Placing communication at the centre of person-centred care

Therapeutic and social relationships

Communication involves complex social activity more than other aspects of nursing practice, such as technical proficiency and skills. Through communication, nurses relate to a variety of people during direct client care and within healthcare organisations. However, the social activity in nursing is different from other forms of social activity, such as friendships. Communication in nursing is professional and therapeutic, and is thus different from communication in friendships.

In therapeutic nurse–client relationships there is an explicit timeframe, a goal-directed approach and a high expectation of confidentiality. The nurse establishes, directs and takes responsibility for the interaction, and the client’s needs take priority over the nurse’s needs. In acting in the client’s best interest, the nurse maintains professional boundaries.

There are clear legal boundaries, as nurses must practise within the scope of their professional knowledge and skill, while codes of conduct (ANMC 2008a, NCNZ 2009) specify ethical boundaries. However, professional boundaries are not always as clearly laid out as geographical ones, for example those between countries. Nurses cross professional boundaries when they do not act in the best interest of the patient (Hartlage 2012), but rather act in a manner that meets their own needs, such as the need to be liked. Having a sexual relationship with a client is a clear boundary violation, as it is focused on the nurse’s needs. More subtly, nurses can cross boundaries when they burden clients with their own problems, such as being short-staffed and under pressure. The relationship is always ‘for the patient’ and this is the best principle to follow in maintaining professional boundaries.

The relationship is also characterised by the nurse’s non-judgemental acceptance of the client. Acceptance conveys a willingness to hear a message or to acknowledge feelings. It does not mean the nurse must always agree with the other person or approve of the client’s decisions or actions.

A therapeutic relationship between nurse and client does not just happen – it is created with care and skill and is built on the client’s trust in the nurse. In her seminal work, Patricia Benner (1984) prefers not to use the term ‘therapeutic’ because of its association with psychotherapy, yet describes a helping role of the nurse in a similar fashion. She states that ‘helping encompasses transformative changes in meanings, and sometimes simply the courage to be with the client, offering whatever comfort the situation allows’ (Benner 1984:48). A helping relationship between nurse and client is one in which the nurse comes to understand the patient as a person with a unique point of view. Forming such relationships enables nurses to provide care that is individualised to that person and their family, therefore providing person-centred nursing care.

The nurse–client relationship is characterised by a natural progression of four goal-directed phases that often begin before the nurse meets the client, and continue until the caregiving relationship ends (Box 12-1). Even a brief interaction uses an abbreviated version of the same pre-interaction, orientation, working and termination phases. For example, the nursing student may gather client information to prepare in advance for caregiving, meet the client and establish trust, accomplish health-related goals through use of the nursing process and say goodbye at the end of the day.

Socialising is often an important initial component of interpersonal communication. It helps people get to know one another and relax. It is easy, superficial and not deeply personal, whereas therapeutic interactions are often more intense, difficult and uncomfortable. A nurse often uses social conversation to help the client feel comfortable and lay a foundation for a closer relationship. Clients value nurses being ‘friendly and chatty’ (Henderson et al 2007, McCabe 2004). An informal and warm communication style helps establish trust, but nurses must get beyond social conversation to talk about issues or concerns affecting the client’s health. During social conversation, clients may ask personal questions about the nurse’s family, place of residence and so on. Students often wonder if it is appropriate to reveal such information; that is, to self-disclose. In an attempt to ‘be professional’ they sometimes assume it is inappropriate to share anything of themselves. Although a high degree of self-disclosure is characteristic of intimate friendships, it does not fit the context of a therapeutic relationship; however, nurses can use self-disclosure to benefit the relationship with the client, provided they remain professional and do not overstep their professional boundaries (Stein-Parbury 2014).

Nurses often encourage clients to share personal stories; in doing so, nurses come to understand the context of other people’s lives and learn what is meaningful for them from their perspective. For example, a nurse asked a client to tell about a time in his life when he had to make a hard decision. He related the following story:

From this brief story, the nurse understood that it was important to the client to put his family’s needs above his personal desires, and that seeking spiritual guidance was an important component of his decision-making.

