chapter 4 interacting with patients critical thinking

These five strategies can help you create positive and compassionate patient interactions without adding significant time to the visit.

SHANNON J. VOOGT, MD, KELLI PRATT, DO, AND AMBER ROLLET, MD

Fam Pract Manag. 2022;29(2):12-16

Author disclosures: no relevant financial relationships.

It has been a busy day in clinic, and your 10th patient of the morning is roomed 30 minutes late. The reason given for the visit is “preventive health.” When you enter the exam room, you introduce yourself and confirm the patient is there for a preventive check-up. Then you ask about health behaviors and screenings, do an exam, and make a plan for testing and immunizations. As you are finishing up the visit, the patient says, “But we never discussed my concerns. I'm having this wrist pain and hand numbness, which have been bothering me a lot. And I keep getting headaches. I'm having one right now, and it's terrible. And my knees are giving out on me a lot, and I'm wondering what you think I should do.” Feeling exasperated, you explain that you don't have time to address these complaints and the patient should follow up at a later date because you have other patients waiting. The patient agrees and leaves, but later gives you a poor review and switches to another practice because “My concerns weren't listened to.”

WHY COMMUNICATION MATTERS

A positive patient experience is the result of multiple factors before, during, and after the patient encounter, but chief among them is effective doctor-patient communication. When patients and physicians communicate well, outcomes are better, 1 in part because patients are more engaged in their health care. Patients who take an active role in their health can confidently bring up concerns and make lifestyle changes. 2

Physicians are constantly being evaluated as communicators — through online ratings, post-visit surveys, etc. Although patient satisfaction scores can push us to improve, they may also add performance pressures if we lose sight of the true goal, which is not to improve “scores” but to build trust. 3

This article describes how we can improve communication with our patients without pushing ourselves toward more burnout. Because time constraints are the primary concern for most physicians, we have chosen to focus on five strategies that create positive and compassionate interactions without adding significantly to the time with the patient.

When patients and physicians communicate well, outcomes are better, and patients are engaged in their health care.

Making a non-medical “connection” with the patient at the beginning of the encounter takes 1–2 minutes but can improve the patient's perception of the interaction.

Agenda-setting, open-ended questions, reflective statements, and visit summaries are strategies that can improve communication without adding much time to the visit.

1. MAKE A POSITIVE CONNECTION WITH THE PATIENT

Making a positive connection is not always easy, especially when our days are rushed and we are stressed and distracted, but each encounter should set the stage for respectful communication.

Before entering the exam room, take a slow, mindful breath to re-center yourself. When entering the room, make eye contact with the patient, warmly introduce yourself, and explain your role. Clarify how the patient would like to be addressed and include others in the room in the introduction. Although it's tempting to start by asking “How are you?” this can be confusing for the patient, who is there seeking care for a concern, and it may jump-start the medical interview before introductions have finished. Making a non-medical “connection” with the patient at the beginning of the encounter takes only 1–2 minutes but can improve the patient's perception of the interaction. 4 This can be a simple comment about weather, sports, or other neutral topics. At the end of the encounter, thank the patient for entrusting their care to you.

Here are some examples of language physicians can use to make positive connections:

“Hi, I am Dr. Smith, one of the family physicians here. How would you like me to call you?”

“Well, it's nice to meet you, Rhonda. Who do you have with you today?”

“It's nice to meet you. Is it still snowing outside? It's been so cold today!”

“Thank you so much for coming to see me today. I really appreciate that you trusted us with this problem.”

2. DEMONSTRATE ACTIVE LISTENING

One common patient complaint is that physicians do not listen carefully to what they have to say. We can demonstrate active listening in several ways:

Attend to patients without multitasking or distractions,

Express nonverbally that we are listening through eye contact, sitting down, nodding, responding with facial expressions, and showing concern,

Provide verbal cues (“Mmhmm”, “Ah-ha,” or “I see”),

Allow patients to speak uninterrupted at the beginning of the visit.

An often-cited study from 1984 demonstrated that it takes patients two minutes at most to explain their complaint, but physicians often interrupt between 18 to 23 seconds. 5 This can make the patient feel unheard and create missed opportunities to gather potentially important data. Interruptions include any statement that stops the patient's flow of thought.

Checking the EHR while the patient is talking can interfere with active listening, so avoid that if possible unless you've explained up front what you are doing (“I am just reviewing your recent labs so I can understand better what is going on”). If the patient drifts off on a tangent, gently redirect the conversation by saying, “That is interesting, but I really want to know more about [health item on agenda].”

3. ESTABLISH A SHARED AGENDA

After listening to the patient's chief complaint uninterrupted, it is imperative to pause and establish an agenda for the visit before gathering more history. To do this, ask “Is there something else you would like to discuss?” until the patient answers “No.” The term “something else” is preferable to “anything else” because it elicits more concerns without unduly lengthening the visit. 6 Eliciting patients' concerns up front will help you avoid “doorknob” moments when you are leaving the room and their hidden agenda emerges after you have already used your allotted time. Once all the patient's concerns are elicited, add your own items as well. Then, negotiate a shared agenda of what you will address at the current visit.

This can be difficult when patients present with multiple concerns that don't match up with the concerns you've identified, or when patients don't have realistic expectations about what you can address given the visit's time constraints. If this is the case, have an open conversation with the patient about the need to prioritize their concerns as well as yours. If less acute concerns cannot be addressed at the current visit, make sure the patient understands that they will be discussed at a follow-up visit, not ignored or put aside. If you have already set the stage for respectful communication, the patient will be more likely to understand and accept the agenda.

4. USE OPEN-ENDED QUESTIONS AND REFLECTIVE STATEMENTS

Open-ended questions and reflective statements demonstrate concern and empathy for the patient.

After introductions and small talk have taken place, starting the patient interview with an open-ended question such as “How can I help you today?” has been shown to have high impact on physician communication scores. 7 Use additional open-ended questions or statements throughout the encounter such as “Tell me more about that,” “What else have you noticed?” or “What are your thoughts about what is going on?”

Physicians are rated as more empathetic when they spend more time listening and making reflective statements. 8 Reflecting the patient's emotional state, either directly (“You are frustrated”) or indirectly (“It seems like that would be frustrating”), can show that you empathize with their feelings. Ignoring a patient's emotional cues out of a sense of haste can backfire, leading to longer encounters. It is best to acknowledge when a patient seems upset, angry, or anxious. Continue using positive nonverbal communication to demonstrate your compassion and concern, and to assure the patient that you are listening. If complaints about care arise, asking “What can I do to make this better?” can help bring the conflict to a mutually agreeable solution.

5. SOLIDIFY THE RELATIONSHIP WITH CLEAR EXPLANATIONS

Patients often come away from their visits not knowing the actual name of their diagnosis, the reasons for their new medications, possible side effects, or what to expect next. It is important to explain things clearly — your thoughts, diagnoses, treatment recommendations, and plan for follow up — and to write down all new diagnoses and medications to allow full patient engagement. Having printed educational materials you can give to the patient can be helpful, as long as patient literacy and educational levels are considered. Visit summaries filled out by staff and physicians can provide helpful follow-up information and instructions post-visit. Even if you have explained things thoroughly during the visit, patients are often overwhelmed with information and may not hear everything correctly. The teach-back method has been shown to improve patient outcomes. 9 You can preface it by saying, “I know we just went over a lot of information, so if you wouldn't mind, can you tell me what the next steps are, so I know I didn't miss anything?” This will ensure patient understanding and prevent further questions, calls, and re-explanations. In addition, at the end of every visit, ask “What questions do you have?” instead of “Do you have any questions?” as this encourages patient involvement.

POCKET GUIDE TO PATIENT COMMUNICATION

WHAT ABOUT TIME CONSTRAINTS?

The time constraints of office visits are a concern shared by physicians and patients. Wait time and visit length can certainly affect patient satisfaction, but one study showed that what mattered more was the patient's perception of the amount of time spent with the physician. 10 The techniques discussed above will enhance patient satisfaction even if the actual time spent with the patient is short. To address the time constraints of office visits, set expectations early on. Be up-front with patients without dismissing complaints by saying, “I know we have a lot of things that we'd both like to discuss, and I want to be able to give each of them the appropriate time and attention. Why don't we schedule another visit in a few weeks to address the remainder of these concerns?”

AN IMPROVED PATIENT VIGNETTE

Let's take another look at the previous patient vignette, this time applying some of the skills and tips discussed above.

It has been a busy day in clinic, and your 10th patient of the morning is roomed 30 minutes late. The reason given for the visit is “preventive health,” but your rooming staff notifies you that the patient has a lot of other concerns to address as well. Before entering the room, you note that you are feeling pretty stressed from the busy morning and remind yourself that you want to be present for your patient. You take a deep breath before entering the room. When you step inside, you say hello to the patient and introduce yourself. You comment on the weather outside and thank the patient for waiting for you, since you are running behind. You then say, “The nurse mentioned you are here for an annual visit but also have a lot of concerns. How can I help you today?” The patient shares complaints regarding her wrists, hands, and knees. You then say, “Before I ask you more about that, is there something else you'd like to discuss today?” The patient nods and tells you about the constant headaches. You ask again if there's something else, and the patient tells you that is all. You tell the patient that you want to give adequate time to these concerns, so you would like to address the hand pain and headaches today and save the long-term knee issue and annual visit for next time. After finishing your history and physical exam, you come up with a plan and write down instructions for the patient. Before saying goodbye, you tell the patient, “Thank you so much for bringing these concerns to me. I hope we can work together to figure out these issues.”

START WITH SMALL CHANGES

These small changes in communication can have a big impact on the patient experience. Just as we advise our patients who are trying to make major lifestyle changes to focus on small steps, we too should work on incorporating small changes one at a time, using your own style and personality, until it starts to feel natural. Don't worry if you slip back into old ways of doing things; just start again with the next patient. We have included a table of the most pertinent tips and phrases, which can be printed as a pocket card . As you seek to improve your communication skills, we hope that your patients will be happier and have better outcomes and that you will experience higher satisfaction.

Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ . 1995;152(9):1423-1433.

Von Korff M, Gruman J, Schaefer J, Curry SJ, Wagner EH. Collaborative management of chronic illness. Ann Intern Med . 1997;127(12):1097-1102.

Morris J, Hotko B, Bates M. The CG CAHPS Handbook: A Guide to Improve Patient Experience and Clinical Outcomes . Studer Group and Fire Starter Publishing; 2015.

Mauksch LB, Dugdale DC, Dodson S, Epstein R. Relationship, communication, and efficiency in the medical encounter: creating a clinical model from a literature review. Arch Intern Med . 2008;168(13):1387-1395.

Beckman HB, Frankel RM. The effect of physician behavior on the collection of data. Ann Intern Med . 1984;101(5):692-696.

Heritage J, Robinson JD, Elliott MN, Beckett M, Wilkes M. Reducing patients’ unmet concerns in primary care: the difference one word can make. J Gen Intern Med . 2007;22(10):1429-1433.

Saad Riegels N, Asher E, Cartright JR, et al.; Listening beyond auscultating: a quality initiative to improve communication scores in the Hospital Consumer Assessment of Health Care Practitioners and Systems survey. Perm J . 2018;22:16-187.

Pollak KI, Alexander SC, Tulsky JA, et al.; Physician empathy and listening: associations with patient satisfaction and autonomy. J Am Board Fam Med . 2011;24(6):665-672.

Ha Dinh TT, Bonner A, Clark R, Ramsbotham J, Hines S. The effectiveness of the teach-back method on adherence and self-management in health education for people with chronic disease: a systematic review. JBI Database System Rev Implement Rep . 2016;14(1):210-247.

Cape J. Consultation length, patient-estimated consultation length, and satisfaction with the consultation. Br J Gen Pract . 2002;52(485):1004-1006.

