acceptance of the patient’s right to his or her present beliefs and practices without condoning them. The next step is to communicate a healthier alternative to the present behavior and assist patients in initiating the new behavior if they choose to make these practices a part of their life.

Questioning: Closed

Much of the information gathered by the nurse about a patient comes from questioning the patient directly. The type of information sought determines what type of questioning is most appropriate (Table 4-3). A closed question is focused and seeks a particular answer. For example, when interviewing a newly admitted patient with diabetes, the nurse asks, “What is your insulin dosage in the morning?” A specific question with a specific answer, it is typical of closed questions, which generally require only one or two words in response. This direct type of questioning is useful if this is the type of information desired. However, if the LPN/LVN wants the patient to give more details on a subject, an open-ended question is a more effective communication technique.

Questioning: Open-Ended

Open-ended questions do not require a specific response and allow the patient to elaborate freely on a subject when replying. This type of question is useful in assessing the patient’s feelings. Consider the different responses possible for a patient who is asked the following questions:

Closed: “Mr. A., are you worried about your scheduled surgery?”
Open-ended: “How you are feeling about having surgery tomorrow, Mr. A.?”

The closed question requires only a yes or no answer and probably elicits a very short response. The open-ended question invites Mr. A. to elaborate in whatever direction he chooses with regard to his feelings about having surgery. Given the opportunity to explore his feelings, Mr. A. may reveal information about other aspects of his life or questions and concerns he may have regarding his upcoming surgery. Open-ended questions also convey the message that the nurse is interested in the patient as an individual, not just in obtaining information.

Restating

When using the technique of restating, the nurse repeats to the patient what is believed to be the main point that the patient is trying to convey. It is another way of letting the patient know that the nurse is listening. Simply by repeating the central theme of the patient’s comments, the patient is encouraged to open up further and provide more information. If the nurse also slightly raises the tone of his or her voice at the end of the restatement, the patient will probably take this as a signal that the nurse is interested in hearing more information.

Restating often feels awkward to the nurse who is not experienced in using this technique. The nurse should avoid overuse of this technique because this sounds as though the nurse is “parroting” what the patient is saying. Parroting can sound like a much planned response and is often annoying to the patient. When used selectively, restating is a valuable technique to encourage the patient to offer helpful information.

Paraphrasing

Although paraphrasing bears some similarity to restating, it differs in intent. Paraphrasing is the restatement of the patient’s message in the nurse’s own words in an attempt to verify that the nurse has correctly interpreted the patient’s message.

Clarifying

Clarifying takes restating and paraphrasing a step further and is useful when the patient’s message is incomplete or confusing or does not go deeply enough into the area being explored. When clarifying, the LPN/LVN suggests some of his or her own ideas about what the patient is trying to communicate back to the patient, in a manner that asks the patient to verify that the nurse’s understanding of the message is accurate. Clarifying prevents misinterpretation of the patient’s comments.

Focusing

The technique of focusing is also used when more specific information is needed to accurately understand the patient’s message. The patient may be providing the nurse with important information, but if the message is too vague or strays from the topic being discussed, it is difficult for the nurse to identify the actual message.

Reflecting

Reflecting is like restating, but it involves inner feelings and thoughts more than facts. This therapeutic technique is used to assist patients to explore their own feelings, often about a choice that lies before them, rather than seeking answers or advice from someone else, such as the nurse. The nurse allows for the expression of the patient’s feelings but, rather than offering advice, reflects the thoughts back to the patient. This empowers the patient to verbalize a possible solution and at the same time places the patient in a position of control and promotes self esteem and autonomy.
Reflecting allows patients to see that their ideas and thoughts are important and have worth. Patients gain confidence in their own decision making instead of feeling the need to rely on others for decision making.

Stating Observations

While interacting with a patient, the nurse is also observing the patient. Communicating the nurse’s observations to the patient is called stating observations and is often useful in validating the accuracy of observations. This technique can be especially helpful when the patient’s verbal message does not seem to match the nonverbal behaviors witnessed by the nurse. With description of the patient’s observed behavior, feedback is provided and the patient is invited to verify that the message received was the one the patient intended to send. Clarification of the confusion between verbal and nonverbal cues allows the nurse to address the patient’s concerns more effectively.

Offering Information

Much of the communicating that the nurse does takes the form of offering information. Preparing a patient for what to expect before, during, and after an invasive diagnostic procedure is one example of how the nurse uses this communication technique. Discharge teaching to prepare the patient for self care at home is another example. The nurse should use the patient’s feedback to determine whether the information given has been understood. Offering information is not the same as giving advice. Giving advice takes decision making away from the patient and puts the nurse-patient relationship at risk.

Summarizing

Summarizing means providing a review of the main points covered in an interaction. This technique is most often used after a lengthy interaction or one that has covered several issues (e.g., at the end of a patient teaching session). It helps the patient to separate the essential information from the “nice to know” information and gives a sense of closure to the session.

Use of Humor

The power of humor during interactions with patients should not be underestimated as an effective communication tool. Old (2012) notes that laughter provides a positive psychological and physiological effect on the body by increasing catecholamine levels, relaxing smooth muscles, and stimulating the release of endorphins and serotonin. These responses lead to enhanced feelings of well being and can help reduce anxiety, pain, and the level of stress hormones (Figure 4-3).

Humor can help put both the nurse and the patient at ease. It is, however, important for the nurse to know when humor is appropriate and when it is inappropriate. It is never appropriate to laugh at a patient; it is only appropriate to laugh with a patient. The timing and context of humor are also important for the nurse to realize. In some serious situations, humor is not appropriate, such as when a patient has just received a serious diagnosis or when a patient is trying to

FIGURE 4-3 Help reduce stress and support a therapeutic relation­ship by sharing a joke or laughing with patients.

convey thoughts or feelings. In general, the nurse should get to know the patient before using humor. Correct perception of the patient and situation allows the nurse to take cues from the patient or the patient’s significant others to predict how the patient might respond to humor. In some situations, the nurse should remember to be especially cautious with the use of humor (e.g., when the patient is from a different culture or background or is confused or cognitively impaired). Another pitfall to watch out for is use of humor to avoid confronting or dealing with issues. Rather than allowing oneself or the patient to resort to humor to mask fears and other difficult emotions, the nurse should try to find a more appropriate technique that helps the patient communicate effectively. Humor is certainly effective and therapeutic in some situations, but it becomes a hindrance, and potentially destructive, if it is the only tool used by the nurse.