Nurses also provide information and use strategies that help clients understand and change behaviour. The nurse also acts as an advocate to keep the client informed of healthcare alternatives and give support in decision-making. For example, the nurse can ask clients and family members for input and suggestions about goals, interventions and evaluation of the plan of care. This type of mutuality (give-and-take, creative mutual exchanges) has been shown to balance power and respect, and to promote productive provider–client communication (Tejero 2012). It gives the other person a greater sense of purpose and direction, encourages personal responsibility for health, helps establish priorities for care, gives the opportunity for self-expression and strengthens the client’s problem-solving ability. This depends on the vulnerability of the client; that is, the degree to which personal resources are available, adequate and appropriate to the situation at hand. Information is one such possible resource.

Collaboration in healthcare team communication

In the contemporary healthcare climate there is a focus on enhancing teamwork and interprofessional collaboration that is focused on improved quality and safety. In part this is due to reports that demonstrate that poor and inadequate interprofessional communication is a major factor in events that result in patient harm (Brock et al 2013). Pannick et al (2014) identified that staff communication and collaboration with colleagues was a major theme in a review of evidence related to quality and safety of general medical units, rather than specialised units that have more stable teams such as intensive care or operating theatre units. Therefore, improving collaborative teamwork as a way to enhance positive patient outcomes is receiving attention because this is believed to have a greater effect than other strategies (Barrow et al 2015).

Team collaboration works best when members of the team are able to communicate effectively and develop an understanding of each other’s perspective. In doing so they develop what is termed a ‘shared mental model’ (McComb & Simpson 2013). Effective collaboration in the form of interdisciplinary rounds has proven to be an effective way to decrease errors and improve patient safety; these rounds work best when there are structured systems for the communication of patient information. Such systems are ‘shared mental models’, which have been shown to improve quality and safety. One of the most widely used formats is the ISBAR tool, which is used for patient handover, as described in Skill 12-1.

Collaboration and conflict

When conflict does arise, there are a number of ways that a healthcare professional can respond. They can become:

These ways of responding in a conflict situation directly relate to communication competence as depicted in Figure 12-3. An aggressive response is domineering communication; a submissive response is accommodation communication. Avoiding or evading conflict is considered to be ineffecitive at resolving conflicts. The competent communicator will approach conflict in a collaborative way. A compromising response relates to all aspects of communication competence. Finding a middle ground through compromise, negotiating a ‘give-and-take’ solution, may work in some contexts, such as conflict over workload; but a compromise in the healthcare setting may jeopardise patient safety and wellbeing. Collaboration, where all voices are heard and understood, including the patient’s viewpoint and wishes, has been shown to result in quality and safety in the healthcare arena (Pannick et al 2014).

Evidence shows that nurses who work in a clinical setting tend to be accommodating and submissive when dealing with interprofessional conflict (Iglesias & de Bengoa Vallerjo 2012, Kaitelidou et al 2012, Mahon & Nicotera 2011). They are likely to meet conflict in the workplace in a passive manner, rather than with active and assertive attempts to collaborate. While this tactic may keep the peace, failing to express a viewpoint that is different from others’ can result in poor quality health care. People who use passive strategies are seen as more likeable and this may be one reason nurses behave this way. Another reason is that nurses are trained to communicate therapeutically; they focus on feelings, rather than finding solutions to conflict (Northam 2009). Because they are caring and compassionate towards patients, nurses may suffer under what Street (1992) has termed the ‘tyranny of niceness’. That is, they may think that active assertion, which is required for successful negotiation, is not compatible with being a caring person (McCartan & Hargie 2004).

