Week # 5 Module Three.

Nursing As An Art
1. Caring
1.a Caring Practice Models
1. 6 C’s of Caring
1.c Caring for Self and others
Week # 6 Communication https://www.youtube.com/watch?v=ZomOEH97xIk(11 mins)
2.a Process and Mode https://youtu.be/HK_ieW0MvL8.(7.05)
2.b Therapeutic Communication
2.c Helping Relationship
2.d Communication and the Nursing Process
1. Teaching
3.a Health Promotion
3.b Disease Prevention
3.c Health Restoration and Maintenance
3.d Rehabilitation
Module Four: Nursing As A Science
1. Problem Solving Process
2. Nursing Process https://youtu.be/Rl1Zo7rbT6s (1hr & 8 minutes)
2.1 ASSESSMENT
2.1a Subjective Health History
2.1b Objective Physical Examination and Diagnostic Tests
2.2 NURSING DIAGNOSIS
2.2a NANDA
Week # 7 & 8 2.2b NANDA Taxonomy II
2.3. PLANNING
2.3a Types; Types, On-going, Discharge
2.3b Nursing Outcomes Classification (NOC
2.4 INTERVENTION
2.4a Nursing Intervention Classification (NIC)
2.4b Types: Independent, Dependent, Interdependent
2.4c Health Education
2.5 EVALUATION
2.5a Types: Planned, On-going, Purposeful
End of MIDTERM
PERIOD
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Intended Learning Outcomes:

After the completion of the module, the learner should be able to:

Discuss the meaning of communication and factors influencing the process.

Discuss nurse-client communication as a dynamic process.
Describe the four phases of helping relationship.
Discuss how nurses uses communication skills in each phase of the nursing process.
State why effective communication is overbearing among health professionals.

COMMUNICATION

What is communication?
Communication is the process of sharing information or the process of generating and transmitting meanings.
Communication is the process of exchanging information or feelings between two or more people. It is a basic
component of human relationship, including nursing.

• It is the act of conveying meanings from one body or group to another through the use of mutually
understood signs, symbols, and semiotic rules.
• It is the foundation of our way of life.
• It is also a requirement for a person’s well-being.
• Social interactions among people are necessary to fulfill some of their most elemental
psychosocial needs, such as love, affection, and recognition.
• Originally came from the Latin word “communicare” which means “to impart, share, or make
common.”
Is the means to establish a helping-healing relationship. All behavior communication influences
behavior. Communication is essential to the nurse-patient relationship for the following reasons:
• Is the vehicle for establishing a therapeutic relationship.
• It the means by which an individual influences the behavior of another, which leads to the
successful outcome of nursing intervention.

General Purposes of Communication The following are the purposes of communication:

• To gather information
• To validate information
• To share information
• To develop a trusting relationship
• To express feelings
• To imagine
• To influence
• To meet social expectations
Elements of Communication The following are the six elements of communication which are needed to perform
effective communication:
1. Referent or Stimulus. It motivates an individual to communicate with another. It may be an
objective, emotion, idea, need, or act.
2. Sender or Encoder. It is the individual who initiates interpersonal communication or message.
3. Message. It is the information that is sent or expressed by the sender
4. Channel. It is the means of conveying messages such as auditory, visual, or tactile senses
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.
5. Receiver or Decoder. It is the person to whom the message is sent.
6. Feedback. It helps to reveal whether the meaning of the message is received or effective.
Steps in Communication Process The following are the steps in the communication process:
1. Thinking. Starts with the information about the idea in the sender’s mind.
2. Encoding. Putting thoughts into a form for possible communication, including translating
experiences into facial expressions, body movements, eye movements, etc.
3. Transmitting. Spreading the message through a medium channel (oral, written, or gestures).
4. Perceiving. Receiver perceives the message through the use of the senses.
5. Decoding. Receiver translates the meaning of the message into an understandable form.
6. Understanding. Receiver understands the intended message from the source.

Channels of Communication It is necessary that whatever type of communication is utilized, the data needs to
be conveyed effectively. Various modes or medium to transmit and receive the information is referred to as
“communication channels.”

1. Auditory
• Hearing. The act of perceiving sound by the ear (e.g., city sounds, traffic, horns, people,
ambiance).
• Listening. The ability to accurately receive and interpret messages in the communication
process. (e.g., radio, audio conferencing).
2. Visual
• Sight. The process, power, or function of seeing (e.g.., the sights of the newly-built hospital)
• Reading. The complex cognitive process of decoding symbols involving word recognition,
comprehension, fluency, and motivation (e.g., written letters, memos, chats and messaging)
• Observation. The action or process of observing something or someone carefully or in order to
gain information (e.g., traffic signs, watching, monitoring, scrutiny, examination, inspection)
• Perception. The ability to see, hear, or become aware of something through the senses (e.g.,
discernment, appreciation, recognition, realization, cognizance)
3. Kinesthetic
• Procedural touch. This is taught in nursing school as part of assessment and procedures (e.g.,
auscultation of the heart and lungs to more “intimate” physical exams)
• Caring touch. An expressive or comfort touch is rarely taught as part of nursing care (e.g., tap
on the shoulder)

