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Communication:

Therapeutic Communication
Is the foundation of every action in healthcare
Is different from normal communication because it adds the element of
Empathy for the patient.
Must be nontechnical but technically accurate
Must be expressed appropriately with regard for the patients emotional
situation and state of mind
Communication will make or break your career/business
Pts have a choice of what doctor to go to. Pts will shop around for the one
that has the best communication with pts. The one that listens, takes time
and answers questions.
Communication Cycle
Communication involves two or more individuals
4 basic elements
o Sender
o Message
o Receiver
o Feedback
Sender- begins the cycle: encodes/ creates the message. Must judge the
situation and the receiver to determine best message in complexity and
content, must consider best mode to deliver message.
Message- is the content that needs to be expressed. There are 4 modes or
channels of communication.
o Speaking
o Listening
o Gestures/body language
o Writing
Channel choice can be affected by
o Physical and Mental development
o Culture
o Education level
o Life experience
o Our impressions of models and mentors
o How we feel and accept ourselves as individuals
Receiver- decode or interpret the meaning.
o Listening is the primary sensory skill for verbal communication
o The receiver must also be aware of tone, pitch and speed as well as
body language
Feedback- is the receivers response to the message. Necessary for the
sender to determine if their message was interpreted properly.

Listening Skills-Must be alert to all aspects of communication; verbal and
nonverbal
o Active listening method- the received message is repeated back to
the sender in the receivers own words.
o Listening with a third ear be aware of what the patient is NOT
saying, pick up on hints to the real message, observe body language
3 Listening goals
1. Improve listening skills so pt is heard accurately
2. Listen for what is not said and for hints of information
3. Be able to determine how accurately the pt is receiving information
Sometimes the only problem is that the patient needs someone
o to listen,
o to acknowledge their difficulty
o to remember that the patient can help find a solution to their own
problem
Communication skills take years of practice, should constantly evolve and
will never be perfect.

Types of communication
Verbal spoken
Nonverbal


Verbal communication is spoken.
Remember the words must have meaning and both the sender and the receiver
must apply the same meaning for the message to be understood.
The 5 Cs
Complete-must include all information the patient needs
Clear- must articulate, using good diction and enunciate each word distinctly.
Patient must have time to process message and verify the meaning.
Concise- must be brief. Should not contain unnecessary information. Dont
overload patient.
Cohesive- must be organized and logical in its progression. Dont ramble or jump
from topic to topic. Patient should be able to follow message easily.
Courteous- It only takes a moment. Be nice, Be respectful.
5 key points: Good communication skills:
1. Helps establish rapport with pt
2. Makes pt feel respected and validated
3. Encourages pt to verbalize their feelings and concerns
4. Helps pt to understand technical information
5. Allows pt to participate in decisions about their personal health needs.
Nonverbal Communication
Also called Body language. Includes unconscious body movements, gestures,
and facial expressions.
Kinesics- study of body language.
Nonverbal- is the first language learned.
Body language usually expresses true feelings
70% of language is transmitted through nonverbal communications.
23% is tone of voice
7% is in the words

Facial Expressions
Considered most important and most observed nonverbal
Of the face, the eyes show the most information.
o Staring is considered dehumanizing
o Interpreted as an invasion of privacy
o However, lack of eye contact may be seen as avoidance or
disinterest.
Medical staff must train themselves not to stare at pt
ailments that look different.

Cultural influence must be considered.
Some nonverbals are universal but others have very different messages
o Prolonged eye contact is rude or invasion of privacy
o Some cultures avoid eye contact to display modesty
o Some see eye contact as a hostile or aggressive action
It is important to understand the cultures of the patients treated in your facility.
Personal Space:
The distance at which we feel comfortable with others while
communicating.
Individuals may feel threatened when someone enters their space
uninvited.
o Based on US culture
Intimate: touching to 1.5 ft
Personal: 1.5ft-4ft
Social: 4ft- 12ft
Public: 12ft-15ft
In Japan, no word for privacy. Public crowding is viewed as a sign if
warmth and pleasant intimacy
American Indians may view a handshake as aggression
Arabs like to touch their companions. To feel and smell them. They
maintain intense eye contact when talking.
Remember: may of the events that occur during a normal office visit may be
considered invasive in other cultures. Ex: vital signs and injections
Make sure you explain what you need to do and get the patients permission
first.
Posture:
Relates to the position of the body or body parts
The manner in which we carry ourselves.
We tend to tense up when threatened or when in unknown situations
Body posture can show a lot about the pt; pain, depression, etc
Position:
The physical stance between two people when they are communicating.
In medical provider-patient relationship face to face is best. It allows
provider to observe pts verbal and nonverbal cues.
Beware of standing over a pt, this can signal superiority but too much
distance can be interpreted as avoidance or exclusivity.
Leaning toward pt is usually considered to express warmth, caring,
interest, acceptance and trust.
Moving away from pt can be interpreted as dislike, disinterest, boredom,
indifference, suspicion or impatience.
It is best, if possible, to start out with pt in a chair. Medical provider can
sit on a stool that can easily be move toward pt.
This set up gives pt a feeling of being valued, listened to and cared for.
Gestures and Mannerisms
Most of us use gestures when talking. Often they help convey message.
But be aware of how gestures may be interpreted.
o Finger-tapping = impatience, nervousness
o Shrugging shoulders = indifference, discouragement
o Rubbing your nose = puzzlement
o White knuckles or clenched fist = anger
o Fidgeting = nervousness

