How the nurse should communicate with the patient

1. NURSE –CLIENT RELATIONSHIP
THERAPEUTIC COMMUNICATION

2. NURSE – CLIENT INTERACTION
(COMMUNICATION)
 COMMUNICATION : is the process that people use to
exchange information.
 Messages are simultaneously sent and received on two
levels:
 Verbally through the use of words
 Non- verbally by behaviors that accompany the words.

3. THERAPEUTIC COMMUNICATION
 Is an interpersonal interaction between the nurse and
client during which the nurse focuses on the client’s
specific needs to promote an effective exchange of
information.

4. THERAPEUTIC COMMUNICATION CAN
HELP NURSES TO ACCOMPLISH GOALS:
 1. Establish a therapeutic nurse- client
relationship
 2. Identify needs
 3. Assess the client’s perception of the proble
 4. CATHARSIS
 5. Implement intervention

5. TO HAVE EFFECTIVE THERAPEUTIC
COMMUNICATION THE NURSE MUST
CONSIDER:
 Privacy and Respect of Boundaries
 Use of Touch
 Active listening and observation

6. 1. PRIVACY AND RESPECT
BOUNDARIES
 Privacy is desirable but not always possible in
Therapeutic Communication.
 An interview or conference room is optimal

7. BOUNDARIES
PROXEMICS: is the study of distance
zones between people during communication.
 People feel more comfortable with smaller distance
when communicating with someone they know rather
than strangers.
 4 Distance Zones:
1. Intimate
2. Personal
3. Social
4. Intimate

8. 4 Distance Zones:
1. Intimate zone ( 0 – ½ feet) : this amount of space is
comfortable for parents with young children,
people who mutually desire personal contact,
or people whispering.
2. Personal zone (1/2 – 4 feet) : this distance is
comfortable between family and friends who are talking.

9.  3. Social zone (4 to 12 feet): this distance is
acceptable for communication in social, work, and
business settings.
 4. Public zone (12 to 25 feet): this is acceptable
distance between a speaker and an audience, small
groups, and other informal functions.

10. 2. TOUCH
 AS INTIMACY INCREASES, THE
NEED FOR DISTANCE DECREASES.
5 TYPES OF TOUCH:
1. Functional- Professional touch: is
used in examination or procedure.
2. Social- Polite touch: is used in
greetings, such as hand shake
3. Friendship- Warmth touch: hug in
greeting, back slapping
4. Love- intimacy touch: tight hugs and
kisses between lovers or close relatives.
5. Sexual- Arousal touch: used by
lovers, specially the married couple.
Four types of touch. A—Functional–
professional touch; B—Social–polite
touch; C—Friendship–warmth touch;
D—Love–intimacy touch.

11. 3. ACTIVE LISTENING AND
OBSERVATION
 To receive the sender’s simultaneous messages, the
nurse must use active listening and active
observation.
 Active listening
 Active observation

13.  COMMON MISCONCEPTION OF STUDENTS
learning the art of THERAPEUTIC
COMMUNICATION = is that they always must be
ready with questions the instant the client has
finished speaking.
 They are constantly thinking ahead regarding the
next question rather than actively listening to
what the client is saying.

14. VERBAL COMMUNICATION
SKILLS
1. USING CONCRETE
MESSAGES
2. USING THERAPEUTIC
COMMUNICATION
TECHNIQUES

15. USING THERAPEUTIC COMMUNICATION
TECHNIQUES:
 The choice of technique depends on the intent of
the interaction and the client’s ability to
communicate verbally.
 Techniques such as exploring, focusing,
restating, and reflecting encourage the client
to discuss his/her feelings or concerns in more
depth.

16. THERAPEUTIC
COMMUNICATION TECHNIQUES:

1. Accepting : indicating reception
 Ex. “yes” “I follow what you said.” Nodding

2. Broad opening: allowing the client to take the
initiative in introducing the topic.
 Ex. “Is there something you’d like to talk about?”
“Where would you like to begin?”

