How can I improve my therapeutic communication with patients? Any resources for that?

Esme12, ASN, BSN, RN · Oct 27, 2012

Believe it or not......and yes it is hokey........it works! YOu will get more comfortable un=sing it .....but the bizarre thing is it works.

What makes you say that? Is one of my favorites. How does that make you feel? is another and reflecting back is another....That makes you angry?

You will use.....don't worry it's fine......Then the famly goes home and the pateint dies....trust me .......you will never say it agan.

Good Luck!

hodgieRN · Oct 27, 2012

I see what you are saying. I also have my own opinions about scripting. Best thing I can tell you is when the pt is asking a question, saying "it will be fine" doesn't offer an explanation. But, if you can tell WHY it will be fine, it will make them feel better. This is where education comes into play. You may know that things will be fine b/c you the understand the disease or medication, but they don't. Some people have zero, and I mean, zero medical knowledge. Brushing them off can actually make the pt believe that you don't even know the answer to the question.

Here's the thing with scripting. You don't have to necessarily say " I understand you have a concern." But the idea is that you have to acknowledge the fact that they have the concern and you have to acknowledge that you understand what they are asking. Saying "I understand you have a concern" does work, but if you can say that phrase in your own way that addresses those two factors, it's ok to have your own interpretation. Things like "I see you have questions about the med" or " What questions can I answer for you?" You have to have an OPEN conversation about it. Questions and answers back and forth. The script "how do you feel about it," allows the pt to express their concern, fear, etc. Acknowledge their fear and understand why they feel that way. Is there anything you can tell them to make them better or understand it? Telling them "don't worry about" doesn't make the fear go away...it makes them feel isolated and it closes the conversation. You have to tell them the "why" and "how". Sometimes, I'll say "Looks like you have something on your mind, " or " You look a little unsure about new medication the doc prescribed, " or "Is there something you would like to ask about your chest tube?" Read their faces...follow their reactions..interpret frustration.

As your knowledge base grows, you will be able to tell pt's more and more about a disease process. When a pt asks me "Why am I on insulin coverage if I have no history of diabetes?" Saying "Because your doctor prescribed it," doesn't work! You can't say " b/c your blood sugar is elevated...it's fine.. you aren't going to go home on it...it's just for here in the hospital." Tell them why..." I understand what you're asking b/c diabetics normally take insulin. In the hospital, we like to keep blood sugars in a specific range b/c high blood sugar can cause many problems. A lot of the medication we give can cause temporary sugar spikes...things like the dextrose in your IV fluids, the steroids you are taking, and even the stress can all add up. This doesn't mean you have diabetes. This just means you have high blood sugars that we like to keep under tight control. Does this answer your question?" If I said "don't worry about, we do this for everyone...you'll be fine," it will leave so many questions unanswered. So, I didn't have to script word-for-word, but I acknowledged them, I explained it, I helped them understand the process of what happens in the hospital, and I left them the opportunity to ask anything else to be clarified.

Being in the hospital can be very scary and sometimes, nurses are the only people who are able to stand at their bedside for longer than 2 minutes, or who actually pull up a chair and talk to them. If you don't know the answer, tell them you will find out. When I leave for the night, I usually shake their hand. It's a sign of respect and good will. That's what pts normally do at the office or among friends... when they aren't trapped in a bed with wires everywhere. It makes them feel human. I don't normally hug pt's b/c some people value space but a handshake acknowledges their presence. It's all about communicating with people, not the pt in room 329. So, try and be open. Let them guide the conversation. And when you ask " Is there anything else you have questions about," when they "No, thank you," then you have done your job right.

Samian Q · Oct 27, 2012

Woah. How do you know so much about insulin and diabetes?! I never thought that they would ask so many questions, though.

But, to be honest... I kind of hope my patients don't ask a lot of questions. I'm still technically a layperson so I don't know tons and tons about (insert medication name or diagnosis here).

I am especially fearful of nutrition and dietary questions. Can I just refer patients to consult with a nutritionist in a hospital?

Esme12, ASN, BSN, RN · Oct 27, 2012

Your patients will ask you questions. You are their teacher......their guide.

You can always say....I new at this....let me get someone who can better answer your question and then stick around and listen to the answers. hodgieRN gave you some excellent advice and no you cannot pawn you patients off on someone else but I do refer patient to the various experts available in the hospital setting.

This is especially good advice

Being in the hospital can be very scary and sometimes, nurses are the only people who are able to stand at their bedside for longer than 2 minutes, or who actually pull up a chair and talk to them. If you don't know the answer, tell them you will find out. When I leave for the night, I usually shake their hand. It's a sign of respect and good will. That's what pts normally do at the office or among friends... when they aren't trapped in a bed with wires everywhere. It makes them feel human. I don't normally hug pt's b/c some people value space but a handshake acknowledges their presence. It's all about communicating with people, not the pt in room 329. So, try and be open. Let them guide the conversation. And when you ask " Is there anything else you have questions about," when they "No, thank you," then you have done your job right.