Not only are passive strategies, such as avoiding and giving in, not always successful in resolving the conflict, but they are also associated with increased stress and decreased mental wellbeing in nurses (Chang et al 2007). Therefore, it is important that nurses learn how to deal with workplace conflict through the use of assertive skills. When used deliberately, compromising and acquiescing can be assertive in their own right; however, more active assertion is often required when dealing with workplace conflict. Successful resolution of conflicts can bring people closer and adds to satisfaction and creativity in the workplace; when handled poorly, conflicts can create extra strain and tension. More importantly, workplace conflict affects patient outcomes and leads to errors (Northam 2009).

Vocabulary

Communication is unsuccessful if people cannot translate each other’s words and phrases. When a nurse cares for a client who speaks another language, an interpreter may be necessary. Even those who speak the same language use variations of certain words: dinner may mean a noon meal to one person and the last meal of the day to another. Medical jargon (technical terminology used by healthcare providers) may sound like a foreign language to clients unfamiliar with the healthcare setting, and should be used only with other healthcare team members. Children have a more limited vocabulary than adults. They may use special words to describe bodily functions or a favourite blanket or toy. Teenagers often use words in unique ways that are unfamiliar to adults.

Meanings of words and phrases

A single word can have several meanings. The denotative meaning is shared by individuals who use a common language: ‘tennis’ has the same meaning for everyone who speaks English, but the word ‘drug’ may have different meanings to a healthcare professional and to a layperson. The connotative meaning is the shade or interpretation of a word’s meaning influenced by the thoughts, feelings or ideas people have about the word. Families who are told a loved one is in a serious condition may believe that death is near, but to nurses ‘serious’ may simply describe the nature of the illness. Nurses should carefully select words that cannot be misinterpreted, especially when explaining a client’s medical condition or therapy. Even a much-used phrase such as ‘I’m going to take your observations’, can be unfamiliar to an adult or frightening to a child.

Clarity and brevity

Effective communication is simple, brief and direct. Fewer words result in less confusion. Speaking slowly and using examples to make explanations easier to understand achieves clarity. Repeating important parts of a message also clarifies communication. Phrases such as ‘you know’ or ‘okay?’ at the end of every sentence detract from clarity. Brevity is achieved by using short sentences and words that express an idea simply and directly. ‘Where is your pain?’ is much better than ‘I would like you to describe for me the location of your discomfort’.

Timing and relevance

Timing is critical in communication. Even though a message is clear, poor timing can prevent it from being effective. For example, the nurse should not begin routine teaching when a client is in severe pain or emotional distress. Often the best time for interaction is when a client expresses an interest in communicating. If messages are relevant or important to the situation at hand, they are more effective. When a client is facing emergency surgery, discussing the risks of smoking is less relevant than explaining how to keep the lungs clear postoperatively.

Intonation

Tone of voice dramatically affects a message’s meaning. Depending on intonation, even a simple question or statement can express enthusiasm, anger, concern or indifference. The nurse must be aware of voice tone to avoid sending unintended messages. For example, clients may interpret a nurse’s patronising tone of voice as condescending, and further communication may be inhibited. A client’s voice tone often provides information about their emotional state or energy level.

Posture and gait

The ways people sit, stand and move reflect attitudes, emotions, self-concept and health status. For example, an erect posture and a quick, purposeful gait communicate a sense of wellbeing and confidence. Leaning forwards conveys attention. A slumped posture and slow, shuffling gait may indicate depression, illness or fatigue.

Facial expression

The face is the most expressive part of the body. Facial expressions convey emotions such as surprise, fear, anger, disgust, happiness and sadness. Some people have an expressionless face, or flat affect, which reveals little about what they are thinking or feeling. An inappropriate affect is a facial expression that does not match the content of a verbal message, such as smiling when describing a sad situation. People can be unaware of the messages their expressions convey. For example, a nurse may frown in concentration while doing a procedure and the client may interpret this as anger or disapproval. Clients often closely observe nurses. Although it is hard to control all facial expression, the nurse should develop awareness of meanings that are conveyed through facial expression.

