What is one of the main purposes of communication in the therapeutic nurse

6 What is empathetic communication?

There are two elements of communication: one involves primarily sharing cognitive or informational content, and the other involves statements that refer or respond to emotional states. Expressing clinical empathy is an essential part of therapeutic communication and has been shown to strengthen the physician-patient relationship, improve patient satisfaction, and enhance treatment adherence. For example:

Family member: John was just mowing his lawn last week. How can this be happening?

Cognitive-informational response: Unfortunately, John's underlying lung disease makes him susceptible to infections, and pneumonia can come on very fast and severe.

Empathetic response: I can't imagine how hard it is for you to see John so sick and for this to happen so fast.

The NURSE mnemonic can be used to express clinical empathy:

Name the emotion

A lot of people in your situation would feel angry.

It sounds like this has been frustrating.

Understand

I can't begin to understand how hard this is.

It is hard to be in a situation like this.

It sounds like you are weighing wanting to be sure everything that can help has been tried against wanting to be sure that if she is at the end of her life she does not suffer.

Respect

We have a lot of respect for how you are so present and supportive of your loved one.

I can tell you have been taking very good care of your mother.

Support

You will not be going through this alone; we are here to help you.

Based on what you have told us, we think you are making the right decision for your loved one.

Explore

What is the most difficult part of this for you?

Can you help me understand…?

Strategic family therapy

Strategic and brief therapy approaches grew out of the influential work in the 1950s and 1960s of a group in Palo Alto, CA, led by Gregory Bateson, an anthropologist, and including Jay Haley (communications theorist), John Weakland (engineer turned anthropologist), Don Jackson (psychiatrist), and Paul Watzlawick (philosopher and Jungian therapist), among others. The group applied communications theory, systems theory, and cybernetics to the understanding of schizophrenic communication, family interaction, and therapeutic communication. Don Jackson and others formed the Mental Research Institute in Palo Alto in 1959, to develop treatment approaches based on the theoretical formulations and findings of the Bateson project, including concepts deriving from their study of the creative, unconventional hypnotherapeutic approaches of psychiatrist Milton Erickson. Landmark articles from this collaboration include ‘Toward a theory of schizophrenia’, which introduced the concept of the double bind, and ‘The question of family homeostasis’. Both strategic family therapy and brief therapy approaches emphasize a here-and-now, problem-centered focus and development of strategies that interrupt the problem-maintaining interactions in the family system. Dramatically brief and counterintuitive interventions became the hallmark of this approach, which is one of the more theory driven of all the schools of family therapy with the notable exception of Bowen family systems therapy.

Fees and Third-Party Reimbursement

In the United States, CBT for CLBP can initially be delivered by licensed behavioral health professionals using CPT codes for psychiatric diagnostic interview examination, including 90801 or 90802, when the goal is to establish a diagnosis and treatment protocol. Psychotherapy, defined as the treatment for mental illness and behavioral disturbances in which the clinician, through definitive therapeutic communication, attempts to alleviate emotional disturbances, reverse or change maladaptive patterns of behavior, and encourage personality growth and development, can be delivered using CPT codes 90804 (20 to 30 minutes), 90806 (45 to 50 minutes), or 90808 (75 to 80 minutes). If additional evaluation and management services are required, CPT codes 90805 (20 to 30 minutes), 90807 (45 to 50 minutes), or 90809 (75 to 80 minutes) can be used instead. These codes are based on the setting in which the psychotherapy session occurred, the type of psychotherapy provided, and the amount of face-to-face time spent with the patient. The decision regarding the appropriate reporting of individual psychotherapy codes should be based solely on the definition of the codes and the work performed. Alternatively, brief CBT for CLBP may be provided by a clinician in the context of an outpatient visit for a new patient using CPT codes 99201 (up to 10 minutes), 99202 (up to 20 minutes), or 99203 (up to 30 minutes). For an established patient, brief CBT for CLBP may be provided during an outpatient visit using CPT codes 99211 (up to 5 minutes), 99212 (up to 10 minutes), or 99213 (up to 15 minutes).

These procedures are widely covered by other third-party payers such as health insurers and worker's compensation insurance. Although some payers continue to base their reimbursements on usual, customary, and reasonable payment methodology, the majority have developed reimbursement tables based on the Resource Based Relative Value Scale used by Medicare. Reimbursements by other third-party payers are generally higher than Medicare. It should be noted that CPT codes listed in the psychiatry section of the CPT manual (90801-90899) are in fact not limited to psychiatrists or mental health professionals, and may be used to designate the services rendered by any qualified physician or other qualified health care professional. Unfortunately, some third-party payers will not reimburse all providers for these codes.