Supporting References:

https://www.youtube.com/watch?v=ZomOEH97xIk (11 mins)

https://youtu.be/HK_ieW0MvL8 .(7.05)
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Modes of Communication

Communication can be verbal and nonverbal. The following are the modes of communication:

1. Verbal Communication. This involves spoken and written words. Words are tools or symbols used to
express feelings or ideas, arouse emotional responses, or describe objects, observations, memories, or
inferences.
• Paraverbal or Paralinguistic cue. It adds meaning to a message. Cues like tones, the pitch of
voice, speed, volume, inflections, and grunts are examples of cues that can lead to understanding
even if a language barrier exists.
Pace and Intonation
• The manner of speech, as in the pace or rhythm and intonation, will modify the feeling and impact
of the message. For example, speaking slowly and softly to an excited client may help calm the
client.
Simplicity
• Includes the use of commonly understood words, brevity, and completeness.
• Nurses need to learn to select appropriate, understandable terms based on the age, knowledge,
culture and education of the client. For example, instead of saying to a client, “the nurses will be
catheterizing you tomorrow for a urinalysis”, I would be more appropriate to say, “Tomorrow we
need to get a sample of your urine, so we will collect it by putting a small tube into your bladder”.
Clarity and Brevity
• A message that is direct and simple will be more effective. Clarity is saying precisely what is
meant, and brevity is using the fewest words necessary.
• The goal is to communicate clearly so that all aspects of a situation or circumstances are
understood. To ensure clarity in communication, nurses also need to speak slowly and enunciate
carefully.
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Timing and Relevance
• No matter how clearly or simply words are stated or written, the timing needs to be appropriate
to ensure that words are heard.
• This involves sensitivity to the client’s needs and concerns. E.g., a client who is enmeshed in fear
of cancer may not hear the nurse’s explanations about the expected procedures before and
after gallbladder surgery.
Adaptability
• What the nurse says and how it is said must be individualized and carefully considered. E.g., a
nurse who usually smiles, appears cheerful, and greets his clients with an enthusiastic “Hi, Mrs.
Jones!” notices that the client is not smiling and appears distressed. It is important for the nurse
to then modify his tone of speech and express concern in his facial expression while moving
toward the client.
Credibility
• Means worthiness of belief, trustworthiness, and reliability. Nurses foster credibility by being
consistent, dependable, and honest.
• Nurses should convey confidence and certainly in what they are saying, while being to
acknowledge their limitations (e.g., “I don’t know the answer to that, but I will find someone who
does”.
Humor
• The use of humor can be a positive and powerful tool in nurse- client relationship, but it must
be used with care. When using humor, it is important to consider the client’s perception of what
is considered humorous.

2. Nonverbal Communication. This involves transmission of messages without the use of words. It involves
facial expression, posture, touch, gestures, physical appearance, eye contact, and other body movements.
These are considered more accurate expressions of true feelings. Gestures impart meanings that are more
powerful than words. The following are examples of nonverbal communication:
• Facial expressions.
Considered as the greatest conveyor of nonverbal messages. It is through the face, mostly the
eyes, where emotions and feelings such as fear, concern, interest, sadness, honesty, anger,
excitement, and flirtation are conveyed.
• No part of the body is as expressive as the face
• Although the faces may express the person’s genuine emotions, it is also possible to control
these muscles so the emotion expresses does not reflect what the person is feeling. When the
message is not clear, it is important to get feedback to be sure of the intent of expression.
• Nurses need to be aware of their own expressions and what they are communicating to others.
• It is impossible to control all facial expression, but the nurse must learn to control expressions of
feelings such as fear or disgust in some circumstances.
Eye contact is another essential element of facial communication
• Posture.
May indicate anxiety, relaxation, negative or positive image, confidence, depression,
bodily condition, acceptance or interest, rejection or aversion, exhaustion, or boredom.
The ways people walk and carry themselves are often reliable indicators of self-concept,
current mood, and health. Erect posture and an active, purposeful stride suggest a feeling
of well-being. Slouched posture and slow, shuffling gait suggest depression or physical
discomfort.
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The nurse clarifies the meaning of the observed behavior, e.g. “You look like it really hurts
you to move. I’m wondering how your pain is and if you might need something to make
you more comfortable?”

• Gestures. Movements of body parts such as shrugging of shoulders, waving the hands, tapping
the feet. Openness and willingness to listen to the patient may be depicted by facing him in a
relaxed position, with hands resting palms up on the lap. Crossed arms pulled close against the
body may indicate non-acceptance and a lack of desire to hear the patient.
• Touch. Can be used to soothe, comfort, and establish rapport. It can reflect a sense of caring
but can also be perceived as hostile. It should be used cautiously to patients or clients who are:

• Confused. They may misinterpret the intent of the touch

• Aggressive. They may see touch as a threat and can cause a commotion
• Suspicious. They may think that touch would cause harm
• Victims of abuse. Touch may frighten them

• Physical Appearance or Artifacts.

