Module 1By: Dr Jennifer Tylee What is Therapeutic Communication? This module provides an introduction to therapeutic communication and explains its relevance to nursing practice. The module further examines the transaction and transmission models of the communication process. Objectives At the completion of this module students will be able to:
What is Therapeutic Communication? The emphasis in this subject is on looking at the beginning knowledge and skills which will enable any interaction to be effective and then to extend the knowledge and skills to enable effective interactions with patients. Students who have traversed life well enough to enter a university course have skills in communication. However, these lay developed skills need to be brought into focus to become a feature of a professional who is to care for people. The knowledge and skills that you begin to develop in this subject will need to be further explored and extended in other subjects as you proceed through the Bachelor of Nursing Course. Indeed many of the concepts introduced in this subject, such as self awareness and listening skills, will be developed on a career /life long basis. Therapeutic and communication are two complex words that are at the heart of all nursing practice. Therapeutic – refers to the science and art of healing (Miller and Keane, 1972); of or pertaining to a treatment or beneficial act (Potter and Perry, 1989). This can be further extended to include what Rogers (1961) calls the helping relationship, which is one that promotes growth and development and improved coping with life for the other person. Communication – has a number of definitions that tend to either emphasise the message or the meaning. Mohan, McGregor and Strano (1992) provide the following: the ordered transfer of meaning: social interaction through messages: reciprocal creation of meaning: sharing of information, ideas or attitudes between or among people. DeVito (1991, p. 5) suggests that communication is an act by one or more persons of sending and receiving messages that are disturbed by ‘noise’, occur within a context, have some effect and provide some opportunity. Therapeutic communication Therapeutic communication means that nurses use their communication (both message and meaning) in such a way that it will be of benefit to their patients. The skills required in therapeutic communication are more than those required in general interpersonal interaction, but sound interpersonal interaction skills are necessary for effective therapeutic communication. Navarra, Lipkowitz and Navarra (1990) maintain that therapeutic communication was devised because we so frequently traumatise each other in the way we interact. In organisations there is much talk that is small talk, gossip, sarcasm or a non-response. In families we frequently feel free to make fun of each other, loose our tempers and criticise. We carry out these forms of interaction automatically – without thinking. However therapeutic communication is aimed at establishing relationships and within these relationships interactions which encourage rather than discourage patients Navarra et al (1990 p.xiv) state
Navarra et al (1990 p. xiv) provide the following examples of how what we often say can be non-therapeutic. Asking a patient "Why…?" is usually threatening and telling a depressed patient that "we all suffer sometimes" discounts their feeling even if you are trying to be warm and sincere and helpful. No nursing interaction with a patient is just a dressing or an injection. The patient is always the whole person with a complete personality and sensitivities. The nursing role with patients is a therapeutic role. The nurse listens, guides and responds to the patient in such a way as to assist the patient in expressing their feelings (Bradley and Edinberg, 1990). You rely heavily on getting along with and talking to your patients. Learning how to listen, to understand, to respond and so forth are all essential for caring for the whole person.
Interpersonal Communication – Some Theoretical Concepts In general we understand what interpersonal communication is, and for most things in life this understanding is sufficient. (Interpersonal Communication is communication between two or more human beings. It is to be distinguished from intra-personal communication, which is the communication with oneself to learn about, evaluate or persuade yourself of things.) However, for a more in-depth understanding of what is happening in communication we need a more detailed model. (A model is something that aids our understanding of what is happening in a situation. It breaks the situation into manageable components. We are able to examine each of the components and gain a better understanding of the overall process.) The Transmission Models of Communication A number of interpersonal communication models have been developed. DeVito (1989) presents several of these models. The Lasswell and Gerbner Models both identify the components of the communication process. The Gerbner model identifies ten components in the communication process
However, as DeVito (1989) suggests this is a very linear process where the communication starts with one person and proceeds via a series of steps to another person. This is a very limiting way to view communication as it ignores the circumstances of the communication; the fact that both the sender and receiver of the messages act at the same time; and that the interaction is circular in nature. Diagram1 The universals of human communication. (Adapted from DeVito, 1990)
This model presents several features of the transmission process. These include:
For interpersonal communication to exist there needs to be the message that is both sent and received. The message can be in a number of forms –auditory, visual, tactile and so forth or indeed any combination of the forms. The message does not have to be verbal. In nursing, touch is a significant form of communication and this aspect will be covered in more detail in a later module. DeVito (1991) maintains that there are three context dimensions to consider in the communication process-
Physical – beside the hospital bed, in the hallway, in the bathroom. Social/psychological – the status relationship of the participants, the roles and games that people play, central rules of society. Temporal – the time of the day, as well as in history. These three context dimensions interact, for example, talking to a patient in the hallway will effect the social/psychological dimensions because of a rule of society that calls for the maintenance of privacy and the confidentiality of information. The hallway is seen as a public area and therefore the level of the communication will need to be of a general nature. The factors in each dimension influence the formality, seriousness and intimacy of the communication. Nurses occupy a unique position in society due to the socially sanctioned role of caring for the personal physical needs of patients. This closeness of physical contact with patients often opens the doors to communication of a deeply personal nature.
