MENTAL HEALTH NURSING

Therapeutic communication
Therapeutic relationship
Dr. Pun Wai Ming
Senior Lecturer
RN, BN, MN, MCoun, MA.(ClinPsy), PsyD (ClinPsy)

By the end of the lecture, students will be able to:

- explain the goals of the therapeutic relationship in the nursing profession.
- understand the phase of therapeutic relationship development.
- comprehends the communication model and its application.
- explain the factors influencing interpersonal communication.
- describe different therapeutic communication skills and apply the skills in clinical practice.

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 What is therapeutic communication?
Therapeutic use of self

“the ability to use one’s personality consciously and in full awareness in an

attempt to establish relatedness and to structure nursing interventions”
(Travelbee, 1971)

▪ Nurses: as a mean to influence others

▪Ongoing, dynamic series of events that involves the transmission of meaning

from sender to receiver

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 Why therapeutic communication is important in nursing?

o A professional attitude and behavior to develop meaningful relationship

→ To show the empathy, and
→ to establish a therapeutic relationship

o An intimate journey with patient and their families

→ Nurse should practice the therapeutic communication skills throughout the nursing
career.
→ The nursing experience is valuable to consolidate the therapeutic communication
skills and facilitate effective communication with the patient.

o Patient-centered care
→ recognize and respects patient / patient’s family as full team members.

Potter, P., & Stockert, H. (2017). Fundamentals of nursing (9th ed.). St. Louis, MO: Elsevier. (Chap 24) 4
 Why therapeutic communication is important?

o Engage the patient and/or the family members effectively for:

→ collect relevant assessment data
→ setting up mutually agreed treatment goals
→ provide psychoeducation

o Professionalism - Lifelong learning process → achieve better patient outcome

→ Promotes personal growth and attainment of patient’s health-related growths
→ A mutual growth during the interactive process.

Potter, P., & Stockert, H. (2017). Fundamentals of nursing (9th ed.). St. Louis, MO: Elsevier. (Chap 24) 5
 Summary of the goals of therapeutic communication

❑ Promote personal growth and well-being of the patient, and/or the family members

❑ Encourage self-disclosure, self realization & self-acceptance especially for patients with
mental/emotional problem

❑ Assist the patient to build up insight regarding their health problems / behavior

❑ Encourage and facilitate problem solving for the patient’s problems

❑ Support and facilitate health related decision making and patient-centered care

❑ Offers immediate psychological support

✓ Stabilize patient’s emotions
✓ Reduce stress

Potter, P., & Stockert, H. (2017). Fundamentals of nursing (9th ed.). St. Louis, MO: Elsevier. (Chap 24) 6
Points to note in therapeutic communication process:
❑ Legal and ethical consideration
✓ Confidential
✓ Do no harm
✓ Ensure client’s safety, reduce risk of errors
✓ Unconditional positive regards (except self-harm, harm others)

❑ Others:
o Improves patient’s outcomes
o Increased patient satisfaction (Teamwork and collaboration)
o Meets legal, ethical, and clinical standard of care
o Cultural awareness
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 Phase of therapeutic relationship development

Phase Major Nursing Goal and Intervention

Pre-interaction phase • Obtain relevant information from patient’s documents, significant others etc
• Self-awareness: MUST examine OWN feelings, actions, and reactions that influenced
by personal value and belief
Orientation (Introductory) phase • Therapeutic contract
• Establish trust and rapport
• Comprehensive assessment
• Identify the client’s strengths and limitation
• Explore feelings
• Nursing Process: Assessment, Diagnosis, Planning, Implementation
Working phase • Promote the client’s insight
• Promote perception of reality problem-solving
• Overcome resistance behaviors
• Nursing Process: Implementation, Evaluation
: Repeat Nursing Process and adjustment PRN
Termination phase • Evaluate goal attainment
• A plan for continuing care recognized
• Explore the feelings about termination of the relationship
• Nursing Process: Repeat Nursing Process and adjustment PRN

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Stuart, G. W. (2013). Principles & practice of psychiatric nursing (10th ed.). St Louis: Elsvier Mosby.
 Circular transactional model of communication process

