Therapeutic Communication

Therapeutic Communication
Student nurses are learning how to use therapeutic communication as they progress through nursing school.  Although a “Process Recording” is another name for “Therapeutic Communication,” a “Process Recording” is generally used exclusively in the psychiatric setting. Since you will be doing this assignment in more than one setting, they will be called Therapeutic Communications. A Therapeutic Communication is based on a health related goal that is therapeutic, and not a social conversation.
 
The purpose of this exercise is for the student to receive feedback from the instructor on how to enhance one’s therapeutic communication and have it become more effective. It is important for the student to document the verbatim conversation that occurred between the client and the student.  Do not hesitate to document conversations in which you later realized a mistake was made. This is a valuable part of the learning process. The instructor will be able to give you feedback on what might have been said differently to evoke a more meaningful response. Difficult conversations in which the student is at a loss for what to say can be the most valuable learning experiences.  Grades are given on progress made and insights gained into effective therapeutic communication. Be sure to include the setting, your positioning, and the other requested details. This also gives the instructor valuable information to enhance feedback.
Why must student nurses practice this skill?

• Nurses will have the opportunity to communicate with clients in many different settings for many different reasons. This is an important time to help clients learn about themselves, their health and what they can do to help themselves. The nurse uses therapeutic communication purposefully in order to implement therapeutic interventions related to health care.

How do I learn to have Therapeutic Communications with my clients?

• By practicing! You will be studying about Therapeutic Communication in your other courses and you will be applying what you learn in the clinical area. Remember, each patient encounter is an opportunity to teach them about health promotion and disease prevention. In the psychiatric setting, it is an opportunity for the student nurse to use “therapeutic self” to help the patient discover what they think, learn to make decisions, learn how to relate to others, etc.

Reading Assignment:

• In your current psychiatric textbook there is a section or chapter related to this subject. This is required reading before attempting therapeutic communication.

What is a Therapeutic Communication?

• Therapeutic communication is a health-related interaction with a client. The nurse must identify the goal of the interaction- either prior to the communication or sometimes after it has begun. It is not a social communication. The nurse will use certain communication skills that will enable a client to express him or herself. Remember, that you are learning to make each encounter with a client a learning experience by using therapeutic communication.

Purpose of Process Recording:

1. To guide the student in the development of self-awareness of the impact of their own behaviors–verbal or non-verbal, on a patient
2. To encourage the student to explore a variety of strategies to accomplish stated communication goal and objective(s)
3. To enable the student to become more objective in the processing of patient messages To create opportunities for students to propose alternative responses to patient messages for faculty feedback
4. To provide the student with a comparative record of own progress in the development of effective therapeutic communication skills
5. To assist the faculty in gaining an understanding of the student’s ability to communicate therapeutically with patients and families and provide concrete examples and remediation

Components of a Process Recording:

• Client’s name– use initials for confidentiality. Include some descriptive information about the patient including age and diagnosis (this is under background information). If this is done in a psychiatric setting, the DSM Axis I-V should be noted. There should also be a nursing diagnosis.

Obtaining DSM diagnoses may require accessing on site on-line information; ask your instructor.

• Nursing Goal for the TC. This is what you hope to achieve by this Therapeutic Communication. The goal is a general, broad statement. Goals are specific and usually limited to one topic area. Conversation remains focused on the goal.

Examples of goals:

1. a) Medication management and use of prn medication
2. b) Symptom management
3. c) Discharge plan
4. d) Crisis intervention

• Write two objectives to reach the goal. Begin objectives with an action verb. You have been given lists of these verbs or they can be found in textbooks and on the Internet. An objective is also called an outcome and is measurable. Use the S.M.A.R.T. acronym as a guide.

      Example of objectives:
By the end of the therapeutic communication, the patient will:

• 1. Describe one or two symptoms that indicate the need for prn medication
  2. Identify one or two factors that lead to increased anxiety
• Student’s thoughts and feelings prior to the interaction- is this the first time you ever tried to talk to a patient who has a mental illness? Are you anxious?
• Setting– state where the interaction occurs, i.e. hospital room, activity room, etc. Describe noise level, staff interruptions, and proximity of other patients. This is the “milieu”. Is it calm, tense, etc?  If there is a change in the milieu, how does it affect your patient? How does it affect you?
• Verbatim interaction:
• Therapeutic Communications are not for conducting assessments (i.e. pain), or psychotherapy.
• Therapeutic Communications are to help the patient express feelings and problems, solve a current issue or concern, etc.
•  Review the handout on safety and boundaries for nursing students in the psychiatric setting.

Remember, your role is not to fix the patient or solve their problems.  Your role is to actively listen, gain trust, and help the patient gain insight to solve their own problems.
What is recorded and how is it recorded:

• Notes are not taken while having a TC. This would be detrimental to the process.
• Student Nurse’s verbal communication verbatim (as much as possible)
• Student Nurse’s non-verbal communication; remember, 70% of communication is non-verbal.
• Patient’s verbal communication verbatim (as much as possible).
• Patient’s non-verbal communication – ie. body position, facial expression, eye contact, etc.
• An analysis of what and why the nurse said and did (body language–non-verbal language) and an analysis of the patient’s verbal and non-verbal communication. Were they congruent, do they match, i.e. was the patient crying while she described the death of her child or smiling?
• Line up the patient’s non-verbal communication with patient’s verbal communication.
• Line up nurse’s non-verbal communication with nurse’s verbal communication.
• READ & FOLLOW ALL THE INSTRUCTIONS AT THE TOP OF EACH COLUMN on the Process Recording Chart in this syllabus.

Evaluation of Patient Communication:      

1. a) Evaluate verbal and non- verbal communication. Are they congruent (i.e. do they match?)
2. b) State what you think is going on, i.e. patient’s interest level, trust, ability to focus, feelings.

Evaluation of Nurse Communication:

1. Label technique as “Therapeutic” or “Non-therapeutic”.
2. Identify and state techniques used; ex. Validation,  Silence,  Probing,
3. If a non-therapeutic technique is used, identify the therapeutic technique that should have been used and give an example of what you could have said. State alternative responses you could have made to facilitate interaction or to promote more open expression of thoughts and feelings by client. Do not be afraid of making a mistake.  Progress, not perfection, is the goal.
4. Evaluate both your verbal and non-verbal communication. Are they congruent?

HINTS:
Learn as much as you can about the patient before you try to begin a conversation.
Consult with unit staff or your instructor for guidance on goals and objectives for your TC.
Keep your TC goal and objectives as simple as possible
Keep a small notebook with you on the unit, or folded process recording forms,
so that you can record conversations verbatim (including nonverbal) as soon
after the interaction as possible, but out of sight of the patient.
Type the Process Recording based on your notes within 24 hours or sooner to aid your memory.