Eye contact

People signal readiness to communicate through eye contact. Maintaining eye contact during conversation shows respect and willingness to listen. Eye contact also allows people to closely observe one another. Lack of eye contact may indicate anxiety, defensiveness, discomfort, or lack of confidence in communicating. However, in some cultures, eye contact with a person who is considered superior can be interpreted as offensive and disrespectful (see Chapter 14).

Gestures

Gestures emphasise, punctuate and clarify the spoken word. Gestures alone carry specific meanings, or they may create messages with other communication cues. A finger pointed towards a person may communicate several meanings, but when accompanied by a frown and a stern voice, the gesture becomes an accusation or threat. Pointing to an area of pain may be more accurate than describing the pain’s location.

Territoriality and personal space

Territoriality is the need to gain, maintain and defend one’s right to space. Territory is important because it provides people with a sense of identity, security and control. Territory can be separated and made visible to others, such as a fence around a yard or a bed in a hospital room. Personal space is invisible, individual and travels with the person. During interpersonal interaction, people maintain varying distances between one another depending on their culture, the nature of their relationship, and the situation (Chapter 14). When personal space is threatened, people respond defensively and communicate less effectively. This is especially important when interacting with a client who is in bed, as ‘standing over’ them is often intimidating. Situations dictate whether the interpersonal distance between nurse and client is appropriate. Examples of nursing actions within zones of personal space are listed in Box 12-2, along with zones of touch. Nurses often move into clients’ territory and personal space due to the nature of caregiving. The nurse must convey confidence, gentleness and respect for privacy, especially when actions require intimate contact or involve a client’s vulnerable zone.

Approval and disapproval

In everyday conversations people often express approval or disapproval, yet in a professional role it is not helpful to clients when nurses impose their own attitudes, values, beliefs and moral standards. Other people have the right to be themselves and make their own decisions. Judgemental responses by the nurse often contain terms such as ‘should’, ‘ought’, ‘good’, ‘bad’, ‘right’ or ‘wrong’. Agreeing or disagreeing sends the subtle message that nurses have the right to make value judgements about client decisions. Approving implies that the behaviour being praised is the only acceptable one. Often, the client shares a decision with the nurse, not in an effort to seek approval but to provide a means for discussing feelings. On the other hand, disapproving implies that the client must meet the nurse’s expectations or standards; for example, commenting that ‘It is silly for you to feel like that’. Instead, the nurse should help clients explore their own feelings, beliefs and decisions. The nursing response ‘I’m surprised you say that you feel that way. Tell me more about it’ gives the client a chance to express ideas or feelings without fear of being judged.

Stereotypical responses

A cliché is a stereotypical comment, such as ‘You can’t win them all’ or ‘Every cloud has a silver lining’ that tends to belittle the other person’s feelings and minimise the importance of their message. These automatic phrases communicate that the nurse is not taking concerns seriously or responding thoughtfully. Most often they are said with a good intention, to reassure a client; however, they are a form of false reassurance and are often not helpful.

False reassurance

Saying ‘Don’t worry, everything will be all right’ may make the nurse feel better, but it does not have the same effect on the client. When a client is seriously ill or distressed, the nurse may be tempted to offer hope to the client with statements such as ‘You’ll be fine’ or ‘There’s nothing to worry about’. When a client is reaching for understanding, false reassurance from the nurse may discourage open communication. Offering reassurance not supported by facts or not based in reality can do more harm than good. Although it might be intended kindly and have the secondary effect of helping the nurse avoid the other person’s distress, it tends to block conversation and discourage further expression.

Active listening

Active listening means listening attentively with one’s whole being – mind, body and spirit. It includes listening for conversational themes, acknowledging and responding, giving appropriate feedback and paying attention to the other person’s total communication, including the content, the intent and the feelings expressed (Stein-Parbury 2014). Active listening allows the nurse to better understand the entire message being communicated, and is an excellent way to build trust. In many nursing situations the other person simply needs someone to listen.