✓ Each person in the communication interaction is both a speaker

and a listener
✓ A continuous and interactive activity
✓ To correct or validated the communication
✓ Role relationship

a. Complementary role relationship

- an elevated position over the other person
eg. nurse educate a DM diet to a patient

b. Symmetrical role relationship

- relationships are more equal
eg. a group of patients discussing their plans after discharge

Potter, P., & Stockert, H. (2017). Fundamentals of nursing (9th ed.). St. Louis, MO: Elsevier. (Chap 24) 9
 Circular transactional model of communication process
Personal perceptions may distort the receiver’s interpretation of the message

Interpersonal variables Culture, expectations, experiences,

- Perceptions sociocultural, pain, illness
- Attitudes
- Potential reaction

Motivate one person to

communicate with one another
Channel
-Visual
Referent -Auditory Referent
-Tactile senses
- Facial expression
-speech

Sender Message Receiver

Note: Communication barriers, education level
➢Verbal and nonverbal : Content, thoughts & feelings ➢Decoding process
▪ Reflects the receiver understood the meaning of the message from the sender
▪ Evaluate process that requires sensitivity of the receiver
Feedback

Environment
Physical and emotional comfort / safety

Potter, P., & Stockert, H. (2017). Fundamentals of nursing (9th ed.). St. Louis, MO: Elsevier. (Chap 24) 10
 Reciprocal nature of interpersonal communication

Riley, J. B. (2017). Communication in nursing (8th ed.). St. Louis, MO: Elsevier. (Chp 1) 11
 Forms of communication
Verbal Communication
❖ Just a small part of interpersonal communication
❖ Effective to deliver FACTUAL information
❖ Less effective to tell feelings or subtle meanings
❖ High variation in social or cultural groups

Non-verbal communication
➢Accurately indicate a person’s meaning and feelings than the words being spoken
➢Unconsciously motivated and more accurate for the intended meaning
➢Nurse should be more sensitive and respond to patient’s non-verbal behaviors.
➢Five senses included
➢ Cultural awareness

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Verbal Communication

a) Vocabulary
▪cultural awareness
▪ Medical jargon
▪ age – limitation
b) Denotative and connotative
Eg. Denotative概念意或者外延的内容
▪ several meanings of certain words
▪ common language eg. CODE = cardiac arrest
Eg. Connotative隱含的意義
▪ shade / interpretation – influence thoughts, feelings, or ideas
eg. serious = death is near (to family)
eg. serious = nature of the illness (health providers)

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Potter, P., & Stockert, H. (2017). Fundamentals of nursing (9th ed.). St. Louis, MO: Elsevier. (Chp 24, 38)
 Verbal Communication
c) Intonation e) Clarity and Brevity = clear and concise
▪ Tone of voice ▪ Keep simple, brief, and direct
→ inhibit /encourage further communication ▪ Repeat important part
e.g. express enthusiasm, anger, concern,
or flat
e.g. emotional states / energy level f) Timing and relevance
e.g. Hurrying manner / top-down ▪ communicate in a right moment
instruction ▪ eg. without pain,
when the client shows interest
d) Pacing
▪ speed of the conversation, synchronize with
the patient
▪ without awkward pauses / rapid shifts

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Potter, P., & Stockert, H. (2017). Fundamentals of nursing (9th ed.). St. Louis, MO: Elsevier. (Chp 24, 38)
Nonverbal communication

a) Personal appearance
▪ physical characteristics, facial expression , grooming and dress
▪ communicate physical / psychological well-being, personality, socioeconomic status,
self-concept, religion etc

b) Posture and gait

▪ self-expression, attitudes, emotions, self-concept
▪ eg. quick, purposeful gait – well-being / confident
▪ eg. slow, shuffling gait – depression, illness, fatigue
▪ eg. leaning forward – attention

c) Facial expression
▪ Express eg. surprise, fear, anger, happiness, or sadness.
▪ aware = expression does not match with circumstances
▪ Nurse = professionalism, avoid reveals own feelings?

