NCM 117-Therapeutic Communication

THERAPEUTIC
COMMUNICATION
NCM 117 CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR
ROBERT MATTHEW A. MARQUEZ, MAN, RN

MANILA DOCTORS COLLEGE OF NURSING
MANILA TYTANA COLLEGES
2/4/22 MANILA TYTANA COLLEGES - RAMARQUEZ 1

THERAPEUTIC USE OF SELF
• In order for the nurse to
understand another person, a
client or a patient, the nurse
should know him/herself
through self awareness

JOHARI WINDOW

PATTERNS OF KNOWING
• PRECONCEPTIONS - one person expects another to behave or speak,
as a roadblock to the formation of an authentic relationship.
(Hildegard Peplau, 1952)
• Example: Mr. Lopez, a client, has the preconceived stereotypical idea
that all male nurses are homosexual and refuses to have Samuel, a
male nurse, take care of him. Samuel has a preconceived stereotypical
notion that all Hispanic men are violent, so he is relieved that Mr.
Lopez has refused to work with him. Both men are missing the
opportunity to do some important work together because of incorrect
preconceptions.

PATTERNS OF KNOWING
• Carper (1978) identified four patterns of knowing in nursing:
• empirical knowing (derived from the science of nursing),
• personal knowing (derived from life experiences),
• ethical knowing (derived from moral knowledge of nursing), and
• aesthetic knowing (derived from the art of nursing).
• Munhall (1993) added another pattern that she called unknowing—
for the nurse to admit he or she does not know the client or the
client’s subjective world, opening the way for a truly authentic
encounter.

CARPER’S PATTERNS OF NURSING KNOWLEDGE
• Carper (1978) identified four patterns of knowing in nursing:

• empirical knowing (derived from the science of nursing),
• Example: The client with panic disorder begins to have an attack. Panic attacks will raise
pulse rate.
• personal knowing (derived from life experiences),
• Example: The client’s face shows the panic.
• ethical knowing (derived from moral knowledge of nursing), and
• Although the nurse’s shift has ended, he or she remains with the client.
• aesthetic knowing (derived from the art of nursing).
• Although the client shows outward signals now, the nurse has sensed previously the
client’s jumpiness and subtle differences in the client’s demeanor and behavior

THERAPEUTIC
COMMUNICATION


LEARNING OUTCOMES
1. Describe the goals of therapeutic communication.
2. Identify therapeutic and nontherapeutic verbal communication skills.
3. Discuss nonverbal communication skills such as facial expression, body
language, vocal cues, eye contact, and understanding of levels of
meaning and context.
4. Discuss boundaries in therapeutic communication with respect to
distance and use of touch.
5. Distinguish between concrete and abstract messages.
6. Given a hypothetical situation, select an effective therapeutic response
to the client.
THERAPEUTIC COMMUNICATION
• Communication is the process that people use to
exchange information.
• Therapeutic communication is an interpersonal

interaction between the nurse and the client during
which the nurse focuses on the client’s specific needs
to promote an effective exchange of information.

• Process denotes all nonverbal messages that the speaker uses to give
meaning and context to the message.
• A congruent message is conveyed when content and process agree. For
example, a client says, “I know I haven’t been myself. I need help.” She
has a sad facial expression and a genuine and sincere voice tone.
• But when the content and process disagree—when what the speaker says
and what he or she does do not agree—the speaker is giving an
incongruent message. For example, if the client says, “I’m here to get
help,” but has a rigid posture, clenched fists, and an agitated and
frowning facial expression and snarls the words through clenched teeth,
the message is incongruent.
Therapeutic communication can help nurses accomplish many goals:
1. Establish a therapeutic nurse–client relationship.
2. Identify the most important client concern at that moment (the client-
centered goal).
3. Assess the client’s perception of the problem as it unfolds. This includes
detailed actions (behaviors and messages) of the people involved and the
client’s thoughts and feelings about the situation, others, and self.
4. Facilitate the client’s expression of emotions.
5. Teach the client and family the necessary self-care skills.
6. Recognize the client’s needs.
7. Implement interventions designed to address the client’s needs.
8. Guide the client toward identifying a plan of action to a satisfying and socially
acceptable resolution.
PRIVACY AND RESPECTING BOUNDERIES
• Privacy is desirable but not always possible in therapeutic
communication. An interview in a conference room is optimal if the
nurse believes this setting is not too isolative for the interaction
• The nurse needs to evaluate whether interacting in the client’s room
is therapeutic. For example, if the client has difficulty maintaining
boundaries or has been making sexual comments, then the client’s
room is not the best setting. A more formal setting would be
desirable.

• Proxemics is the study of distance zones
between people during communication.
People feel more comfortable with
smaller distances when communicating
with someone they know rather than
with strangers (McCall, 2017).
• If a nurse performing an assessment in a

community setting needs to take the client’s
blood pressure, he or she should say, “Mr.
Smith, to take your blood pressure I will
wrap this cuff around your arm and listen
with my stethoscope. Is this acceptable to
you?”
• The therapeutic communication
interaction is most comfortable
when the nurse and client are 3 to
6 ft apart.
• If a client invades the nurse’s
intimate space (0–18 in), the nurse
should set limits gradually,
depending on how often the client
has invaded the nurse’s space and
the safety of the situation.