Involve items in the client’s environment such as grooming or use of clothing and jewelry.
They may convey nonverbal messages that might enhance or hinder the real message
of the spoken words.
When the symbolic meaning of an object is unfamiliar the nurse can inquire about its
significance, which may foster rapport with the client.
How a person dresses is often an indicator of how person feels. E.g. For acutely ill clients
n hospital or home care settings, a change in grooming habits may signal that the client
is feeling better. A man may request a shave, or a woman may request a shampoo and
some makeup.

• Proxemics. Involves distance.

• Intimate (0–18 inches)
• Personal (18 inches–4 feet)
• Social (4 feet–12 feet)
• Public (12 feet–limit)
• Chronemics. The study of the use of time. It includes punctuality, willingness to wait, and
interactions. The use of time affects lifestyle, daily agenda, speed of speech and movements.
2. Personal Appearance
• When the symbolic meaning of an object is unfamiliar the nurse can inquire about its significance,
which may foster rapport with the client.
• How a person dresses is often an indicator of how person feels. E.g. For acutely ill clients n
hospital or home care settings, a change in grooming habits may signal that the client is feeling
better. A man may request a shave, or a woman may request a shampoo and some makeup.
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3. Posture and Gait

• The ways people walk and carry themselves are often reliable indicators of self-concept, current
mood, and health. Erect posture and an active, purposeful stride suggest a feeling of well being.
Slouched posture and slow, shuffling gait suggest depression or physical discomfort.
• The nurse clarifies the meaning of the observed behavior, e.g. “You look like it really hurts you to
move. I’m wondering how your pain is and if you might need something to make you more
comfortable?”
4. Facial Expression
• No part of the body is as expressive as the face
• Although he face may express the person’s genuine emotions, it is also possible to control these
muscles so the emotion expresses does not reflect what the person is feeling. When the message
is not clear, it is important to get feedback to be sure of the intent of expression.
• Nurses need to be aware of their own expressions and what they are communicating to others.
• It is impossible to control all facial expression, but the nurse must learn to control expressions of
feelings such as fear or disgust in some circumstances.
• Eye contact is another essential element of facial communication
5. Gesture
• Hand and body gestures may emphasize and clarify the spoken word, or they may occur without
words to indicate a particular feeling or give a sign

1. Electronic Communication– many health care agencies are moving toward electronic medical records
where nurses document their assessments and nursing care.
E-mail
• Most common form of electronic communication.
• Advantage: It is fast, efficient way to communicate and it is legible. It provides a record of the
date and time of the message that was sent or received.
• Disadvantage: risk of confidentiality
• When Not to Use Email:
a. When information is urgent b. Highly confidential information (e.g. HIV status, mental health, chemical
dependency) c. Abnormal lab data
• Agencies usually develop standards and guidelines in use of e-mail

Types of Communication
1. Social Communication. Conversation is usually superficial and meets the needs of both parties.
Its purpose is for enjoyment and prevents boredom.
2. Therapeutic Communication. Promotes the establishment of the nurse-patient relationship for
the creation of a beneficial outcome for the client. Its purpose is to improve the patient’s ability to
function.
3. Formal Communication. Includes written messages and the medium may consist of reports,
lectures, charting in the patient’s record, and public speaking. Generally, with formal
communication, there is one sender transmitting messages to several other.
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Benefits of Effective Communication By applying effective communication in the work setting, there are many
benefits that emerge from it.
1. The sender and the receiver can exchange information simultaneously with a lesser possibility
of confusion or missing out on information. Therefore, allow more accurate assessment of the
information and avoid any decline in productivity.
2. Effective communication allows individuals to work mutually without any apprehensions about
being ignored due to their different backgrounds or status. Members manage to do better when
they are recognized, appreciated, respected, and be heard by others.
3. One would be able to establish his self-confidence and self-respect and be more assured when
they have to speak and respond to others.
4. It helps strengthen relationships with other people. Through good communication, the individual
is able to interact and collaborate efficiently with others and thus, build a stronger relationship by
trust.