Typical fees reimbursed by Medicare in New York and California for these services are summarized in Table 21-4.

Suggested Outline for Culturally Sensitive Therapeutic Discourse

Bonder and colleagues11 and Bonder and Gurley10 suggest a three-step process of conducting culturally sensitive occupational therapy interaction:

If you are scheduled to meet a client from a culture that is different from yours, educate yourself about at least the basic characteristics of his or her culture. This will help you develop the cultural sensitivity necessary for communication with the client in such a way that rapport may be established quickly. Self-education may be achieved by attending “workshops, courses, or reading about specified cultures” in order to gain “helpful insights and strategies for working with people of those cultures” (p. 172).26 An addition to this list could be searching for information on the Internet or interviewing people who may know about the culture in question.

Make a hypothesis about how the client's occupational performance issues may be framed based on an understanding of his or her culture. At the same time, reflect on how your own view of the clues you are picking up in the therapeutic discourse may be influenced by your own cultural perspective, and how this cultural interpretation may color your hypothesis about the client.

Finally, test your hypothesis by questioning the client about whether or not your interpretation of cues and attribution of meanings to them is accurate.

The above three steps infer that, as a therapist, you need to maintain vigilance by paying attention at every moment to the client's “word choice, facial expression, body posture, voice tone, gestures, and other clues to the feelings and attitudes of the individual” (p. 166).11 This is the same kind of vigilance needed for therapeutic communication in general (see section on the therapeutic relationship above).

1 Background

One of the primary goals of therapeutic communication in healthcare is to develop a rapport with patients and their families and to foster an environment of compassion, understanding, and empathy (Peplau, 1997). Therapeutic communication between patients and members of the healthcare team in community and hospital settings is, therefore, essential in ensuring clarity in the provision of care, to mitigate medical errors and enhance patient safety (Rosen and Pronovost, 2014). The World Health Organisation recognizes the need for patients to be included in health care decision making and planning (Rimal & Lapinski, 2009). With a global agenda of improving quality and safety in healthcare, nurse educators need to find engaging and impactful ways to integrate communication skills training into undergraduate and graduate nursing education (Mullan and Kothe, 2010).

Dealing with patients and families during difficult conversations can be challenging particularly about explaining complex treatments, working through mental health issues, and discussions about end of life care. Such conversations are often a source of anxiety and fear for many healthcare professions' students as well as practicing clinicians (Martin & Chanda, 2015; Nestel et al., 2010; Eid et al., 2009). Simulation provides an innovative approach to emphasise the critical role of communication skills and for students to develop a repertoire of effective techniques (Kelly et al., 2014). Simulation can be described as a teaching strategy to replicate real life experiences (Brown, 2015) and offers an alternative learning experience given some of the limitations of clinical rotations (Howley et al., 2008). Several studies attest to the reliability, validity and feasibility of the simulated patient (SP) approach for communication skills training (CST) in nursing education (Bolstad et al., 2012; Ebbert and Connors, 2004; Vu and Barrows, 1994). A recent meta-analysis highlighted the efficacy of simulation training in nursing across diverse clinical domains (Shin et al., 2015). The meta-analysis examined 20 studies and provided evidence that using SPs in education across different areas in nursing was a useful technique over traditional learning methods. The results presented evidence, with a medium to large effect sizes, to advocate for the use of SPs to improve learner outcomes (Shin et al., 2015).

For students, rehearsing clinical conversations with peers offers a level of exposure to ‘real life’ situations (Schlegel et al., 2012). However, the interactions may not be authentic because individuals may ‘hold back’ in the type and level of responses. Role-plays with simulated patients (SPs) offer opportunities for students to immerse themselves in a more authentic experience within a protected and controlled environment (Nestel et al., 2014). SPs are primarily well people trained to act as a patient in a clinical scenario (Nestel et al., 2014). The terms simulated patient and standardized patient are often used interchangeably. From the 1960s SPs have been utilised for teaching and evaluating medical students in clinical assessment techniques (Barrows, 1993). More recently, SPs have been used to train clinicians to assess the effectiveness of communication training programs (Trickey et al., 2016) and to teach students' culturally sensitive communication skills (Bahreman and Swoboda, 2016). A variety of health professional schools are now using SPs for teaching and students feedback, with the use of SPs in nursing programs gaining increasing momentum. In this educational context, the authenticity of role-play and quality of feedback provided by SPs is of utmost importance (Bahreman and Swoboda, 2016).