To listen attentively, the nurse faces the client at a distance of about 90 cm, removes any physical barriers if possible, maintains eye contact (if culturally appropriate), assumes a relaxed posture and sits quietly, leans forward slightly and nods in acknowledgment when the client talks about important points or looks for feedback. Fidgeting, breaking eye contact, daydreaming during conversation or only pretending to listen conveys the message that what the other person has to say is not important. These inhibit conversation and undermine trust.

Being available means offering oneself and expressing a willingness to listen, talk or be physically present with another person when the client needs it. By expressing availability, even though the client may not make their needs known, the nurse shows a caring attitude. When clients feel that the nurse is listening they sense a connection that enables the relationship to develop; they value nurses who take the time to listen to them (Kagan 2008, Marshall et al 2012). Therefore, listening is essential to the process element of therapeutic communication.

Availability and active listening are often described as nursing presence, an inter-subjective encounter between a nurse and a client in which the nurse encounters the client as a unique human being in a unique situation and chooses to ‘spend’ themself on the client’s behalf (Zyblock 2010). Presence is the nursing quality of ‘being there’ for the client – not just physically present, but also listening attentively from a caring perspective: ‘I’ll stay with you a while. If you want to talk, I’ll be glad to listen.’ However, the ability to be fully present does not lie simply within the nurse; it requires a healthcare environment that is conducive to the formation of relationships between nurses and clients (Fingeld-Connett 2008, McMahon & Christopher 2011).

Using silence

It takes time and experience to become comfortable with silence. Most people have a natural tendency to fill empty spaces with words, but sometimes those spaces give time for the nurse and client to collect their thoughts and consider what has been communicated. Silence also allows the nurse to pay particular attention to nonverbal messages, such as worried expressions or loss of eye contact. Remaining silent demonstrates the nurse’s patience and willingness to wait for a response when the other person is unable to reply quickly. Silence may be especially therapeutic during times of profound sadness or grief.

Sharing observations

Nurses make observations by commenting on how the other person looks, sounds or acts. Stating observations often helps the client communicate without the need for extensive questioning, focusing or clarification. For example, the nurse observes a young client holding his body rigidly erect and his voice being sharp as he says, ‘Going to surgery is no big deal’. The nurse replies, ‘You say having surgery doesn’t bother you, but you look a little worried. It is natural to worry about surgery.’ This approach may result in encouraging the client to further express current concerns.

Sharing feelings

Emotions are subjective feelings that result from one’s thoughts and perceptions. Feelings are not right, wrong, good or bad, although they may be pleasant or unpleasant. If feelings are not expressed, stress and illness can worsen. Nurses can help clients express emotions by making observations, acknowledging feelings, encouraging communication, giving permission to express ‘negative’ feelings and modelling healthy emotional self-expression. At times, clients may direct anger or frustration prompted by their illness towards the nurse, who should not take such expressions personally. Acknowledging clients’ feelings communicates that the nurse listened to and understood the emotional aspects of their illness.

When nurses care for clients they must be aware of their own emotions, because feelings are difficult to hide. Students may wonder whether it is helpful for the nurse to share feelings with clients. Sharing emotion makes nurses seem more human and can bring people closer. It is appropriate to share feelings of caring, or even cry with others, as long as the nurse is in control of how those feelings are expressed and does so in a way that does not burden the client. Feelings are shared with clients in an effort to assist them, not the nurse.

Expressing empathy

Empathy is the ability to understand and accept another person’s reality and to accurately perceive feelings. Empathic communication conveys that the nurse not only has heard what the client has expressed, but also understands what the client means. In expressing empathy, the nurse communicates this understanding to the client. Such empathic understanding requires the nurse to be both sensitive and imaginative, especially if the nurse has not had similar experiences. Statements reflecting empathy are highly effective because they tell the person that the nurse heard the feeling content, as well as the factual content, of the communication. This results in clients feeling accepted and valued, thereby facilitating the therapeutic relationship.

