The nurse uses all the therapeutic communication techniques and skills previously described to help achieve the following goals:
Establish rapport with the client by being empathetic, genuine, caring, and unconditionally accepting of the client regardless of his or her behavior or beliefs.
Actively listen to the client to identify the issues of concern and to formulate a client-centered goal for the interaction.
Gain an in-depth understanding of the client’s perception of the issue, and foster empathy in the nurse–
client relationship.
Explore the client’s thoughts and feelings.
Facilitate the client’s expression of thoughts and feelings.
Guide the client to develop new skills in problem solving.
Promote the client’s evaluation of solutions.
Often the nurse can plan the time and setting for therapeutic communication, such as having an in-depth, one-on-one interaction with an assigned client. The nurse has time to think about where to meet and what to say and will have a general idea of the topic, such as finding out what the client sees as his or her major
•
•
•
•
concern or following up on interaction from a previous encounter. At times, however, a client may approach the nurse saying, “Can I talk to you right now?” Or the nurse may see a client sitting alone, crying, and decide to approach the client for an interaction. In these situations, the nurse may know that he or she will be trying to find out what is happening with the client at that moment in time.
When meeting the client for the first time, introducing oneself and establishing a contract for the relationship is an appropriate start for therapeutic communication. The nurse can ask the client how he or she prefers to be addressed. A contract for the relationship includes outlining the care the nurse will give, the times the nurse will be with the client, and acceptance of these conditions by the client.
Nurse: “Hello, Mr. Kirk. My name is Joan, and I’ll be your nurse today. I’m here from 7 AM to 3:30 PM. Right now I have a few minutes, and I see you are dressed and ready for the day. I would like to spend some time talking with you if this is convenient.” (giving recognition and introducing self, setting limits of contract)
After making the introduction and establishing the contract, the nurse can engage in small talk to break the ice and to help get acquainted with the client if they have not met before. Then the nurse can use a broad opening question to guide the client toward identifying the major topic of concern. Broad opening questions are helpful to begin the therapeutic communication session because they allow the client to focus on what he or she considers important. The following is a good example of how to begin the therapeutic communication:
Nurse: “Hello, Mrs. Nagy. My name is Donna, and I am your nurse today and tomorrow from 7
AM to 3:30 PM. What do you like to be called?” (introducing self, establishing limits of relationship) Client: “Hi, Donna. You can call me Peggy.”
Nurse: “The rain today has been a welcome relief from the heat of the past few days.”
Client: “Really? It’s hard to tell what it’s doing outside. Still seems hot in here to me.”
Nurse: “It does get stuffy here sometimes. So tell me, how are you doing today?” (broad opening)
Nondirective Role
When beginning therapeutic interaction with a client, it is often the client (not the nurse) who identifies the problem he or she wants to discuss. The nurse uses active listening skills to identify the topic of concern. The client identifies the goal, and information gathering about this topic focuses on the client. The nurse acts as a guide in this conversation. The therapeutic communication centers on achieving the goal within the time limits of the conversation.
The following are examples of client-centered goals:
The client will discuss her concerns about her 16-year-old daughter who is having trouble in school.
The client will describe difficulty she has with side effects of her medication.
The client will share his distress about son’s drug abuse.
The client will identify the greatest concerns he has about being a single parent.
The nurse is assuming a nondirective role in this type of therapeutic communication, using broad openings and open-ended questions to collect information and to help the client identify and discuss the topic of
concern. The client does most of the talking. The nurse guides the client through the interaction, facilitating the client’s expression of feelings and identification of issues. The following is an example of the nurse’s nondirective role:
Client: “I’m so upset about my family.”
Nurse: “You’re so upset?” (reflecting)
Client: “Yes, I am. I can’t sleep. My appetite is poor. I just don’t know what to do.”
Nurse: “Go on.” (using a general lead)
Client: “Well, my husband works long hours and is very tired when he gets home. He barely sees the children before their bedtime.”
Nurse: “I see.” (accepting)
Client: “I’m busy trying to fix dinner, trying to keep an eye on the children, but I also want to talk to my husband.”
Nurse: “How do you feel when all this is happening?” (encouraging expression)
Client: “Like I’m torn in several directions at once. Nothing seems to go right, and I can’t straighten everything out.”
Nurse: “It sounds like you’re feeling overwhelmed.” (translating into feelings)
Client: “Yes, I am. I can’t do everything at once all by myself. I think we have to make some changes.”
Nurse: “Perhaps you and I can discuss some potential changes you’d like to make.” (suggesting collaboration)
In some therapeutic interactions, the client wants only to talk to an interested listener and feel like he or she has been heard. Often, just sharing a distressing event can allow the client to express thoughts and emotions that he or she has been holding back. It serves as a way to lighten the emotional load and release feelings without a need to alter the situation. Other times, the client may need to reminisce and share pleasant memories of past events. Older adults often find great solace in reminiscing about events in their lives such as what was happening in the world when they were growing up, how they met and when they married their spouses, and so forth. Reminiscence is discussed further in Chapter 24.
Directive Role
When the client is suicidal, experiencing a crisis, or out of touch with reality, the nurse uses a directive role, asking direct yes/no questions and using problem solving to help the client develop new coping mechanisms to deal with present here-and-now issues. The following is an example of therapeutic communication using a more directive role:
Nurse: “I see you sitting here in the corner of the room away from everyone else.” (making observation) Client: “Yeah, what’s the point?”
Nurse: “What’s the point of what?” (seeking clarification) Client: “Of anything.”
Nurse: “You sound hopeless.” (verbalizing the implied) “Are you thinking about suicide?” (seeking information) Client: “I have been thinking I’d be better off dead.”
The nurse uses a very directive role in this example because the client’s safety is at issue.
As the nurse–client relationship progresses, the nurse uses therapeutic communication to implement many interventions in the client’s plan of care. In Unit 4, specific mental illnesses and disorders are discussed, as are specific therapeutic communication interventions and examples of how to use the techniques effectively.