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Today's Medical Assistant > CH # 4: Interacting w/Patients > Flashcards

CH # 4: Interacting w/Patients Flashcards

Paying close attention 2 a speaker w/out thinking of anything else

Active listening

A vague unpleasant emotion of fear or dread often accompanied by restlessness or nervousness

Communication that is expressed through facial expressions, body position, muscle activity and other nonverbal means

Body language

Existing over a long period of time

Questions that anticipate a yes or no short answer

Closed questions

Failure to acknowledge the reality of a situation

Unconscious mental process that offers psychological protection

Ego defense mechanism

Objective awareness and sensitivity to the feelings and emotions of others

Classified according to rank or importance

An organization that manages care 4 dying patients including comfort, pain relief and personal care

Critical or negative

Making judgements based on what is good/bad based on personal opionions

Judgemental

Communication that occurs w/out words

Example: body posture or facial expression

Questions that could have a variety of answers and encourage a personal response

Open questions

Pertaining 2 the mouth

A restatement of the words of another, often 2 clarify meaning

Paraphrasing

Pertaining 2 bodily processes

Physiologic

Experiencing one’s own emotions as those of another

Expressing the meaning and emotions of another’s words back 2 the person

The fulfillment of each individual’s potential

Self-actualization

Expressing the most important points of a conversation or a written document

Summarizing

Feeling the same emotions as another

The last stage of illness

Usually means 6 months or less of life

Terminal phase

Using words 2 communicate

Small video camera attached 2 a computer that allows video 2 b transmitted on the Internet

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Communication

2.3 Communicating with Patients

Therapeutic communication is a type of professional communication used by nurses with patients and defined as, “The purposeful, interpersonal information-transmitting process through words and behaviors based on both parties’ knowledge, attitudes, and skills, which leads to patient understanding and participation.” [1] Therapeutic communication techniques used by nurses have roots going back to Florence Nightingale, who insisted on the importance of building trusting relationships with patients and believed in the therapeutic healing that resulted from nurses’ presence with patients. [2] Since then, several professional nursing associations have highlighted therapeutic communication as one of the most vital elements in nursing.

Read an example of a nursing student effectively using therapeutic communication with patients in the following box.

An Example of Nursing Student Using Therapeutic Communication

Ms. Z. is a nursing student who enjoys interacting with patients. When she goes to patients’ rooms, she greets them and introduces herself and her role in a calm tone. She kindly asks patients about their problems and notices their reactions. She does her best to solve their problems and answer their questions. Patients perceive that she wants to help them. She treats patients professionally by respecting boundaries and listening to them in a nonjudgmental manner. She addresses communication barriers and respects patients’ cultural beliefs. She notices patients’ health literacy and ensures they understand her messages and patient education. As a result, patients trust her and feel as if she cares about them, so they feel comfortable sharing their health care needs with her. [3] , [4]

Active Listening and Attending Behaviors

Listening is obviously an important part of communication. There are three main types of listening: competitive, passive, and active. Competitive listening happens when we are focused on sharing our own point of view instead of listening to someone else. Passive listening occurs when we are not interested in listening to the other person and we assume we understand what the person is communicating correctly without verifying. During active listening , we are communicating verbally and nonverbally that we are interested in what the other person is saying while also actively verifying our understanding with the speaker. For example, an active listening technique is to restate what the person said and then verify our understanding is correct. This feedback process is the main difference between passive listening and active listening. [5]

Touch is a powerful way to professionally communicate caring and empathy if done respectfully while being aware of the patient’s cultural beliefs. Nurses commonly use professional touch when assessing, expressing concern, or comforting patients. For example, simply holding a patient’s hand during a painful procedure can be very effective in providing comfort. See Figure 2.7 [6] for an image of a nurse using touch as a therapeutic technique when caring for a patient.

Therapeutic Techniques

Therapeutic communication techniques are specific methods used to provide patients with support and information while focusing on their concerns. Nurses assist patients to set goals and select strategies for their plan of care based on their needs, values, skills, and abilities. It is important to recognize the autonomy of the patient to make their own decisions, maintain a nonjudgmental attitude, and avoid interrupting. Depending on the developmental stage and educational needs of the patient, appropriate terminology should be used to promote patient understanding and rapport. When using therapeutic communication , nurses often ask open-ended statements and questions, repeat information, or use silence to prompt patients to work through problems on their own. [7] Table 2.3a describes a variety of therapeutic communication techniques. [8]

Table 2.3a Therapeutic Communication Techniques

In addition to the therapeutic techniques listed in Table 2.3a, nurses and nursing students should genuinely communicate with empathy. Communicating honestly, genuinely, and authentically is powerful. It opens the door to creating true connections with others. [9] Communicating with empathy has also been described as providing “unconditional positive regard.” Research has demonstrated that when health care teams communicate with empathy, there is improved patient healing, reduced symptoms of depression, and decreased medical errors. [10]

Nurses and nursing students must be aware of potential barriers to communication. In addition to considering common communication barriers discussed in the previous section, there are several nontherapeutic responses to avoid. These responses often block the patient’s communication of their feelings or ideas. See Table 2.3b for a description of nontherapeutic responses. [11]

Table 2.3b Nontherapeutic Responses

Strategies for Effective Communication

In addition to using therapeutic communication techniques, avoiding nontherapeutic responses, and overcoming common barriers to communication, there are additional strategies for promoting effective communication when providing patient-centered care. Specific questions to ask patients are as follows:

• What concerns do you have about your plan of care?
• What questions do you have about your medications?
• Did I answer your question(s) clearly or is there additional information you would like? [12]

Listen closely for feedback from patients. Feedback provides an opportunity to improve patient understanding, improve the patient-care experience, and provide high-quality care. Other suggestions for effective communication with hospitalized patients include the following:

• Round with the providers and read progress notes from other health care team members to ensure you have the most up-to-date information about the patient’s treatment plan and progress. This information helps you to provide safe patient care as changes occur and also to accurately answer the patient’s questions.
• Review information periodically with the patient to improve understanding.
• Use patient communication boards in their room to set goals and communicate important reminders with the patient, family members, and other health care team members. This strategy can reduce call light usage for questions related to diet and activity orders and also gives patients and families the feeling that they always know the current plan of care. However, keep patient confidentiality in mind regarding information to publicly share on the board that visitors may see.
• Provide printed information on medical procedures, conditions, and medications. It helps patients and family members to have multiple ways to provide information. [13]

Adapting Your Communication

When communicating with patients and family members, take note of your audience and adapt your message based on their characteristics such as age, developmental level, cognitive abilities, and any communication disorders. For patients with language differences, it is vital to provide trained medical interpreters when important information is communicated.

Adapting communication according to the patient’s age and developmental level includes the following strategies:

• When communicating with children, speak calmly and gently. It is often helpful to demonstrate what will be done during a procedure on a doll or stuffed animal. To establish trust, try using play or drawing pictures.
• When communicating with adolescents, give freedom to make choices within established limits.
• When communicating with older adults, be aware of potential vision and hearing impairments that commonly occur and address these barriers accordingly. For example, if a patient has glasses and/or hearing aids, be sure these devices are in place before communicating. See the following box for evidence-based strategies for communication with patients who have impaired hearing and vision. [14]

Strategies for Communicating with Patients with Impaired Hearing and Vision

Impaired Hearing

• Gain the patient’s attention before speaking (e.g., through touch)
• Minimize background noise
• Position yourself  2-3 feet away from the patient
• Facilitate lip-reading by facing the patient directly in a well-lit environment
• Use gestures, when necessary
• Listen attentively, allowing the patient adequate time to process communication and respond
• Refrain from shouting at the patient
• Ask the patient to suggest strategies for improved communication (e.g., speaking toward better ear and moving to well-lit area)
• Face the patient directly, establish eye contact, and avoid turning away mid sentence
• Simplify language (i.e., do not use slang but do use short, simple sentences), as appropriate
• Note and document the patient’s preferred method of communication (e.g., verbal, written, lip-reading, or American Sign Language) in plan of care
• Assist the patient in acquiring a hearing aid or assistive listening device
• Refer to the primary care provider or specialist for evaluation, treatment, and hearing rehabilitation [15]

Impaired Vision

• Identify yourself when entering the patient’s space
• Ensure the patient’s eyeglasses or contact lenses have current prescription, are cleaned, and stored properly when not in use
• Provide adequate room lighting
• Minimize glare (i.e., offer sunglasses or draw window covering)
• Provide educational materials in large print
• Apply labels to frequently used items (i.e., mark medication bottles using high-contrasting colors)
• Read pertinent information to the patient
• Provide magnifying devices
• Provide referral for supportive services (e.g., social, occupational, and psychological) [16]

Patients with communication disorders require additional strategies to ensure effective communication. For example, aphasia is a communication disorder that results from damage to portions of the brain that are responsible for language. Aphasia usually occurs suddenly, often following a stroke or head injury, and impairs the  patient’s expression and understanding of language. Global aphasia is caused by injuries to multiple language-processing areas of the brain, including those known as Wernicke’s and Broca’s areas. These brain areas are particularly important for understanding spoken language, accessing vocabulary, using grammar, and producing words and sentences. Individuals with global aphasia may be unable to say even a few words or may repeat the same words or phrases over and over again. They may have trouble understanding even simple words and sentences. [17]

The most common type of aphasia is Broca's aphasia . People with Broca’s aphasia often understand speech and know what they want to say, but frequently speak in short phrases that are produced with great effort. For example, they may intend to say, “I would like to go to the bathroom,” but instead the words, “Bathroom, Go,” are expressed. They are often aware of their difficulties and can become easily frustrated.  See the hyperlink in the box below for evidence-based strategies to enhance communication with a person with impaired speech. [18]

Strategies to Improve Communication with Patients with Impaired Speech

• Modify the environment to minimize excess noise and decrease emotional distress
• Phrase questions so the patient can answer using a simple “Yes” or “No,” being aware that patients with expressive aphasia may provide automatic responses that are incorrect
• Monitor the patient for frustration, anger, depression, or other responses to impaired speech capabilities
• Provide alternative methods of speech communication (e.g., writing tablet, flash cards, eye blinking, communication board with pictures and letters, hand signals or gestures, and computer)
• Adjust your communication style to meet the needs of the patient (e.g., stand in front of the patient while speaking, listen attentively, present one idea or thought at a time, speak slowly but avoid shouting, use written communication, or solicit family’s assistance in understanding the patient’s speech)
• Ensure the call light is within reach and central call light system is marked to indicate the patient has difficulty with speech
• Repeat what the patient said to ensure accuracy
• Instruct the patient to speak slowly
• Collaborate with the family and a speech therapist to develop a plan for effective communication [19]

Maintaining Patient Confidentiality

When communicating with patients, their friends, their family members, and other members of the health care team, it is vital for the nurse to maintain patient confidentiality. The Health Insurance Portability and Accountability Act (HIPAA)  provides standards for ensuring privacy of patient information that are enforceable by law. Nurses must always be aware of where and with whom they share patient information. For example, information related to patient care should not be discussed in public areas, paper charts must be kept in secure areas, computers must be logged off when walked away from, and patient information should only be shared with those directly involved in patient care. For more information about patient confidentiality, see the “ Legal Considerations & Ethics ” section in the “Scope of Practice” chapter.

Read more information about the Health Insurance Portability and Accountability Act of 1996 (HIPAA) .