3. Consensual validation: searching to
mutual understanding, for accord in the meaning of the
words.
 Ex. “ Tell me whether my understanding of it agrees
with yours.”

17. 
4. Exploring: delving further into a subject or
idea.
 Ex. “ Tell me more about that.” “Would you describe it
more fully?”

5. Focusing: concentrating on a single point.
 Ex. “This point seems worth looking at more closely.”

18. A FEMALE VICTIM OF A SEXUAL ASSAULT IS BEING SEEN IN
THE CRISIS CENTER FOR A THIRD VISIT. SHE STATES THAT
ALTHOUGH THE RAPE OCCURRED NEARLY 2 MONTHS AGO,
SHE STILL FEELS “AS THOUGH THE RAPE JUST HAPPENED
YESTERDAY.” THE NURSE WOULD RESPOND BY STATING:
A. “What can you do to alleviate some of your
fears about being assaulted again?”
B. “Tell me more about those aspects of the rape
that cause you to feel like the rape just
occurred.”
C. “In time, our goal will be to help you move on
from these strong feelings about your rape.”
D. “In reality, the rape did not just occur. It has
been over two months now.”

19. 
6. General leads: giving encouragement to
continue.
 Ex. “Go on” “and then?” “Tell me about it.”

7. Giving information: making available the
facts that the client needs.
 Ex. “My name is....” “Visiting hours are...” “My purpose
in being here is.....”

20. A 4-YEAR-OLD CHILD WHO WAS RECENTLY
HOSPITALIZED IS BROUGHT TO THE CLINIC BY HIS
MOTHER FOR A FOLLOW-UP VISIT. THE MOTHER
TELLS THE NURSE THAT THE CHILD HAS BEGUN TO
WET THE BED EVER SINCE THE CHILD WAS BROUGHT
HOME FROM THE HOSPITAL. THE MOTHER IS
CONCERNED AND ASKS THE NURSE WHAT TO DO. THE
APPROPRIATE NURSING RESPONSE WOULD BE:
A. “You need to discipline the child.”
B. “This is a normal occurrence following
hospitalization.”
C. “We need to discuss this behavior with
the physician.”
D. “The child probably has developed a
urinary tract infection.”

21. 
8. Giving recognition: acknowledging,
indicating awareness: “Good morning, Mr. S.......” “ I
notice that you’ve combed your hair.”

9. Making observations: verbalizing what
the nurse perceives.
 Ex. “You appear tense.” “ I notice you’re biting your
lip.”

10. Offering self: making oneself available.
 Ex. “ I’ll sit with you awhile.”

22. A NURSE OBSERVES AN ANXIOUS CLIENT
BLOCKING THE HALLWAY, WALKING THREE
STEPS FORWARD AND THEN TWO STEPS
BACKWARD.OTHER CLIENTS ARE AGITATED
TRYING TO GET PAST. THE NURSE
INTERVENES BY:
A. Standing alongside the client and saying,
“You’re very anxious today.”
B. Stopping the behavior and saying: “You’re
going to get exhausted.”
C. Taking the client to the TV lounge and saying,
“Relax and watch television now.”
D. Walking alongside the client and saying, “
You’re not going to get anywhere very fast
doing this.”

23. A MALE CLIENT DIAGNOSED WITH CATATONIC
STUPOR DEMONSTRATES SEVERE WITHDRAWAL
BY LYING ON THE BED WITH THE BODY PULLED
INTO A FETAL POSITION. THE NURSE PLANS TO:
A. Leave the client alone and intermittently check on
him.
B. Take the client into the day room with other
clients so they can help watch him.
C. Sit beside the client in silence and occasionally ask
open-ended questions.
D. Ask direct questions to encourage talking.

24. 
11. Presenting reality: offering for
consideration that which is real.
 Ex. “ I’ll see no one else in the room.”

16. Reflecting: directing client actions. Thoughts,
and feelings back to client.
 Ex. Client: “do you think I should tell the doctor....?
Nurse: “do you think you should?”

