Part I: Foundations for Practice
Chapter 4: Therapeutic Listening
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istening is an active and dynamic process of interaction with a client that requires intentional effort to attend to a client’s verbal and nonverbal cues. Listening is an integral part and foundation of nurse–client relationships, and one of the most effective therapeutic techniques available to nurses. The theoretical underpinnings of listen-ing can be traced back to counsellisten-ing psychology and psychotherapy.Rogers (1957) used counseling and listening to foster independence and promote growth and development of clients. Rogers also empha-sized that empathy, warmth, and genuineness with clients were neces-sary and sufficient for therapeutic changes to occur. Listening has been identified as a significant component of therapeutic communication with patients and therefore fundamental to a therapeutic relationship between the nurse and patient (Foy & Timmins, 2004). Listening is also a key to improving health professionals’ teamwork effectiveness and patient safety in complex clinical settings (Denham et al., 2008).
DEFINITION
Many modifiers are used with the word listening—active, attentive, empathic, therapeutic, and holistic. The choice of modifier seems to depend more on an author’s paradigm than on differences in the descriptions of listening (Fredriksson, 1999). Unless active listening was explicitly used by researchers in the articles reviewed in this chapter, the term
therapeutic listening is used here to focus on the formal, deliberate actions of listening for therapeutic purposes (Lekander, Lehmann, & Lindquist, 1993). Therapeutic listening is defined as “an interpersonal, confirma-tion process involving all the senses in which the therapist attends with empathy to the client’s verbal and nonverbal messages to facilitate the understanding, synthesis, and interpretation of the client’s situation”
(Kemper, 1992, p. 22). Beyond the therapist, this empathetic attending pertains to nurses and to other care providers.
SCIENTIFIC BASIS
Therapeutic listening is a topic of interest and concern to a variety of disciplines. A number of qualitative and quantitative studies provide a scientific basis of intervention effects in relation to process— behavioral changes of providers that foster communication—and outcomes: client satisfaction, improved clinical indicators.
A systematic review of 20 intervention studies that aimed at improv-ing patient–doctor communication revealed the effectiveness of inter-ventions that typically increased patient participation and clarification (Harrington, Noble, & Newman, 2004). Although few improvements in patient satisfaction were found, significant improvements in perceptions of control over health, preferences for an active role in health care, adher-ence to recommendations, and clinical outcomes were achieved. Likewise, preferable client outcomes were found in another study in nursing. A sur-vey of 195 parents of hospitalized pediatric patients demonstrated that health care providers’ use of immediacy and perceived listening were positively associated with satisfaction, care, and communication (Wanzer, Booth-Butterfield, & Gruber, 2004).
Qualitative studies provide rich understanding of the nature of therapeutic listening and explore the meaning and experience of being listened to in the context of real-world settings. Self-expression opportunities that enable clients to be listened to and understood can promote clients’ self-discovery—meaning reconstruction and healing (Sandelowski, 1994). A discourse analysis of 20 nurse–patient pairs at community hospitals, however, indicated insufficient active listening skills on the part of nurses (Barrere, 2007). The study results showed that nurses often missed cues that patients needed nurses to listen to their concerns, or overlooked potential opportunities for health teach-ing, especially in “asymmetrical” communication patterns (dominance of nurse or patient) as compared to “symmetrical” patterns (nurse–
patient communication involving active listening).
Studies evaluating training of health care providers in therapeu-tic communication skills have shown that training can be effective in
4. tHeraPeutIc LIstenInG 41 improving therapeutic communication skills. A randomized controlled study tested the efficacy of 25-hour training sessions in self-control tech-niques and communication skills with 61 nurse volunteers. The partici-pating nurses were presented with simulated encounters with relatives of seriously ill patients and their role-plays were evaluated by blinded raters. The results showed significant improvements in the skills of listen-ing, empathizlisten-ing, not interruptlisten-ing, and coping with emotions after con-trolling for baseline performance scores (Garcia de Lucio, Garcia Lopez, Marin Lopez, Mas Hesse, & Caamano Vaz, 2000).
A combination of learning sessions (cognitive interventions), administrative support, and coaching activities (affective and behav-ioral interventions) enables long-term improvement in communication styles of nurses. A quasiexperimental study was undertaken to test the effectiveness of an integrated communication skills training program for 129 oncology nurses at a hospital in China. Continued significant improvements in overall basic communication skills, self-efficacy, out-come expectancy beliefs, and perceived support in the training group were observed after 1 and 6 months of training intervention. No signifi-cant improvements were found in the control group (Liu, Mok, Wong, Xue, & Xu, 2007).