• Abdolrahimi, M., Ghiyasvandian, S., Zakerimoghadam, M., & Ebadi, A. (2017). Therapeutic communication in nursing students: A Walker & Avant concept analysis. Electronic Physician, 9 (8), 4968–4977. https://doi.org/10.19082/4968 ↵
• Karimi, H., & Masoudi Alavi, N. (2015). Florence Nightingale: The mother of nursing. Nursing and Midwifery Studies, 4 (2), e29475. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4557413/ . ↵
• “ beautiful african nurse taking care of senior patient in wheelchair ” by agilemktg1 is in the Public Domain ↵
• This work is a derivative of Human Relations by LibreTexts and is licensed under CC BY-NC-SA 4.0 ↵
• Flickr - Official U.S. Navy Imagery - A nurse examines a newborn baby..jpg ” by MC2 John O'Neill Herrera/ U.S. Navy is in the Public Domain ↵
• American Nurse. (n.d.). Therapeutic communication techniques . https://www.myamericannurse.com/therapeutic-communication-techniques/ ↵
• Balchan, M. (2016). The Magic of Genuine Communication. http://michaelbalchan.com/communication/ ↵
• Morrison, E. (2019). Empathetic Communication in Healthcare. https://www.cibhs.org/sites/main/files/file-attachments/empathic_communication_in_healthcare_workbook.pdf?1594162691 ↵
• Burke, A. (2021). Therapeutic Communication: NCLEX-RN. https://www.registerednursing.org/nclex/therapeutic-communication/   ↵
• Smith, L. L. (2018, June 12). Strategies for effective patient communication. American Nurse . https://www.myamericannurse.com/strategies-for-effective-patient-communication/ ↵
• Smith, L. L. (2018, June 12). Strategies for effective patient communication. American Nurse. https://www.myamericannurse.com/strategies-for-effective-patient-communication/ ↵
• Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018). Nursing interventions classification (NIC) . Elsevier, pp. 115-116 ↵
• Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018 ). Nursing interventions classification (NIC) . Elsevier, pp. 115-116 ↵
• National Institute on Deafness and Other Communication Disorders (NIDCD). (2017, March 6). Aphasia. https://www.nidcd.nih.gov/health/aphasia ↵
• Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018). Nursing interventions classification (NIC) . Elsevier, pp. 115-116. ↵
• Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C. (2018). Nursing interventions classification (NIC). Elsevier, pp. 115-116. ↵

Learning Activities

(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)

Apply the concepts you learned from this chapter to the following patient scenario [1] .

Joe is a 68-year-old male who was recently diagnosed for colon cancer last week and underwent a colon resection three days ago. See Figure 11.15 for an image of Joe. [2] In the change of shift report, you hear that he is receiving morphine by PCA pump for pain, but he is not using it very often. Staff reports he “needs much encouragement” to get out of bed and participate in self-cares. He has crackles in his lung bases and his oxygen saturation is 88% on room air.

• What additional assessments (subjective and objective) will you perform on Joe?
• List the top three priority nursing diagnoses for Joe.
• Joe states, “I don’t want to use morphine. I am afraid I will become addicted to it like my friend did after he came home from the war.” How will you respond to therapeutically address his concerns, yet also teach Joe about good pain management?
• What are common side effects of opioids and how will you plan to manage these side effects for Joe?
• Emotional issues could also be affecting Joe’s perception of pain. What will you further physically assess and therapeutically address?
• After providing patient education about morphine and the PCA pump, you check on Joe later in the day and notice he has had five self-doses every hour with 15 attempts in the past hour. The pump is set for a maximum of 6 doses per hour. What further assessments will you perform?

Nurses play an essential role in performing comprehensive pain assessment. Assessments include asking questions about the presence of pain, as well as observing for nonverbal indicators of pain, such as grimacing, moaning, and touching the painful area. It is especially important to observe for nonverbal indicators of pain in patients unable to self-report their pain, such as infants, children, patients who have a cognitive disorder, patients at end of life, non-English speaking patients, or patients who tend to be stoic due to cultural beliefs. See Figure 11.14 [3] for an image of a patient who is expressing pain nonverbally.

Recall that pain is defined as whatever the person experiencing it says it is. Subjective assessment includes asking questions regarding the severity rating, as well as obtaining comprehensive information by using the “PQRSTU” or “OLDCARTES” methods for assessing a chief complaint. For some patients who are unable to quantify the severity of their pain, a visual scale like the FACES scale is the best way to perform subjective assessment regarding the severity of pain.

Objective data includes observations of nonverbal indications of pain, such as restlessness, facial grimacing and wincing, moaning, and rubbing or guarding painful areas. For patients who cannot verbalize their pain, using a scale like the FLACC, COMFORT, or PAINAD is helpful to standardize observations across different staff members. Keep in mind that patients experiencing acute pain will also likely have vital signs changes, such as increased blood pressure, increased heart rate, and increased respiratory rate.

It is important to assess the impact of pain on a patient’s daily functioning. This can be accomplished by asking what effect the pain has on their ability to bathe, dress, prepare food, eat, walk, and complete other daily activities. Assessing the impact of pain on daily functioning is a new standard of care that assists the interdisciplinary team in tailoring treatment goals and interventions that are customized to the patient’s situation. For example, for some patients, chronic pain affects their ability to be employed, so effective pain management is vital so they can return to work. For other patients receiving palliative care, the ability to sit up and eat a meal with loved ones without pain is an important goal. [4]

When performing a patient assessment, any new complaints of pain or pain that is unresponsive to the current treatment plan should be reported to the health care provider. Instances of sudden, severe pain or chest pain require immediate notification or contact of emergency services.

Commonly used NANDA-I nursing diagnoses for pain include Acute Pain (duration less than 3 months) and Chronic Pain . See Table 11.5 for more information regarding these diagnoses. [5] For more information about defining characteristics and related factors for other NANDA-I nursing diagnoses, refer to a current nursing diagnosis resource.

Table 11.5 Pain NANDA-I Nursing Diagnoses [6]

Outcome Identification

An overall goal when providing pain management is, “ The patient will report that the pain management treatment plan achieves their comfort-function goals. ” [7]

SMART outcomes are customized to the patient’s unique situation. An example of a SMART goal is, “ The patient will notify the nurse promptly for pain intensity level that is greater than their comfort-function goal throughout shift. ” [8]

Planning Interventions

Several pharmacological and nonpharmacological interventions have been described throughout this chapter. See the following box for a summarized list of interventions for acute pain management.

Acute Pain Management [9]

• Identify pain intensity during required recovery activities (e.g., coughing and deep breathing, ambulation, transfers to chair, etc.)
• Explore patient’s knowledge and beliefs about pain, including cultural influences
• Question patient regarding the level of pain that allows a state of comfort and desired function and attempt to keep pain at or lower than identified level
• Ensure that the patient receives prompt analgesic care before the pain becomes severe or before pain-inducing activities
• Administer analgesics around-the-clock as needed the first 24 to 48 hours after surgery, trauma, or injury except if sedation or respiratory status indicates otherwise
• Monitor sedation and respiratory status before administering opioids and at regular intervals when opioids are administered
• Follow agency protocols in selecting analgesia and dosage
• Use a combination of prescribed medications (e.g., opioids, nonopioids, and adjuvants), if pain level is severe
• Select and implement interventions tailored to the patient’s risks, benefits, and preferences (e.g., pharmacological and nonpharmacological) to facilitate pain relief
• Cautiously use analgesics that may have adverse effects in older adults
• Administer analgesics using the least invasive route available, avoiding the intramuscular route
• Advocate PCA, intrathecal, and epidural routes of administration when appropriate
• Modify pain control measures on the basis of the patient’s response to treatment
• Prevent and/or manage medication side effects
• Notify prescribing provider if pain control measures are unsuccessful
• Provide accurate information to family members or caregivers about the patient’s pain experience with the patient's permission

See the following box for a summarized list of interventions for chronic pain management.

Chronic Pain Management [10]

• Explore the patient’s knowledge and beliefs about pain, including cultural influences
• Determine the pain experience on quality of life (e.g., sleep, appetite, activity, cognition, mood, relationships, job performance, and role responsibilities)
• Evaluate the effectiveness of past pain control measures with the patient
• Question the patient regarding the level of pain that allows a state of comfort and appropriate functioning and attempt to keep pain at or lower than identified level
• Control environmental factors that may influence the patient’s pain experience
• Ensure that the patient receives prompt analgesic care before the pain becomes severe or before activities that are anticipated to be pain-inducing
• Select and implement intervention options tailored to the patient’s risks, benefits, and preferences (e.g., pharmacological, nonpharmacological, interpersonal) to facilitate pain relief, as appropriate
• Instruct the patient and family about principles of pain management
• Encourage the patient to monitor own pain and to use self-management approaches
• Encourage appropriate use of nonpharmacological techniques (e.g., biofeedback, TENS, hypnosis, relaxation, guided imagery, music therapy, distraction, play therapy, activity therapy, acupressure, heat and cold application, and massage) and pharmacological options as pain control measures
• Avoid use of analgesics that may have adverse effects on older adults
• Collaborate with the patient, family, and other health professionals to select and implement pain control measures
• Prevent or manage side effects
• Evaluate the effectiveness of pain control measures through ongoing monitoring of the pain experience
• Watch for signs of depression (e.g., sleeplessness, not eating, flat affect, statements of depression, or suicidal ideation)
• Watch for signs of anxiety or fear (e.g., irritability, tension, worry, or fear of movement)
• Incorporate the family in the pain relief modality, when possible
• Utilize a multidisciplinary approach to pain management, when appropriate
• Consider referrals for the patient and family to support groups and other resources, as appropriate
• Evaluate patient satisfaction with pain management at specified intervals
• Evaluate barriers to adherence with past pain management care plans

Implementing Pharmacological Interventions

Patients should be involved and engaged in their plan of care to treat pain. By demonstrating empathy and collaborating with patients and the interdisciplinary team, it is more likely the treatment plan will be effective based on the patient’s goals.

When administering analgesic medication, holistic nursing care is important. Begin by considering the patient’s goals for pain relief and ask if they have been met effectively by previously administered medications. If they have not been met, it may be necessary to advocate for additional or alternative medication with the health care provider. It is also important to consider if the patient is experiencing any side effects that may impact the patient’s desire to take additional pain medication.

When administering medications that have been ordered on an “as-needed” basis, it is vital for the nurse to verify the amount of medication the patient received in the past 24 hours and if any dosage limits have been met to ensure patient safety.

Prior to administration, consider the best route of administration for this patient at this particular time. For example, if the patient is nauseated and vomiting, then an oral route may not be effective. On the other hand, if a patient’s pain has improved when receiving intravenous medications during the recovery process, it may be possible for the patient to begin taking oral pain medications in preparation for discharge home. Keep the WHO ladder in mind when selecting medications to reach patient goals while also avoiding potential adverse effects when possible.

When preparing opioid medications, it is important to remember that these medications are controlled substances with special regulations regarding storage, count auditing, and disposal/wasting of medication. Follow agency policy regarding these issues. It is also important to assess the patient’s level of sedation and respiratory status before administering additional doses of opioids and withhold the medication if the patient is oversedated or their respiratory rate is less than 12/minute. However, when providing pain management during end-of-life care, these parameters no longer apply because the emphasis is on providing comfort according to the patient’s preferences. Read more about end-of-life care in the “ Grief and Loss ” chapter.

It is vital for the nurse to regularly evaluate if the established interventions are effectively meeting the pain management and function goals established collaboratively with the patient. Additionally, when administering analgesics, the patient should be reassessed in an hour (or other time frame based on the onset and peak of the medication) to determine if the medication was effective. If interventions are not effective, then follow-up interventions are required, which may include contacting the health care provider.

For patients living with chronic pain, it can be helpful for them or their caregiver to maintain a pain journal. In the journal they can document activities that precipitated pain, medications taken to manage the pain, and whether these medications were effective in helping them to meet their functional goals. This journal is shared with the health care provider during follow-up visits to enhance the treatment plan. [11]

The nurse must continually monitor for potential adverse effects of pain medications. For example, if a patient is receiving acetaminophen daily for chronic osteoarthritis pain, signs of liver dysfunction, such as jaundice and elevated liver function bloodwork, should be monitored. For older adults receiving NSAIDs, it is important to watch for early signs of gastrointestinal bleeding, such as melena. Patients receiving opioids should be continually monitored for oversedation, respiratory depression, constipation, nausea and vomiting, urinary retention, and pruritus. Side effects should be reported to the health care provider and orders received for treatment.

Acute pain: Pain that is limited in duration and is associated with a specific cause.

