2. 2
Table of Contents
1. Introduction ............................................................................................... 3
2. Communication skills, Engagement and Therapeutic alliance............... 3
2.1. Therapeutic relationship and Engagement...................................... 3
2.2. Communication skills.................................................................... 4-6
3. “Bucket” and Timeline assessment ........................................................... 6
4. Reflection on communication skills during the assessment ...................... 6
5. Incorporate the knowledge of the assessment tools and communication
skills in my future nursing practice. ........................................................... 7
6. Conclusion ................................................................................................ 7
7. References........................................................................................... 8-10
Appendix I...................................................................................................... 10
Appendix II................................................................................................ 11-14
3. 3
1. Introduction
Communication is a fundamental principle in the evolution of therapeutic nurse-
patient relationship by utilising effective interpersonal communication techniques
(Juvé-Udina et al., 2014). This essay will first discuss the therapeutic relationship,
engagement and communication skills; followed by completing the “Bucket” list and
Timeline through interviewing Blanca; then reflect on my communication skills
throughout the interview. Lastly, it will incorporate the knowledge of the assessment
tools and communication skills in my future nursing practice.
2. Communication skills, Engagement and Therapeutic alliance
2.1. Therapeutic relationship and Engagement
One of the core mental health assessment tools is mini-Mental State Examination
(MMSE), which is appropriate for assessing client’s mental health condition by using
therapeutic communication to build-up therapeutic relationship with the client
(Zelonis, 2006). It provides a positive outcome to establish a diagnosis or judgement,
as all interventions and management plans are depending on the facts collected
throughout assessment (Martin & Street, 2003).
Therapeutic rapport comforts and relaxes a patient’s state of mind. A strong
therapeutic rapport cultivates a calming environment to create ease, thereby
reducing the level of anxiety (Gardner, 2010). Trust is greatly vital in maintaining
communication. If clients do not have confidence in the health professionals, it is
possible that they will not disclose all information that can be significantly important
and helpful to their nursing care plan and future management. Nurses should show
care for their patients by being available and present, actively listening to patients
and maintaining confidentiality during trust development (Stickley, 2011). By
providing resources and suggestions, a therapeutic alliance empowers the patient to
make appropriate decision for themselves. For instance, this would prevent them
from resorting to negative coping strategies such as alcoholism, drug abuse, self-
harm or violence. Empathy is another important therapeutic feature that nurses must
practice repeatedly. A compassionate understanding of the individuals’ awareness of
his/her struggles is essential to the development of rapport. It is crucial to have the
skills to enter the patient’s “own world” and understand their feelings and thoughts
without judgement (Casella, 2015). Moreover, genuineness is beneficial to both client
and nurse for building successful therapeutic rapport. Juvé-Udina et al. (2014)
4. 4
pointed out that it is important for nurses to be honest and approachable instead of
being rigid and controlling. In addition, respect is part of the holistic care in nursing
practice. It is the duty of a Registered Nurse never to be stereotypical (Martin &
Street, 2003). If patients are respected, they will feel less anxious and more involved
in the process of assessment. Additionally, nurses should continually show positive
regard to patients while conducting the assessment. According to Williams and Irurita
(2004), health professionals should demonstrate acceptance sincerely rather than
superficially. Casella (2015) also points out that it is important for the health
professionals to be capable of isolating their opinions from the clients. With this,
clients should be able to get involved without worry of being disregarded, so as to
build-up self-confidence. Therefore, nurses must possess these basic skills to avoid
subjective biases, and provide an accepting and safe atmosphere for the client.
2.2. Communication skills
Registered Nurses should implement their knowledge of cultural diversity to
establish a racially ingenious nursing practice, as cultural sensitivity, competence
and awareness play a crucial role in nursing practice (Rasheed, 2015). This allows
Registered Nurses to be more efficient in carrying on assessments and delivering
care. For instance, nurses should hire an interpreter to eliminate the issue of
language barriers during assessment, which would gain the patient’s trust and gather
accurate data despite cultural differences.