Touch:
Is a powerful tool
Has well defined boundaries
Is closely linked to personal space
Must understand cultural differences.
o Vietnamese, Cambodian, Hmong, and Thai traditionally consider
the head to be the site of the soul. Avoid touch the head unless
necessary. If you must explain and get permission before.
o Southeast Asian pts may fear body intrusion, physical exams and tx
must be explained thoroughly before they are performed.
o Most pt understand and accept touch that expresses caring,
sincerity, understanding and reassurance.
o However, not all pts are comfortable with physical contact.
o If a pt seems uncomfortable with physical contact, ask permission
and work to create a safe and reassuring environment.
Congruency in Communication:
Make sure verbal and nonverbal messages are congruent. No mixed
messages.
Clustering is the grouping of nonverbal messages
Masking involves an attempt to hide true feeling or message.
Perceptive medical staff must be on the lookout for this.
Perception- the conscious awareness of ones own feelings and the
feelings of others.
Factors affecting Therapeutic communication
Anything that interferes with the pts ability to focus has a negative impact
on communication.
Age and Gender Barriers
Have strong influences of how we communicate
Economic Barriers
Discussions of billing and payment procedures at the first office visit or
before a major procedure will be helpful to both the pts and the medical
staff.
Education and Life experience Barriers
Will in part determine how pts react to their care
Pts with family history of a disease or illness will understand better how it
will affect them.
Individuals who have already suffered loss and grief may handle life-
threatening illnesses more calmly that someone who has never
experienced grief.
Bias and Prejudice Barriers
Bias- a slant toward a particular belief
Prejudice- an opinion or judgment formed before all the facts are in.
Common biases
o Preference for western style of medicine
o Choosing providers based on gender
o Discriminating based on race/religion
o Prejudice based on sexual preference
o Hostile attitudes towards people with difference values
o Belief that people who cannot afford care should get less care
*Medical personnel should not let their biases and prejudices prevent them
from responding appropriately with therapeutic communication.
Verbal Road blocks to Therapeutic Comminucation
o See chart from page 60
o It must be the concern of every health care professional to facilitate
communication by encouraging and enabling pts to express themselves
honestly and without fear.
Defense mechanisms
o Behavior used to protect the ego from guilt, anxiety or loss of self esteem.
o Regression
o Repression
o Projection
o Sublimation
o Displacement
o Compensation
o Rationalization
o Undoing
Barriers caused by Cultural and Religious Diversity
o Culture-a pattern of many concepts, beliefs, values, habits, skills,
instruments, and art of a given belief.
Communication Context
o Low-context communication
o Uses few idioms to convey idea.
o Relies on explicit and highly detailed language
o Is direct and in your face
o May be seen as rude or arrogant
o High-context communication
o Relies of body language, reference to environmental objects and
culturally relevant phraseology to communicate an idea.
o Indirect and seems to take forever to get to the point
o Thought of as mentally slow or uneducated
o Neither method is superior
o Medical personnel should attempt to utilize the style used by the pt when
practical.
Time focus-
o Future
o Present
o Past
Human needs as a barrier
o Maslows hierarchy of needs
o Joseph Maslow
o See and know chart page 64
Therapeutic communication action
o Interview techniques
o Closed ended questions
o Open ended questions
o Indirect statements
Point of Care Techniques
o Point of care is the time/location at which the pt and the medical
personnel interact.
o The principle barrier to communication at Point of care is Emotional
tension.
o Pt may be in pain
o Pt may be worried about health problem
o Pt may be scared
The goal of therapeutic communication is to reassure the pt and to provide the
best care possible through building rapport, active listening and reducing or
removing barriers.