Barriers to Effective Communication

1. Giving an Opinion. This takes decision-making away from the client. It inhibits spontaneity, stalls
problem-solving, and creates doubt.
2. Offering False Reassurances. This involves twisting the truth into something that sounds
reassuring but is indefinite enough that it could mean anything.
3. Being Defensive. Defensive behaviors are usually harmful to both the person doing them and
those on the receiving end.
4. Showing Approval or Disapproval. Expressing approval can be as harmful to both parties as
stating disapproval. Offering unnecessary approval on the other hand implies that the behavior
being praised is the only acceptable one.
5. Stereotyping. Making assumptions about someone because of factors like race, status, beliefs,
etc. The use of stereotypes inhibits communication and threatens the relationship between both
parties.
6. Changing the Subject Matter Inappropriately. This approach shows lack of empathy.
Changing the subject halts the progress of the communication process.
7. Language barrier. Conflicting language might occur and the communicators might not be able
to understand each other. This can happen in any setting because everyone has their own mother
tongue language as well as their own understanding of certain words and phrases.
8. Time Barrier. Choosing when to approach an individual to talk to about something is very
significant because if you do not choose the appropriate time, the person whom you are trying to
convey the message might not be engaged in listening to you.
9. Lack of knowledge on the topic. Lack of understanding of the topic would make communication
complicated for both the sender and the receiver. Normally, people communicate easier when
the topic is something that both of them are familiar with.
10. Information overload. Processing information takes time and if communication does not go at
a pace where both parties can have sufficient time to carry out their thought process, then it will
cause communication breakdown as concentration and attention might be haltered.
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Reasons for Ineffective Communication What are the instances where communication may fail? Any
interference or failure in the process can create ineffective communication.
1. The sender may not be able to send the message he thought he already sent
2. The receiver may not hear or receive the message intended
3. Conflict of verbal and nonverbal messages
4. Multiple meanings of certain words.
5. The message may be considered abstract and may be confusing
6. The receiver may not be ready to hear or receive further information

Phases of Communication-HELPING RELATIONSHIP

Orientation Phase
• The tone and guidelines for the relationship are established.
• The nurse and client are strangers to each other, however, each individual has preconceptions
of what to expect – based on previous relationships, experiences, attitudes, and beliefs.
• The parameters of the relationship are established (e.g., place of meeting, length, frequency, role
or service offered, confidentiality, duration of relationship).
• The client and nurse begin to learn to trust and know each other as partners in the relationship.
• Trust, respect, honesty, and effective communication are key principles in establishing a
relationship.

Working Phase
• The working phase is the longest phase.
• This is where nursing interventions usually take place.
• Problems and issues are identified and plans to address these are put into action. Positive
changes may alternate with resistance and/or lack of change
• Interaction is the essence of this phase.
• It is vital for the nurse to validate thoughts, feelings, and behaviors.
• The nurse aids the client to explore thoughts (e.g., views of self, others, environment, and
problem-solving), feelings (e.g., grief, anger, mistrust, sadness), and behaviors (e.g.,
promiscuity, aggression, withdrawal, hyperactivity).
• The content to be explored is chosen by the client although the nurse facilitates the process.
• The nurse resumes assessment throughout all phases of the relationship.
• Further problems and needs may arise as the nurse-client relationship develops and as earlier
identified issues are addressed.
• The nurse advocates for the client to ensure that the client’s perspectives and priorities are
reflected in the plan of care.
• The interactions that occur at this time are purposeful in that they have been designed to ensure
achievement of mutually agreed-upon goals and objectives.
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Termination Phase
• The resolution or ending phase is the final stage of the nurse-client relationship.
• This occurs when the conclusion of the initial agreement is acknowledged.
• After the client’s problems or issues are addressed, the relationship needs to be completed
before it can be terminated.
• The ending of the nurse-client relationship is based on mutual understanding and a celebration
of goals that have been met.
• Both the nurse and the client experience growth.
• Termination may be met with uncertainty.
• The nurse and the client must recognize that loss may accompany the ending of a relationship.
• Both should share feelings related to the ending of the therapeutic relationship.
• Validating plans for the future may be a useful strategy.
• Increased autonomy of both the client and the nurse is recognized in this phase.

HELPING RELATIONSHIP

Nurse–client relationships are referred to by some as interpersonal relationships, by others as therapeutic relationships,
and by still others as helping relationships. Helping is a growth-facilitating process that strives to achieve three basic goals
:
1. Help clients manage their problems in living more effectively and develop unused or underused opportunities more
fully.
2. Help clients become better at helping themselves in their everyday lives.
3. Help clients develop an action-oriented prevention mentality in their lives.

A helping relationship may develop over weeks of working with a client, or within minutes. The keys to the helping
relationship are
(a) the development of trust and acceptance between the nurse and the client and (b) an underlying belief that the nurse
cares about and wants to help the client.

The personal and professional characteristics of the nurse and the client influence the helping relationship. Age, gender,
appearance, diagnosis, education, values, ethnic and cultural background, personality, expectations, and setting can all
affect the development of the nurse–client relationship. Consideration of all these factors, combined with good
communication skills and sincere interest in the client’s welfare, will enable the nurse to create a helping relationship.

Characteristics of helping relationships are listed in Box 26–2.

Phases of the Helping Relationship

The helping relationship process can be described in terms of four sequential phases, each characterized by identifiable
tasks and skills. The relationship must progress through the stages in succession because each builds on the one before.
Nurses can identify the progress of a relationship by understanding these phases: pre-interaction phase, introductory
phase, working (maintaining) phase, and termination phase. Table 26–3 summarizes the tasks and skills required.
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PREINTERACTION PHASE
The preinteraction phase is similar to the planning stage before an interview. In most situations, the nurse has information
about the client before the first face-to-face meeting. Such information may include the client’s name, address, age,
medical history, and/or social history. Planning for the initial visit may generate some anxious feelings in the nurse. If the
nurse recognizes these feelings and identifies specific information to be discussed, positive outcomes can evolve.