These studies attempted to identify complex relationships among multiple phenomena and variables, including the immediate and long-term effects of training interventions, clinical supervision and support, and cognitive and behavioral changes on the part of nurses. Further sys-tematic studies are needed to enhance knowledge related to intervention effectiveness, especially the link between client characteristics, client sat-isfaction, and type of interventions. This is particularly important in light of today’s health care emphasis and reimbursement aligned with patient satisfaction, patient engagement, and symptom management such as alle-viation of pain.
INTERVENTION
Therapeutic listening enables clients to better understand their feelings and to experience being understood by another caring person. Effective engagement in therapeutic listening requires nurses to be aware of ver-bal and nonverver-bal communication that conveys explicit and implicit messages. When verbalized words contradict nonverbal messages, com-municators rely more often on nonverbal cues; facial expression, tone of voice, and silence become as important as words in determining the meaning of a message (Kacperek, 1997). Nonverbal communication is inextricably linked to verbal communication and can change, emphasize, or distract from the words that are spoken (Bush, 2001).
Guidelines
Listening is an active process, incorporating explicit behaviors as well as attention to choice of words, quality of voice (pitch, timing, and volume), and full engagement in the process (Burnard, 1997). Therapeutic listen-ing requires a listener to tune in to the client and to use all the senses in analyzing, inferring, and evaluating the stated and underlying meaning of the client’s message. As providers feel increasing time pressures, it can be easy to attempt to guide or limit the conversation rather than allowing the patient to fully express concerns. However, to be fully heard without interruption can be viewed as supportive by the patient (Bryant, 2009), and may ultimately strengthen the therapeutic relationship. Therapeutic listening requires concentration and an ability to differentiate between what is actually being said and what one wants or expects to hear. It may be difficult to listen accurately and interpret messages that one finds dif-ficult to relate to, or to listen to information that one may not want to hear. Therapeutic listening is both a cognitive and an emotional process (Arnold & Underman Boggs, 2007). When not fully engaged, it can be easy to become distracted or to start formulating a response rather than to stay focused on the message. Three components have been identified as being foundational to therapeutic listening:
1. Rephrasing the patient’s words and thoughts to ensure clarity and accuracy
2. Conveying an understanding of the speaker’s perceptions 3. Asking questions and prompting to clarify (De Vito, 2006)
These and other techniques for therapeutic listening intervention are pre-sented in Exhibit 4.1.
Therapeutic listening with children can be even more complex because it frequently involves the presence or participation of more par-ties: the nurse, the child, parents, and/or other family members. This may take particular skill on the part of the nurse as he or she attends to both the spoken messages as well as the nonverbal communication/
reactions of two, three, or more persons simultaneously. In addition, the nurse must be sensitive to the clarification of information and cues in front of either the child or the caregiver, depending on the child’s age and developmental stage.
Adolescents especially may be willing to talk openly with an adult who is not a family member. However, they may respond quickly, abruptly, or defensively to any perceived indications of judgment, indifference, or disrespect on the part of the listener. It is extremely important with ado-lescents to be fully attentive, allow for complete expression of thoughts, and avoid statements or facial expressions that imply disapproval or that can be misinterpreted.
4. tHeraPeutIc LIstenInG 43 Exhibit 4.1. Therapeutic Listening Techniques
Active presence: Active presence involves focus on the client to interpret the message that he or she is trying to convey, recognition of themes, and hearing what is left unsaid. Short responses such as “yes” or “uh-huh”
with appropriate timing and frequency may promote clients’ willingness to talk.
Accepting attitude: Conveying an accepting attitude is assuring, and can help clients to feel more comfortable about expressing them-selves. This can be demonstrated by short affirmative responses or gestures.
Clarifying statements: Clarifying statements and summarizing can help the listener verify message interpretation and create clar-ity. Encourage specificity rather than vague statements to facilitate communication. Rephrasing and reflection can assist the client in self- understanding. Using phrases such as “tell me more about that”
or “what was that like?” may be helpful, rather than asking “why,”
which may elicit a defensive response from the client.
Use of silence: Use of silence can encourage the client to talk, facilitate the nurse’s focus on listening rather than the formulation of responses, and reduce the use of leading questions. Sensitivity toward cultural and individual variations in the seconds of silence may be developed by paying detailed attention to the patterns of client communication.
Tone: Tone of voice can express more than the actual words through empathy, judgment, or acceptance. Match the intensity of the tone to the message received to avoid minimizing or overemphasizing.