Addiction: A chronic disease of the brain’s reward, motivation, memory, and related circuitry reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. Addiction is characterized by several symptoms, such as the inability to consistently abstain from a substance, impaired behavioral control, cravings, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response.

Adjuvant: Medication that is not classified as an analgesic but has been found in clinical practice to have either an independent analgesic effect or additive analgesic properties when administered with opioids.

Analgesics: Medications used to relieve pain.

Chronic pain: Pain that is ongoing and persistent for longer than six months.

Misuse: Taking prescription pain medications in a manner or dose other than prescribed; taking someone else’s prescription, even if for a medical complaint such as pain; or taking a medication to feel euphoria (i.e., to get high).

Neuropathic pain: Pain caused by a lesion or disease of the somatosensory nervous system that is typically described by patients as “burning” or “like pins and needles.”

Nociceptor: A sensory receptor for painful stimuli.

Pain: An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.

Patient-Controlled Analgesia (PCA): A method of pain management that allows hospitalized patients with severe pain to safely self-administer opioid medications using a programmed pump according to their level of discomfort.

Physical dependence: Withdrawal symptoms that occur when chronic pain medication is suddenly reduced or stopped because of physiological adaptations that occur from chronic exposure to the medication.

Referred pain: Pain perceived at a location other than the site of the painful stimulus. For example, pain from retained gas in the colon can cause pain to be perceived in the shoulder.

Substance abuse disorder: Significant impairment or distress from a pattern of substance use (i.e., alcohol, drugs or misuse of prescription medications).

Tolerance: A reduced response to pain medication when the same dose of a drug has been given repeatedly, requiring a higher dose of the drug to achieve the same level of response.

Learning Objectives

• Assess factors that put patients at risk for problems with sleep
• Identify factors related to sleep/rest across the life span
• Recognize characteristics of sleep deprivation
• Consider the use of nonpharmacological measures to promote sleep and rest
• Identify evidence-based practices

Maslow’s hierarchy of needs indicates sleep as one of our physiological requirements. Getting enough quality sleep at the right times according to our circadian rhythms can protect mental and physical health, safety, and quality of life. Conversely, chronic sleep deficiency increases the risk of heart disease, kidney disease, high blood pressure, diabetes, and stroke, as well as weakening the immune system. [12] This chapter will review the physiology of sleep and common sleep disorders, as well as interventions to promote good sleep.

Nursing Fundamentals (Nicolet College) Copyright © by Chippewa Valley Technical College is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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Chapter 4: Communication Skills for Ambulatory Care

Stacey Hobbick

Learning Objectives

By the end of this chapter, the learner should be able to:

• Explain the importance of effective communication in ambulatory care settings, including verbal and nonverbal communication skills.
• Demonstrate cultural competence in communication with diverse populations in the ambulatory care setting.
• Collaborate effectively with the interdisciplinary healthcare team through clear and concise communication.
• Utilize health informatics and electronic communication tools appropriately in ambulatory care settings.
• Advocate for patients by effectively communicating their needs, concerns, and rights.
• Reflect on personal communication and interpersonal skills, identifying areas for improvement and strategies for enhancing communication effectiveness in ambulatory care settings.

Introduction to Chapter 4

In this chapter, we will explore the essential communication skills required in ambulatory care nursing. Effective communication is crucial for building therapeutic relationships, promoting patient-centered care, and achieving positive health outcomes. Through understanding and developing these communication skills, ambulatory care nurses can enhance the quality of care they provide and establish meaningful connections with their patients.

Chapter 4 Key Terms

Verbal Communication : The use of spoken or written words to convey information and ideas.

Nonverbal Communication : The transmission of messages through body language, gestures, facial expressions, and other nonverbal cues.

Active Listening : The attentive and engaged listening process that involves fully understanding and responding to the speaker’s message.

Health Literacy : The ability of individuals to obtain, process, and understand basic health information and services needed to make informed decisions about their health.

Cultural Competence : The ability to effectively communicate and interact with individuals from diverse cultural backgrounds, taking into consideration their beliefs, values, and practices.

Interprofessional Communication : Communication and collaboration among healthcare professionals from different disciplines to ensure comprehensive and coordinated patient care.

Plain Languag e: Clear and simple language that is easily understood by the general population, free from jargon and technical terms.

Health Informatics : The use of technology and information systems to manage, store, and exchange healthcare information.

Patient Advocacy : The act of supporting and promoting the rights, needs, and interests of patients to ensure they receive the best possible care.

Informed Consent : The process of obtaining permission from patients, after providing them with relevant information, to make decisions about their healthcare.

4.1 Overview

Chapter 4 focuses on the essential communication skills required for effective practice in ambulatory care settings. Communication plays a vital role in establishing strong patient-provider relationships, promoting patient engagement, and ensuring high-quality care. In this chapter, we will explore the importance of clear and empathetic communication, cultural competence, interdisciplinary collaboration, health informatics, patient advocacy , and reflective practice.

By developing strong communication skills, nurses can effectively engage with patients from diverse backgrounds, ensure their needs are understood and addressed, and foster collaborative relationships with the interdisciplinary healthcare team. The chapter will delve into various communication techniques, including active listening, verbal and nonverbal communication, health literacy, and the use of technology to enhance communication.

Through interactive learning activities, case studies, and self-reflection exercises, students will have the opportunity to practice and refine their communication skills. By the end of this chapter, students will have a solid foundation in communication skills necessary to provide patient-centered care in ambulatory settings and promote positive healthcare outcomes.

By mastering these communication skills, nurses will be well-equipped to establish trusting relationships, promote shared decision-making, and deliver patient-centered care in the dynamic ambulatory care environment.

4.2 Effective Verbal Communication

Effective verbal communication is a critical skill for ambulatory care nurses as it serves as the primary mode of interaction with patients, colleagues, and other healthcare professionals. In this section, we will explore the key components of effective verbal communication and how they contribute to patient-centered care in ambulatory settings.

Clear and concise communication is essential for building rapport, establishing trust, and ensuring mutual understanding between the nurse and the patient. We will discuss the importance of active listening , which involves fully focusing on the patient, maintaining eye contact, and using verbal cues to show engagement and understanding. Active listening allows nurses to gather important information, identify patient needs, and address any concerns or questions.

The use of open-ended questions is another valuable technique in effective verbal communication. By asking questions that require more than a simple “yes” or “no” response, nurses encourage patients to express themselves freely, leading to a deeper understanding of their health concerns and goals. Open-ended questions also promote patient engagement, empowerment, and shared decision-making, as they encourage patients to actively participate in their care.

Language and tone are critical aspects of effective communication. Nurses should use clear and concise language, avoiding medical jargon and adapting their vocabulary to the patient’s level of health literacy. Additionally, maintaining a warm and empathetic tone helps to create a supportive and caring environment, ensuring that patients feel comfortable and valued.

Put it into Practice

The SPIKES protocol is a six-step model developed by Robert Buckman for delivering bad news to patients in a way that minimizes distress and improves understanding. Each letter of the acronym represents a step in the process.

Here’s what each letter stands for along with a description and example:

• S – Setting Up: Arrange for some privacy, ensure the patient is comfortable, and involve any significant others at the patient’s discretion. Limit interruptions during the conversation. Example: The healthcare provider arranges a private room for the conversation and ensures that the patient’s spouse is present, as per the patient’s wish. The provider also switches off their cell phone to avoid interruptions.
• P – Perception: Ask the patient about their understanding or perception of the situation before sharing the news. This helps to gauge how much the patient already knows and is prepared to hear. Example: The provider might ask, “Can you tell me what you understand about your tests so far?”
• I – Invitation: Obtain the patient’s invitation to share the information. Not all patients will want all the information at once. Some might prefer a loved one to receive the details. Example: The provider could ask, “Are you okay with discussing your test results now?”
• K – Knowledge: Warn the patient that bad news is coming to prepare them for the information (“a warning shot”). Then, provide the medical facts clearly and avoid using excessive medical jargon. Example: The provider might say, “Unfortunately, I have some serious news to share. The biopsy shows that you have lung cancer.”
• E – Emotions: Address the patient’s emotions with empathic responses. Observe, identify, and acknowledge their feelings, then validate and express support. Example: If the patient starts crying, the provider might say, “I can see that this is very upsetting for you. It’s completely understandable to feel this way. We are here to support you.”
• S – Strategy and Summary: Summarize the information given, check the patient’s understanding, and collaboratively develop a strategy or treatment plan going forward. Example: The provider may say, “Just to summarize, we’ve found that it’s lung cancer. There are several treatment options we can consider, such as surgery, radiation, and chemotherapy. We’ll work together to decide on the best plan for you.”

This protocol, when followed properly, ensures that patients are well-prepared for the news, have a clear understanding of their condition, and feel supported emotionally while taking part in decision-making about their care.

In the dynamic environment of ambulatory care, effective verbal communication is much more than a mere exchange of information; it’s about forging a meaningful connection with patients. At the core of this connection lies active listening, a skill that goes beyond hearing words to fully engaging with the patient’s context. This involves not only acknowledging their statements but also asking clarifying questions and paraphrasing to demonstrate understanding and respect.

Tailoring conversations to each patient’s unique needs is a critical facet of effective communication. Whether it’s simplifying complex medical terms for better comprehension or spending additional time to ease the concerns of an anxious patient, adapting your approach can significantly enhance the patient’s comfort and understanding. Empathy is integral to these interactions, as it deepens the nurse-patient relationship. Responding with genuine understanding to patient worries or fears, and validating their feelings with reassuring phrases, can transform the nature of the care experience.

The art of questioning plays a significant role in effective communication. Open-ended questions encourage patients to express themselves more fully, promoting a deeper engagement in their care. Summarizing key points throughout the conversation ensures mutual understanding and helps patients process their own thoughts more coherently. When conveying information, clarity and structure are essential. Presenting information in a logical, jargon-free manner, broken into digestible segments, aids in patient understanding and empowerment.

Role-play and simulation exercises with peers are invaluable for practical application of these skills. They provide a safe and constructive environment for refining communication techniques and receiving feedback. This practice is crucial for preparing for real-life patient interactions and developing a personal style of communication that is both empathetic and effective.

Finally, the journey of enhancing communication skills is continuous, involving regular reflection and learning from each interaction. This ongoing process of self-assessment and adaptation is key to personal and professional growth in the field of ambulatory care nursing. By weaving together these diverse yet interconnected strategies, nurses can significantly improve their ability to communicate effectively, thereby elevating the overall quality of patient care in ambulatory settings.

Case Scenario: Effective Verbal Communication in Ambulatory Care

You are an ambulatory care nurse working in a community health center. One of your patients, Mr. Johnson, is a 65-year-old man with multiple chronic conditions, including diabetes, hypertension, and chronic kidney disease. Today, he has come in for his regular check-up and to discuss his recent lab results. Mr. Johnson appears concerned and anxious about his health and the management of his conditions. Your role as an ambulatory care nurse is to effectively communicate with him, address his concerns, and provide the necessary support and education.

During the visit, you greet Mr. Johnson with a warm and welcoming demeanor, putting him at ease and creating a safe space for open communication. You initiate the conversation by asking him how he has been feeling and if he has any specific concerns or questions. By actively listening and using open-ended questions, you encourage him to share his thoughts, concerns, and goals related to his health.

Mr. Johnson expresses his frustration with the complexity of his medication regimen and struggles with dietary modifications. You acknowledge his concerns and validate his feelings, emphasizing that managing chronic conditions can be challenging. You take the time to explain the importance of each medication and its role in his overall treatment plan. Using clear and concise language, you provide step-by-step instructions on how to take each medication and offer strategies to help him remember and stay organized.

To address Mr. Johnson’s dietary concerns, you engage in a collaborative conversation, discussing his current eating habits and exploring practical ways to make healthier choices. You explain the impact of nutrition on his health conditions and offer personalized recommendations based on his preferences and lifestyle. By actively involving him in the decision-making process, you empower Mr. Johnson to take ownership of his dietary choices and motivate him to make positive changes.

