Therapeutic communication is a skill that nurses should master not only in psychiatric areas of practice. It is a skill that would enable the nurse to apply its principles across all care settings because communication also happens in other patient care situations.
A nurse must know the barriers and the proper technique to help ensure that the purpose of communicating with the patient is met and able to bring a positive experience for the nurse and patient.
This NCLEX-RN review notes will help you to hurdle therapeutic communication questions and pass your exams.
Communication: The Basics
Communication is one of the most important facets of the human interactive process. In nurse-patient interaction, the use of communication also helps both parties to:
- Send messages;
- Convey emotions;
- Share information;
- Understand one another; and
- Help in the successful enforcement of a care plan.
Communication can be verbal and non-verbal. Verbal communication uses words, whether written or spoken, to send a message from one person to another, while non-verbal communication relies on a different aspect to gain more insight on what is being said. These include:
- Tone of voice
- Facial expressions
- Stance- how the person stands or sits
- Eye movements
Communicating well means that both verbal and non-verbal cues of communication match one another. The facial expression, tone of voice and gestures should also match the words being said. For example, a person who tells another that he is happy should also show in his facial expressions that he is happy.
The same is true for nurses who are interacting with their patients. However, when it comes to communicating with patients, nurses must practice the use of therapeutic communication.
Therapeutic Communication and Techniques
Therapeutic communication is the manner in which the nurse uses a set of techniques and strategies to help her patient maintain or attain mental or emotional well-being by using words, gesture and other body movements. In using this, the nurse is able to provide support and even valuable information while ensuring that the relationship between her and the patient remains purely professional and objective.
In implementing therapeutic communication, the nurse must always remember that it is important for her to maintain therapeutic use of the self, maintain unconditional positive regard for the patient and be consistent. In these instances, the best therapeutic tool is usually the nurse.
The success of the interaction depends on how well she can direct the flow and tone of the interaction so that she can gain deeper insight into the issues or problems faced by the patient.
This should also be done in a manner that empowers the patient and lets them realize that only they can resolve their problems, and the nurse would only guide them to arrive at the best possible solution.
The following techniques can be used when using therapeutic communication:
1. Use of Silence. This technique is effective when the nurse wants to provide the patient with an opportunity to think about what he is saying or experiencing or when she wants to direct him to speak about the topic on hand. Silence can also be used to denote that the patient has the nurse’s attention.
2. Accepting. Not being entirely the same with agreement, accepting is used to help affirm and acknowledge what is being said. It is used to convey that the nurse has heard the patient, and she understands what was being said. In some cases, the following responses may also be used:
a. Yes, I understand you.
b. Yes, I am listening.
c. Yes, I follow.
3. Providing recognition. Recognizing means that the behavior of the patient is being acknowledged without having to compliment it. This is more about objectively telling the patient what he was able to accomplish. Examples of its would be:
a. I noticed you made your bed today.
b. I saw that you were able to finish your meal.
c. You had a haircut.
d. We saw you wear a new tie today.
4. Offering the self/Offering oneself. In this particular technique, the nurse offers the patient her presence, especially in most trying or stressful situations. Offering the self may come in the form of staying with the patient while watching TV, sitting with them as they go through a trying time, or just being present.
5. Providing broad openings. Giving broad openings allows the patient to choose a topic that he wants to talk about or explore more on. Openings such as, “What do you want to talk about?” or “What’s on your mind?” are examples of this.
6. Active Listening. Using non-verbal cues to send to the patient signals that the nurse is interested in the conversation. Active listening involves nodding, paying close attention to what the patient says or even showing signs to the patient that he has her full attention.
7. Seeking clarification. When using this technique, the nurse usually provides cues to the patient about wanting to gain clearer information from him. Comments such as, “I am not sure that I follow you.” Or “Can you explain this one to me?” are some of the most common phrases used when this technique is employed.
8. Placing things or event in sequence. This technique compels patients to think about the order or sequence of events that he is talking about, especially when the nurse wants to get a cleared picture of what happened. This is helpful when the topic being discussed is important to help the nurse understand how an event has impacted the patient.
9. Making observations. While it may be similar in a sense with providing recognition, making observation also includes giving clear and objective comments or suggestions about the patient’s behavior, appearance or demeanor. This can be done by the nurse telling or asking the patient about what is seen without sounding to be overly concerned. Examples of this would be:
a. I see dark circles around your eyes this morning.
b. You have a new hair bush.
c. You seem to be agitated today.
10. Asking for Descriptions. Sensory perceptions experienced by the patient, especially those who have hallucinations, need to be explained and described in detail to the nurse. When asking for descriptions, this should be done with the goal to understand what is going on and not to encourage the hallucinations.
