THERAPEUTIC COMMUNICATION

AND
NURSE - PATIENT RELATIONSHIP

Siti Fatimah Binti Md. Shariff

Master of Nursing
University Collage of Islam, Melaka

Abstract

Therapeutic communication is defined as the face-to-face process of interacting that focuses

on advancing the physical and emotional well-being of a patient. It may be necessary to use a

variety of techniques to accomplish nursing goals in communicating with a patient. It is very

important for nurses to practice a wide range of effective communication strategies and

interpersonal skills to appropriately establish a therapeutic nurse – patient relationship. Today,

ineffective communication is the single most common reason for patient complaints against

healthcare professionals. The healthcare provider who has strong communication skills will

always be more effective in helping patients. Therefore, nurses should be able to use

therapeutic communication techniques to provide support and information to patients in

helping them in their recovery phase. This article provides therapeutic communication

techniques for nurses to enhance therapeutic nurse – patient relationship.

Introduction

Communication is defined as the exchange of information, thoughts and feelings among

people using speech or other technique. According to Virginia Henderson, communication is

one of the needs in the fourteens activities daily. Therapeutic communication is defined as the

face-to-face process of interacting that focus on advancing the physical and emotional well-

being of a patient. As a caring profession despite all the complex technological advancement

of medicine and the machinery that is used at the patient’s bedside, the fact remains that the

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nurse is the first person that the client usually comes in contact with in any emergency or

hospital setting. Therefore, the term, “caring” is an essential emotion that all nurses must

possess in fact all individuals in the health profession.

According to Mosby medical dictionary, therapeutic communication is a process in which the

nurse consciously influences a client or helps the client to a better understanding through

verbal or nonverbal communication. Therapeutic communication involves the use of specific

strategies that encourage the patient to express feelings and ideas and that convey acceptance

and respect.

A therapeutic nurse-patient relationship is defined as a helping relationship that’s based on

mutual trust and respect, the nurturing of faith and hope, being sensitive to self and others,

and assisting with the gratification of your patient’s physical, emotional, and spiritual needs

through your knowledge and skill. This caring relation- ship develops when you and your

patient come together in the moment, which results in harmony and healing.1 Effective verbal

and nonverbal communication is an important part of the nurse-patient interaction, as well as

providing care in a manner that enables your patient to be an equal partner in achieving

wellness.(Pullen, 2010)

Messages are sent and received simultaneously in therapeutic communication which involves

the verbal and nonverbal of information exchange between sender and receiver. Verbal

communication includes the arrangement of words into sentences, including the content as

well as the context which means the area where the conversation takes place which might

include the time and the physical, social, emotional and cultural environment. .(Bach & Grant,

2009)

Nonverbal communication includes the behaviour accompanying the verbal content such as

body language, eye contact, facial expression, the tone of the voice and others. Nonverbal

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communication mainly indicates the thoughts, needs or feelings of the client that happens

spontaneously.

As communication is a vital element in nursing, practising therapeutic communication

provides nursing care for the patient will lead to an opportunities for nurses to learn as much

as they can about the patient in relation about his illness. Together with empathy, nurses

should be able to understand patients feeling even more then what they reported verbally.

With the abilities of nurses to translate nonverbal communication is greatly helpful to

effectively create an effective communication between them and their patients. Nurses must

aware that they must always have a therapeutic reason for invading a patient’s privacy.

Therapeutic nurse – patient relationship

Communication is so greatly rooted in human behaviours and the contexts of society that it is

difficult to imagine social or behavioural transactions without it. For these reasons

communication is fundamental to all nursing and interpersonal relationships. Nurses can use

this dynamic and interactive process to motivate, influence, educate, facilitate mutual support,

and acquire essential information necessary for survival, growth, and an overall sense of well-

being.

The nurse– client relationship challenges the nurse to clarify the meaning or expression of the

client’s problems and distress and maintain continuity during the conversation when the nurse

picks up threads of conversation the client offers during nurse–client interactions.

Interpersonal skills are by nature relational and process driven and the consequences of

effective communication are rapport and trust, acceptance, warmth, empathy, support, and

stress and anxiety reduction (Duffy et al., 2004).

Therapeutic communication involves the interpersonal communication between nurses and

patients which means to guide the patients in their activities daily. The skills required in

therapeutic communication are delicate and far numerous than those required in general

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interpersonal interaction, and mastering of therapeutic techniques helps the nurse understand

the patient better.

Being in the ward, a nurse is the closest person in contact with the patients. As the backbone

of the healthcare services, nurses are there around the clock to look after the patients’ needs

and listening to the feeling allows patients to disclose concerns that they are not shared with

doctors; sharing a joke; and providing explanations where doctors’ communication has failed.

