Bridges, Barriers, and Therapeutic Communication Techniques

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N302: Lecture 5

Therapeutic communication:

- A specialized form of communication used in health care to support, educate, and empower people to cope with health care issues.
- Purposeful form of communication to help a patient achieve health care goals.
- Reinforces a person's self-esteem.
- Most people dying of chronic illnesses, it takes a lot to live with this, we need to help people get through this with therapeutic communication.

You will spend your entire career learning techniques of therapeutic communication.

This is the essence of nursing and the hardest skill to teach because what works in one situation may not work in another. It is highly individualized.

Ultimately it comes back to why you are even in this field.

There are skills to be learned, but underlying therapeutic communication is good knowledge of oneself.

Bridges to the relationship:

- Respect
- Caring
- Empowerment
- Trust
- Empathy
- Mutuality

Respect

- Foundation of the professional relationship.
- What does it look like when you don't show respect? It looks like broken communication.
- What are some techniques to enhance respect? In order to respect another's values and beliefs you first have to take the time to learn what those are.

Mirroring

- Technique to convey respect.
- Follow the patient's lead on level of formality (Mrs. Jones versus Betty), U.S. has become more casual, nurses are looked to at a higher level.
- Use similar similar vocabulary. Use repeat-back method to ensure understanding.
- Matching tone of response to client's tone, if client is somber and sad then you should be somber and sad, feel out the mood.
- Observe nonverbal messages your patient is sending before you engage in conversation.

Active listening:

- Most therapeutic.
- An interactive process, not just staring and listening.
- Interested not just in what is said, but also in how it is said.
- Allows nurses to see situation from client's perspective.
- Eye contact but not staring.

Techniques to enhance active listening:

- Sitting at eye level.
- Providing private space for conversation (limit distracters).
- Head nod, acknowledge grunt.
- Smile.
- Leaning forward.
- "Hmm...go on..."

Barriers to active listening:

- Preoccupation with other tasks by nurse.
- Feeling insecure or intimidated by patient.
- Client rambling and can't make sense of it, might want to interrupt patient.
- Too much information.
- Check yourself: are you interrupting the patient frequently, trying to steer the conversation towards you, indifferent to what is being said?
- Do deep breathing, change mood for change in scene.

Silence

- Powerful technique.
- Allows time to take a deep breath and react to what has been said.
- Emphasizes to patient that you are really listening because you're on same page.
- Allows patient to portray thoughts and feelings.

Body language:

- Facial expression, gestures, body position, touch, personal space.
- Much of what we communicate to others is nonverbal.
- Nurses need to consciously observe patient's body language and be aware about how our body language speaks to them.
- This may be the only way a patient is able or willing to communicate i.e. stroke, on ventilator.

Caring:

- Moral and knowledge component.
- What does it look like when it is present? Active, engaged process with patient, curiosity about the patient's condition, enthusiasm for the work of nursing, even if I worked 3 days in a row for 12 hours each shift, I am a nurse because I want to be here.
- What does it look like when care is provided without caring? Apathetic, perfunctory (done with little interest).

Touch:

- Can be very effective for sensory deprived.
- Can convey caring to patients who feel isolated or grotesque (obese, homeless, disfigured, disabled).
- Sometimes there are no words that can help and touch can be therapeutic.
- Can also be tricky between males/females because touching thighs, forearms, shoulders may be inappropriate.

Empowerment:

- Assisting patient's to take charge of their own life.
- What does it sound like when it is present? Coaching, suggesting, affirming, not telling what they NEED to do.
- What does it sound like when communication is not empowering? Paternalistic: "You don't need to worry about that." Telling patients what they should do or not do.
- Coaching: how can you encourage patients without taking over for them?
- Cheerleading versus coaching, encourage people.

Trust:

- Key to establishing working relationship.
- Allow patient to make choices.
- Be honest/give complete information.
- Provide consistency.
- Plan schedule, lay out day for patient.
- Follow through on promises, if we say we'll be back come back.
- Provides non-threatening interpersonal climate in which the client feels comfortable revealing his or her needs to nurse.

