181CHAPTER 10 Communication and the Clinical Interview

can become a definite barrier to communication. To avoid overuse of restating, the nurse can combine restatements with direct questions that encourage descriptions: “What does your life lack?” “What kind of meaning is missing?” “Describe a day in your life that appears empty to you.”

Reflecting. Reflection is a means of assisting people to better understand their own thoughts and feelings. Reflecting may take the form of a question or a sim-ple statement that conveys the nurse’s observations of the patient when sensitive issues are being discussed. The nurse might then describe briefly to the patient the apparent meaning of the emotional tone of the patient’s verbal and nonverbal behavior. For example, to reflect a patient’s feelings about his or her life, a good begin-ning might be, “You sound as if you have had many disappointments.”

Sharing observations with a patient shows accep-tance and that the patient has your full attention. When you reflect, you make the patient aware of inner feelings and encourage the patient to own them. For example, you may say to a patient, “You look sad.” Perceiving your concern may allow the patient to spontaneously share feelings. The use of a question in response to the patient’s question is another reflective technique (Arnold & Boggs, 2007). For example:

Patient: “Nurse, do you think I really need to be hospitalized?”

Nurse: “What do you think, Jane?”Patient: “I don’t know; that’s why I’m asking you.”Nurse: “I’ll be willing to share my impression with

you at the end of this first session. However, you’ve probably thought about hospitalization and have some feelings about it. I wonder what they are.”

Exploring. A technique that enables the nurse to examine important ideas, experiences, or relationships more fully is exploring. For example, if a patient tells you he does not get along well with his wife, you will want to further explore this area. Possible openers include:

“Tell me more about your relationship with your wife.”

“Describe your relationship with your wife.”“Give me an example of how you and your wife don’t

get along.”Asking for an example can greatly clarify a vague or

generic statement made by a patient.Patient: “No one likes me.”Nurse: “Give me an example of one person who

doesn’t like you.”orPatient: “Everything I do is wrong.”Nurse: “Give me an example of one thing you do

that you think is wrong.”Table 10-2 lists more examples of therapeutic com-

munication techniques.

Asking Questions and Eliciting Patient ResponsesOpen-Ended Questions. Many of the examples above and in Table 10-2 are open-ended. Open-ended questions and comments encourage lengthy responses and information about experiences, perceptions, or responses to a situation. For example:

• “What do you perceive as your biggest problem right now?”

• “Give me an example of some of the stresses you are under right now.”

• “Tell me more about your relationship with your wife?”

TAble 10-2 Therapeutic Communication Techniques

therapeutic technique Description Example

Using silence Gives the person time to collect thoughts or think through a point.

Encouraging a person to talk by waiting for the answers.

Accepting

Indicates that the person has been understood. An accepting statement does not necessarily indicate agreement but is nonjudgmental. (Nurse should not imply understanding when (s)he does not understand.)

“Yes.”“Uh-huh.”“I follow what you say.”

Giving recognition

Indicates awareness of change and personal efforts. Does not imply good or bad, right or wrong.

“Good morning, Mr. James.”“You’ve combed your hair today.”“I see you’ve eaten your whole lunch.”

Offering self

Offers presence, interest, and a desire to understand. Is not offered to get the person to talk or behave in a specific way.

“I would like to spend time with you.”“I’ll stay here and sit with you awhile.”

Continued

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182 Unit 3 Psychosocial Nursing Tools

TAble 10-2 Therapeutic Communication Techniques—cont’d

therapeutic technique Description Example

Offering general leads

Allows the other person to take direction in the discussion. Indicates that the nurse is interested in what comes next.

“Go on.”“And then?”“Tell me about it.”

Giving broad openings

Clarifies that the lead is to be taken by the patient. However, the nurse discourages pleasantries and small talk.

“Where would you like to begin?”“What are you thinking about?”“What would you like to discuss?”

Placing the events in time or sequence

Puts events and actions in better perspective. Notes cause-and-effect relationships and identifies patterns of interpersonal difficulties.

“What happened before?”“When did this happen?”

Making observations

Calls attention to the person’s behavior (e.g., trembling, nail biting, restless mannerisms). Encourages patient to notice the behav-ior and describe thoughts and feelings for mutual understanding. Helpful with mute and withdrawn people.

“You appear tense.”“I notice you’re biting your lips.”“You appear nervous whenever John enters

the room.”

Encouraging description of perception

Increases the nurse’s understanding of the patient’s perceptions. Talking about feelings and difficulties can lessen the need to act them out inappropriately.

“What do these voices seem to be saying?”“What is happening now?”“Tell me when you feel anxious.”