Nonverbal behaviors: Clients relaying sensitive information may be very aware of the listener’s body language and will be viewed as either accepting of the message or closed to it, judgmental, and/or disinter-ested. Eye contact, or a nodding head, are essential to conveying the listener’s true interest and attention. Maintaining a conversational distance and judicious use of touch may increase the client’s comfort.
Cultural and social awareness are important so as to avoid undesired touch.
environment: Distractions should be eliminated to encourage the therapeutic interchange. Therapeutic listening may require careful planning to provide time for undivided attention or may occur sponta-neously. Some clients may feel very comfortable having family present;
others may feel inhibited when others are present.
Because therapeutic listening involves both cognitive and emotional processes, it is important that nurses recognize the role of emotional intelligence in their therapeutic interactions. Emotional intelligence is
defined as an ability to recognize emotions in self and other, and to understand and utilize these emotions in thinking processes and inter-actions with others (Vitello-Cicciu, 2002). Nursing requires a significant amount of emotional labor, resulting in expectations of expressions of caring, understanding, and empathy with patients and families.
Strategies such as reflection, empathizing, and skilled therapeutic lis-tening can promote a healing environment for patients and families (Molter, 2003).
A listening technique referred to as change-oriented reflective listening targets behavioral change of health care providers (Strang, McCambridge, Platts, & Groves, 2004) and has a strong potential for incorporation into the repertoire of nursing interventions. This technique has been adapted from the core principles of motivational interviewing (Rollnick et al., 2002). Change-oriented reflective listening is a brief motivational enhancement intervention that encourages providers’ consideration of the quality of primary care, and then stimulates their intent to change behavior in the direction desired. This method takes the form of a brief telephone conversation (15–20 min), in which reflective listening state-ments are interspersed with open questions about the issue at hand. A menu of questions with the range of possible areas for discussion is con-structed in advance. The technique has been successfully piloted with general practitioners to motivate them to intervene with opiate users and as part of alcohol intervention (McCambridge, Platts, Whooley, & Strang, 2004; Strang et al., 2004).
Communicating with a patient and family in difficult situations neces-sitates careful and considerate listening skills. Basic communication skills such as “ask-tell-ask” and “tell me more” principles have been introduced to oncology settings (Back, Arnold, Baile, Tulsky, & Fryer-Edwards, 2005) and end-of-life care in critical care settings (Shannon, Long-Sutehall, &
Coombs, 2011). The first “ask” is used for the provider to assess percep-tions and understanding of a patient or family regarding the current situ-ation or issue at hand. This step would help the provider to obtain a basic idea about the patient’s or family’s level of knowledge or emotional state.
The “tell” portion is used for the provider to convey the most pressing needed or desired information to the patient/family. The information should be provided in understandable, brief chunks, kept at no more than three pieces of information at a time. Then, the second “ask” is used to check understanding of the patient/family and their additional ques-tions. The “ask-tell-ask” cycle would be repeated until a final “ask” is a summary of agreed-upon decisions or plans. “Tell me more” can be used to get back on track when the conversation appears diverted. It also can be used to allow patient/family to share more of their emotions, while letting the health provider get past his or her own initial reactions and respond in a less defensive or emotional mode (Back et al., 2005; Shannon et al., 2011).
4. tHeraPeutIc LIstenInG 45 Measurement of Outcomes
Inclusion of multiple measurements, such as self-report, behavioral observation, physiological indicators, and qualitative accounts, pro-vides rich data for the study of therapeutic listening. For example, the Active Listening Observation Scale (ALOS-global) is a validated seven-item behavioral observational scale that measures the general practitioner’s attentiveness and acknowledgment of suffering among patients presenting minor ailments (Fassaert, van Dulmen, Schellevis,
& Bensing, 2007).
Challenges to outcome measurement may include the isolation of therapeutic listening as an independent variable from other confounding variables. Other challenges may be related to the complexity of the multi-faceted phenomenon of therapeutic listening that may necessitate different study designs. Antecedents to interventions such as clients’ characteris-tics have to be taken into consideration; likewise, the process-related com-ponents of interventions such as short- and long-term improvements in nurses’ knowledge, skills, and attitudes after training and client outcomes need to be evaluated (Harrington et al., 2004; Kruijver, Kerkstra, Francke, Bensing, & van de Weil, 2000).
