The Nurse as Communicator and Counselor

Part One: Therapeutic Communication

Objectives: Following completion of this program the Behavioral Health Nurse will be able to: Describe the process of human communication. Describe the process of human communication. Define and Describe communication, non-verbal communication, therapeutic communication, therapeutic relationships, listening skills and core dimensions of counseling techniques. Define and Describe communication, non-verbal communication, therapeutic communication, therapeutic relationships, listening skills and core dimensions of counseling techniques.

Therapeutic Communication is… A process that involves at least two people. A process that involves at least two people. The exchange of thoughts, messages, or information as by speech, signals, writing, or behavior. The exchange of thoughts, messages, or information as by speech, signals, writing, or behavior. The art and technique of using words effectively to impart information or ideas. The art and technique of using words effectively to impart information or ideas.

Sender has responsibility for clarity Sender has responsibility for clarity Reputation plays a role Reputation plays a role Success may depend on the therapeutic relationship Success may depend on the therapeutic relationship Awareness of personal values and biases is essential Awareness of personal values and biases is essential Feedback plays an important role Feedback plays an important role Therapeutic Communication Basic Principles

Therapeutic Communication Verbal - through words. Verbal - through words. Non-verbal - does not use spoken language. Sometimes may be the behaviors that accompany words. Non-verbal - does not use spoken language. Sometimes may be the behaviors that accompany words. Para-verbal- information communicated by the way words are spoken, the rate, tone, volume, emphasis, inflection. Para-verbal- information communicated by the way words are spoken, the rate, tone, volume, emphasis, inflection.

Non-Verbal Communication May be obvious to you but hidden to the patient. May be obvious to you but hidden to the patient. May be obvious to the patient and hidden to you. May be obvious to the patient and hidden to you. Patients respond to your non-verbal behavior with or without their awareness. Patients respond to your non-verbal behavior with or without their awareness. Is important and may not be intentional. Is important and may not be intentional. Differ across cultures – eye contact, physical distance, touch Differ across cultures – eye contact, physical distance, touch Be aware of your own and the patient’s. Be aware of your own and the patient’s.

Non-Verbal Communication Is interrelated with verbal behavior. Is interrelated with verbal behavior. Examples of how verbal and non-verbal messages are related: Congruence – when the verbal message and the non-verbal message agree ex. “Come in” and a person smiles and gestures to a chair. Congruence demonstrates how the body shows intensity ex. A person talks about being scared and talks faster. when the verbal message and the non-verbal message agree ex. “Come in” and a person smiles and gestures to a chair. Congruence demonstrates how the body shows intensity ex. A person talks about being scared and talks faster. Non-Congruence – when the non-verbal message and the verbal message disagree ex. Person states, “I like you” with a frown face and an angry voice. The non-verbal message often carries more “weight”. when the non-verbal message and the verbal message disagree ex. Person states, “I like you” with a frown face and an angry voice. The non-verbal message often carries more “weight”.

Non-Verbal Communication Facial expressions communicate emotions. Primary emotions are hard-wired, automatic and universal. The whole body conveys the intensity of the emotion. Facial expressions communicate emotions. Primary emotions are hard-wired, automatic and universal. The whole body conveys the intensity of the emotion. Personal space is patient specific, adjust and be aware, some patients may need 3 to 4 feet between them and the professional. Personal space is patient specific, adjust and be aware, some patients may need 3 to 4 feet between them and the professional. Sends information to the listener ex. When one nods their head, a person keeps talking and if one shifts their body position, a person pauses when talking. Sends information to the listener ex. When one nods their head, a person keeps talking and if one shifts their body position, a person pauses when talking.

Non-Verbal Communication It is often helpful to match or pace your behaviors with the patients. It is often helpful to match or pace your behaviors with the patients. Unless the patient is very agitated, use the same intensity of voice, body posture and breathing pattern as the patient. Unless the patient is very agitated, use the same intensity of voice, body posture and breathing pattern as the patient.

Silence…. A period of reflection, confusion, guarded behavior or a cultural difference. A period of reflection, confusion, guarded behavior or a cultural difference. Do not fill-in short periods with talk automatically. Do not fill-in short periods with talk automatically. Pause and ask yourself about the meaning. Check your assumptions – ask – “You’re sitting very quietly, What is going on with you? Or “We were talking about… and there was a period of silence, what does that mean to you?” Pause and ask yourself about the meaning. Check your assumptions – ask – “You’re sitting very quietly, What is going on with you? Or “We were talking about… and there was a period of silence, what does that mean to you?”