Throughout the interaction, you pay attention to your non-verbal cues, such as maintaining eye contact, nodding to show understanding, and using a calm and reassuring tone. These non-verbal elements help to convey empathy, understanding, and support, reinforcing the therapeutic relationship with Mr. Johnson.

Reflective Questions:

• How did you establish a rapport with Mr. Johnson and create a safe and open environment for effective verbal communication?
• Describe the active listening techniques you employed during the conversation with Mr. Johnson and how they facilitated a deeper understanding of his concerns and goals.
• Reflect on how you effectively explained complex medical information to Mr. Johnson in a clear and understandable manner. How did you ensure he understood his medication regimen and its importance?
• Discuss the strategies you utilized to engage Mr. Johnson in the decision-making process regarding his dietary choices. How did you empower him to make informed decisions about his nutrition?
• Reflect on the non-verbal communication cues you used to convey empathy, understanding, and support. How did these cues contribute to the therapeutic relationship with Mr. Johnson?

4.3 Nonverbal Communication and Body Language

Nonverbal communication and body language play a significant role in ambulatory care nursing. As an ambulatory care nurse, it is crucial to recognize and utilize nonverbal cues effectively to enhance patient-provider communication and build therapeutic relationships. Nonverbal communication encompasses facial expressions, gestures, body movements, eye contact, and tone of voice. These nonverbal cues can convey emotions, attitudes, and intentions, often complementing or contradicting the verbal message Nonverbal cues can convey emotions, attitudes, and intentions, often complementing or contradicting the verbal message . By being aware of and interpreting these cues, nurses can gain deeper insights into patients’ feelings, needs, and concerns.

Maintaining appropriate eye contact demonstrates attentiveness and interest in the patient’s words. It conveys a sense of presence and engagement in the conversation. Open body posture, facing the patient directly, and leaning slightly towards them demonstrates active listening and shows that the nurse is fully present. Nodding and smiling at appropriate moments can show understanding, empathy, and encouragement. Conversely, closed-off body language, such as crossed arms, avoiding eye contact, or fidgeting, may signal disinterest or discomfort, hindering effective communication.

Body language, including the positioning of arms and legs, can indicate openness or defensiveness. Crossing one’s arms may unintentionally convey a sense of being closed off or defensive, while open arms can create a welcoming and approachable atmosphere. Mirroring the patient’s body language, to some extent, can help establish rapport and build trust. However, it is important to do so subtly and respectfully, avoiding mimicry or imitation.

Cultural competence is essential when considering nonverbal communication, as gestures, facial expressions, and personal space can vary across cultures. What may be interpreted as appropriate or respectful in one culture may be perceived differently in another. Being aware of cultural differences and adapting one’s nonverbal communication style accordingly demonstrates respect, sensitivity, and the ability to effectively communicate with patients from diverse backgrounds.

In ambulatory care nursing, mastering nonverbal communication and body language enhances the patient-centered approach and fosters therapeutic relationships. It helps create a supportive and empathetic environment, where patients feel heard, understood, and valued. By understanding and utilizing nonverbal cues effectively, ambulatory care nurses can enhance the quality of patient interactions and contribute to improved health outcomes.

4.4 Health Literacy and Effective Patient Education

Health literacy is a critical aspect of ambulatory care nursing, as it directly impacts the ability of patients to understand and effectively manage their health conditions. Ambulatory care nurses play a vital role in providing patient education that is tailored to the individual’s health literacy level, ensuring they have the knowledge and skills necessary to make informed decisions and actively participate in their care.

Effective patient education begins with assessing the patient’s health literacy level, which involves evaluating their ability to comprehend health information, navigate healthcare systems, and use the information to make informed decisions. By understanding a patient’s health literacy level, nurses can adapt their communication style, use plain language , and provide visual aids or written materials that are appropriate for the patient’s comprehension level.

During patient education sessions, ambulatory care nurses engage in active listening and ask open-ended questions to assess the patient’s understanding and clarify any misconceptions. They employ clear and concise language, avoiding medical jargon or complex terminology. By breaking down information into manageable chunks, nurses can enhance comprehension and retention of key concepts.

Health literacy also encompasses the ability to navigate the healthcare system, including understanding insurance coverage, accessing healthcare resources, and scheduling follow-up appointments. Ambulatory care nurses play a crucial role in empowering patients to navigate these systems effectively, providing guidance, resources, and referrals as needed.

Moreover, patient education should consider cultural and linguistic diversity. Ambulatory care nurses must be sensitive to different cultural backgrounds and language barriers, ensuring that educational materials and communication methods are appropriate and accessible to all patients. Utilizing interpreters or translated materials, when necessary, can help bridge language gaps and ensure effective communication.

By promoting health literacy and providing effective patient education, ambulatory care nurses empower patients to actively participate in their care, make informed decisions, and adopt healthy behaviors. This supports improved health outcomes, enhances patient satisfaction, and strengthens the patient-provider relationship.

Cultural Competence

Use of Medical Interpreter: Engage a professional medical interpreter to facilitate the communication process. It is critical to use a certified interpreter instead of relying on a family member or friend of the patient. A certified interpreter is trained to handle sensitive health information and maintain confidentiality.

Use of Visual Aids: Utilize charts, diagrams, or other visual aids to help explain complex medical conditions and procedures. Visual aids can help transcend language barriers and provide a clearer understanding of health conditions.

Use of Plain Language: Even when working with an interpreter, it’s important to use plain, non-medical language whenever possible. This helps ensure the patient understands their conditions and the necessary care procedures.

Confirm Understanding: Ask the patient to repeat back the information or instructions you’ve given them. This technique, known as the “teach-back method”, can help confirm that the patient understood the information correctly.

Cultural Sensitivity: Understand and respect the patient’s cultural beliefs and practices. This could affect how they perceive their health conditions and treatment options.

4.5 Communication with Diverse Populations

Effective communication with diverse populations is a crucial aspect of ambulatory care nursing. Ambulatory care nurses interact with individuals from various cultural, ethnic, linguistic, and socioeconomic backgrounds. It is essential for nurses to employ culturally competent and sensitive communication strategies to ensure effective and meaningful interactions.

Cultural competence involves understanding and respecting the beliefs, values, customs, and practices of different cultural groups. Ambulatory care nurses should approach each interaction with an open mind and a willingness to learn about the cultural backgrounds of their patients. They should strive to build trust and rapport by showing respect, listening attentively, and validating the patient’s experiences.

To communicate effectively with diverse populations, ambulatory care nurses need to be mindful of potential language barriers. They should use clear and concise language, avoid medical jargon, and speak at a pace that allows for easy comprehension. When language barriers exist, nurses can utilize interpreter services, language support tools, or trained bilingual staff to facilitate communication and ensure accurate understanding.

Non-verbal communication also plays a significant role in cross-cultural interactions. Ambulatory care nurses should be aware of their body language, facial expressions, and gestures, as they may have different meanings across cultures. They should practice active listening, maintain eye contact, and demonstrate empathy and understanding through non-verbal cues.

Additionally, understanding the social determinants of health can enhance communication with diverse populations. Ambulatory care nurses should be sensitive to the impact of socioeconomic factors, such as income, education, and access to healthcare, on patients’ health outcomes. By acknowledging these factors and tailoring communication strategies accordingly, nurses can address barriers and provide patient-centered care that promotes health equity.

By effectively communicating with diverse populations, ambulatory care nurses can foster trust, build strong therapeutic relationships, and improve health outcomes. They contribute to reducing health disparities by ensuring that patients from different backgrounds receive equitable and culturally sensitive care.

4.6 Interprofessional Communication and Collaboration

Interprofessional communication and collaboration are essential skills for ambulatory care nurses to provide comprehensive and coordinated care to patients. In the ambulatory care setting, nurses work alongside various healthcare professionals, including physicians, pharmacists, social workers, and allied health professionals. Effective communication and collaboration among the interprofessional team are crucial for delivering high-quality and patient-centered care.

Ambulatory care nurses must possess strong communication skills to effectively convey patient information, discuss care plans, and facilitate seamless transitions of care. They need to communicate clearly, concisely, and accurately, using appropriate terminology and formats that are understood by all team members. By sharing relevant patient data, assessments, and interventions, nurses contribute to a comprehensive understanding of the patient’s health status and support informed decision-making.

Collaboration within the interprofessional team is essential for developing and implementing effective care plans. Ambulatory care nurses must actively participate in interprofessional meetings, case conferences, and care coordination activities. They should engage in open and respectful dialogue, share their expertise, and contribute to the development of individualized care plans that align with the patient’s goals and needs.

Building trusting relationships with other healthcare professionals is also crucial for effective interprofessional collaboration. Ambulatory care nurses should demonstrate respect, professionalism, and a willingness to listen and learn from others. They should value and appreciate the unique contributions of each team member and foster a culture of collaboration and mutual support.

Effective interprofessional communication and collaboration in the ambulatory care setting contribute to improved patient outcomes, reduced healthcare costs, and enhanced patient satisfaction. By working together as a cohesive team, healthcare professionals can provide holistic and coordinated care that addresses the complex needs of patients in ambulatory care settings.

4.7 Communication in Challenging Situations

Communication in challenging situations is a critical skill for ambulatory care nurses, as they often encounter various difficult or sensitive situations while providing care to patients. These situations may include delivering bad news, addressing conflicts, or managing emotional distress. Effective communication in such circumstances is essential for maintaining trust, managing expectations, and promoting positive outcomes for both patients and healthcare providers.

In challenging situations, ambulatory care nurses should strive to maintain a calm and empathetic demeanor while effectively conveying information. They need to actively listen to patients and their families, validating their concerns and providing emotional support. By showing empathy and compassion, nurses can create a safe and supportive environment that encourages open communication and understanding.

When delivering bad news, ambulatory care nurses should use clear and concise language, avoiding medical jargon and providing information in a sensitive manner. They should allow patients and their families the time and space to process the information while being available to answer questions and provide additional support. Nurses should demonstrate sensitivity to cultural, religious, or personal beliefs that may influence the patient’s response to the news.

Conflicts or disagreements may arise between patients, family members, and healthcare providers. In these situations, ambulatory care nurses should employ effective communication and conflict-resolution strategies. They should actively listen to all parties involved, acknowledging their perspectives and facilitating open dialogue. Nurses can help find common ground and work towards a mutually satisfactory resolution while maintaining professionalism and respect.

Managing emotional distress in patients and their families requires a compassionate and supportive approach. Ambulatory care nurses should be skilled in offering emotional support, active listening, and providing appropriate resources or referrals to address the emotional needs of patients and their families. They should demonstrate empathy, validate emotions, and offer reassurance throughout the communication process.

Effective communication in challenging situations requires ongoing self-awareness and reflection. Ambulatory care nurses should continuously strive to enhance their communication skills by seeking feedback, participating in professional development opportunities, and learning from experiences. By effectively navigating challenging communication scenarios, nurses can promote patient satisfaction, enhance patient-provider relationships, and contribute to positive patient outcomes.

Scenario: A patient, Mr. Johnson, arrives at the ambulatory care clinic for a follow-up appointment after being diagnosed with a chronic illness. During the appointment, the nurse, Sarah, discovers that Mr. Johnson’s condition has worsened, requiring additional interventions and lifestyle changes. Sarah needs to communicate this news to Mr. Johnson in a sensitive and supportive manner.

• How would you approach delivering the news to Mr. Johnson about his worsened condition?
• What nonverbal cues can you utilize to convey empathy and support during the conversation?
• How would you address any potential emotional distress or concerns that Mr. Johnson may have?
• What strategies can you employ to ensure effective understanding and engagement during the conversation?
• How would you tailor your communication approach based on Mr. Johnson’s cultural background or personal preferences?

In this scenario, Sarah approaches the conversation with empathy and compassion. She begins by ensuring a private and comfortable setting for the discussion, allowing Mr. Johnson to express any initial concerns or questions. Sarah uses clear and understandable language, avoids medical jargon, and breaks down complex information into manageable segments to facilitate understanding.