INTRODUCTORY PHASE
The introductory phase, also referred to as the orientation phase or
the pre helping phase, is important because it sets the tone for the rest of the relationship. During this initial encounter,
the client and the nurse closely observe each other and form judgments about the other’s behavior. The goal of the nurse
in this phase is to develop trust and security within the nurse–client relationship (Boyd, 2012). Other important tasks of
the introductory phase include getting to know each other and developing a degree of trust.

After introductions, the nurse may initially engage in some social interaction to put the client at ease. For example, the
nurse and client may talk about what a nice day it is and what they would like to do if at home.

During the initial parts of the introductory phase, the client may display some resistive behaviors.

Resistive behaviors are those that inhibit involvement, cooperation, or change. They may be due to difficulty in
acknowledging the need for help and thus a dependent role, fear of exposing and facing feelings, anxiety about
the discomfort involved in changing problem-causing behavior patterns, and fear or anxiety in response to the
nurse’s approach, which may, in the client’s opinion, be inappropriate. Resistive behaviors can be overcome by
conveying a caring attitude, genuine interest in the client, and competence. These behaviors of the nurse also
foster the development of trust in the relationship. Trust can be described as a reliance on someone without
doubt or question, or the belief that the other person is capable of assisting in times of distress and in all likelihood
will do so. To trust another person involves risk; clients become vulnerable when they share thoughts, feelings,
and attitudes with the nurse. Trust, however, enables the client to express thoughts and feelings openly.

By the end of the introductory phase, clients should begin to:

Develop trust in the nurse.
View the nurse as a competent professional capable of helping.
View the nurse as honest, open, and concerned about their welfare.
Believe the nurse will try to understand and respect their cultural values and beliefs.
Believe the nurse will respect client confidentiality.
Feel comfortable talking with the nurse about feelings and other sensitive issues.
Understand the purpose of the relationship and the roles.
Feel that they are active participants in developing a mutually agreeable plan of care.

WORKING PHASE

During the working phase of a helping relationship, the nurse and the client begin to view each other as unique
individuals. They begin to appreciate this uniqueness and care about each other. Caring is sharing deep and
genuine concern about the welfare of another person. Once caring develops, the potential for empathy increases.
The working phase has two major stages: exploring and understanding thoughts and feelings, and facilitating
and taking action. The nurse helps the client to explore thoughts, feelings, and actions and helps the client plan
a program of action to meet preestablished goals.
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EXPLORING AND UNDERSTANDING THOUGHTS AND FEELINGS

The nurse must have the following skills for this phase of the helping relationship:

• Empathetic listening and responding.

Nurses must listen attentively and communicate (respond) in ways that indicate they have listened to what was
said and understand how the client feels. The nurse responds to content or feelings or both, as appropriate. The
nurse’s nonverbal behaviors are also important. Nonverbal behaviors indicating empathy include moderate head
nodding, a steady gaze, moderate gesturing, and little activity or body movement. According to Boyd (2012),
empathy is “the ability to experience, in the present, a situation as another did at some time in the past; the ability
to put oneself in another person’s circumstances and feelings” (p. 112). Empathetic listening focuses on a kind
of “being with” clients to develop an understanding of them and their world. This understanding, however, must
also be communicated effectively to the client in the form of an empathetic response. The end result of empathy
is comforting and caring for the client and a helping, healing relationship.

• Respect
The nurse must show respect for the client’s willingness to be available, desire to work with the client, and a
manner that conveys the idea of taking the client’s point of view seriously.

• Genuineness
Kneisl and Trigoboff (2013) describe genuineness as “the ability to be real or honest with another” (p. 195). To
be effective, genuineness must be based on a solid relationship that is empathic and not phony. Phoniness can
be expressed in a variety of ways, such as pretending to like someone when you do not or overstressing your
professional role (e.g., I am the expert, the one with all the answers). Phoniness is incompatible with respect
(Egan, 2014). The nurse who is genuine is more likely to help the client.

Concreteness. The nurse must assist the client to be concrete and specific rather than to speak in generalities.
When the client says, “I’m stupid and clumsy,” the nurse narrows the topic to the specific by pointing out, “You
tripped on the rug.”

Confrontation. The nurse points out discrepancies between thoughts, feelings, and actions that inhibit the client’s
self-understanding or exploration of specific areas. This is done empathetically, not judgmentally. During this
first stage of the working phase, the intensity of interaction increases, and feelings such as anger, shame, or
self-consciousness may be expressed. If the nurse is skilled in this stage and if the client is willing to pursue self-
exploration, the outcome is a beginning understanding on the part of the client about behavior and feelings.