11. Encouraging Comparisons. Encouraging comparisons help the nurse guide the patient to look into his past experience to deal with a current issue that he is facing. This technique often leads the patient to realize that his past experiences can provide solutions to his current situation.
12. Summarizing. Oftentimes, during the entire nurse-patient interaction, several topics may be covered or discussed prior to its end or pause. The nurse may use this technique to summarize what has transpired and to let the patient know that she is listening.
13. Reflecting. In some cases, the patients asks the nurse for advice on what to do in a particular situation. However, giving advise is not recommended. What the nurse must do is to encourage the patient to be accountable for his actions and what they should do. This also helps them gain a sense of control in terms of coming up with solutions themselves. Examples of this would be:
a. What do you think you should do?
b. How do you plan to go on with that?
c. What can you suggest we plan for?
14. Confronting. Although this is not usually done on routine nurse-patient interactions, confronting can be employed when the nurse has already established trust and rapport with the patient. This is normally done when there is a need to present reality or break a patient’s destructive routines in order to help them towards finding a solution to their problems.
15. Voicing Doubt. Used as a means to call attention to words and thoughts of the patient that may be delusional, voicing doubt may help guide the patient to reexamine his/her thoughts. This allows them to realign their thinking to reality.
16. Offering Hope and Humor. In instances where the patient is faced with something stressful and overwhelming, offering hope and humor can help lighten up the mood and lift his spirit. This allows him to refocus on what is at hand, aiding in finding solutions to his issues and concerns. While offering hope can sometimes be helpful, it is important to remember that false reassurances must be avoided.
Barriers to Therapeutic Communication
If there are techniques that help the nurse in establishing good nurse-patient interaction, there are also measures that should be avoided because they close the channels of communication between the nurse and the patient. These also make it almost impossible for the nurse to gain valuable insight into the patient’s issues and problems and therefore, must be avoided.
1. Challenging. Challenging involves forcing the patient to take a stand on their views, beliefs, words and actions. It compels him to be on the defensive mode, trying to make the nurse understand his feelings, thoughts or actions through justifying them. It also makes them feel less credible and not respected—usual questions in this start with the word why.
2. Probing. This technique is considered a barrier to therapeutic communication because it makes the patient feel less secured and uncomfortable. Probing normally happens when the nurse asks questions that the patient finds to be too invasive or personal for them to give an answer and may not be relevant to the problem being discussed. For example, when the patient told the nurse about a recent breakup and instead of focusing on the feelings and perceptions of the patient, she asks the details about the place where the breakup happened.
3. Changing the subject. Showing a lack of regard for what the patient is saying or wanting to share, changing the subject is not acceptable and usually happens when the nurse puts into priority her/his own thoughts and feelings rather than the patients.
4. Being Defensive. A barrier that is often committed by the nurse, being defensive happens when the nurse feels the need to defend her behavior in front of the patient. This displays her focus on herself rather than her patient.
5. Providing false reassurances. These are comments that tend to give the patients cliched advice or responses to the patient. Examples of this include:
a. Everything will be fine.
b. The doctors are going to cure you.
c. Nothing wrong will happen.
6. Disagreeing. This happens when the nurse tends to correct words or information shared by the patient. Disagreeing with the patient may make them feel defensive, sad and even angry because the nurse does not believe or agree with them. Statements using disagreeing normally starts with no.
7. Making/Passing judgement. Completely opposite of providing unconditional positive regard, making judgments happen when the nurse gives positive or negative comments about words or behaviors of the patient. This makes them feel like they have to say or do what the nurse would agree on or the opposite so they can get the attention they seek.
The following NCLEX-RN questions will test your skills in therapeutic communication and apply knowledge on establishing nurse-patient interaction. Read each item carefully, and choose the best possible answer/s from the set of options provided.
Always remember to time your practice test to stimulate the time-bound NCLEX-RN examinations. After answering, you may check the answers and rationale provided in the next page.
1. A client with a diagnosis of depression attempted suicide says to the nurse, “I should have died. I’ve always been a failure. Nothing ever goes right for me.” Which response by the nurse demonstrates therapeutic communication?
A. “You have everything to live for.”
B. “Why do you see yourself as a failure?”
C. “Feeling like this is all part of being depressed.”
D. “You’ve been feeling like a failure for a while?”
2. A young client diagnosed with paranoid schizophrenia is talking with the nurse. “You know, when I thought everyone was out to get me, I was staying in my apartment all the time. Now, I’d like to get out and do things again.” What is the best initial response by the nurse?