Therapeutic communication skills are valuable for all health professionals while
engaging with clients. These skills include the practice of active listening, rephrasing
and reflection. Health professionals actively listen by assuring the clients that they
have heard and completely understood the issue. It is essential to observe client’s
behaviour as well as filter through the given information so that assessment is not
conducted blindly. (Xu, Staples & Shen, 2012). To ensure that the health
professional has received fully comprehensive information, rephrasing is highly
encouraged. Rephrasing is a response method used by nurses where information is
reiterated back to the patient. This helps patients elaborate on their situation so that
all aspects of the issue are thoroughly covered (Ünsal et al., 2014). Lastly, reflection
is a skill implemented across active listening which alters questions to direct the
patient’s thoughts to the subject at hand. Through this, nurses ask relevant questions
to help patients self-recognise the specific issue related to the initial problem
(Gardner, 2010).
5. 5
Registered Nurses should have the appropriate linguistic skills that encompass
confidentiality, courtesy, professionalism and reassurance. In the process of
interpersonal communication, Registered Nurses should be sensitive towards the
client instead of being apathetic (Xu et al., 2012). This can be done by maintaining a
calm manner while conducting assessments. Using a soft and warm tone with proper
facial expressions and gestures are ways to achieve a calm stance (Lima-Basto,
Gomes, Potra, Diogo & Reis, 2010). While verbal communication is essential, silence
gives clients an opportunity to reflect.
Questioning is another important tool of verbal communication as it helps in
developing trust and rapport, demonstrating empathy, recognizing patient’s
experience and bringing out necessary health information (Casella, 2015). The semi-
structured interview layout is a first choice in almost all circumstances, as the
conversation is logical without being controlled (Philpin, Jordan & Warring, 2005).
During the semi-structured interview, clients are asked a list of exploratory questions
on several topics. Their answers may create some further questions that have to be
responded prior to the next topic (Zelonis, 2006). However, nurses should not limit
the interaction based on the questions from the paper. It allows clients to provide
substantially detailed responses because they feel involved in the assessment.
Nurses have to be aware of their behaviour as it may alter the success of the
interview (Philpin et al., 2005). Primarily, nurses should start off with standard
questions, in order to bond with the client and allow them to be at ease. The
interview should commence in a relaxing and quiet environment at all times. It is also
important to encourage the client to carry through the interview accurately and fully.
Breckman (2007) explored the abbreviation SOLER of Egan’s theory. It is the non-
verbal communication that helps make a client feel cared and comfortable during the
interview. This can be done by sitting directly facing the client, keeping an open
posture, leaning towards the client to some extent, creating and maintaining eye
contact and choosing a comfortable position. These are distinct approaches that
handle communication development and encourages clients to discuss their thoughts
and feelings. Therapeutic communication should be carried out in a quiet, peaceful
and positive tone of voice to house a harmless and safe aura (Stickley, 2011). The
patient should be encouraged to practice any kinds of communication such as writing
and drawing to promote effective communication. Furthermore, MMSE helps clients
to assess his/her beliefs and explore alternatives that promote therapeutic
engagement (Lima-Basto et al., 2010).
6. 6
3. “Bucket” and Timeline assessment
I have conducted a face-to-face semi-structured interview with Blanca, who is a
29 year-old Singaporean Registered Nurse. I have utilised the Brabban and
Turkington (2002) of stress vulnerability “Bucket” model as given in Appendix I. The
timeline can be seen in Appendix II, which recognizes her stress aspects across the
lifespan and coping strategies to stressors.
4. Reflection on communication skills during the assessment
I utilised the first stage of Egan’s model in my interview to explore Blanca’s life
story (Breckman, 2007). I actually used active listening techniques during the
interview with Blanca. I clarified what she said to me and made sure I understood the
initial meaning of her messages. Additionally, I maintained eye contact, relaxed body
language and showed interest in her responses as well as sent proper messages to
her through calming gestures. Therefore, she felt comfortable to do the interview with
me. During the interview, I tried to sound compassionate and encouraging when I
started my opinion by saying, “I understood it was hard for you to fail academics and
face disappointment from family, but you have done an excellent job of coping with it
by seeking help from friends and teachers.” (Appendix II) Blanca was feeling
supported after hearing my response as she felt my empathy, genuineness and had
faith in me. This enhanced a stronger bonding of therapeutic relationship between
us. However, I did not adapt summarising techniques while interacting with Blanca.