Positive changes in psychological variables such as anxiety, depres-sion, hostility, or nursing care satisfaction are potential client outcomes of therapeutic listening. It may also be useful to examine physiologi-cal measures (e.g., heart rate, blood pressure, respiratory rate, immu-nological measures, electroencephalography results) as outcomes of therapeutic interchange. Outcomes may include clinical variables such as patients’ response to illness, mood, adherence, disease control, mor-bidity, and health care cost. Boudreau and colleagues believe that thera-peutic listening can result in multiple outcomes: listening gives patients opportunities to articulate concerns that provide insight into their “per-sonhood”; it can generate data for providers to use in the provision of optimal care and it may actually assist in healing (Boudreau, Cassell,
& Fuks, 2009).
Precautions
Therapeutic listening has at its heart the intent to be helpful; however, a few precautions are warranted. Questions that start with the word
“why” may take clients out of the context of their experience or feelings and direct them into an intellectual thinking mode or cause defensive responses. Rather, phrases such as “tell me more about that,” or “what was that like?” (Shattell & Hogan, 2005, p. 31) may be helpful.
The provider needs to be engaged fully when using therapeutic lis-tening. If the provider is only half-listening, using selective listening, or is distracted, the patient may sense his or her concerns are being minimized
or the provider may actually reach an inaccurate diagnosis. This weak-ens the therapeutic relationship between patient and provider (Boudreau et al., 2009).
The provider also needs to be aware of the potential negative self- consequences if the caregiver is involved in emotionally charged situa-tions. Clinical supervision may be helpful for the provider in addressing such difficulties (Jones & Cutcliffe, 2009).
Practitioners and clinicians are cautioned to avoid use of active lis-tening skills especially with patients presenting minor ailments. Active listening behavior of general practitioners was observed to correlate with nonadherence of medication regimens if patients felt good prior to the con-sultation. Rather, general practitioners’ being sensitive to the emotional state of a patient, and providing a clear explanation of the condition and preferable prognosis were observed to correlate with patients’ reduced anxiety and better overall health (Fassaert, van Dulmen, Schellevis, van der Jagt, & Bensing, 2008).
Maintaining professional boundaries during therapeutic listening is important; empathy is to be demonstrated, but within the professional relationship with clients. Referrals for professional counseling may be indicated in such cases as psychiatric crises. Ethical dilemmas may result if the principle of respecting clients’ autonomy and confidentiality con-flicts with the principle of maintaining professional responsibility and integrity, such as taking action based on sensitive information shared in the therapeutic exchange. Open discussion and negotiation of the use of such sensitive information, within the context of the nurse–client relation-ship, relies on the trust relationship that has been established such that the trust is retained or even deepened.
USES
Therapeutic listening is an intervention that is applicable to a virtually unlimited number of care situations. It is beneficial for practitioners to continue listening to a patient throughout the entire visit. Indeed, according to a study of audiotaped office visits, approximately 21% of patients disclosed new and vital information in the closing moments of an appointment (White, Levinson, & Roter, 1994). Selected patient population-based examples in which the use of listening is described are included in Exhibit 4.2. Managers in the health care field may also reap benefits from active listening (Kubota, Mishima, & Nagata, 2004).
Exhibit 4.3 presents websites of national and international professional organizations where online resources for therapeutic listening can be found.
Technology is becoming increasingly important in assuring that patients have effective means to communicate and ways to be fully
4. tHeraPeutIc LIstenInG 47 Exhibit 4.2. Selected Uses of Listening With Patient
Populations or in Care Settings
Adolescent mental health (Claveirole, 2004) Cancer (Back et al., 2005; Liu et al., 2007)
Culturally diverse populations (Davidhizar, 2004) Day surgery (Foy & Timmins, 2004)
Emergency care (O’Gara & Fairhurst, 2004; O’Hagan, Webb, & Moore, 2004)
End-of-life care in critical care settings (Shannon et al., 2011) Heart failure: To improve self-care (Riegel et al., 2006) Older adults (Williams, Kemper, & Hummert, 2004) Perinatal care (Battersby & Deery, 2001)
Posttraumatic stress (Gidron et al., 2001)
Relatives of critically ill patients: Use of training simulation for providers (Garcia de Lucio et al., 2000)
Terminal care (Cherin, Enguidanos, & Brumley, 2001)
Traumatic stress/disasters (Liehr, Mehl, Summers, & Pennebaker, 2004) Women with breast cancer (Harris & Templeton, 2001)
Young people in foster care (Murphy & Jenkinson, 2012)
Exhibit 4.3. Professional Organizations and Online Resources for Therapeutic Listening
The International Communication Association (www.icahdq.org) The International Listening Association (www.listen.org) Communication Institute for Online Scholarship (www.cios.org)
heard and understood. Devices such as Passy-Muir tracheal valves that can allow mechanically ventilated patients to speak, computer programs that can “speak” the patient’s electronic input, and laryngeal devices are now more frequently available and expected to promote communication.