A. “With whom do you want to do things?”
B. “What activities did you enjoy in the past?”
C. “What kind of transportation do you use?”
D. “How much money can you spend?”
3. A client experiencing disturbed thought processes believes that his food is being poisoned. Which communication technique should the nurse use to encourage the client to eat?
A. Using open-ended questions and silence
B. Sharing personal preference regarding food choices
C. Documenting reasons why the client does not want to eat
D. Offering opinions about the necessity of adequate nutrition
4. The nurse should plan which goals of the termination stage of group development? Select all that apply.
A. The group evaluates the experience.
B. The real work of the group is accomplished.
C. Group interaction involves superficial conversation.
D. Group members become acquainted with one another.
E. Some structuring of group norms, roles, and responsibilities takes place.
F. The group explores members’ feelings about the group and the impending separation.
5. A client diagnosed with terminal cancer says to the nurse, “I’m going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I’m the one who’s dying.” Which response by the nurse is therapeutic?
A. “Have you shared your feelings with your family?”
B. “I think we should talk more about your anger with your family.”
C. “You’re feeling angry that your family continues to hope for you to be cured?”
D. “You are probably very depressed, which is understandable with such a diagnosis.”
6. A client reports having thoughts of being followed by foreign agents who are after his secret papers. Which response by the nurse is most appropriate when responding to the client’s disturbed thought process?
A. “I don’t see any foreign agents.”
B. “I think these thoughts are frightening to you.”
C. “I don’t know what you mean.”
D. “I’d like you to come to group with me right now.”
7. A client admitted voluntarily for treatment of an anxiety disorder demands to be released from the hospital. Which action should the nurse take initially?
A. Contact the client’s health care provider (HCP).
B. Call the client’s family to arrange for transportation.
C Attempt to persuade the client to stay “for only a few more days.”
D. Tell the client that leaving would likely result in an involuntary commitment.
8. When reviewing the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this client?
A. Monitor closely for harm to self or others.
B. Assist in completing an application for admission.
C. Supply the client with written information about his or her mental illness.
C. Provide an opportunity for the family to discuss why they felt the admission was needed.
9. A patient is presenting with behaviors that indicate anger. When approached, the patient states harshly, “I’m fine! Everything’s great.” Which response should the nurse provide to the patient?
A. “Okay, but we are all here to help you, so come get one of the staff if you need to talk.”
B. “I’m glad everything is good. I am going to give you your schedule for the day and we can discuss how the groups are going.”
C. “I don’t believe you. You are not being truthful with me.”
D. “It looks as though you are saying one thing but feeling another. Can you tell me what may be upsetting you?”
10. The parents of a 20-year-old female client diagnosed with paranoid schizophrenia admitted 4 days ago are attending a family psychoeducation group in the hospital. Which of the following statements by the mother indicates that she understands her daughter’s illness and management?
A. “I know that I’ll have to do everything for my daughter when she comes home.”
B. “Tasks as simple as getting out of bed and showering in the morning may be difficult for her.”
C. “I know that visits from her friends at home should be discouraged for a while.”
D. “She won’t experience a relapse as long as she takes her prescribed medication.”
11. The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, “How is Carol doing? She is my best friend and is seen at your clinic every week.” Which is the most appropriate nursing response?
A. “I cannot discuss any client situation with you.”
B. “If you want to know about Carol, you need to ask her yourself.”
C. “Only because you’re worried about a friend, I’ll tell you that she is improving.”
D. “Being her friend, you know she is having a difficult time and deserves her privacy.”
12. The nurse calls security and has physical restraints applied to a client who was admitted voluntarily when the client becomes verbally abusive, demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? Select all that apply.
E. False imprisonment
13. The nurse in the mental health unit plans to use which therapeutic communication techniques when communicating with a client? Select all that apply.
C. Asking the client “Why?”
D. Maintaining neutral responses
E. Providing acknowledgment and feedback
F. Giving advice and approval or disapproval
14. A patient is sitting with arms crossed over his or her chest, his or her left leg is rapidly moving up and down, and there is an angry expression on his or her face. When approached by the nurse, the patient states harshly, “I’m fine! Everything’s great.” Which statement related to communication should the nurse focus on when working with this patient?
A. Verbal communication is always more accurate than nonverbal communication.
B. Verbal communication is more straightforward, whereas nonverbal communication does not portray what a person is thinking.
C. Nonverbal and verbal communication may be different; nurses must pay attention to the nonverbal communication being presented to get an accurate message.
D. Nonverbal communication is about 10% of all communication, and verbal communication is about 90%.
15. A client is participating in a therapy group and focuses on viewing all team members as equally important in helping the clients to meet their goals. The nurse is implementing which therapeutic approach?
A. Milieu therapy
B. Interpersonal therapy
C. Behavior modification
D. Support group therapy