Empathy:

- Ability to put oneself into the client's position.
1. Unaware of patient's feelings (worst).
2. Superficial acknowledgement of message.
3. Recognize message and feelings (where most of us are).
4. Willingness to understand.
5. Full acknowledgement of hidden message and meaning (best).

Communication Techniques:

- Questioning
- Clarification
- Paraphrasing
- Reflection
- Physical characteristics that convey meaning with patients.
- Nonverbal behaviors patients use to reduce anxiety.
- Restatement
- Modulating tone, posture.
- Proxemics.

Questioning:

- Open-ended, usually starts with how, what.
- Closed-ended: can be answered as "yes" or "no" or with simple answer (try to stay away from this when getting assessment data).
- Focused: more appropriate when time is limited.

Clarification:

- Asks client to expand on point i.e. if don't understand what patient meant.
- "Oh, when I get out of here I am calling my lawyer."
- "I'm not quite sure I understand what you meant. Can you tell me more about that?"

Paraphrasing:

- Different from restating in that nurse restates what the client said in her own words.
- "Dr. J just keeps ordering this tramadol for my pain and I told him it isn't working."
- "So, in other words, you feel that you aren't being listened to by your doctor."

Reflection

- "I am sick of being a guinea pig for every student who has to practice starting an IV. I'm not letting anyone else use me as a pincushion!"
- "It sounds like you are really frustrated with how difficult it has been to get an IV started."

Physical characteristics that convey meaning with patients...

- Degree of cleanliness
- Hairstyle
- Style of clothing
- Piercing, tattoos, fetishes
- Posture
- Proxemics: about 3 feet for casual communication (depends on mood and scenario, some cultures agree that standing close is appropriate, some want distance between nurse and patient).

Nonverbal behaviors patients use to reduce anxiety...

- Nervous movements: shifting position, hands constantly moving, vibrating leg, foot movements.
- Grunting, giggling.
- Playing with hair.
- Grinding teeth.
- Are you feeling anxious?

Restatement

- Useful when patient is exaggerating or overgeneralizing.
- "I need to get out of this hospital. Nothing you are doing is helping and I feel worse than when I got here!"
- Let me see if I have this right, you think the medications aren't helping you at all?
- Try to unbundle the information.

Modulating tone, posture...

- High pitched loud voice conveys alarm.
- Best to sit at eye level; looking down at patients sets up power differential.
- Moving in closer or stepping back.

Proxemics

- Individual's use of space.
- Amount of preferred space varies by culture, individual preference.
- Increase intensity by moving closer.
- Decrease intensity by moving apart.
- Eye contact enters into person's personal space.
- Need to respect the hospitalized patient's space, belongings, treat like entering their own home.

Barriers to therapeutic communication:

Anxiety

Facial expression:

- Usually reflects underlying emotional state.
- Look for congruence between what is said verbally and what the facial expression conveys.
- Eyebrows: raised or squeezed together.
- Eyes: making direct eye contact or not; sad eyes, happy eyes, squinting.
- Lips: biting or curling lip, pursed.
- Jaw-clenched
- Facial color and muscles.
- Smiling but states anger, figure out what's going on.
- Read patient over time, take contextual data and knows how to respond to patient, experienced nurse.

Nurse anxiety:

- Before you can be therapeutic you have to manage your own anxiety.
- Deep breathing.
- Body scan on yourself.
- Mental rehearsals on things that make me anxious.
- Will be anxious throughout shift, know how to manage.

Non-pharmacological strategies to reduce patient anxiety...

- Close curtains to avoid extra stimuli, noise may be distracting.
- Lower lights, close shades.
- Assess technology (t.v., ipod, cell phone): relax or more anxious?
- Warm compresses/blanket "cocoon".
- Foot massage.
- Comfortable temperature in the room.
- Decaf tea.
- Eliminate clutter from bedside table.
- Troubleshoot alarms (IV, tube feeding, bed, telemetry, etc.)
- Take 15 minutes of your time to do this.

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