Listening is hard work We must concentrate We must concentrate We must focus on the other We must focus on the other When truly listening – our pulse and B/P rise, we start sweating! When truly listening – our pulse and B/P rise, we start sweating!

SPEED Speech – 150 words per minute Thought – words per minute What happens in the gap? Jump to conclusions Jump to conclusions Daydream Daydream Plan a reply Plan a reply Mentally argue with the speaker Mentally argue with the speaker

Levels of Listening Superficial listener Hears sounds and words – not meaning and content Hears sounds and words – not meaning and content May be in the “speed gap” May be in the “speed gap” Non – Listener Doesn’t hear; may pretend listening while mentally elsewhere; interrupts; last word Doesn’t hear; may pretend listening while mentally elsewhere; interrupts; last word

Levels of Listening Evaluative listener Actively trying to hear, but not making an effort to understand intent Actively trying to hear, but not making an effort to understand intent Logical listener Content over feelings/meaning Content over feelings/meaning Catch the verbal, but miss the visual and vocal Catch the verbal, but miss the visual and vocal Believes that they understand Believes that they understand

Definitions of Listening Responses (Core Counseling Skills) Clarification – a question such as – “Do you mean that” or “Are you saying that “ plus a rephrasing of the client’s message Clarification – a question such as – “Do you mean that” or “Are you saying that “ plus a rephrasing of the client’s message Para-phrase – a response to content, a rephrasing of the content of the client’s message Para-phrase – a response to content, a rephrasing of the content of the client’s message Reflection – a response to feelings, a rephrasing of the affective part of the client’s message Reflection – a response to feelings, a rephrasing of the affective part of the client’s message Summarization – two or more paraphrases or reflections that condense the client’s messages or the session Summarization – two or more paraphrases or reflections that condense the client’s messages or the session

More Examples… It seems like…. It seems like…. It appears as… It appears as… From my perspective.. From my perspective.. As I see it… As I see it… I see what you mean.. I see what you mean.. It looks like… It looks like… Sounds like… Sounds like…

Communication Speaker doesn’t always feel understood. Speaker doesn’t always feel understood. Due to gap between listening and thinking most of us are either superficial or evaluative listeners.

Essentials of Communication Things that get in the way: Distractions - noise, activity, people, heat, cold, weather Distractions - noise, activity, people, heat, cold, weather Interruptions Interruptions Can it wait? Do you need to do it now? Can it wait? Do you need to do it now? Will the message create stress? Will the message create stress? How will the listener perceive and value the message? How will the listener perceive and value the message? Are their cultural or language barriers? Are their cultural or language barriers? Are we stereotyping? race, socio- economic, regional, geographic, faith or sexual preference Are we stereotyping? race, socio- economic, regional, geographic, faith or sexual preference

Use Clear concise words Use Clear concise words Use language that the listener understands Use language that the listener understands Evaluate your and the other persons stress level Evaluate your and the other persons stress level Focus on the present Focus on the present Choose the right environment Choose the right environment Choose the right time Choose the right time Perceptions Perceptions Culture Culture Need to convey an atmosphere - that Need to convey an atmosphere - that regardless of time constraints you are regardless of time constraints you are able to spend time able to spend time Keys to Communication

Barriers to Good Communication  You are bad or you did something bad  Expressing dissatisfaction thru a third party  Assuming rather than checking out  Communication cutoff  Put-down question  Should, could, would  Sarcasm  Commanding  Premature advice

The 3 V’s of communication __ % Verbal – the words we use ___% Vocal – our tone and intensity “The music we play with our voice “The music we play with our voice ___% Visual – Everything the listener can see ___ 100% Total = the actual meaning received

Messages - Facilitative or Open Create positive outcomes Create positive outcomes –People communicating with each other feel good about their interaction –Usually begin with what or how –Draw out feeling and ideas –Encourage specific information on needs, wants, problems –Stimulate thinking

Obstructive or Negative These messages are fraught with difficulty and make effective communication nearly impossible –Personalized criticism Negative comments about abilities Negative comments about abilities Causes loss of confidence/self-esteem Causes loss of confidence/self-esteem –Judgmental Comments Negative or critical remarks about the work Negative or critical remarks about the work Offers no information on what needs improving Offers no information on what needs improving