Offering hope

Hope is productive to healing, and offering hope communicates a ‘sense of possibility’ to clients (Fitzgerald Miller 2007). Appropriate encouragement and belief that the client can cope, along with concrete feedback about how the client is progressing, are important in fostering hope by boosting self-confidence and helping clients achieve their potential. Sharing a vision of the future and reminding others of their resources and strengths can also strengthen hope. Clients can be reassured that there are many kinds of hope and that meaning and personal growth can come from illness experiences (Fitzgerald Miller 2007).

Sharing humour

Humour is an important therapeutic resource in nursing interactions. It serves to build relationships by conveying respect for the personhood of the patient and creates a sense of cohesiveness between nurses and their clients. It helps decrease client anxiety, depression and embarrassment. Laughter can be good medicine when nurses use humour to help clients adjust to stress imposed by illness. Humour can increase the nurse’s effectiveness in providing emotional support to clients and can humanise the illness experience. Laughter provides both a psychological and a physical release for both nurse and client. Humour can help others to interact more openly and comfortably and can make nurses’ own humanity more apparent.

Using touch

Touch is one of the nurse’s most potent forms of communication. Nurses are privileged to experience more of this intimate form of personal contact than almost any other professional. Many messages, such as affection, emotional support, encouragement, tenderness and personal attention, are conveyed through touch. Comfort touch, such as holding a hand, is especially important for vulnerable clients who are experiencing severe illness with its accompanying physical and emotional losses.

Since much of what nurses do involves touching, nurses must learn to be sensitive to others’ reactions to touch and use it wisely. There are times when touch should be withheld; highly suspicious or angry people may respond negatively or even violently to the nurse’s touch.

Asking relevant questions

Asking questions allows nurses to seek information that is vital to client care. Nurses should ask only one question at a time, and fully explore one topic before moving to another area. During client assessment, questions follow a logical sequence and usually proceed from the general to the more specific. Open-ended questions allow the client to take the conversational lead and introduce pertinent information about a topic: ‘What happens when you and your husband argue?’ Focused questions are used when more-specific information is needed in an area: ‘What do you argue about most often?’ The nurse should allow clients to fully respond to an open-ended question before asking more-focused questions. Closed-ended questions elicit a yes, no or single-word response: ‘How many arguments did you have last week?’ They are generally less useful during therapeutic exchanges, although they are often essential to client assessment.

Paraphrasing

Paraphrasing is re-stating another’s message briefly, using one’s own words. Through paraphrasing, the nurse sends feedback that lets others know whether their messages were understood. If the meaning of a message is changed or distorted through paraphrasing, communication may become ineffective. For example, a client may say ‘I’ve been overweight all my life and never had any problems. I can’t understand why I need to be on a diet’. Paraphrasing this statement by saying ‘You don’t care if you’re overweight or not’ is incorrect. It would be more accurate to say ‘You’re not convinced you need a diet because you’ve stayed healthy’.

Paraphrasing is an effective way to clarify what a client is communicating. By putting their words into the nurse’s own words, clients can not only correct any misunderstandings, for example, ‘That’s not exactly what I meant’, but can also expand and elaborate on what they are meaning. A paraphrase is a useful way to encourage further interaction by demonstrating that the nurse is trying to understand the client’s experience.

Clarifying

To check whether understanding is accurate, the nurse can re-state an unclear or ambiguous message to clarify the meaning. Instead of paraphrasing the message, the nurse can also ask the other person to rephrase it, explain further or give an example of what the person means. Without clarification, the nurse may make invalid assumptions and miss valuable information. Despite efforts at paraphrasing, the nurse may not understand the client’s message and should let the client know if this is the case: ‘I’m not sure I understand what you mean by “sicker than usual”. What is different now?’