FACILITATING AND TAKING ACTION

Ultimately the client must make decisions and take action to become more effective. The responsibility for action
belongs to the client. The nurse, however, collaborates in these decisions, provides support, and may offer
options or information.
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TERMINATION PHASE

The termination phase of the relationship is often expected to be difficult and filled with ambivalence. However,
if the previous phases have evolved effectively, the client generally has a positive outlook and feels able to
handle problems independently. On the other hand, because caring attitudes have developed, it is natural to
expect some feelings of loss, and each person needs to develop a way of saying good-bye. Many methods can
be used to terminate relationships. Summarizing or reviewing the process can produce a sense of
accomplishment. This may include sharing reminiscences of how things were at the beginning of the relationship
and comparing them to how they are now. It is also helpful for both the nurse and the client to express their
feelings about termination openly and honestly. Thus, termination discussions need to start in advance of the
termination interview. This allows time for the client to adjust to independence. In some situations, referrals are
necessary, or it may be appropriate to offer an occasional standby meeting to give support as needed. Follow
up phone calls or e-mails are other interventions that ease the client’s transition to independence.

Developing Helping Relationships

Whatever the practice setting, the nurse establishes some type of helping relationship in which mutual goals
(outcomes) are set with the client or, if the client is unable to participate, with support people. Although special
training in counseling techniques is advantageous, there are many ways of helping clients that do not require
special training:

Listen actively. Help to identify what the person is feeling. Often clients who are troubled are unable to
identify or to label their feelings and consequently have difficulty working them out or talking about them.
Responses such as “You seem angry about taking orders from your boss” or “You sound as if you’ve
been lonely since your wife died” can help clients recognize what they are feeling and talk about it.
Put yourself in the other person’s shoes (i.e., empathize). Communicate to the client in a way that shows
an understanding of the client’s feelings and the behavior and experience underlying these feelings.
Be honest. In effective relationships nurses honestly recognize any lack of knowledge by saying “I don’t
know the answer to that right now”; openly discuss their own discomfort by saying, for example, “I feel
uncomfortable about this discussion”; and admit tactfully that problems do exist, for instance, when a
client says “I’m a mess, aren’t I?”
Be genuine and credible. Clients will sense whether you are truly concerned.
Use your ingenuity. There are always many courses of action to consider in handling problems. Whatever
course is chosen needs to further the achievement of the client’s goals (outcomes), be compatible with
the client’s value system, and offer the probability of success.
Be aware of cultural differences that may affect meaning and understanding. To facilitate nurse–client
interaction, recognize the language(s) and/or dialect(s) the client uses. Provide a bilingual interpreter as
needed for clients who have limited English language skills.
Maintain client confidentiality. To maintain the client’s right to privacy, share information only with other
health care professionals as needed for effective care and treatment.
Know your role and your limitations. Every person has unique strengths and problems. When you feel
unable to handle some problems, the client should be informed and referred to the appropriate health
professional. Clarify functions and roles, specifically what is expected of the client, the nurse, and the
primary care provider.
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MODULE III
NURSING AS AN ART