Regardless of the educational context - whether clinical or communication skills training - SPs are in a position of being able to provide valuable feedback to students from the patient's perspective (Nestel et al., 2014). In this teaching role, they can be viewed as active facilitators of the specific training objective. Alternatively, SPs can also be engaged in scenarios to determine the impact of simulation interventions for research purposes, quality assurance, and program evaluation (Weaver and Erby, 2012). In such instances, SPs may take on a more passive role within the evaluative protocol. However, the extent to which the various positions of SPs are utilised, supported, evaluated, and reported is under reported in the extant literature (Weaver and Erby, 2012).

Measuring learner performance in simulations with SPs, nursing researchers should seek advice on tool selection and use to build rigor into emerging research (Kardong-Edgren et al., 2016). However, the range and use of validated instruments in the literature remains weak, and an area where more sound approaches in research methods are warranted. While there are many approaches to the recruitment and training of SPs, Nestel et al. (2014) concede that few procedures are evidenced based. Some of the methods described in the literature include demonstrations, video-clips, observation of real patients, coaching by experienced SPs or professional actors, and feedback by students and teaching faculty regarding SP performance (Meier et al., 1982). In a review of 121 SP articles Howley et al. (2008) identified that few authors provided sufficient detail about SP recruitment and training for reproducibility of research studies.

A recent text by Nestel et al. (2014) provides the most detailed instructions on the recruitment and training of SPs currently available. These authors developed a four-stage model that draws on evidence in the field of dramatic arts as an exemplar on which to standardize SP training. The model allows SPs to be recruited and trained for multiple roles, for different scenarios, and in a range of health care contexts (Nestel et al., 2014). In sum, SPs can offer valuable feedback and perspective to learners, and provide health educators with the opportunity to improve or expand on their program. As the use of SPs rises it is now opportune to review the literature and report on current aspects of SP training and use including the preparation and support of these partners in learning. Of particular interest is an investigation of the scope and efficacy of using SPs in the training and evaluation of nurses' communication skills.

3.4.3 Language use, power dynamics, and communication styles

Language barrier was a frequently reported issue as affecting therapeutic communication across different healthcare settings in the literature (Amoah et al., 2019; Kruger & Schoombee, 2010; Mabuto et al., 2017; Madula et al., 2018; Nwosu et al., 2017; Taiwo, 2014). Given the linguistic diversity in most African countries, language use is certainly a challenging issue in the healthcare setting, since English or French is the language of medical education. Patients who cannot speak English and do not have interpreters to assist may find it difficult to communicate with healthcare providers. Regarding the language issue, one Malawian patient stated that it was difficult for him to communicate with nurses who could not speak Chitumbuka because he could not speak English and lacked proficiency in the Chichewa language (Madula et al., 2018, p. 6).

Due to this language problem, and coupled with the higher social status nurses and other healthcare providers enjoy as knowledge and care providers, power imbalance was also reported to constrain communication between nurses and patients (Amoah et al., 2019; Cubaka et al., 2018; Gourlay et al., 2014; Moola, 2010; Ondenge et al., 2017; Yakong et al., 2010). As a result of the power imbalance, nurse-patient communication styles which were impersonal, involved rigid questioning styles, and ignored patient feelings, opinions, and uniquenesses (Murira et al., 2003) or discriminated against patients and did not respect patients’ rights (Mensah, 2013) affected nurse-patient communication and patient disclosure. However, communication styles that employed effective non-verbal cues such as touch, smile, and active listening (Moola, 2010), used open-ended questions to engage patients, took patients concerns into account, (Labhardt et al., 2009), or were polite and provided enough information to patients (Adugbire & Aziato, 2018) promoted communication and interaction between healthcare providers and patients. Thus, as Hurley et al. (2017, 2018) noted, nurses who ‘shared the talk’ and encouraged open discussions promoted more therapeutic nurse-patient interactions than those who ‘owned the talk’ (i.e., dominated every process of the interaction).

4.7 Family Partnership Model (FPM)

FPM (Davis and Day, 2010) is a model for therapeutic communication wherein the helper uses skills of active listening to help the parent or family identify how best to address their own health needs and to take the steps necessary to do this. In each of the trials, health visitors used different forms of knowledge plus skills and abilities to judge individual situations, inform complex health needs assessments which they acted upon using with finely honed FPM skills and abilities such as engagement, displaying genuine respect and empathy, problem exploration, challenging, and goal setting to achieve health gain. Details of the three trials illustrating the particular health visitor skills required for this way of working are identified in Box 1. In each case, the service delivery context was important as, in addition to extra post-qualification training and education in the FPM, health visitors also had reduced caseloads and so the opportunity to visit families intensively, giving time in the way that adhering to the FPM requires.