Today, ineffective communication is the single most common reason for patient complaints

against healthcare professionals. The healthcare provider who has strong communication

skills will always be more effective in helping patients. Good communication has been shown

to improve patient satisfaction, patient compliance, and therapeutic nurse – patient

relationship bring for better outcomes.

Nurturing these qualities requires understanding of the essential ingredients of

communication. It is difficult for the nurses to practice effective communication in very

challenging situations such as busy hospitals with high demands of nursing care from the

patients.

For this purposes, nurses must be able to understand and practiced the technique of

therapeutic communication effectively to help them understands physically and emotionally

needs of their patients to foster their recovery process.

Technique of effective therapeutic communication

Broad Opening Statements. The use of a broad opening statement allows the patient to set

the direction of the conversation and an opportunity to begin expressing himself. Such

questions as “Is there something you’d like to share?”, this broad opening statement implies

nurses focuses the conversation directly on the patient and communicates to him that she is

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interested in him and his problems that will help to initiate open discussion. When the patient

opens the conversation, the nurse should lead the conversation by encouraging him with

question or comment to express his feeling further. Whether what he has said is of an

obviously serious nature such “Am I dying”? or less emotionally charged as “I’m going

home tomorrow,” the nurse should avoid making assumptions as to its meaning or the need he

may be expressing.

General Leads. The major purposes of general leads is to encourage the patient to

continuously speak spontaneously, so that the nurse can learn from him how he perceives his

situation, and get some idea of what his need. General leads such as “yes” or simply the “uh

hum” will usually convey to him that the nurse is listening and that she is interested in what

he will say next, encourage the patient to continue. With correct response of nonverbal

action such as nodding and facial expression demonstrate that nurses are attentiveness and

concern towards them. This will develop patients trust towards the nurses and they feel safe to

express their feeling. Some additional samples of general leads are: “I see.” “And then….”,

“go on” and incomplete or open-minded sentences such as “You were saying that…”

This kind of response will help nurses in assisting the patient to freely share their information

that is requires for the nurses in developing nursing plan pertaining to the needs of the

patients. This response will also help the patient from drawing out.

Reflecting. In reflecting, nurses can repeat either all or part of the patient’s statement to

encourage him or her to go on. If he says, “Everyone here hates me” the nurse might reply, “hates

you?” Letting him hear all of what he has said, or part of what he has said may lead him to more

fully consider and expand upon his remark. Selective reflecting can be used once the nurse has

begun to understand what the patient is driving at. For example, if the patient says, “I feel so sad, I

don’t like it here,” the nurse can either reflect, “Sad..?” or “You don’t like it here,” depending on

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which part of his statement she thinks is most important. Proper repeating response in reflecting

the patients feeling are important so that the patients will not likely to become annoyed if his own

words or statements are continually repeated to him. If this happens, it will hinder the open

communication. By reflecting genuine interest and listening attentively, they opened up a

dialogue, allowing them to better understand their patients, as(Rosenberg & Sciences, 2008)

Sharing Observations. Here, the nurse shares with the patient her observations regarding

behaviours. Most of the time patients reluctant to verbalized their felling but it can be observed in

their some kind of behaviours such as nail biting, scratching, hand clenching, or general

restlessness. By sharing her observations of this behaviour with him, the nurse is inviting the

patient to verify, correct or elaborate on her observations. This will help nurses to find out from

him the meaning of his behaviours rather than assuming she knows.

Nurses should phrase her remarks of her observations on patient’s behaviours carefully and

tentatively. What is to be explain is her observations of patient’s behaviours, rather than patient’s

behaviours which is being questioned. This observation can be accomplished by “afraid” or

“angry” may evoke a response of denial from the emotional impact, e.g., “tense”, “upset”, or

“restless.”

Nonverbal messages can enhance or interfere with the verbal messages that are delivered. There

must be congruency, or consistency, between the verbal and nonverbal messages. If there is

conflict, then the nonverbal messages tend to be believed .(Soediono, 1989)

Acknowledging the patient’s feeling. The nurse must be ready to distinguish between the

patient’s needs and intentions; he might need to set the limits in case he feels that they are going

to be violated. Professional communication is very important for the relationship between the

nurse and the patient.(Wachtel, 2011). The nurse helps the patient to know that his feelings are

accepted, understood and encouraged him made him continue expressing his feelings. If he were

to say, “I don’t like it here. I wish I could go home”, the nurse might respond, “It must be difficult

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to stay in a place you don’t like.” When a patient talks about something that making him sad, he’ll

expresses a complaint or criticism, the nurse acknowledging the feelings he is expressing without

disagreeing or agreeing with them. If the patient senses or is told that the nurse does not approve

with what he is expressing, it is extremely unlikely that he will continue, or that a positive nurse-

patient relationship will ensue.