As you gain experience you will gain confidence. When I first started caring for open hearts I was not comfortable at all with pre-op questions......but with time I got pretty good.

hodgieRN · Oct 28, 2012

I understand it's intimidating to have pt's ask you questions that you are still learning yourself. I felt the exact same way. I didn't want to seem incompetent or let the pt's know I didn't know something. We are all perfectionists in some way. As time goes on, the amount of knowledge you posses will grow exponentially and you will be able to offer all types of descriptions and definitions. As for me, it happens all time that I can't answer something. For example, my weaknesses are in Hematology/ oncology. I took me freakin forever to remember what was b-cells, t-cells, immunoglobulins, humoral immunity...wait, t-cells fight what... and b-cells are made where...i hated it! And sure, I know the different types of brain cancer, how to interpret a CBC, or how to care for pt's with sickle cell, but if a pt threw different questions at me about gliomas, I wouldn't be able to answer all of them. But, that's ok. Actually, pt's like the fact that you can't answer everything. It shows humility. but I try to answer as much as I can within my scope of practice. The first time I had to discharge a pt and go over the discharge instructions/ meds, I was sweating. I was worried he was gonna leave and tell everyone I didn't know what I was talking about. But, as my career progressed, I was able to answer almost anything b/c I was always learning. I wouldn't have been able to give all that insulin info when I was in school either. I barely knew that stuff when I worked in the ER. In ER, the pt wasn't there long enough to see the effects of steroids or stress. We put them on an insulin drip and zipped them to the floor. Once I was in ICU, I got to see a different perspective...how things played out over time.

It's great you brought up the nutrition topic. I think a lot of nurses take nutrition for granted. Best person to ask about dietary is a registered nutritionist. They LOVE when nurses are curious about their field b/c some nurses blow it off. Nutrition is more than just giving a pt an 1800 cal ada diet. There's a whole science behind it (obviously). I constantly asked the nutritionist random questions. Next time you come across a pt with tube feeding, read dietary's primary assessment note. They calculate calories, protein intake, free water, dietary requirement, recommendation to switch tube feeding, vitamin supplementation, etc. Did you know that Propofol (diprivan) on vented pt's is counted as caloric intake and the tube feeds are sometimes lowered until they are extubated? That pt's with decub ulcers are given Vitamin C/ Zinc supplementation to promote wound healing? That tube feeds containing Omega-3 fatty acids may increase the survival rate in pt's with ARDS by possibly eliminating free radicals due to it's antioxidant potential? That giving tube feeds can somewhat combat 3rd spacing by providing proteins, which is involved in oncotic/ hydrostatic pressure (albumins?) That too much protein in liver failure pt's can raise ammonia levels? That Omega-3 is contraindicated in pt's with intracranial hemorrhages b/c it is a natural anticoagulant? And that grapefruit is contraindicated with certain medication b/c it can change the therapeutic drug levels? Nutrition is VERY important, especially with so many people taking herbal supplements. I find it fascinating, But, I didn't know one thing about nutrition in ER. Not one. Didn't care b/c everyone was NPO and there was more important things to do. But as time went on, I learned. Still to this day, I randomly ask staff questions...even hypotheticals. Nutrition, speech, physical therapy, RT's....anything. And if there is something I don't know, I have to find out, or it bothers me. Just like Esme12 said, "As you gain experience, you will gain knowledge." And in time you will be able to answer all their questions until they have nothing more to ask. If you consult ancillary staff, make sure you get their input. Always be curious....

Samian Q · Oct 28, 2012

Thanks so much. It's just really hard for me now, as a nursing student, especially since I'm in an accelerated program. For me, the clinical days sometimes just feel like a hurdle I need to get over with, so I can move on to the next day's assignments, or Wednesday's patho test, etc. etc.

I feel like if I actually had lots of time to sit down and imbibe that patho material in, and the nutritional info, over a long, long period of time I'd be an expert at it.

But when I'm on the unit I'm trying to juggle millions of procedural-related things on my mind ("Are there any drugs up on my eMAR yet? Should I go look at my other patient? I didn't get a chance to write a nurse's note in 3 hours - am I gonna get in trouble?!") that I always fear that some information or some thing to do is going to slip out of my mind just when I need it.

Plus, reporting it and understanding it in a medical language is a Herculean task in itself for me. I feel like I have to a physical therapist-slash-IV specialist-slash-computer programmer (those computer systems are TOUGH to navigate!)-slash-nutritionist-slash-"therapeutic counselor" all at the same time. AND I have to be able to document it all in a foreign language!

hodgieRN · Oct 28, 2012

Yeah, it's a lot to take on. Feeling like you are not on top of game will continue on into you career. Finishing nursing is just preparing you for the basics. I believe that the real learning begins with on-the-job training. I didn't feel on top my game until about a year into my hospital position. Learning to prioritize your patient care seems impossible in the beginning. You are always in the weeds. But after a while, it suddenly clicked. At month seven, I thought "I can't do all this....it's too much...how can anyone juggle all this stuff and not make errors." Around month 12, I was a different person. So, give it time. You will learn all the jargon, clinical standards, etc and before you know it, things that you had to actively think about doing will suddenly become second nature.

Esme12, ASN, BSN, RN · Oct 28, 2012

Baby steps....baby steps.....this is like nothing you have ever done.....you will graduate and pass boards then you get a job and realize you have much to learn. It really is true the first year after graduation is the hardest.

It's The nature of the beast.

classicdame, MSN, EdD · Oct 29, 2012

I think the OP wants to do two things with the comment "Don't worry---". 1) assure the patient and 2) stop the conversation. I recommend practicing on other people, like classmates or friends. Create some sentences that the patient might say (your text might offer suggestions). Then hand out the sentence to a friend and ask them to role play with you. Remember, it is ALWAYS about the patient, never about you, so don't use "I" very often if at all.