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Potter, P., & Stockert, H. (2017). Fundamentals of nursing (9th ed.). St. Louis, MO: Elsevier. (Chp 24, 38)
Nonverbal communication
d) Eye contact
▪ signal readiness to communicate
▪ Respect, willingness to listen
▪ anxiety, defensiveness, discomfort, lack of confidence etc
▪ Culture awareness – intrusive, threatening / harmful
▪ Same eye level = safe, equality

e) Gestures
▪ clarify the spoken words, create message

f) Sounds
▪ eg. sighs, moans → help to send clear message
▪ sometimes have difference meaning,
▪ nursing profession → clarify and avoid miss interpret

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Potter, P., & Stockert, H. (2017). Fundamentals of nursing (9th ed.). St. Louis, MO: Elsevier. (Chp 24, 38)
 Nonverbal communication
g) Territoriality and personal space

▪ Gain, maintain, and defend one’s

right to space.
▪ Sense of privacy, security, identity,
and control
▪ sometimes invisible, eg. distance
▪ when threatened → respond
defensively and communicate less
effectively
▪ Nursing profession → respect for
privacy

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Potter, P., & Stockert, H. (2017). Fundamentals of nursing (9th ed.). St. Louis, MO: Elsevier. (Chp 24, 38)
Establish therapeutic relationship with therapeutic communication skills

✓ Active listening
✓ Broad / Open questions
✓ Clarification
✓ Restating
✓ Reflection
✓ Emotional labeling
✓ Presenting reality

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Establish therapeutic relationship with therapeutic communication skills
Active listening
✓Be attentive, both verbal and non-verbal
✓Promote acceptance
✓Respect and trust the client
✓Skills
– SOLER
- Encourage expression
▪ Appropriate smile
▪ Head nodding
▪ Minimal encouragers

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Establish therapeutic relationship with therapeutic communication skills

SOLAR

✓ Squarely → Face the client squarely

✓ Open posture
✓ Lean towards the others
✓ Eye contact – be gentle
✓ Relaxed and natural

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Establish therapeutic relationship with therapeutic communication skills

Broad Opening
✓ Let the patient know:
→ nurse is accessible
→ following what the patient is saying
→ Encouraging the patient to select topics for discussion
eg. “what are you thinking about?”

➢ Therapeutic value:
→ Indicates acceptance by the nurse and the value of the patient’s initiative

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Establish therapeutic relationship with therapeutic communication skills

Restating / paraphrasing
✓Be sensitive of the key message of client’s expression
✓→ rephrase the main thought the patient expressed.

eg. Patient “I need to cook, I need to clean the house, I need to take care of my siblings…. She passed away when I was 5-
years old”

Nurse “You say that your mother left you when you were 5-years old and from that point you started to take up the
responsibility of her in the house”

→ Do not overdoing for simple “restating”

eg. Patient : “I am lonely” vs Nurse: “You are lonely”

➢ Therapeutic value:
→ Indicates that the nurse present, listening, validates, reinforces, and able to identify something is important to the
patient’s story

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Establish therapeutic relationship with therapeutic communication skills

Clarificaton
✓ To organize vague ideas or thoughts that are implicit or explicit in the patient’s verbal message
→ eg. “I’m not sure what you mean. Could you tell me about that again?”
✓ Do not “assume” understand

➢ Therapeutic value:
→ Helps to clarify feelings, ideas, and perceptions of the patient and
→ be transparent and open

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Establish therapeutic relationship with therapeutic communication skills

Reflection / emotional labelling

✓ Show understanding, empathy, interest, and respect for the patient
✓ Based on the verbal and non-verbal cues, helps the client ventilate the emotion explicitly
→ directing back the patient’s ideas, feelings questions, or content
eg. “You’re feeling tense and anxious, and it’s related to a conversation you had with your
husband last night, correct me if I am wrong?”

➢ Therapeutic value:
→ Validates the nurse’s understanding of what the patient is saying and
→ signifies empathy, interest, and respect for the patient

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Establish therapeutic relationship with therapeutic communication skills

Focusing
✓A professional nurse is sensitive to identify the important message that a patient not
aware of it
✓Use of prompting questions to discuss further especially when the patient shifting topics
abruptly
✓Patient may feel that the nurse is helpful and attentive

Pacing
✓ Speed of the conversation
✓ Mutually affected
✓ Avoid rapid shifting

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Establish therapeutic relationship with therapeutic communication skills
Silence
✓Making use of the silence –a powerful non-verbal communication
✓An opportunity for both nurses and patients to think through and process