According to Ünsal et al. (2014), nurses should summarise the patients’ response to
confirm the truthfulness of their thoughts and feelings. In the future, I will ask patients
to summarize the topics, ideas, learning and problem-solving methods made
throughout the engagement. It also assists patients to gain confidence and self-
awareness of their improvement as the nurse is concentrating on them during the
communication (Lima-Basto et al., 2010). Moreover, I did not apply the leading
techniques well during the interview with Blanca. However, due to the high comfort
level between Blanca and I, she sometimes drifted off from the question. This
resulted in unnecessary information as she lost focus of the purpose of the
assessment. For example, while we were discussing the relationship with Daniel, she
started to digress to Daniel’s family, instead of concentrating on her feelings and
thoughts towards the cheating problem (Appendix II). It is important for the health
professional to lead the conversation as they can target the patient’s emotions to
better understand their situation (Rasheed, 2015). In the future, I will develop my
7. 7
skills in leading by politely redirecting clients to the main subject of the interview
which will only collect important data for recognising his/her problem, as well as
enabling them to share his/her feelings and ideas through the assessment.
5. Incorporate the knowledge of the assessment tools and communication
skills in my future nursing practice.
In future nursing practices, I will apply therapeutic communication skills into the
stress vulnerability assessment to build up a therapeutic interpersonal relationship,
which will readily recognize initial patient’s life stress events and adverse coping
strategies that highly likely induce their vulnerability to experience mental health
illness (Williams & Irurita, 2004). In Blanca’s case, she was comfortable to openly tell
me about dealing with Daniel by binge eating and drinking which did not help her
unhappiness and increased her low self-esteem. Furthermore, this assessment
provides a complete picture of the clients’ life to health professionals by using
effective communication skills, which enhance the patient-focused care and support
the acceptance of prolonging care (Williams & Irurita, 2004). In the future, I will
strengthen my therapeutic communication skills by including verbal and non-verbal
language, active listening, compassion, fair-mindedness and honesty. The rapport
enables patients to feel comfortable and have faith in receiving adequate nursing
care. For instance, when comforting patients receiving bad news, nurses should let
them know we would be there to support and listen to them. These nursing
techniques allow the best quality of care for every patient. Lastly, I will remember to
take my time to reflect on how I think the interview went and how I could do better
next time. I will make sure that the patient’s problem is not misunderstood after
interpretation and ensure that the patient does not deviate from the topic.
6. Conclusion
To sum up, the main points that have been explained in this paper are the factors
of therapeutic communication skills, my strengths and weaknesses of communication
techniques, as well as implementing these skills and tools in my future nursing
practice. As a nurse, I should deliver comprehensive care for each patient with
compassionate understanding. In addition, I should be fair-minded regardless of the
patient’s crisis or culture differences. In general, nurses use positive and therapeutic
communication skills while engaging with clients, which can help to develop a
therapeutic relationship for my future nursing practice.
8. 8
7. References
Brabban, A., & Turkington, D. (2002). Search for meaning: Detecting congruence
between life events underlying schema and psychotic symptoms. In A.P.
Morrison (Ed.), Casebook of cognitive therapy for psychosis ch. 5 (pp. 59-75).
Retrieved from
http://link.library.curtin.edu.au/p?pid=CUR_ALMA51113460380001951
Breckman, B. (2007). Egan's skilled helper model - developments and applications in
counselling. Nursing Standard, 21, 30. Retrieved from
http://search.proquest.com/docview/219863104?accountid=10382
Casella, S. M. (2015). Therapeutic rapport: The forgotten intervention. Journal of
Emergency Nursing, 41, 252-254. http://dx.doi.org/10.1016/j.jen.2014.12.017
Gardner, A. (2010). Therapeutic friendliness and the development of therapeutic
leverage by mental health nurses in community rehabilitation settings.