Sarah utilizes active listening skills, giving Mr. Johnson the opportunity to express his emotions and concerns. She demonstrates nonverbal cues such as maintaining eye contact, nodding to show understanding and adopting an open and attentive posture. Sarah validates Mr. Johnson’s emotions and offers reassurance throughout the conversation.

To address any potential emotional distress or concerns, Sarah provides Mr. Johnson with information about available support resources, such as support groups or counseling services. She encourages him to ask questions, ensuring that he feels empowered and involved in his care decisions.

Throughout the conversation, Sarah checks for understanding by periodically summarizing key points and asking Mr. Johnson to repeat the information in his own words. She uses visual aids or written materials, if necessary, to enhance comprehension. Sarah adapts her communication approach based on Mr. Johnson’s cultural background, taking into consideration any specific beliefs or preferences that may impact his understanding and acceptance of the information.

By effectively navigating this challenging communication situation, Sarah builds trust with Mr. Johnson, promotes his engagement in his own care, and supports his emotional well-being.

4.8 Electronic Communication and Health Informatics

Electronic communication and health informatics play a vital role in ambulatory care settings, facilitating the efficient and secure exchange of information among healthcare professionals, patients, and other stakeholders. In this section, we will explore the various aspects of electronic communication and health informatics in ambulatory care nursing.

One key aspect is the use of electronic health records (EHRs), which allow nurses to access and document patient information electronically. Nurses must demonstrate proficiency in navigating EHR systems, entering accurate and comprehensive data, and utilizing the available tools and features to enhance patient care and safety. This includes documenting patient assessments, care plans, medication administration, and other relevant information in a timely and organized manner.

Furthermore, the section will cover the importance of maintaining patient privacy and confidentiality in electronic communication. Nurses must adhere to ethical and legal guidelines, such as HIPAA regulations, when communicating patient information through electronic means. They should be knowledgeable about security measures, such as encryption and secure messaging platforms, to safeguard patient data and maintain trust in the healthcare system.

Additionally, the section will explore the role of telehealth and telecommunication technologies in ambulatory care. With the increasing adoption of telehealth services, nurses need to understand how to effectively communicate with patients remotely, using videoconferencing, telephone, or secure messaging platforms. They should be able to provide patient education, conduct virtual assessments, and facilitate remote monitoring when appropriate.

As part of this section, students will have the opportunity to explore various health informatics tools and technologies used in ambulatory care settings. They will learn how to navigate electronic communication platforms, utilize health information exchange systems, and access reliable online resources to support evidence-based practice.

Through interactive activities and case studies, students will apply their knowledge of electronic communication and health informatics to real-world scenarios. They will develop skills in utilizing electronic communication effectively, maintaining privacy and security, and leveraging health informatics tools to improve patient outcomes and streamline care delivery.

4.9 Active Listening

Active listening is a fundamental communication skill that is essential for effective patient advocacy. It involves not only hearing the words spoken by patients but also paying attention to their nonverbal cues, emotions, and underlying concerns. By actively engaging in the process of listening, nurses can create a supportive and empathetic environment that fosters open communication.

One aspect of active listening is giving full attention to the speaker. Nurses should make a conscious effort to be present in the moment, maintain eye contact, and minimize distractions. This sends a message to patients that their thoughts and feelings are valued, helping to build trust and rapport.

Another important component of active listening is providing verbal and nonverbal feedback. Nurses can demonstrate their attentiveness by nodding, using encouraging gestures, and providing verbal cues such as “I understand” or “Please tell me more.” These responses indicate to patients that they are being heard and understood, encouraging them to share more information.

Paraphrasing and summarizing are effective techniques in active listening that allow nurses to clarify and confirm their understanding of the patient’s message. By restating what the patient has said in their own words, nurses can ensure that they have correctly interpreted the information and provide an opportunity for the patient to confirm or correct any misconceptions.

Empathy is a crucial aspect of active listening and patient advocacy. Nurses should strive to understand and acknowledge the emotions and experiences of their patients. By expressing empathy through verbal affirmations and compassionate body language, such as a comforting touch or a gentle tone of voice, nurses can create a safe space for patients to express their concerns and fears.

By actively listening to patients, nurses can gain valuable insights into their needs, preferences, and goals. This information forms the foundation for effective patient advocacy, allowing nurses to tailor their care and communication to meet the individual needs of each patient. Through active listening, nurses can foster a collaborative and empowering relationship with patients, supporting them in making informed decisions and promoting their overall well-being.

4.10 Communication and Ethical Considerations

Effective communication in healthcare is not only about conveying information but also involves ethical considerations that ensure respectful and ethical care delivery. In the context of ambulatory care, nurses must navigate complex ethical issues while maintaining open and honest communication with patients, colleagues, and other healthcare professionals.

One key aspect of communication and ethical considerations is respect for patient autonomy and confidentiality. Nurses should uphold the principles of informed consent , respecting the patient’s right to make decisions about their healthcare. This involves providing clear and comprehensive information about treatment options, risks, benefits, and alternatives, ensuring that patients have the necessary information to make informed choices.

Confidentiality is another crucial ethical consideration in communication. Nurses must respect patient privacy and confidentiality, safeguarding their personal health information. This includes being mindful of discussing sensitive information in private settings and ensuring that electronic communication is secure and protected.

Additionally, ethical communication requires cultural competence and sensitivity. Nurses should recognize and respect the cultural values, beliefs, and practices of diverse patient populations. This involves actively listening, being open-minded, and adapting communication styles to meet the unique needs of each individual. Cultural competence promotes trust and collaboration between nurses and patients, facilitating effective communication and shared decision-making.

Integrity and honesty are essential ethical principles in communication. Nurses should provide accurate and truthful information to patients, even when delivering difficult news or discussing potential risks. Honesty builds trust and enables patients to make informed choices based on accurate information.

Lastly, effective communication and ethical considerations extend to interprofessional collaboration. Nurses must communicate effectively with other healthcare professionals, respecting their roles and expertise while advocating for the best interests of the patient. Collaborative communication fosters a team-based approach to care, leading to better patient outcomes.

By integrating ethical considerations into communication practices, nurses can ensure that their interactions with patients and other healthcare professionals are respectful, transparent, and patient-centered. Ethical communication promotes trust, facilitates shared decision-making, and upholds the principles of patient autonomy, confidentiality, cultural competence, and integrity in ambulatory care settings.

Chapter 4 Summary

Chapter 4 focused on communication skills for healthcare professionals in the context of ambulatory care. Effective communication is essential for providing patient-centered care, promoting positive health outcomes, and building strong relationships with patients and interprofessional teams. The chapter explored various aspects of communication, including verbal and nonverbal communication, health literacy, communication with diverse populations, interprofessional collaboration, communication in challenging situations, electronic communication, and ethical considerations.

In ambulatory care settings, nurses play a crucial role in advocating for patients and ensuring their needs are met. Communication skills, such as active listening, effective verbal and nonverbal communication, and the ability to adapt communication styles to diverse populations, are vital for building trust, promoting shared decision-making, and fostering positive patient experiences.

The chapter emphasized the importance of health literacy and patient education, recognizing that effective communication involves providing clear and understandable information to patients. Nurses need to assess patients’ health literacy levels, tailor educational materials to their needs, and use appropriate teaching techniques to promote understanding and adherence to healthcare recommendations.

Communication in challenging situations, such as delivering difficult news or addressing conflicts, requires sensitivity, empathy, and effective communication strategies. Nurses need to be adept at managing emotions, maintaining professionalism, and finding collaborative solutions to address conflicts and promote positive outcomes.

The integration of electronic communication and health informatics in ambulatory care has revolutionized healthcare delivery. Nurses must be proficient in utilizing electronic communication platforms, maintaining patient privacy and confidentiality, and ensuring secure and effective communication in the digital era.

Ethical considerations underpin all aspects of communication in ambulatory care. Nurses must respect patient autonomy, uphold confidentiality, demonstrate cultural competence, and maintain integrity and honesty in their communication practices. Ethical communication promotes trust, respect, and collaboration among healthcare professionals and patients.

By developing and honing effective communication skills, nurses can enhance patient-centered care, improve health outcomes, and contribute to a positive healthcare experience in ambulatory care settings.

Key Takeaways

• Effective communication is crucial for providing patient-centered care in ambulatory settings.
• Verbal and nonverbal communication skills are essential for building rapport, understanding patient needs, and promoting shared decision-making.
• Health literacy plays a significant role in patient education and understanding of healthcare information.
• Communication with diverse populations requires cultural competence and the ability to adapt communication styles to meet individual needs.
• Interprofessional communication and collaboration are vital for coordinated and comprehensive patient care.
• Communication in challenging situations, such as delivering difficult news or addressing conflicts, requires sensitivity, empathy, and effective communication strategies.
• Electronic communication and health informatics have transformed healthcare delivery, and nurses must be proficient in utilizing digital platforms securely and effectively.
• Ethical considerations underpin all aspects of communication and require respecting patient autonomy, upholding confidentiality, and demonstrating cultural competence.
• Developing strong communication skills enhances patient-centered care, improves health outcomes, and fosters positive relationships in ambulatory care settings.
• Ongoing self-reflection and continuous improvement are essential for enhancing communication skills and providing high-quality care

Check Your Understanding

Now that you have completed this chapter, take a moment to review what you’ve learned and assess your understanding. Please answer the following 10 items designed to reinforce key concepts from this chapter. You can navigate through the questions by clicking the blue right-facing arrow located at the bottom right of the question block. This exercise will help ensure that you have grasped the essential information before moving on. Your responses can provide valuable feedback on areas where you may need further review or where you have a strong understanding of the material.

The act of supporting and promoting the rights, needs, and interests of patients to ensure they receive the best possible care.

The use of spoken or written words to convey information and ideas.

The attentive and engaged listening process that involves fully understanding and responding to the speaker's message.

The transmission of messages through body language, gestures, facial expressions, and other nonverbal cues.

The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.

Clear and simple language that is easily understood by the general population, free from jargon and technical terms.

The ability to effectively communicate and interact with individuals from diverse cultural backgrounds, taking into consideration their beliefs, values, and practices.

Communication and collaboration among healthcare professionals from different disciplines to ensure comprehensive and coordinated patient care.

The process of obtaining permission from patients, after providing them with relevant information, to make decisions about their healthcare.

Foundations of Ambulatory Care Nursing Copyright © by Stacey Hobbick is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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2.4 Critical Thinking and Clinical Reasoning

Prioritization of client care should be grounded in critical thinking rather than just a checklist of items to be done. Critical thinking is a broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.” [1] Certainly, there are many actions that nurses must complete during their shift, but nursing requires adaptation and flexibility to meet emerging client needs. It can be challenging for a novice nurse to change their mindset regarding their established “plan” for the day, but the sooner a nurse recognizes prioritization is dictated by their clients’ needs, the less frustration the nurse might experience. Prioritization strategies include collection of information and utilization of clinical reasoning to determine the best course of action. Clinical reasoning is defined as, “A complex cognitive process that uses formal and informal thinking strategies to gather and analyze client information, evaluate the significance of this information, and weigh alternative actions.” [2] Clinical reasoning is fostered within nurses when they are challenged to integrate data in various contexts. The clinical reasoning cycle begins when nurses first consider a client situation and progress to collecting cues and information. As nurses process the information, they begin to identify problems and establish realistic goals. They then take appropriate actions and evaluate outcomes. Finally, they reflect upon the process and the learning that has occurred. The reflection piece is critical for solidifying or changing future actions and developing knowledge.

When nurses use critical thinking and clinical reasoning skills, they set forth on a purposeful course of intervention to best meet client-care needs. Rather than focusing on one’s own priorities, nurses utilizing critical thinking and reasoning skills recognize their actions must be responsive to their clients. For example, a nurse using critical thinking skills understands that scheduled morning medications for their clients may be late if one of the clients on their care team suddenly develops chest pain. Many actions may be added or removed from planned activities throughout the shift based on what is occurring holistically on the client-care team.