Using Silence. Silence means thousand words to interpret about. An attentive silence may be

preferable to a verbal response in certain situations that gives the patient an opportunity to

reflect upon the topic that being discus. Somehow, temporarily slow the pace of the

conversation allows the patients to collect his taught before speak further about his feelings.

Silence will also give nurses an opportunity to observe body language of the patients and try

to deeply understand what are in their mind. Maintaining an attentive, remain silence at this

time let him know that his silence is accepted. It is important to practice silence as the nurse

tends to increase the period of time a silence lasts, due to her own anxiety. After several

minutes of silence, the nurse can help the patient to resume verbal activity and on the non-

verbal cues from the patients. They often give non-verbal information about their pain level

by the way they hold themselves, grimace or wince with movement. In many ways, we rely

on these cues during assessment and treatment, especially for patients with language and

verbal communication barriers. Does the patient appear cold, confused, nervous or

uncomfortable? Don’t assume that patients will feel comfortable or safe enough to speak up.

Be responsive to patients’ non-verbal cues, and be sure to check in regularly with them.

(Zembrzuski & Saybrook, 2013)

Giving Information. It is very important for nurses to give correct information to reduce

anxiety. Lack of information will bring patients down in darkness that will affect their trust

towards nurses. Clear information such as hospital routine, meal times, nursing care that plan

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to meet their needs and many more .By providing such information it will help to establish an

atmosphere of helpfulness and trust in nurse –patient relationship.

Therapeutic Communication is one of the most valuable tools that nurses have to build

rapport or trust. This trust allows the nurse to provide reverse care. This means that the nurse

allows the patient to feel secure enough to share information, such as his/her feelings,

frustration, pain, happiness, or improvement. The information provided by therapeutic

communication gives nurses the clues or heads up of any exacerbation in the patient’s

condition, as well as any developing disease. (Rosenberg & Sciences, 2008)

Clarifying. Clarifying any doubt will prevent misinterpretation that causes misunderstanding

which is one of the main barriers that can hinder communication. If the nurse has not

understood the meaning of what the patient has said, she clarifies immediately. She can use

such phrases as “I’m not sure I follow…” or “Are you using this word to mean…” to request

that the patient make his meaning clear to her. Nurse’s efforts in clarifying will demonstrate

her continued interest in what the patient is saying, the use of this technique can help motivate

him to go on. Understand clearly what each has said, will bring up to a meaningful

conversation. The nurse should not hesitate to interrupt the patient if there is any confusion in

her mind about his meaning. She might say, “Before you go on, I want to understand what

you meant by…” it is important for nurses to identify patient apparent level of understanding

to help nurses used simple words for patients to understand. Nurses should avoid the use of

medical terminology or jargon whenever possible, and attempt to express herself in

appropriate word to ensure massages are c To successfully bridge some of these barriers, it is

best to avoid using language such as idioms such as “no pain, no gain” which can be

misunderstood. Remember to speak slowly and use simple language effectively.(Canadian &

Act, 2005)

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Verbalizing Implied Thoughts and Feelings. It is important for nurses to response

according to how the patients implies rather than what he verbalize. Observe the nonverbal

expression and impressions of the patient rather than what he has actually said. For example,

if a patient has said, “It’s a waste of time to do these exercises’ she might reply, “You fell

they aren’t benefiting you?” Besides, enabling the nurse to verify her impressions, verbalizing

implied thoughts and feelings, the nurse should be careful to verbalize only what the patient

has fairly obviously suggested so that she does not get into the area of offending

interpretations

Exploring or delving further into a subject or idea. The nurse should recognize when to

delve further – she should refrain from probing or prying. If the patient chooses not to

elaborate, the nurse should respect the patient’s wishes. Probing usually occurs when the

nurse introduces a topic because she is anxious. These are an examples of exploring topics

which the patient has brought up for discussion such as “Tell me more about that”, “Would

you describe it more fully?” and “What kind of work?” Through therapeutic communication

they should establish a relationship, identify the patients’ worries and needs, and estimate the

perceptions of the patient including detailed actions (behaviour, messages).