When alternative methods are being used, nonverbal communication is even more important to observe and monitor.
Sidebar 4.1. Nurses’ Therapeutic Listening Skills Used for Older Postesophagectomy Patients in Japan
Shigeaki Watanuki, Tokyo, Japan
Many esophageal cancer patients in Japan undergo thoracoabdominal esophageal surgery. Such patients frequently experience multiple signs and symptoms after surgery for months and sometimes even years due to gastrointestinal (GI) conditions. Such conditions may include vocal cord paralysis, esophageal stenosis, or reflux, which may result in coughing, dysphagia, difficulty swallowing, vomiting, weight loss, or reduced physical activity.
Surgeons, due to their limited time and a large number of patients, have only a few minutes to listen to postsurgical patients in outpatient departments. Older Japanese patients usually hesitate to ask surgeons about their symptoms, changes in daily life, or their concerns. It is as though these elders think they have problems that are “too small” to ask their surgeons. Such problems, however, are often very important
(continued)
CULTURAL APPLICATIONS
Sensitivity and awareness of cultural variations in communication styles are vital to intervention effectiveness. Cultural differences in meanings of certain words, styles, and approaches, or in certain nonverbal behav-iors such as silence, touch, eye contact, or smile may adversely affect the effectiveness of therapeutic communication. For example, there may be tendencies for clients from certain cultures to talk loudly, to be direct in conversation, and to come to the point quickly. Clients from other cul-tures may tend to talk softly, be indirect in their communication, or “talk around” points while emphasizing attitudes and feelings. In some cul-tures, it is believed that open expression of emotions is unacceptable.
Whether in the dominant culture or in nondominant cultures, however, persons may simply smile when they do not comprehend. The skills of therapeutic listening are particularly useful in ensuring that communi-cation in such cases is effective. It is important that nurses explore and understand clients’ cultural values and assumptions, as well as their pat-terns of behavior related to communication, while avoiding stereotyping (Seidel et al., 2011). Awareness of cultural differences is key to therapeutic communication. Sidebar 4.1 provides a look at the use of therapeutic lis-tening in a Japanese population.
4. tHeraPeutIc LIstenInG 49
Sidebar 4.1. Nurses’ Therapeutic Listening Skills Used for Older Postesophagectomy Patients in Japan (continued)
and may actually be an indication of major complications or GI condi-tions; reporting them may actually aid in diagnosis.
Nurses’ therapeutic listening skills play a key role in detecting patients’
problems. Nurses at this hospital are trained in the “ask-tell-ask” and “tell me more” educational programs. Designated nurses are assigned to the GI surgical outpatient department to see postsurgical patients and to listen to their stories. If the nurses “sense” patients’ problems through therapeutic exchange, they continue to explore the type and degree of the patients’
problems, and how the problems affect their daily lives. The nurses listen to the patients’ entire experiences of living after esophagectomy.
One day, a nurse saw a patient who complained of nothing special, but had eaten sushi the previous evening as a celebration of his 80th birthday—3 months after his esophagectomy. The nurse kept explor-ing the client’s story, and found that he had continuously experienced decline in food intake, due to increased difficulty in passing food through his esophagus. The nurse assessed that such a condition might be associated with esophageal stenosis, an indication of balloon or bou-gie for dilatation by his surgeon. The nurse immediately reported this to the surgeon. The surgeon examined his patient and, as expected, diag-nosed that the client had severe esophageal stenosis. This patient’s con-dition might otherwise have been overlooked by nurses and surgeons, if this nurse had not had an outstanding “sense” and effective therapeutic listening skills.
The nurses additionally provide the patients with assurance and positive feedback if the patients are on the right track and are trying to adhere to the expected “healthy behavior.” Such behavior includes eating small amounts of food slowly, engaging in regular physical activity, and keep-ing the upper body elevated while asleep. If patients would benefit from behavioral changes in their daily lives, nurses work with them to find acceptable common ground.
After seeing patients, the nurses convey the clients’ critical information or questions to the surgeon if indicated and desired.
Otherwise, nurses encourage the patients to relate their concerns to the surgeons; or the nurse may ask surgeons questions on behalf of the patients. The patients and surgeons of this department have reported that the nurses are sensitive to the patients’ needs, and have noted how helpful nurses are in working together on behalf of the patients. The nurses’ outstanding therapeutic listening skills truly enhance the quality of care at the outpatient department of this hospital.