THERAPEUTIC COMMUNICATION TECHNIQUES

TECHNIQUE DESCRIPTION EXAMPLE

Broad opening To allow the patient to pick the topic, take the Is there anything you would like to
statements initiative to express self, and set the direction discuss? Where would you like to begin?
of the conversation. Note: there is no topic is What is on your mind today? What are you
given by the student. The patient gives the thinking about?
topic in response
Offering general Encourages the client to continue and that the Go on. And then? Tell me about it.
leads nurse is interested in what comes next.
Exploring Examines certain ideas, experiences, or children? Tell me about your coping
relationships more fully. mechanisms? What brought you here to the
hospital? What kind of relationship do you
have with your
Helps the patient focus on a certain point when Let’s stop and look more closely at your
they are jumping from topic to topic. The feelings about managing your medications.
Focusing
patient is talking about many things at once You’ve mentioned many things. Let’s go
and you focus in on one topic. back to your thinking of “giving up”.
Provides time for the patient to put thoughts or
Silence feelings into words, regain composure or
continue talking
Indicated the patient has been understood. It Uh-hmm. Yes. I’m following you. Nodding
Accepting does not indicate agreement and is
nonjudgmental.
Indicated awareness of change in personal Good morning, Mr. Jones. I see you have
Giving recognition efforts. Does not imply good or bad, right or put on your jewelry today. You’ve finished
wrong. your list of things to do.
Offers presence, interest, and a desire to listen I’ll sit with you her for a while. I would like to
Offering self to the patient. spend some time with you. I’m available if
you need to talk.
Calls attention to the patient’s physical
You appear tense. I noticed that you are
behavior or emotional state. How a person
Sharing observations biting your lip. You seem upset. You are
looks, sounds or acts. Verbalizing what the
trembling
nurse perceives
Repeating the main idea in order to be sure the Patient: “I have been tossing and turning all
patient has been understood. Restating night.” Nurse: “You are having difficulty
another’s message more briefly using one’s sleeping.” Patient: “I just give up.” Nurse:
own words “You don’t see the point of trying
Paraphrasing anymore.” Patient: “I’ve been overweight all
my life and never had any problems. I can’t
understand why I need to be on a diet.”
Nurse: “You are not convinced that you need
a diet because you’ve stayed healthy.”
Patient: “What do you think I should do about
Directing questions, feelings and ideas back to telling my employer about my illness?”
Reflecting the patient. Acknowledges the patient’s right to Nurse: “What have you been thinking about
have opinions and make decisions. this situation?” Patient: “Everyone ignores
me”. Nurse: “Ignores you?”
 FUNDAMENTALS OF NURSING PRACTICE
MIDTERM PERIOD-LECTURE
MODULE III
NURSING AS AN ART
THERAPEUTIC COMMUNICATION TECHNIQUES
TECHNIQUE DESCRIPTION
Providing information Makes facts available in order to assist in
decision-making or drawing conclusions
Sharing Empathy
Acknowledging feelings. To help the patient
know that feelings are understood and
accepted. Attempting to see the situation
through the client’s eyes.
Seeking Clarification To make clear that which is vague or
maximize understanding between the nurse
and patient. Asking for further explanation
or an example.
Verbalizing implied
thoughts and
feelings To voice what the patient has implied. To
verify impressions to help the patient more
fully aware of feelings expressed.
Sharing humor Discharge of energy through comic
enjoyment of the imperfect. Can reduce
tension and promote mental well-being.
Must be used carefully and sparingly
Seeking consensual Searching for mutual understanding
validation especially when slang terms have been
used.
Encouraging Brings out recurrent themes by looking at
comparison similarities or differences
Encouraging Assists the patient in considering things
evaluation from their own set of values or perspective
Encouraging Asking the patient to verbalize things from
description of their own perspective. Asking to describe
perception thoughts and feelings
Placing the event in
To help the patient see cause and effect or
time or in sequence
identify patterns of events and actions.
EXAMPLE
This medication is for you high blood
pressure. This test will determine your
treatment options. My purpose for being here
is…
Patient: “I hate it here. I wish I could go
home.” Nurse: “It must be difficult to stay in a
place you hate.” This diagnosis has been life
changing. You have a lot on your plate.
I am not sure I follow you. What would you
say the main point of what you said was? Can
you give me an example of a time you
thought everyone hated you.
Patient: “I can’t talk to you or anyone else
because it’s a waste of time.” Nurse: “Do you
feel that no one understands?” Patient: “My
wife pushes me around just like my mother and
sister did.” Nurse: “Is it your impression that
women are domineering?”
This gives a whole new meaning to “just
relax”.
Tell me whether my understanding of it
agrees with yours. Are you using this word to
convey that …?
Was it something like…..? Have you had a
similar experience? Has this ever happened
before?
What did it mean to you when he said her
couldn’t stay? How do you feel about your
recovery this time in the hospital?
What is happening right now? What are you
are thinking when you feel anxious?
When did this happen? What seemed to lead
up to….? Was it before or after….?
 FUNDAMENTALS OF NURSING PRACTICE
MIDTERM PERIOD-LECTURE

MODULE III
NURSING AS AN ART
THERAPEUTIC COMMUNICATION TECHNIQUES
TECHNIQUE DESCRIPTION EXAMPLE

Expressing uncertainty about the reality of

the patient’s perceptions. The patient can
Voicing become aware that others do not
Really? That’s hard to believe. Isn’t that unusual.
doubt necessarily perceive things in the same
way. This is not an attempt to get the
patient to change their point of view.
Sharing hope Communicating a sense of possibility to
achieve their potential. Commenting on the
positive aspects of the patient’s behavior,
I believe you will find a way to face your situation because I
performance, and responses. You must
have seen how you interact with your children in this
personally see the patient display the
situation.
behavior you base this hope on. It can’t be
based on things you did not observe because
that is a block called “false reassurance”.
Attempting to Patient: “I’m dead inside.” Nurse: “Are you saying you
Seeking to verbalize the patient’s feelings
translate into feel lifeless?” Patient: “I’m way out in the ocean.”
that are expressed only indirectly.
feelings Nurse: “Are you saying you feel lonely or deserted?”
Encouraging What could you do to let your anger our
Asking patient to consider kinds of
formulation harmlessly? Next time this comes up, how might you
behavior likely to be appropriate in future
of an action handle it? What are other ways you could approach
situations
plan your boss?
works out. During the past hour, you and I have
Concise review of the key aspects of the
discussed… We have discussed many ways to deal
Summarizing interaction to bring a sense of satisfaction
with your anger toward you mother. You have agreed
and closure.
to try a few and let me know how it
That happened to me once, too. It was devastating,
and I had to face some things about myself that I didn’t
GENERALIZED sharing of personal
Self- like. I went for counseling, and it really helped….What
experiences about the self to benefit the
disclosure are your thoughts about seeing a therapist?
patient.
helped….What are your thoughts about seeing a
therapist?
Calls attention to the patient’s physical You say you have already decided what to do; yet you
behavior or emotional state. How a are still talking a lot about your options. You said you
Confrontation
person looks, sounds or acts. Verbalizing wanted to attend the support group but you stayed in
what the nurse perceives. your room all day.
Recommend Repeating the main idea in order to be
or suggest sure the patient has been understood. Have you thought about….? Here are some things
options (do Restating another’s message more briefly other people in your situation have considered…..?
not advise) using one’s own words.
Directing questions, feelings and ideas
Let’s see if we can figure this out. Let’s work together
Suggesting back to the patient. Acknowledges the
to identify triggers to your anxiety. Let’s go to your
collaboration patient’s right to have opinions and make
room. I’ll help you find what you are looking for.
decisions.
Makes facts available in order to assist in Holding a patient’s hand or placing your hand on a
Using Touch
decision-making or drawing conclusions. patient’s shoulder.
Presenting Indicated what is real without arguing. Your mother is not here. I am the nurse. I see no one
reality Presenting the facts of a situation else in the room.
 FUNDAMENTALS OF NURSING PRACTICE
MIDTERM PERIOD-LECTURE