Additionally, in today’s complex health care environment, it is important for the novice nurse to recognize the realities of the current health care environment. Clients have become increasingly complex in their health care needs, and organizations are often challenged to meet these care needs with limited staffing resources. It can become easy to slip into the mindset of disenchantment with the nursing profession when first assuming the reality of client-care assignments as a novice nurse. The workload of a nurse in practice often looks and feels quite different than that experienced as a nursing student. As a nursing student, there may have been time for lengthy conversations with clients and their family members, ample time to chart, and opportunities to offer personal cares, such as a massage or hair wash. Unfortunately, in the time-constrained realities of today’s health care environment, novice nurses should recognize that even though these “extra” tasks are not always possible, they can still provide quality, safe client care using the “CURE” prioritization framework. Rather than feeling frustrated about “extras” that cannot be accomplished in time-constrained environments, it is vital to use prioritization strategies to ensure appropriate actions are taken to complete what must be done. With increased clinical experience, a novice nurse typically becomes more comfortable with prioritizing and reprioritizing care.

• Klenke-Borgmann, L., Cantrell, M. A., & Mariani, B. (2020). Nurse educator’s guide to clinical judgment: A review of conceptualization, measurement, and development. Nursing Education Perspectives, 41 (4), 215-221. https://doi.org/10.1097/01.nep.0000000000000669 ↵

A broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.”

A complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions.

Nursing Management and Professional Concepts 2e Copyright © by Chippewa Valley Technical College is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

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Chapter 2 Therapeutic Communication and the Nurse-Client Relationship

2.1. introduction, learning objectives.

• Review basic concepts of client-centered communication
• Outline effective therapeutic communication techniques
• Describe barriers to effective therapeutic communication
• Explore guidelines for effective communication during teletherapy

Nurses engage in compassionate, supportive, professional relationships with their clients as part of the “art of nursing.” [ 1 ] This chapter will review the nurse-client relationship, therapeutic communication, and motivational interviewing. It will also introduce teletherapy and telehealth.

2.2. BASIC CONCEPTS OF COMMUNICATION

Communication standard of professional performance.

The Standard of Professional Performance for  Communication  established by the American Nurses Association (ANA) is defined as, “The registered nurse communicates effectively in all areas of professional practice.” [1] See the following box for the competencies associated with the  Communication  standard.

ANA’s Communication Competencies

The registered nurse:

• Assesses one’s own communication skills and effectiveness.
• Demonstrates cultural humility, professionalism, and respect when communicating.
• Assesses communication ability, health literacy, resources, and preferences of health care consumers to inform the interprofessional team and others.
• Uses language translation resources to ensure effective communication.
• Incorporates appropriate alternative strategies to communicate effectively with health care consumers who have visual, speech, language, or communication difficulties.
• Uses communication styles and methods that demonstrate caring, respect, active listening, authenticity, and trust.
• Conveys accurate information to health care consumers, families, community stakeholders, and members of the interprofessional team.
• Advocates for the health care consumer and their preferences and choices when care processes and decisions do not appear to be in the best interest of the health care consumer.
• Maintains communication with interprofessional team members and others to facilitate safe transitions and continuity in care delivery.
• Confirms with the recipient if the communication was heard and if the recipient understands the message.
• Contributes the nursing perspective in interactions and discussions with the interprofessional team and other stakeholders.
• Promotes safety in the care or practice environment by disclosing and reporting concerns related to potential or actual hazards or deviations from the standard of care.
• Demonstrates continuous improvement of communication skills.

Review basic communication concepts for nurses in the “ Communication ” chapter in Open RN  Nursing Fundamentals .

Nurse-client relationship.

Establishment of the therapeutic nurse-client relationship is vital in nursing care. Nurses engage in compassionate, supportive, professional relationships with their clients as part of the “art of nursing.” [2] This is especially true in psychiatric care, where the therapeutic relationship is considered to be the foundation of client care and healing. [3] The  nurse-client relationship  establishes trust and rapport with a specific purpose; it facilitates therapeutic communication and engages the client in decision-making regarding their plan of care.

Therapeutic nurse-client relationships vary in depth, length, and focus. Brief therapeutic encounters might last only a few minutes and focus on the client’s immediate needs, current feelings, or behaviors. For example, in the emergency department setting, a nurse may therapeutically communicate with a client in crisis who recently experienced a situational trauma. During longer periods of time, such as inpatient care, nurses work with clients in setting short-term goals and outcomes that are documented in the nursing care plan and evaluated regularly. In long-term care settings, such as residential facilities, the therapeutic nurse-client relationship may last several months and include frequent interactions focusing on behavior modification.

Read more about crisis and crisis intervention in the “ Stress, Coping, and Crisis Intervention ” chapter.

Phases of development of a therapeutic relationship.

The nurse-client relationship goes through three phases. A well-known nurse theorist named Hildegard Peplau described these three phases as orientation, working, and termination. [4]

Orientation Phase

During the brief orientation phase, clients may realize they need assistance as they adjust to their current status. Simultaneously, nurses introduce themselves and begin to obtain essential information about clients as individuals with unique needs, values, beliefs, and priorities. During this brief phase, trust is established, and rapport begins to develop between the client and the nurse. Nurses ensure privacy when talking with the client and providing care and respect the client’s values, beliefs, and personal boundaries.

A common framework used for introductions during patient care is AIDET, a mnemonic for Acknowledge, Introduce, Duration, Explanation, and Thank You.

• Acknowledge:  Greet the patient by the name documented in their medical record. Make eye contact, smile, and acknowledge any family or friends in the room. Ask the patient their preferred way of being addressed (for example, “Mr. Doe,” “Jonathon,” or “Johnny”) and their preferred pronouns (e.g., he/him, she/her, or they/them).
• Introduce:  Introduce yourself by your name and role. For example, “I’m John Doe, and I am a nursing student working with your nurse to take care of you today.”
• Duration:  Estimate a timeline for how long it will take to complete the task you are doing. For example, “I am here to perform an admission assessment. This should take about 15 minutes.”
• Explanation:  Explain step by step what to expect next and answer questions. For example, “I will be putting this blood pressure cuff on your arm and inflating it. It will feel as if it is squeezing your arm for a few moments.”
• Thank You:  At the end of the encounter, thank the patient and ask if anything is needed before you leave. In an acute or long-term care setting, ensure the call light is within reach and the patient knows how to use it. If family members are present, thank them for being there to support the patient as appropriate. For example, “Thank you for taking time to talk with me today. Is there anything I can get for you before I leave the room? Here is the call light (Place within reach). Press the red button if you would like to call the nurse.”

Working Phase

The majority of a nurse’s time with a client is in the working phase. During this phase, nurses use active listening and begin by asking the reason the client is seeking care to determine what is important to them. They use assessment findings to develop a nursing plan of care and plan patient education. If a care plan has already been established on admission, nurses use this time to implement interventions targeted to meet short-term outcomes and long-term goals. During the working phase, clients begin to accept nurses as health educators, counselors, and care providers. Nurses use therapeutic communication techniques to facilitate clients’ awareness of their thoughts and feelings and mutually develop goals and an individualized plan of care. Nurses provide reflective and nonjudgmental feedback to clients to help them clarify their thoughts, goals, and coping strategies. [5] Therapeutic communication techniques used during this phase, including motivational interviewing, are discussed later in this chapter.

Termination Phase

The final phase of a nurse-client relationship is the termination phase. This phase typically occurs at the end of a shift or on discharge from care. If the previous working phase has been successful, the client’s needs have been successfully met by collaboration among the client, nurses, and interprofessional health care team members. The nurse should be aware the client may try to return to the working phase to avoid termination of the relationship. During the termination phase, the nurse can encourage the client to reflect on progress they have made and review post-discharge goals. The nurse also makes community referrals for follow-up and continuation of support in meeting goals.

• American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
• Ross C. A., Goldner E. M. Stigma, negative attitudes and discrimination towards mental illness within the nursing profession: A review of the literature. Journal of Psychiatric and Mental Health Nursing. 2009; 16 (6):558–567. [ PubMed : 19594679 ] [ CrossRef ]
• Hagerty T. A., Samuels W., Norcini-Pala A., Gigliotti E. Peplau’s Theory of Interpersonal Relations: An alternate factor structure for patient experience data? Nursing Science Quarterly. 2018; 30 (2):160–167. [ PMC free article : PMC5831243 ] [ PubMed : 28899257 ] [ CrossRef ]

2.3. THERAPEUTIC COMMUNICATION

Therapeutic communication has roots going back to Florence Nightingale, who insisted on the importance of building trusting relationships with patients. She taught that therapeutic healing resulted from nurses’ presence with patients. [ 1 ] Since then, several professional nursing associations have highlighted therapeutic communication as one of the most vital elements in nursing.  Therapeutic communication  is a type of professional communication defined as the purposeful, interpersonal, information-transmitting process that leads to client understanding and participation. [ 2 ] Read an example of a nursing student using therapeutic communication in the following box.

Example of Nurse Using Therapeutic Listening

Ms. Z. is a nursing student (as simulated in Figure 2.1 ) [ 3 ] who enjoys interacting with patients. When she goes to patients’ rooms, she greets them and introduces herself and her role in a calm tone. She kindly asks patients about their problems and notices their reactions. She provides information and answers their questions. Patients perceive that she wants to help them. She treats patients professionally by respecting boundaries and listening to them in a nonjudgmental manner. She addresses communication barriers and respects patients’ cultural beliefs. She notices patients’ health literacy and ensures they understand her messages and patient education. As a result, patients trust her and feel as if she cares about them, so they feel comfortable sharing their health care needs with her. [ 4 ]

Nursing Student Using Therapeutic Communication

Therapeutic communication is different from social interaction. Social interaction does not have a goal or purpose and includes casual sharing of information, whereas therapeutic communication has a goal or purpose for the conversation. An example of a nursing goal before using therapeutic communication is, “The client will share feelings or concerns about their treatment plan by the end of the conversation.”

Therapeutic communication includes active listening, professional touch, and a variety of therapeutic communication techniques.

Active Listening

Listening is an important part of communication. There are three main types of listening, including competitive, passive, and active listening. Competitive listening occurs when we are mostly focused on sharing our own point of view instead of listening to someone else. Passive listening occurs when we are not interested in listening to the other person, and we assume we understand what the person is communicating correctly without verifying their message. During  active listening , we communicate both verbally and nonverbally that we are interested in what the other person is saying while also actively verifying our understanding with them. For example, an active listening technique is to restate what the person said and then verify our understanding is correct. This feedback process is the major difference between passive listening and active listening. [ 5 ]

Nonverbal communication is an important component of active listening.  SOLER  is a mnemonic for establishing good nonverbal communication with clients. SOLER stands for the following [ 6 ]:

• S:   S itting and squarely facing the client
• O:  Using  o pen posture (i.e., avoid crossing arms)
• L:   L eaning towards the client to indicate interest in listening
• E:  Maintaining good  e ye contact
• R:  Maintaining a  r elaxed posture

Professional touch is a powerful way to communicate caring and empathy if done respectfully while also being aware of the client’s preferences, cultural beliefs, and personal boundaries. Nurses use professional touch when assessing, expressing concern, or comforting patients. For example, simply holding a patient’s hand during a painful procedure can effectively provide comfort.

For individuals with a history of trauma, touch can be negatively perceived, so it is important to ask permission before touching. Inform the person before engaging in medical procedures requiring touch such as, “I need to hold down your arm so I can draw blood.”

Nurses should avoid using touch with individuals who are becoming agitated or experiencing a manic or psychotic episode because it can cause escalation. It is also helpful to maintain a larger interpersonal distance when interacting with an individual who is experiencing paranoia or psychosis.

Therapeutic Communication Techniques

There are a variety of therapeutic techniques that nurses use to engage clients in verbalizing emotions, establishing goals, and discussing coping strategies. See Table 2.3a for definitions of various therapeutic communication techniques discussed in the  American Nurse , the official journal of the American Nurses Association.