Providing information

Providing relevant information tells other people what they need or want to know so that they can make decisions, experience less anxiety and feel safe and secure. It is also an integral aspect of health teaching. It is usually not helpful to hide information from clients, particularly when they seek it. Clients have a right to know about their health status and what is happening in their environment.

Research has shown that the provision of information is highly individual in the sense that some clients require more information than others (Tobiano et al 2015). Identification of the amount and type of information needed by an individual client is essential in the use of this intervention.

Instructing

This technique is similar to providing information, but is a more direct way of communicating. For example, a nurse might need to provide instructions to a postoperative client about how to splint the incision when attempting to cough.

Suggesting

Nurses often help clients by offering suggestions about what might be of benefit. For example, a nurse might suggest distraction as a useful way to cope with worry about pending diagnostic results. Suggestions should be posed tentatively and operate from an understanding of the client situation and knowledge of health. They are not based on the nurse’s personal opinions or values.

Advising

Nurses are often in a position to offer sound advice about health matters. Like suggestions, advice is not based on personal opinions of the nurse, but rather on an understanding of the health event.

Persuading

When advising and suggesting do not seem to be helpful to the client, a nurse often has to become persuasive in pursuing a therapeutic aim. For example, emergency-room nurses may need to persuade family members of a client who has died suddenly not to drive themselves home from the hospital while still in a state of shock at the death.

Focusing

Focusing is used to centre on key elements or concepts of a message. If conversation is vague or rambling or clients begin to repeat themselves, focusing is a useful technique. The nurse does not use focusing if it interrupts clients while discussing an important issue. Rather, the nurse uses focusing to guide the direction of conversation to important areas: ‘We’ve talked a lot about your medications, but let’s look more closely at the trouble you’re having in taking your tablets on time.’

Summarising

Summarising is a concise review of key aspects of an interaction. Summarising brings a sense of satisfaction and closure to an individual conversation and is especially helpful during the termination phase of a nurse–client relationship. By reviewing a conversation, participants focus on key issues and can add relevant information as needed. Beginning a new interaction by summarising a previous one helps the client recall topics discussed and shows the client that the nurse has analysed communication. Summarising also clarifies expectations, as in this example of a nurse manager who had been working with a dissatisfied employee: ‘You’ve told me a lot of things about why you don’t like this job and how unhappy you’ve been. We’ve also come up with some possible ways to make things better, and you’ve agreed to try some and let me know if any of them help.’

Self-disclosing

To use self-disclosure, the nurse reveals personal experiences, thoughts, ideas, values or feelings in the context of the relationship with the intent of helping the other person. This is not therapy for the nurse; rather, it shows clients that their experiences can be understood and are not unique. Self-disclosures should be relevant and appropriate and made to benefit the client rather than the nurse. They are used sparingly so that the client is the focus of the interaction: ‘That happened to me once, too. It was devastating, and I had to face some things about myself that I didn’t like. I went for counselling, and it really helped … What are your thoughts about seeing a counsellor?’

Confronting

To confront someone in a therapeutic way, the nurse helps the client to become aware of inconsistencies in his or her feelings, attitudes, beliefs and behaviours. This technique improves client self-awareness and helps the client recognise growth and deal with important issues. Confrontation should be used only after trust has been established, and it should be done gently, with sensitivity: ‘You say you’ve already decided what to do, yet you’re still talking a lot about your options.’

Encouraging

Like offering hope, nurses are often in a position to encourage clients, especially when discouragement is evident. Encouragement is best offered in concrete terms, such as ‘I can see that you are able to walk much better today. It only took you a few minutes to get to the toilet today. A few days ago it took nearly 20 minutes.’

Offering direct assistance

It may seem obvious that nurses assist clients. However, a direct offer of assistance can help when clients are overwhelmed with unpleasant feelings. ‘Here, let me help you with putting on your shoes’ is an example of direct assistance. In doing so, it is important that the nurse does not take over for clients and make them feel useless and more vulnerable.