Summarizing
✓ One of the way to demonstrate actively listening
✓ Usually use before the end of the conversation

Presenting reality
✓Defines reality by indicating own perception of the situation of the client
✓Facilitate patient to contact to the reality, useful in psychotic patient
Example:
“ I understand that the voice seem real to you, but I do not hear the voice”
“There is no one else in the room but you and me”

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Establish therapeutic relationship with therapeutic communication skills

Therapeutic touch
✓ A non-verbal message - Most personal

✓ Establishing value, exploring benefits, discerning barriers

✓Can be supportive: Expressing a feeling of concern, empathy, or caring

✓Can also be threatening!!!

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Establish therapeutic relationship with therapeutic communication skills

Questioning Skills
✓ Closed question
➢ Yes/No
➢ Multiple choice
✓ Open Question
➢ How
➢ What
➢ When
➢ Who
➢ Where
➢ Why

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Factors influencing interpersonal communication

❖ Environmental factors
❖ Facial expressions
❖ Eye movement
❖ Physical appearance and dress
❖ Intrapersonal factors
❖ Territory and personal space
❖ Vocal cues

Riley, J. B. (2017). Communication in nursing (8th ed.). St. Louis, MO: Elsevier. (Chp 1) 29
 What are the challenges?

❑ Special needs (speech / visual / hearing disabilities)

❑ Silence
❑ Difficulty in expressing feelings or needs
❑ Sad and depressed
❑ Uncooperative / resent / angry / confrontational / defense
❑ Demanding / manipulating
❑ Talkative / very emotionally dependent
❑ Frightened, anxious, having difficulty coping
❑ Confused / disorientated
❑ Language barrier
❑ Flirtatious / sexually inappropriate

Potter, P., & Stockert, H. (2017). Fundamentals of nursing (9th ed.). St. Louis, MO: Elsevier. (Chap 24) 30
 Be sensitive to non-verbal cues when communication

Micro expression
- Conscious suppression (intentional)
- Unconscious repression (unintentional)

Nurse shall be able to:

❖ Spot concealed emotions
❖ Improve your emotional intelligence
❖ Enhance your relationship
❖ Develop your capacity for empathy
❖ Understand others

Riley, J. B. (2017). Communication in nursing (8th ed.). St. Louis, MO: Elsevier. (Chp 1) 31
Any other consideration?
▪ It is good to giving reassurance?
o A good intention but can also devalue the client’s feelings if used inappropriately
o Discourage further expression of feelings
▪ Approving or disapproving / agreeing or disagreeing
o Avoid directly disapproving the client’s idea/behavior
o Avoid judgmental → eg. “good” or “bad”; right or wrong

▪ Giving advice
o Involve the patient in health decision making as a patient-centered care instead of
directly instruct the patient

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Summary
Nurse Patient Relationship

Nurse
Patient
Values
Values
Culture race
Nurse Patient Culture race
Beliefs Relationship
Beliefs
Past experiences
Past experiences
Expectations
Expectations
Preconceived ideas

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Summary

Initiate the conversation appropriately

1. Ensure environment is private, safe & comfort for effective communication

2. Introduce self
3. Explain the purpose of the interview

4. Reassure client about confidentiality

Establish rapport and trust

1. Demonstrate SOLAR*
2. Show respect and non-judgmental manner*

3. Demonstrate congruity between verbal and non verbal behavior

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 Summary

Demonstrate two-way verbal communication

1. Speak clearly and concisely

2. Address client’s express feelings

3. Demonstrate listening and questioning skills

e.g. use paraphrasing and clarification appropriately

4. Response with accurate information*

5. Summarize and close the conversation appropriately

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Reference

Potter, P., & Stockert, H. (2017). Fundamentals of nursing (9th ed.). St. Louis, MO:
Elsevier.

Stuart, G. W. (2013). Principles & practice of psychiatric nursing (10th ed.). St Louis:
Elsvier Mosby.

Townsend, M. C., & Morgan, K. I. (2019). Essentials of psychiatric mental health

nursing: Concepts of care in evidence-based practice (9th ed.). Philadelphia, PA: F. A.
Davis Company.

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