Contemporary Nurse: A Journal for the Australian Nursing Profession, 34,
140-148. Retrieved from
http://search.proquest.com/docview/374988030?accountid=10382
Juvé-Udina, M., Pérez, E. Z., Padrés, N. F., Samartino, M. G., García, M. R., Creus,
M., . . . Calvo, C. M. (2014). Basic nursing care: Retrospective evaluation of
communication and psychosocial interventions documented by nurses in the
acute care setting. Journal of Nursing Scholarship, 46, 65-72. Retrieved from
http://search.proquest.com/docview/1537382722?accountid=10382
Lima-Basto, M. B., Gomes, I., Potra, T., Diogo, P., & Reis, A. (2010). Therapeutic
instruments used in therapeutic interventions: Is there evidence in nursing
care? A systematic review of the literature. International Journal of Caring
Sciences, 3, 12-21. Retrieved from
http://search.proquest.com/docview/1114167663?accountid=10382
Martin, T., & Street, A. F. (2003). Exploring evidence of the therapeutic relationship in
forensic psychiatric nursing. Journal of Psychiatric and Mental Health
Nursing, 10, 543-551. Retrieved from
http://search.proquest.com/docview/198657333?accountid=10382
Philpin, S. M., Jordan, S. E., & Warring, J. (2005). Giving people a voice: Reflections
on conducting interviews with participants experiencing communication
impairment. Journal of Advanced Nursing, 50, 299-306. Retrieved from
http://search.proquest.com/docview/232499908?accountid=10382
Rasheed, S. P. (2015). Self-awareness as a therapeutic tool for Nurse/Client
relationship. International Journal of Caring Sciences, 8, 211-216. Retrieved
from http://search.proquest.com/docview/1648623531?accountid=10382
Stickley, T. (2011). From SOLER to SURETY for effective non-verbal
communication. Nurse Education in Practice, 11, 395-398.
http://dx.doi.org/10.1016/j.nepr.2011.03.021
Ünsal, G., Karaca, S., Arnik, M., Oz, Y., Asik, E., Kizilkaya, M., . . . Sipkin, S. (2014).
The opinions of nurses who work in psychiatry clinics related to the roles of
psychiatry nurses. Marmara Üniversitesi Saglik Bilimleri Enstitüsü Dergisi, 4,
90. http://dx.doi.org/10.5455/musbed.20140527033928
9. 9
Williams, A. M., & Irurita, V. F. (2004). Therapeutic and non-therapeutic interpersonal
interactions: The patient's perspective. Journal of Clinical Nursing, 13, 806-
815. Retrieved from
http://search.proquest.com/docview/235001002?accountid=10382
Xu, Y., Staples, S., & Shen, J. J. (2012). Nonverbal communication behaviors of
internationally educated nurses and patient care. Research and Theory for
Nursing Practice, 26, 290-308. Retrieved from
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Zelonis, J. I. (2006). Therapeutic interaction in nursing. The Journal of Continuing
Education in Nursing, 37, 280. Retrieved from
http://search.proquest.com/docview/223321187?accountid=10382
10. 10
Appendix I
Lack
of
family
attention
after
younger
brother
was
born
Poor
academic
performance
Parental
disappointment
Didn’t
fit
into
social
group
at
school
Parents
argued
in
front
of
her
most
of
the
time
Failed
to
get
into
university
Mother
stopped
caring
Worst
break
up
Caught
boyfriend
(Daniel)
cheating
Binge
eating
and
drinking
alcohol
Got
tutoring
Went
clubbing;
smoking
and
drinking
heavily;
loss
of
appetite
Hangout
more
with
a
friend
(Jane)
Got
into
Nursing
School
Listened
to
best
friend
(Nicolle)
Positive
Coping
Strategies
Negative
Coping
Strategies
(Brabban & Turkington, 2002) – Bucket Filling Analogy
11. 11
Appendix II
Timeline
Date Significant Events Mental Health Issues
Born 1986 Happy early childhood
Good memories
1990 Started Kindergarten.
Enjoyed seeing friends at
school.
