techniques of Therapeutic communication

Using Reassuring Cliches

"Everything will be all right," "You don't need to worry," "You're doing fine" are reassuring clichés which are often given automatically, or may be used when a person has difficulty knowing what to say . Although the nurse may say, "Everything will be all right' out of a sincere desire to reduce the patient's anxiety, such a response may also result from an unrecognized need to reduce her own anxiety to feel more comfortable herself. When a patient who has expressed apprehension is told, "Everything will be alright" he is likely to feel that the nurse is not interested in his problem and thus will refrain from discussing it further. Reassuring clichés tend to contradict the patient's perception of his situation, thus implying that his point of view is incorrect or unimportant . When there are facts that are reassuring, the nurse can, give genuine reassurance by communicating them to the patient. A less direct, but basic reassurance is given as the nurse communicates to the patient understanding, acceptance, inte

Agreeing with the Patient

"I agree with you," or "You must be right." "When the nurse introduces her own opinions or values into the conversation, it can prevent the patient from expressing himself freely. Be agreeing with the patient she can make it difficult for him to later change or modify the opinion he has stated. Or, if he has expressed something other than what he actually believes to be true (sometimes to test the nurse to see if she's interested in him) he may be prevented from saying what he really thinks at a later time. Rather than stating her own views, the nurse should accept the patient's statements and encourage him to elaborate on them by using responses such as General leads or reflecting.

Belittling the Patient's Feelings

"I know just how you feel," Everyone gets depressed at times." Because the patient is usually primarily concerned with himself and his own problems, telling him that others have experienced or are experiencing the same feelings will seldom do much to comfort him. On the contrary, to do so devalues his feelings, implying that his discomfort is common place and insignificant. The nurse can communicate understanding, acceptance, and interest in him as an individual by simply acknowledging his feelings. "This must be very difficult (upsetting, exhausting, annoying, etc.) for you."

Challenging

"If you're dead, why is your heart beating?" "Your sister couldn't be coming, she's dead." Often the nurse feels that if she can challenge the patient to prove his unrealistic ideas; he will realize he has no proof. She forgets that the patient's ideas and perceptions serve a purpose for him, that they conceal feelings and meet needs that are real. When challenged, the patient tends only to strengthen and expand his misinterpretations as he seeks support for his point of view. Rather than challenging the patient's views, the nurse might restate, or ask him to "say more about that" so she can understand the patient's viewpoint more clearly.

Giving Approval

"That's the right attitude" or "That's the thing to do." Although conceivably a useful response when the nurse wishes to motivate or encourage a patient, giving approval can sometimes create a block by shifting the focus of the discussion to the nurse's values or feelings, and by implying standards of what is and what is not acceptable. The nurse's approval of a patient's statement such as "I know I shouldn't let it get me down" makes it difficult for him to admit that it is getting him down. Approval also implies that the nurse's concepts of right and wrong will be used in judging the patient's behavior. For it is possible that the nurse may approve behavior of which the patient himself disapproved--such as crying or expressing strong feelings. In such cases, the values and goals of the nurse would conflict with those of the patient. To the extent then that (1) a standard has been set that the patient may not at another time be able to achieve, (2) a value judgment has been given and the patient may be consciously or subconsciously aware that non-acceptance of at least some type of behavior has been implied, (3) that the patient may be motivated to repeat the behavior for the sake of approval, rather than because he himself values the results, (4) that the focus of the conversation is on the nurse's values of goals rather than the patient's and (5) that the patient may not value or may disapprove those actions or expressed feelings of which the nurse approved - to this extent giving approval may function to block communication.

Requesting and Explanation

"Why did you do that?" "Why are you here?" "Why are you upset?" are examples of questions which some patients find difficult and even intimidating because they call for the patient to immediately analyze and explain his feelings or actions. Patients who cannot answer "why" questions frequently invent answers. The nurse should avoid asking "why" questions except when asking simple, direct questions pertaining to patient care, e.g., "Why are you going to the bathroom?" In general, the nurse is of more assistance, however, if she assists the patient to describe his feelings. There are two types of questions the nurse can ask in order to get descriptive information; closed and open questions. A closed question is phrased so that a yes or no answer is indicated, e.g., "Did you sleep well last night?" or so that a specific choice of answers is given within the questions, e.g. "Do you want this injection in your right or left arms?" Although this type of question does not encourage the patient to express himself or give him the lead, it can be useful in eliciting specific information needed to assist the patient once his need has been identified. It is also useful in caring for the patient who has limited energy or who by reason of age or severe stress is mentally or emotionally incapacitated. Open questions, though still determined by the subject, let the patient provide his own answers. Words such as "who", "what", "when", and "where" elicit factual information and will help the patient to begin learning to describe his experiences. "How" questions should usually be avoided also since they ask by what process or for what reasons; some patients will respond to "how do you feel?" with my fingers.