MODULE III
NURSING AS AN ART

NON - THERAPEUTIC COMMUNICATION TECHNIQUES

TECHNIQUE DESCRIPTION EXAMPLE

Nurse imposes own opinion and solutions What you should do is…. Why don’t
Giving
on the patient. Implies the patient cannot you…? Get out of that situation
advice/personal
make own decisions. These are decisions immediately. I would leave that person if
opinions
that are not ours to make. they did that to me.
Asking personal questions not relevant to
Asking personal the situation. These questions may be Why have you never gotten married? What
questions/probing asked due to personal curiosity and not for is your political party?
the client’s benefit.
Don’t worry, everything will be all right.
Attempts to dispel anxiety by implying there
False reassurance You’re doing fine. I wouldn’t worry about
is not sufficient reason for concern.
that. I’ve felt that way myself sometimes.
Everything happens for a reason. God
Automatic responses like these are
doesn’t give you more than you can handle.
Automatic responses/ belittling to the patient’s experience.
Keep your chin up. Everyone gets down in
clichés Minimizes the significance of the patient’s
the dumps. All old people are hard of
feelings.
hearing.
Not client centered. Opinions and
conclusions should come exclusively from
the patient. Nurses are neutral. Both can That’s good thinking. Great job! I agree. I’m
Giving approval/
cause dependence on the healthcare glad that… That’s bad for you. I’d rather you
Disapproval
professional because the patient may want wouldn’t. That’s not right.
to please the nurse. Avoid using good, bad,
right, or wrong.
Implies right and wrong, good or bad from
the nurse’s point of view. Now, if the client
That’s the right attitude. I agree. You must
Agreeing/ Disagreeing changes their mind, they are “wrong”. Limits
be right. That’s not true. You’re wrong.
their freedom to think or act in a certain
way.
“Why” questions can also imply right or Why do you think that? Why do you feel
Asking for
wrong and may be perceived as threatening that way? Why don’t you take your
explanations/ “Why”
or intimidating. If the client doesn’t know the medications? Why are you upset? Tell me
questions
answer they may become defensive. why you did that?
Sympathy may be a compassionate
response however it is not effective as I’m so sorry that your leg was amputated. It
Sympathy empathy in a therapeutic context. Feeling must be terrible. I’m so sorry you lost your
sorry for the patient may impair good mother.
judgment by the nurse and anger the client.
Suggests criticism is unfounded and that Your doctor is quite capable. I can’t believe
Defensive responses the patient has no right to voice their that nurse would give you the wrong
opinion. medication. No one here would…
The nurse takes the initiative for the
Patient: “I can’t stop thinking about my
Changing the subject interaction away from the patient, which is
diagnosis.” Nurse: “Let’s go for a walk now.”
usually due to the nurse’s discomfort.
 FUNDAMENTALS OF NURSING PRACTICE
MIDTERM PERIOD-LECTURE

MODULE III
NURSING AS AN ART

NON - THERAPEUTIC COMMUNICATION TECHNIQUES

TECHNIQUE DESCRIPTION EXAMPLE

Suggests criticism is unfounded and
Defensive responses that the patient has no right to voice
their opinion.
The nurse takes the initiative for the
interaction away from the patient,
Changing the subject
which is usually due to the nurse’s
discomfort.
Denies that the patient’s perception
Arguing
was real or accurate.
Your doctor is quite capable. I can’t believe
that nurse would give you the wrong
medication. No one here would…
Patient: “I can’t stop thinking about my
diagnosis.” Nurse: “Let’s go for a walk now.”
How can you say you didn’t sleep a wink
when I heard you snoring all night? You are
not working for the CIA.

Prepared by:

Maria Haydi P. Medina, RN,MAN

Clinicial Instructor

References :

Kozier and Erb’s (2009) Fundamentals of Nursing Concepts, Process, and Practice 8 th Edition
Kozier and Erb’s (2016) Fundamentals of Nursing Concepts, Process, and Practice 10 th Edition
Kozier and Erb’s (2020) Fundamentals of Nursing Concepts, Process, and Practice 11 th Edition
Udan J. (2009) Mastering Fundamentals of Nursing Concepts and Clinical Application 3 rd Edition
Perry Et Al., (2020) Fundamentals of Nursing 10th edition