Therapeutic Communication Techniques [7]

Nontherapeutic Responses

Nurses must be aware of potential barriers to communication and avoid nontherapeutic responses. Nonverbal communication such as looking at one’s watch, crossing arms across one’s chest, or not actively listening may be perceived as barriers to communication. Nontherapeutic verbal responses often block the client’s communication of feelings or ideas. See Table 2.3b for a description of nontherapeutic responses to avoid.

Nontherapeutic Responses [8],[9]

See the following box for a summary of tips for using therapeutic communication and avoiding common barriers to therapeutic communication.

Tips for Effective Therapeutic Communication

• Establish a goal for the conversation.
• Be self-aware of one’s nonverbal messages.
• Observe the client’s nonverbal behaviors and actions as ‘cues’ for assessments and planning interventions.
• Avoid self-disclosure of personal information and use professional boundaries. (Review boundary setting in the “ Boundaries ” section of Chapter 1.)
• Be patient-centered and actively listen to what the client is expressing (e.g., provide empathy, not sympathy; show respect; gain the client’s trust; and accept the person as who they are as an individual).
• Be sensitive to the values, cultural beliefs, attitudes, practices, and problem-solving strategies of the client.
• Effectively use therapeutic communication techniques.
• Recognize themes in a conversation (e.g., Is there a theme emerging of poor self-esteem, guilt, shame, loneliness, helplessness, hopelessness, or suicidal thoughts?).

Common Barriers to Therapeutic Communication

• Using a tone of voice that is distant, condescending, or disapproving.
• Using medical jargon or too many technical terms.
• Asking yes/no questions instead of open-ended questions.
• Continually asking “why,” causing the client to become defensive or feel challenged by your questions.
• Using too many probing questions, causing the client to feel you are interrogating them, resulting in defensiveness or refusal to talk with the nurse.
• Lacking awareness of one’s biases, fears, feelings, or insecurities.
• Causing sensory overload in the client with a high emotional level of the content.
• Giving advice.
• Blurring the nurse-client relationship boundaries (e.g., assuming control of the conversation, disclosing personal information, practicing outside one’s scope of practice).

Recognizing and Addressing Escalation

When communicating therapeutically with a client, it is important to recognize if the client is escalating with increased agitation and becoming a danger to themselves, staff, or other patients. When escalation occurs, providing safety becomes the nurse’s top priority, and the focus is no longer on therapeutic communication. Read more information in the “ Crisis and Crisis Intervention ” section of the “Stress, Coping, and Crisis Intervention” chapter.

Cultural Considerations

Recall the discussion from Chapter 1 on how cultural values and beliefs can impact a client’s mental health in many ways. Every culture has a different perspective on mental health. For many cultures, there is stigma surrounding mental health. Mental health challenges may be considered a weakness and something to hide, which can make it harder for those struggling to talk openly and ask for help. Culture can also influence how people describe and feel about their symptoms. It can affect whether someone chooses to recognize and talk openly about physical symptoms, emotional symptoms, or both. Cultural factors can determine how much support someone gets from their family and community when it comes to mental health. [ 10 ]

Nurses can help clients understand the role culture plays in their mental health by encouraging therapeutic communication about their symptoms and treatment. For example, a nurse should ask, “What do you think is wrong? How would you treat your symptoms?”

Read more about providing culturally responsive care in the “ Diverse Clients ” chapter of Open RN  Nursing Fundamentals .

2.4. motivational interviewing.

Patient education and health promotion are core nursing interventions.  Motivational interviewing (MI)  is a communication skill used to elicit and emphasize a client’s personal motivation for modifying behavior to promote health. MI has been effectively used for several health issues such as smoking cessation, diabetes, substance use disorders, and adherence to a treatment plan. [ 1 ]

The spirit of motivational interviewing is a collaborative partnership between nurses and clients, focused on patient-centered care, autonomy, and personal responsibility. It is a technique that explores a client’s motivation, confidence, and roadblocks to change. During motivational interviewing, nurses pose questions, actively listen to client responses, and focus on where the client is now with a current health behavior and where they want to be in the future. [ 2 ]

Motivational interviewing uses these principles [ 3 ]:

• Express empathy.  Use reflective listening to convey acceptance and a nonjudgmental attitude. Rephrase client comments to convey active listening and let clients know they are being heard.
• Highlight discrepancies.  Help clients become aware of the gap between their current behaviors and their values and goals. Present objective information that highlights the consequences of continuing their current behaviors to motivate them to change their behavior.
• Adjust to resistance.  Adjust to a client’s resistance and do not argue. The client may demonstrate resistance by avoiding eye contact, becoming defensive, interrupting you, or seeming distracted by looking at their watch or cell phone. Arguing can place the client on the defensive and in a position of arguing against the change. Focus on validating the client’s feelings.
• Understand motivations.  Uncover a client’s personal reasons for making behavioral changes and build on them.
• Support self-efficacy.  Encourage the client’s optimistic belief in the prospect of change and encourage them to commit to positive behavioral changes. Ask clients to elaborate on past successes to build self-confidence and support self-efficacy.
• Resist the reflex to provide advice.  Avoid imposing your own perspective and advice.

When implementing motivational interviewing, it is important to assess the client’s readiness for change. Motivational interviewing is especially useful for clients in the contemplation stage who are feeling ambivalent about making change. Recall these five stages of behavioral change [ 4 ]:

• Precontemplation:  Not considering change.
• Contemplation:  Ambivalent about making change.
• Preparation:  Taking steps toward implementing change.
• Action:  Actively involved in the change process.
• Maintenance:  Sustaining the target behavior.

Identify clients who are ambivalent about making a behavioral change or following a treatment plan by listening for the phrase, “Yes, but.” The “but” holds the key for opening the conversation about ambivalence. For example, a client may state, “I want to take my medication, but I hate gaining weight.” The content in the sentence after the “but” reveals the client’s personal roadblock to making a change and should be taken into consideration when planning outcomes and interventions. [ 5 ]

See the following box for an example of a nurse using motivational interviewing with a client.

Example of Motivational Interviewing [ 6 ]

Mr. L. had been in treatment for bipolar I disorder with medication management and supportive therapy for many years. He had a history of alcohol dependence but was in full recovery. Mr. L. was admitted to the intensive care unit with a toxic lithium level. He had been seen in the emergency room the preceding evening and was noted to have a very high blood alcohol level. The next day the nurse asked the client about his alcohol use using motivational interviewing.

Client:  I am so sick of everyone always blaming everything on my drinking!

Nurse (Using reflective listening):  You seem pretty angry about the perception that you were hospitalized because you had been drinking.

Client:  You better believe it! I am a man! I can have a few drinks if I want to!

Nurse: (Expressing empathy and acceptance): You want to be respected even when you are drinking.

Client:  I have had some trouble in the past with drinking, but that is not now. I can quit if I want to! Compared to what I used to drink, this is nothing.

Nurse (Rolling with resistance):  So you see yourself as having had drinking problems in the past, but the drinking you’ve done recently is not harmful for you.

Client:  Well, I guess I did end up in the hospital.

Nurse (Using open-ended questioning):  Tell me more about what happened.

Client:  I was pretty angry after an argument with my girlfriend, and I decided to buy a bottle of whiskey.

Nurse (Exploring):  And then?

Client:  Well, I meant to have a couple of shots, but I ended up drinking the whole fifth. I really don’t remember what happened next. They said I nearly died.

Nurse (Summarizing):  So after many years of not drinking, you decided to have a couple of drinks after the argument with your girlfriend, but unintentionally drank enough to have a blackout and nearly die.

Client:  I guess that does sound like a problem…but I don’t want anyone else telling me whether or not I can drink!

Nurse (Emphasizing autonomy):  Tell me how the choice to drink or not continues to support or oppose your health goals.

View the following supplementary YouTube videos about motivational interviewing:

Introduction to Motivational Interviewing [ 7 ]

Motivational Interviewing – Good Example – Alan Lyme  [ 8 ]

Complete Western Region Public Health Training Center’s  Motivational Interviewing  course and receive a certificate of completion.

2.5. teletherapy and telehealth.

Telehealth  is the use of digital technologies to deliver medical care, health education, and public health services by remotely connecting multiple users in separate locations. Nurses must be aware of potential barriers affecting client use of telehealth (such as lack of Internet access or lack of support for individuals learning new technologies), as well as state and federal policies regarding telehealth and their nursing license across state lines.

Read more about telehealth licensing requirements and interstate compacts at the  Telehealth.hss.gov webpage .

Teletherapy  is mental health counseling over the phone or online with videoconferencing. COVID-19 has led to reduced access to medical and mental health care, so delivering behavioral health care via telehealth is one way to address this issue. When using teletherapy, nurses should treat clients as if they are sitting across from them and focus on eye contact and empathetic expressions to build a connection, just during a face-to-face encounter. [ 1 ]

Group therapy can be accomplished via telehealth. Connecting clients through telehealth creates a group dynamic that can build community, reduce feelings of isolation, and offer new perspectives. Group therapy via telehealth can create a sense of belonging and build a trusted support system.

Here are a few guidelines for group therapy telehealth sessions [ 2 ]:

• Prescreen group members:  Group members may have various needs, experiences, or personalities. It is helpful to screen each potential client to ensure every member can benefit from group therapy and that their needs match the goals of the group.
• Require completion of online consent forms:  Group telehealth sessions involve multiple people and are conducted outside of a controlled setting like an office. Client consent forms should be required and available online. The consent forms should outline any associated risks, benefits, and limits to confidentiality.
• Develop group guidelines:  Make clear ground rules covering what is acceptable and what is not acceptable. Some common ground rules include requiring all participants to have their camera on, attend from a room where they can be alone during the session, and use the digital “raise hand” feature (or raise their hand) when they want to speak. Prohibiting recording of the session is a common ground rule to protect confidentiality. Address logistical topics like how many missed sessions are allowed and how to contact the group leader(s).
• Select your settings and technology:  Choose the telehealth video platform that best suits your needs for encryption and privacy, user controls, and more. Go through all of the settings ahead of time to select the options that provide the highest level of privacy. Think about what will help you and the group communicate effectively such as screen sharing options or a virtual whiteboard.
• Be engaging:  When you are on screen instead of in person, it is even more important to be conscious of the group dynamic and take steps to keep group members interested, energized, and engaged. Start with introductions and greetings using first names only for privacy. Make eye contact with group members by looking into the camera and use body language and hand gestures to help express your ideas. Build in moments for clients to interact and contribute to the conversation, such as breakout rooms or paired discussions.

2.6. LEARNING ACTIVITIES

II. GLOSSARY

Communicating both verbally and nonverbally that we are interested in what the other person is saying while also actively verifying our understanding with them.

A communication skill used to elicit and emphasize a client’s personal motivation for modifying behavior to promote health.

A relationship that establishes trust and rapport with a specific purpose of facilitating therapeutic communication and engaging the client in decision-making regarding their plan of care.

A mnemonic for effective nonverbal communication that stands for the following [ 1 ]:

• S: Sit and squarely face the client
• O: Open posture
• L: Lean towards the client to indicate interest in listening
• E: Eye contact

The use of digital technologies to deliver medical care, health education, and public health services by remotely connecting multiple users in separate locations.

Mental health counseling over the phone or online with videoconferencing tools.

A type of professional communication defined as the purposeful, interpersonal, information-transmitting process that leads to client understanding and participation. [ 2 ]

Licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/ .

• Cite this Page Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing: Mental Health and Community Concepts [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022. Chapter 2 Therapeutic Communication and the Nurse-Client Relationship.
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In this Page

• INTRODUCTION
• BASIC CONCEPTS OF COMMUNICATION
• THERAPEUTIC COMMUNICATION
• MOTIVATIONAL INTERVIEWING
• TELETHERAPY AND TELEHEALTH
• LEARNING ACTIVITIES

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