DeVtio (1989, 5) presents the following fuller diagram displaying the major elements of the transmission approach to communication. Some Universals of Interpersonal Communication (DeVito, 1989, 5)
The models that we have looked at to this point do not consider messages that go from one person to another in a chain or series of relays. The grapevine circulation of information is an example of messages that can spread very quickly. The transmission can have a number of forms. Mohan, McGregor and Strano (1992) suggest the following:
In each of these cases the initiator of the information is A. These forms of communication are common in organisations. So in form 1 above the nurse is (A), giving a message to an enrolled nurse (B), who then passes the message to the patient (C). In form 2 above (A) is gossiping with others. In form 3 above a message from administration (A) is passed to some members of the staff (B and D) who then pass the message onto other members of the staff, but not all members of the staff end up with the message and so forth. The transmission models emphasise the message and consider communication to be a process made up of various steps. The transmission models are used to analyse the success or failure of communication and rectify the faults in the transmission system. The main weakness of the transmission model is that it deals inadequately with the concept of meaning (Mohan et al, 1992). It is assumed that the meaning is contained in the message and has no specific place in the transmission models. The Transaction Models of Communication The transaction model does not see the communication as flowing from the sender to the receiver and back. Mohan et al (1992, p. 42) state that:
Transactional Model of Communication (Mohan et al, 1989, 42)
Mohan et al (1992) suggest that aspects of the transactional model include:
Therapeutic communication in nursing is the process whereby nurses use their skills in interpersonal interaction for the benefit of their patients. Understanding the nature of communication, with its attendant variables, and how skills in communication can be used for the benefit of the patient are at the heart of nursing practice. There are two main models of communication – the transmission and the transaction. The transmission considers that essentially communication is the transfer of messages from a source to a receiver and the transactional model that communication is the creation and negotiation of meaning by people responding to the environment and each other. Some of the variables in the transmission models are the senders/receivers, noise, feedback, encoding, decoding and the physical, social/psychological and temporal dimensions. The transaction approach is interested in the negotiation of meaning and the changing, irreversible, unrepeatable nature of communication.
Additional Reading and Exercises
Stein-Parbury, J. 1993, Patient and Person: Developing Interpersonal Skills in Nursing, Churchill Livingstone, Melbourne. and DeVito, J.A., 1989, The Interpersonal Communication Book, 5th edn, Harper and Row, New York. or
Bradley, J.C. & Edinberg, M.A. 1990, Communication in the Nursing Context, 3rd edn, Appleton and Lange, Norwalk. DeVito, J.A. 1990, Human Communication: The Basic Course, 5th edn, Harper Collins, New York. Miller, B. & Keane, C. 1972, Encyclopedia and Dictionary of Medicine and Nursing, W. B. Saunders, London. Mohan, T., McGregor, H. & Strano, Z. 1992, Communicating! Theory and Practice, 3rd edn, Harcourt Brace, Sydney. Navarra, T., Lipkowitz, M.A. & Navarra, J.G. 1990, Therapeutic Communication: A Guide to Effective Interpersonal Skills For Health Care Professionals, Slack, New Jersey. Potter, P.A. & Perry, A.G. 1989, Fundamentals of Nursing: Concepts, Process and Practice, 2nd edn, Mosby, St. Louis. Rogers, C.R. 1961, On Becoming a Person, Houghton Mifflin, Boston.
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