Box 1

Home visiting programmes: interventions, outcomes and skills.

Oxford Intensive Home Visiting study (Barlow et al., 2003, 2005; Barlow et al., 2007)

Intervention: weekly visits starting early in pregnancy from a health visitor trained in the Family Partnership Model (FPM).

Outcomes: Mothers who received a visit from the FPM trained health visitor (intervention group) showed better maternal sensitivity and infant cooperativeness compared to those in the control group.

Skills: In advanced assessment and especially in identifying and promoting indicators of parental bonding and parental sensitivity during pregnancy,

skills in helping parents change;

skills in focusing on the needs of both mother and baby including the maternal infant relationship;

helping without being directive;

developing trusting relationships;

assessing individual risk and resilience factors in families prenatally and using these to determine the level of future health visiting support;

drawing evidence-based theories to help parents and carers manage difficult and challenging issues which may affect their transition to parenthood, e.g. parental and infant disability, chronic illness, perinatal depression, toxic stress, family conflict, and social isolation;

recognise signs of relationship distress and refer to specialist services where necessary;

observe parent–infant interaction and use strengths-based interventions to support sensitive parent–infant interaction;

facilitate one-to-one interventions at home visits with the family using strengths-based parenting approaches.

European Early Prevention Project (Davis and Tsiantis, 2005; Puura et al., 2005a, 2005b)

Intervention: ante-natal and post-natal (promotional) interview and follow-up from health visitors (or the equivalent elsewhere in Europe) trained in the FPM.

Outcomes: improved infant/mother interaction, in the form of mothers giving more and better positive signals to their infant and in infant responsiveness to those signals.

Skills: assessment of maternal infant relationship and home environment,

using the assessment to identify the required future level of health visiting support;

challenging parental behaviours which may be harmful or increase infant risk and vulnerability;

recognise signs of relationship distress and refer to specialist services where necessary;

observe parent–infant interaction and use strengths-based interventions to support sensitive parent–infant interaction;

Maternal and Early Childhood Sustained Home Visiting Programme (MECSH) (Kemp et al., 2011), Australian programme being implemented in some English sites (Plastow, 2013)

Intervention: mothers receive the 25 home visits from the equivalent of a British health visitor, a child and family health nurse, trained in the FPM.

Outcomes: intervention group mothers were found to be more emotionally and verbally responsive to their infants during the first 2 years of life, and they were more likely to breastfeed their infant for longer than mothers in the comparison group who did not receive the scheduled home visits.

Skills: in-depth health needs assessment incorporating ‘fine’ observation of individual relationships and the home environment,

skills in assessing the impact of the neighbourhood and environmental ecology on family life.

skills in working with and supporting parents' risk taking;

enhanced knowledge and skills in assessing child development;

ability to tailor content of home visit to the mother's needs;

skills in negotiating, modelling experimentation, and supporting mothers' experimentation;

offering support to enhance coping skills;

helping mothers develop problem-solving skills;

helping families develop supportive relationships in their communities;

monitoring and assessing maternal infant bonding and attachment;

providing primary care and health education;

giving information about immunisations, prevention of sudden infant death syndrome, advice on how to reduce risk and vulnerability, advice on infant nutrition and child safety;

‘straight talking’;

showing respect for the parent's position.

In summary, the orientation to practice and the three core practices identified the generic knowledge, skills, and abilities needed for health visitors. Research reviewed for the levels of practice affirmed these and contributed to our understanding of how health visitors need to function in order to deliver the service. Together, they illustrate the complexity of what students need to learn in order to work salutogenically within the current system.

Several studies also described what happens when health visitors do not demonstrate these abilities in practice. Bacchus et al. (2003), for example, found that health visitors lacked the requisite knowledge of indicators for domestic violence, knowledge of appropriate services, or communication skills to intervene effectively. Robinson and Spilsbury (2008); Peckover (2003a, 2003b), and Frost (1999) had similar findings. Merely being within the home is not enough to bring about change. Several studies (Almond and Lathlean, 2011; Tranter et al., 2010) also identified the particular, and often unmet, challenges for health visitors in effecting cross-cultural communication in order to bring the HCP to families of different ethnic origin and sometimes in extreme need through asylum seeking and possibly also lack of access to public funds. In these studies, health visitors were identified as having the commitment to make health creating change but possessed neither the knowledge of what was best to do nor the skills or time for relationship formation or thorough and on-going needs assessment.