TOUCH
• As intimacy increases, the need for distance decreases. Knapp (1980) identified five
types of touch:
• Functional–professional touch is used in examinations or procedures such as when

the nurse touches a client to assess skin turgor or a massage therapist performs a
massage.
• Social–polite touch is used in greeting, such as a handshake and the “air kisses”
some people use to greet acquaintances, or when a gentle hand guides someone in
the correct direction.
• Friendship–warmth touch involves a hug in greeting, an arm thrown around the
shoulder of a good friend, or the backslapping some people use to greet friends and
relatives.
• Love–intimacy touch involves tight hugs and kisses between lovers or close relatives.
• Sexual–arousal touch is used by lovers.
ACTIVE LISTENING AND ACTIVE OBSERVATION
• Active listening means refraining from other internal mental activities
and concentrating exclusively on what the client says.
• Active observation means watching the speaker’s nonverbal actions

as he or she communicates.
• Peplau (1952) used observation as the first step in the therapeutic

interaction. The nurse observes the client’s behavior and guides him
or her in giving detailed descriptions of that behavior. The nurse also
documents these details.
ACTIVE LISTENING AND ACTIVE OBSERVATION
Active listening and observation help the nurse:
1. Recognize the issue that is most important to the client at this
time
2. Know what further questions to ask the client
3. Use additional therapeutic communication techniques to guide
the client to describe his or her perceptions fully
4. Understand the client’s perceptions of the issue instead of
jumping to conclusions
5. Interpret and respond to the message objectively

VERBAL COMMUNICATION SKILLS
• In a concrete message, the words are explicit and need no
interpretation; the speaker uses nouns instead of pronouns—for
example, “What health symptoms caused you to come to the hospital
today?” or “When was the last time you took your antidepressant
medications?”
• Abstract messages, in contrast, are unclear patterns of words that

often contain figures of speech that are difficult to interpret. They
require the listener to interpret what the speaker is asking. For
example, a nurse who wants to know why a client was admitted to
the unit asks, “How did you get here?”
THERAPEUTIC COMMUNICATION TECHNIQUES
Adapted from Hays, J. S., & Larson, K. (1963). Interactions
with patients. New York, NY: Macmillan Press. Cited in
Videbeck (2020), Psychiatric Mental Health Nursing.














EXAMPLES OF THERAPEUTIC THECHIQUES
Client: “I had a boyfriend when I was younger.”
Nurse: “You had a boyfriend?” (reflecting)
Nurse: “Tell me about you and your boyfriend.”

(encouraging description)
Nurse: “How old were you when you had this boyfriend?”
(placing events in time or sequence)

Nurse: “Hello, Mrs. Nagy. My name is Donna, and I am your nurse today and
tomorrow from 7 am to 3:30 pm. What do you like to be called?”
(introducing self, establishing limits of relationship)
Client: “Hi, Donna. You can call me Peggy.”
Nurse: “The rain today has been a welcome relief from the heat of the past
few days.”
Client: “Really? It’s hard to tell what it’s doing outside. Still seems hot in here
to me.”
Nurse: “It does get stuffy here sometimes. So tell me, how are you doing
today?” (broad opening)
Client: “My son’s bedroom looks like a bomb went off.”
Nurse: “You’re saying your son is not very neat.”

(verbalizing the implied)
Client: “My mind is like mashed potatoes.”
Nurse: “I sense you find it difficult to put thoughts together.”

(translating into feelings)

Client: “Life is hard. I want it to be done. There is no rest. Sleep, sleep is

good ... forever.”
Nurse: “I hear you saying things seem hopeless. I wonder if you are
planning to kill yourself.” (verbalizing the implied)

QUESTION IN THE BOARD
SITUATION: A 20-year-old college student is admitted to the medical ward
because of sudden onset of paralysis of both legs. Nikki reveals that the
boyfriend has been pressuring her to engage in premarital sex. The most
therapeutic response by the nurse is:
a. “I can refer you to a spiritual counselor if you like.”

b. “You shouldn’t allow anyone to pressure you into sex.”
c. “It sounds like this problem is related to your paralysis.”
d. “How do you feel about being pressured into sex by your boyfriend?”

The nurse observes a client pacing in the hall. Which statement by the
nurse may help the client recognize his anxiety?
a. “I guess you’re worried about something, aren’t you?

b. “Can I get you some medication to help calm you?”
c. “Have you been pacing for a long time?”
d. “I notice that you’re pacing. How are you feeling?”

A male client tells the nurse he was involved in a car accident while he
was intoxicated. What would be the most therapeutic response from
nurse Julia?
a. “Why didn’t you get someone else to drive you?”

b. “Tell me how you feel about the accident.”
c. “You should know better than to drink and drive.”
d. “I recommend that you attend an Alcoholics Anonymous meeting.”

AVOIDING NONTHERAPEUTIC COMMUNICATION









THERAPEUTIC
COMMUNICATION


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THERAPEUTIC

ROBERT MATTHEW A. MARQUEZ, MAN, RN

2/4/22 MANILA TYTANA COLLEGES - RAMARQUEZ 1

2/4/22 MANILA TYTANA COLLEGES - RAMARQUEZ 2

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2/4/22 MANILA TYTANA COLLEGES - RAMARQUEZ 4

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• Carper (1978) identified four patterns of knowing in nursing:

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ROBERT MATTHEW A. MARQUEZ, MAN, RN

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• Therapeutic communication is an interpersonal

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• If a nurse performing an assessment in a

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• Functional–professional touch is used in examinations or procedures such as when

• Active observation means watching the speaker’s nonverbal actions

• Peplau (1952) used observation as the first step in the therapeutic

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• Abstract messages, in contrast, are unclear patterns of words that

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Nurse: “Tell me about you and your boyfriend.”

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Client: “Hi, Donna. You can call me Peggy.”

Nurse: “You’re saying your son is not very neat.”

Client: “My mind is like mashed potatoes.”

Nurse: “I sense you find it difficult to put thoughts together.”

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Client: “Life is hard. I want it to be done. There is no rest. Sleep, sleep is

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a. “I can refer you to a spiritual counselor if you like.”

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a. “I guess you’re worried about something, aren’t you?

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a. “Why didn’t you get someone else to drive you?”

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