25. COMMUNICATION TECHNIQUE
SHOULD THE NURSE USE WHEN
COMMUNICATING WITH A CLIENT
WHO IS EXPERIENCING AUDITORY
HALLUCINATIONS?
 A "My sister has the same diagnosis as you and
she also hears voices."
B "I understand that the voices seem real to you,
but I do not hear any voices."
C "Why not turn up the radio so that the voices
are muted.”
D "I wouldn't worry about these voices. The
medication will make them disappear.

26.  Auditory hallucinations, the most common type,
involve hearing sounds, most often voices, talking
to or about the client.
 Command hallucinations are voices demanding
that the client take action, often to harm self or
others, and are considered dangerous.
 The nurse reorients the patient to reality and
assesses for the presence of such hallucinations to
ensure safety.
 Address him by name to ask him if he is hearing
voices again
 “I do not hear the voice you say you hear.”

27. 
12. Restating: repeating the main idea expressed.
 Ex. Client: “ I can’t sleep. I stay awake all the night.”
Nurse: “you have difficulty sleeping.”
13. Reflecting—directing client actions, thoughts, and
feelings back to client
 Client: “Do you think I should tell the doctor . . . ?”
Nurse: “Do you think you should?”
Client: “My brother spends all my money and then has nerve to ask for
more.”
Nurse: “This causes you to feel angry?”

28. A CLIENT 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.”
THE NURSE MAKES WHICH THERAPEUTIC
RESPONSE TO THE CLIENT?
A. You’re feeling angry that your family continues
to hope for you to be cured?”
B. “I think we should talk more about your anger
at your family.”
C. “Well, it sounds like you’re being pretty
pessimistic. After all, years ago, people died of
pneumonia.”
D. “Have you shared your feelings with your
family?

30. AVOIDING NONTHERAPEUTIC
COMMUNICATION
 In contrast, there are many therapeutic
techniques that nurses should avoid. These
responses cut off communication and make
it more difficult for the interaction to
continue.
 Responses such as “Everything will work out”
or “May be tomorrow will be a better day”
may be intended to comfort the client, but
instead may impede the communication process.

31. NONTHERAPEUTIC
COMMUNICATION TECHNIQUES:
 1. Advising: telling the client what to do.
 Ex. “ I think you should...”
 2. Agreeing: indicating accord with the client.
 Ex. “That’s right.”
 3. Belittling feelings expressed: misjudging the
degree of the client’s discomfort.
 Ex. Client: “ I have nothing to live for... I wish I
was dead.” Nurse: “ Everybody gets down in the
dumps.” or “I’ve felt that way myself.”

32.  4. Challenging: demanding proof from client.
 Ex. “But how can you be president of the United
State?” “If you’re dead, why is you heart beating?”
 5. Defending: attempting to protect someone or
something from verbal attack.
 Ex. “This hospital has a fine reputation.” “ I’m sure
your doctor has your best interests in mind.’

33.  6. Disagreeing: opposing the client’s ideas.
 Ex. “that’s wrong.”
 7. Disapproving: denouncing the client’s behavior or
ideas.
 Ex. “That’s bad” “I’d rather you wouldn’t
 8. Giving approval: sanctioning the client’s behavior
or ideas.
 Ex. “That’s good.” “I’m glad that...’

34.  9. Interpreting: asking to make conscious that which
is unconscious; telling the client the meaning of his or
her experience.
 Ex. “What you really mean is....” “Unconsciously you’re
saying....”
 10. Probing: persistent questioning of the client.
 Ex. “Now tell me about this problem. You know I have
to find out.”

35. INTERPRETING SIGNALS OR
CUES
 To understand what the client means, the nurse
watches and listens carefully for cues.
 CUES: are verbal or nonverbal messages that
signal key words or issues for the client.

36. NONVERBAL COMMUNICATION
SKILLS
 Is behavior that a person exhibits while
delivering verbal content.
 It includes:
 facial expression,
 eye contact,
 space ,
 time,
 boundaries, and
 body movements.