Nurses should act on the non-verbal cues get from patients. They often give non-verbal

information about their pain level by the way they hold themselves, grimace or wince with

movement. Nurses must always alert themselves with body language cues during assessment

and treatment, especially for patients with language and verbal communication barriers. Does

the patient appear cold, confused, nervous or uncomfortable? Don’t assume that patients will

feel comfortable or safe enough to speak up. Be responsive to patients’ non-verbal cues, and

be sure to check in regularly with them.(Canadian & Act, 2005)

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Presenting Reality. Presenting reality is requires to help patients facing reality. Examples of

presenting reality are: “I see no one else in the room”, “That sound was a car backfiring, “and

“Your mother is not here; I’m a nurse.” When it is obvious that the patient is

misapprehending reality, the nurse can indicate that which is real. This is done not in an

arguing manner or belittle patients own experiences but rather by calmly and quietly

expressing her own slants or the facts. This technique is highly useful with patients who are

confused and geriatric patients who show signs of confusion, or psychiatric patients showing

high anxiety and patients who are confused.

Voicing Doubt. Statements like the following express uncertainty as to the reality of the

patient’s perceptions: “Isn’t that Unusual?” “Really? That’s hard to believe.” Another means

of responding to distortions of reality is to express doubt. Such expression permits the patient

to become aware that others do not necessarily comprehend events in the same way or draw

the same conclusions that he does. This does not mean that he will alter this point of view,

but, at least he will be encouraged to reconsider and re-evaluate what has occurred. And, the

nurse has neither agreed nor disagreed, yet, at the same time, she has not let misinterpretations

and distortions pass uncommented upon. Avoid making rash comments, or sending an

immediate written response that might be regretted later(Zembrzuski & Saybrook, 2013)

Suggesting Collaboration. The nurse seeks to offer the patient a relationship in which he can

identify his problems in living with others, grow emotionally, and improve his ability to form

satisfying relationships with others. Nurses are always there to help patients to do things not

for him or to him, but with him (Windows et al., 2014)

Example is by offering to share, to strive, to work together with the patient for his benefit

such as, “Perhaps you and I can discuss and discover what produces your anxiety such as

pain, frustration or any other problems that is in your mind”

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Validating. Nurses should validate their quality of nursing care either or not that the patient’s

need has been met. This can be done by asking the patients such a question as “Do you feel

relaxed?” or “Are you feeling better now?” If patients need has not been completely met, the

nurse should renew her efforts to assist him. The nurse should not assume that she has been

successful in meeting a patient’s need until this has been validated with him. Give him an

opportunity to voice out his needs and requirement apart from validating with nursing

assessment observation of patients nonverbal behaviour.

Conclusion

Nurse’s responsibilities in the 21st century are changing. Demand on the higher quality of health care

has been a great challenge for nurses to effectively communicate in a therapeutic manner with their

patient’s event with patient’s relatives.

With managed care, and the quest for universal health coverage, there will be greater demands upon

our system to provide high quality care with a high rate of efficiency. Using therapeutic

communication effectively helps to create a nurse-patient relationship that promotes choice and

responsibility, gains patient input and cooperation, maximizes positive care outcomes, and helps to

avoid disputable confrontations. It is only when the patient is able to partner in the management of his

own healthcare that the nurse’s work can be fully utilized and the patient’s success maximized.

Integrating knowledge with compassion, reducing stress and establishing rapport, the skill of

therapeutic communication is the nurse’s greatest asset.

Effective therapeutic communication prevail the effective nurse – patient therapeutic relation

incorporates with nurses caring behaviours towards their patient. It’s a win- win situation in

which nurses and patients can experience growth by sharing “the moment” with each other.

Unquestionably, today’s nurse must possess skills that enable her or him to integrate effective

verbal and nonverbal communication skills in a healthy interactions with clients, families, and

other staff are critical in today’s fast- paced and information-driven society.

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References

Bach, S., & Grant, A. (2009). Communication and Interpersonal Skills for Nurses.
Canadian, T., & Act, C. (2005). Did you know that... Read, 16–25.
http://doi.org/10.1037/e624942009-009
Mccabe, C. (n.d.). ISSUES IN CLINICAL NURSING Nurse–patient communication: an
exploration of patients’ experiences.
Pullen, R. (2010). Fostering therapeutic nurse-patient relationships. Nursing Made Incedibly
Easy!, (May/June), 4. http://doi.org/10.1097/01.NME.0000371036.87494.11
Rosenberg, S., & Sciences, A. (2008). Therapeutic Communication in the Clinical Setting,
72–84.
Soediono, B. (1989). No Title No Title. Journal of Chemical Information and Modeling (Vol.
53). http://doi.org/10.1017/CBO9781107415324.004
Wachtel, P. (2011). Therapeutic Communication, 4(7), 457–466.
Zembrzuski, B. C., & Saybrook, O. (2013). Communication Difficulties : Assessment and
Interventions in Hospitalized Older Adults with Dementia.
http://doi.org/10.1097/WAD.0b013e3181bd66a3.de

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