Disagreeing with the Patient

"You're wrong", "That's not true," "No, it isn't." By contradicting the patient, the nurse indicates to him that what he has said has not been accepted. Because the nurse's judgment may cause him to feel threatened he may refrain from expressing himself further on the subject, or he may become defensive or angry. When the patient makes a statement with which the nurse disagrees, she can acknowledge his feelings and opinions without agreeing with them, e.g., "Then you feel..." or "I hear what you are saying."

Defending

"Your doctor is quite capable." "She's a very good nurse." In defending herself, others, or the hospital in response to criticism from a patient, the nurse not only communicates a non-accepting attitude to him, but also, in becoming defensive, may lead to believe that his criticism is justified. Thus, this response may reinforce rather than change the patient's point of view. By acknowledging the patient's feelings, without agreeing or disagreeing—for example, "It must be difficult for you to feel this way" - the nurse avoids putting herself in opposition to the patient.

Making Stereotyped

Comments "How are you feeling?" "Isn't it a beautiful day?" "It's for your own good," "You'll be home in no time." By using social clichés or trite phrases, the nurse may lead the patient to reply in a like manner, thus keeping the conversation at a superficial level. While comments such as "How are you feeling?" may be used purposefully to elicit information, they are often made automatically, or out of a subconscious desire to avoid uncomfortable topics. In addition to social clichés she already uses, the nurse in her daily work may develop or adopt "stock" replies which she used in her interactions with patients. Because they are easy to use, they are a convenient substitute for a more thought out and individualized response. They may also be used when the nurse is unsure of an answer to a patient's question, and she is reluctant to admit that she does not have the answer. When the nurse has nothing meaningful to say, she should remain silent. Social cliches and stock replies function to keep distance between nurse and the patient. Behind stereotyped responses, there may be stereotyped attitudes on the part of the nurse.

Changing the Subject

Patient "I'd like to die" Nurse: "Don't you have visitors this weekend?" or "by the way..." or "That reminds me..." Generally, the nurse changes the subject to avoid discussing a topic which makes her uncomfortable (consciously or unconsciously) or to initiate discussion of a topic which she is more interested. In either case, by taking the lead in the conversation away from the patient, she can block any attempt he may be making to express his needs to her. Even when he is discussing a matter which seems to be of relatively little significance, the nurse may be able to pick up clues that will help identify his needs, or the patient may be proceeding in a round-about way toward making his needs known.

Giving Literal Response

Patient: "They're looking in my head with a TV". Nurse: "What channel?" or Patient: "That doctor is a pain in the neck." Nurse: "Would you like your pain medication?" Patients who are confused or highly anxious may have difficulty describing their experiences. They may use words in a very personal sense which has meaning to them, but can be misinterpreted by the nurse. If the nurse responds to his comment as if it were a statement of fact, she tells the patient she cannot understand when anxiety-producing feelings are being described. Instead, she could respond with, "Tell me what means to you." or "I'd like to understand that better; tell me more."

Giving Advice

What you should do is..."Why don't you..." By telling the patient what he should do, the nurse imposes her own opinions and solutions on his, rather than helping him to explore his ideas so that he can arrive at his own conclusions. Even when a patient clearly asks for advice, the nurse should be cautious in her response, and supply only pertinent information that may give him a better basis for decision-making. Giving the patient advice may imply to him that the nurse thinks she knows what is best for him, and that she feels his problem can be easily solved. If the patient does not accept these implications, he may resent the nurse for advising him, if he does accept them, it may reinforce his feelings of dependency. If, instead of giving advice, the nurse helps the patient to think through and attempt to resolve his problems for himself, she makes an important contribution to his feelings and self esteem. When a patient asks for advice, the nurse can assist him by asking such questions as "Tell me what your feelings are about..." She can provide pertinent information (facts, resource people, services, etc.) and help him examine all parts of the problem by encouraging him to express his own thoughts and feelings about the problem and helping him to identify possible solutions and the factors involved in possible outcomes. While it is obvious that some patients, by reason of age or extreme physical or emotional stress are incapable of this kind of activity, the nurse should foster decision-making to whatever extent is possible.

Expressing Disapproval

You should stop worrying like this" "You shouldn't do that." When the nurse indicates that she disapproves of the patient's feelings or actions, she imposes her own values, rather than accepting the patient's. Such negative value judgment may intimidate or anger the patient, and will often block communication by expressing disapproval; the nurse implies that she is entitled to make negative value judgments regarding his behavior, and that he is expected to conform to her standards. If the patient accepts this role, communication will probably be hindered as he modifies his behavior to avoid incurring further disapproval. Rather than making value judgments about a patient's behavior, the nurse can encourage further examination of a remark with statements such as "You feel that..." or "You seem to be..."