37. 1. FACIAL EXPRESSION
 The human face produces the most visible, complex,
and sometimes confusing nonverbal messages.
 Facial movements connect with words to illustrate
meaning; this connection demonstrates the speaker’s
internal dialogue.
Facial expression can be
categorized into:
 Expressive
 Impassive
 Confusing

39. FACIAL EXPRESSION
often affect the listener’s
response. The nurse should
identify the facial expression and
ask the client to validate nurse’s
interpretation of it.
Ex. “ you’re smiling, but I
sense you are very angry.”

40. 2. BODY LANGUAGE
Gesture , postures, movements,
and body positions.
Is a nonverbal form of
communication.
Closed Body Position
Accepting Body Position

41. VOCAL CUES
 Are nonverbal sound signals transmitted
along with the content: voice volume, tone,
pitch, intensity, emphasis, speed, and
pauses augment the sender’s message.

42. EYE CONTACT
 The eyes have been called the mirror of the soul
because they often reflect our emotions.
 Although maintaining good eye contact is usually
desirable, it is important that the nurse doesn’t
“STARE” at the client.

43. SILENCE
 Or long pauses in communication may indicate many
different things.
 The client may be depressed
 Sometimes pauses indicate the client is thoughtfully
considering the question before responding.
 It is important to allow the client sufficient time
to respond, even if it seems like a long time.

45. THERAPEUTIC
RELATIONSHIP

46. THERAPEUTIC RELATIONSHIP
The nurse’s relationship with the
patient consists of a series of goal-
directed interactions through which
the nurse assesses patients’
problems, elicits patient input,
selects interventions, and evaluates
the effectiveness of care.

47. RELATIONSHIP:
3 Types :
Social
Intimate
Therapeutic

48. THERAPEUTIC RELATIONSHIP
 The nurse uses communication skills,
personal strengths, and
understanding of human behavior to
interact with the client.
 The nurse must constantly focus on
the client’s needs not his/her own.

49. COMPONENTS OF A
THERAPEUTIC RELATIONSHIP
 Trust
 Genuine interest
 Empathy
 Acceptance
 Positive regard
 Self-awareness
 Therapeutic use of self

50. TRUST
Trust develops when the
client believes that the
nurse will be consistent in
his/her words and actions
and can be relied on to do
what he or she says.

51. GENUINE INTEREST
The client perceives a
genuine person showing
genuine interest.

52. EMPATHY
Is the ability of the nurse to
perceive the meaning and feelings of
the client and to communicate that
understanding to the client.
 It is considered one of the essential skills a nurse
must develop.
 Being able to put himself/herself in the client’s
shoes
 Ex. Empathy : “I see you are sad.... How can I
help you?”
 Ex. Sympathy : “ I feel so sorry for you.”

53. ACCEPTANCE
The nurse who does not become
upset or respond negatively to a
client’s outbursts, anger, or acting
out conveys acceptance to the client.

54.  The nurse must set boundaries in the nurse-
client relationship.
 Ex. A client puts his arm around the nurse’s
waist.
 An appropriate response would be what?

55. POSITIVE REGARD
The nurse who appreciates the
client as a simple worth while
human being can respect the client
regardless of his or her behavior,
background, or lifestyle.

56. SELF- AWARENESS
 Before the nurse can begin to understand
clients, the nurse must know himself /herself.
 Self – awareness: is the process of developing an
understanding of one own’s values, beliefs, thoughts,
feelings, attitude, motivations, prejudices, strengths,
and limitations and how these qualities affect others.

57. THERAPEUTIC USE OF SELF
 By developing self- awareness and
beginning to understand his/ her
attitudes, the nurse can begin to use
aspects of his/her personality,
experiences, values, feelings, intelligence,
needs, coping skills, and perceptions to
establish relationships with client.
 Nurses use themselves as therapeutic tool to
establish therapeutic relationships with clients
and help clients grow, change, and heal.