Felt love overflow from
parents
She said “parents and
grandparents always gave
me hugs and kisses
regardless where we
were.”
1992 Started first year of private
primary school.
Felt like a princess in the
family as they all “spoiled”
her as she was the only
child in the family tree
1993 Brother born. He took
away all the attention from
adults because he is the
first baby boy.
Didn’t like young brother
very much.
Made loads of friends at
school.
Couldn’t keep up with
schoolwork and had loads
of tutoring after school
time.
She stated “feeling like an
idiot for not being able to
understand stuff at school.”
1996 Ended primary school.
Mother was disappointed
that her daughter couldn’t
get into private school with
her average grades.
She said “I’m such a loser
and ruining my family’s
reputation.” “Don’t know
how to behave in the
family gathering!”
1997 Started public secondary
school.
Overwhelmed with the
transition from single-sex
to coeducational school.
Didn’t fit into group in
relation to her geeky look.
Had a few friends only.
Low self-esteem
1999-2001 Parents started to fight a
lot every day.
Felt annoyed and didn’t
like to stay home.
Became closer to a friend
She said ”I hated when I
starting to hear them shout
or yell at each other no
matter what time it was ”
12. 12
(Jane) who taught her the
way to “fit into” the school.
2002 1st
relationship.
Treated “boyfriend” like a
step-brother rather than
having real boyfriend-
girlfriend feelings.
Wanted to try what is like
to be in a “relationship”.
Didn’t feel that was a
special thing as it was
boring.
2003-2004 Senior year- Mutual break
up with the “boyfriend”.
Felt fine with it.
Failed the examination and
didn’t get into college.
Mother didn’t care about
her as much afterwards.
She stated “I’m used to
being a disappointment to
the family, and it’s not the
first time being neglected
anyway.”
2005 Started Diploma of
Enrolled Nurse, due to
insufficient points to get
into school of education.
Always wanted to become
a teacher.
Had poor appetite. Loss
weight rapidly.
Started to go clubbing,
drinking and smoking, as
she didn’t want to stay
home and watch her
parents fight.
2006-2009 2nd
relationship – with
Daniel who was a
bartender but became
unemployed once the
relationship started.
Smoked at least 2 packs a
day due to negative
influence from him.
Fully supported his
finances.
Felt so in love with him
and couldn’t live without
him.
Lost her virginity under
Daniel’s pressure.
Low self-image because
Daniel called her “fat” and
“obese”.
Broke up after caught him
Overthinking and worried
that he would cheat again.
She said “I was too
paranoid that a random girl
from the street was able to
take him away from me.”
Started binge eating and
drinking alcohol everyday
after 1st
break up
Ran away from home to
stay with boyfriend multiple
times
Extremely heartbroken
after 2nd
break up
13. 13
cheating.
Patched back after he
swore to change.
She consistently imagined
him cheated everyday
again.
She caught him cheating
the 2nd
time.
Stopped working and
studying for weeks and
just stayed at home.
2010 Her nursing school best
friend (Nicolle) suggested
further studies as a
distraction from the heart
breaking experience.
She decided to complete a
nursing degree in America.
Felt like a turning point in
life.
She stated “I think Nicolle’s
idea wasn’t bad. Changing
the environment would
help me move on.”
2011 Started college in America.
Found a part-time carer
job and made some
friends at work and
university.
3rd
relationship – with
Ayman who was a medical
student in the same
college.
He made her feel happy
and confident.
She had never felt this
happy to be in a
relationship before.
She said “Ayman makes
me feel like I’m living in a
dream, as I haven’t felt this
happy since I was little. I’m
glad that my life has turned
away from darkness ”
2012-2014 Finished nursing degree
with honours.
Became a Registered
Nurse in a private hospital.
Present Engaged to Ayman.
Planning the wedding.
Feeling happy and excited.
She said “I want to be a
good housewife and
mother. I especially want
my kids to feel loved and
cared for at all times.”