Encouraging comparison

Brings out recurring themes in experiences or interpersonal relationships. Helps the per-son clarify similarities and differences.

“Has this ever happened before?”“Is this how you felt when . . . ?”“Was it something like . . . ?”

Restating

Repeats the main idea expressed. Gives the patient an idea of what has been communicated. If the message has been misunderstood, the patient can clarify it.

Patient: “I can’t sleep. I stay awake all night.”Nurse: “You have difficulty sleeping?”orPatient: “I don’t know . . . he always has some

excuse for not coming over or keeping our appointments.”

Nurse: “You think he no longer wants to see you?”

Reflecting

Directs questions, feelings, and ideas back to the patient. Encourages the patient to accept his or her own ideas and feelings. Acknowledges the patient’s right to have opinions and make decisions and encourages the patient to think of self as a capable person.

Patient: “What should I do about my hus-band’s affair?”

Nurse: “What do you think you should do?”orPatient: “My brother spends all of my money

and then has the nerve to ask for more.”Nurse: “You feel angry when this happens?”

Focusing

Concentrates attention on a single point. It is especially useful when the patient jumps from topic to topic. If a person is experiencing a severe or panic level of anxiety, the nurse should not persist until the anxiety lessens.

“This point you are making about leav-ing school seems worth looking at more closely.”

“You’ve mentioned many things. Let’s go back to your thinking of ‘ending it all.”

Exploring

Examines certain ideas, experiences, or relationships more fully. If the patient chooses not to elaborate by answering no, the nurse does not probe or pry. In such a case, the nurse respects the patient’s wishes.

“Tell me more about that.”“Would you describe it more fully?”“Could you talk about how it was that you

learned your mom was dying of cancer?”

183CHAPTER 10 Communication and the Clinical Interview

TAble 10-2 Therapeutic Communication Techniques—cont’d

therapeutic technique Description Example

Giving information

Makes facts the person needs available. Supplies knowledge from which decisions can be made or conclusions drawn. For example, the patient needs to know the role of the nurse; the purpose of the nurse-patient relationship; and the time, place, and duration of the meetings.

“My purpose for being here is . . . ”“This medication is for . . . ”“The test will determine . . . ”

Seeking clarification

Helps patients clarify their own thoughts and maximize mutual understanding between nurse and patient.

“I am not sure I follow you.”“What would you say is the main point of

what you just said?”“Give an example of a time you thought

everyone hated you.”

Presenting reality

Indicates what is real. The nurse does not argue or try to convince the patient, just describes personal perceptions or facts in the situation.

“That was Dr. Todd, not a man from the Mafia.”

“That was the sound of a car backfiring.”“Your mother is not here; I am a nurse.”

Voicing doubt

Undermines the patient’s beliefs by not reinforcing the exaggerated or false perceptions.

“Isn’t that unusual?”“Really?”“That’s hard to believe.”

Seeking consensual validation

Clarifies that both the nurse and patient share mutual understanding of communications. Helps the patient become clearer about what he or she is thinking.

“Tell me whether my understanding agrees with yours.”

Verbalizing the implied

Puts into concrete terms what the patient implies, making the patient’s communication more explicit.

Patient: “I can’t talk to you or anyone else. It’s a waste of time.”

Nurse: “Do you feel that no one understands?”

Encouraging evaluation

Aids the patient in considering people and events from the perspective of the patient’s own set of values.

“How do you feel about . . . ?”“What did it mean to you when he said he

couldn’t stay?”

Attempting to translate into feelings

Responds to the feelings expressed, not just the content. Often termed decoding.

Patient: “I am dead inside.”Nurse: “Are you saying that you feel lifeless?

Does life seem meaningless to you?”

Suggesting collaboration

Emphasizes working with the patient, not doing things for the patient. Encourages the view that change is possible through collaboration.

“Perhaps you and I can discover what produces your anxiety.”

“Perhaps by working together, we can come up with some ideas that might improve your communications with your spouse.”

Summarizing

Brings together important points of discussion to enhance understanding. Also allows the opportunity to clarify communications so that both nurse and patient leave the interview with the same ideas in mind.

“Have I got this straight?”“You said that . . . ”“During the past hour, you and I have

discussed . . . ”

Encouraging formulation of a plan of action

Allows the patient to identify alternative actions for interpersonal situations the patient finds disturbing (e.g., when anger or anxiety is provoked).

“What could you do to let anger out harmlessly?”

“The next time this comes up, what might you do to handle it?”

“What are some other ways you can approach your boss?”

Adapted from Hays, J. S., & Larson, K. (1963). Interacting with patients. New York: Macmillan. Copyright © 1963 Macmillan Publishing Company.