THERAPEUTIC COMMUNICATION FOR THE STUDENT NURSE - RICHARD OPOKU ASARE

THERAPEUTIC
COMMUNICATION FOR
THE STUDENT NURSE
RICHARD OPOKU ASARE

THERAPEUTIC
COMMUNICATION FOR
THE STUDENT NURSE
RICHARD OPOKU ASARE
M.Phil, B.Ed. (Hons), RN (Dip-RMN), Cert.Ed., Dip.MH (Alison), ENCS, NCF
College of Nursing and Midwifery, Ntotroso
Ahafo Region, Ghana
Copy right ©2024
All rights reserved.
ISBN: 978 – 9988 – 3 – 7543 – 0
Author contact: 024 080 3140 / 020 908 2000
Email: asareor@gmail.com / asareor@yahoo.com
Designed and Printed by Forsamuel Printing Press, Fiapre, Sunyani
Email: samuelakakpo53@gmail.com
Tel: 024 507 9342 / 055 196 4635

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ACKNOWLEDGEMENTS
I wish to express my profound gratitude to my family, especially Mrs. Martha Asare, for doing the
typing and standing tall with me despite the challenges in producing this handbook.
Credit goes to both past and present trainee nurses and midwives at the College of Nursing and
Midwifery, Ntotroso, who in one way or the other spurred me on to put the pieces of my lecture
notes together to come out with this handbook.
Finally, I wish to express my appreciation to Dr. Ruth Nimota Nukpezah (Department of
Preventive Health Nursing, School of Nursing and Midwifery, University for Development
Studies, Tamale), Ms. Emelia Mills (Department of Nursing, College of Nursing and Midwifery,
Kumasi), distinguished publishers, authors, and institutions, especially the Nursing and Midwifery
Council of Ghana, whose curriculum guided the putting together of materials for the purpose of
this handbook.
I thank you and God bless you all.

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TABLE OF CONTENTS
ACKNOWLEDGEMENTS .......................................................................................................... i
LIST OF FIGURES.....................................................................................................................iii
PREFACE..................................................................................................................................... iv
CHAPTER ONE ........................................................................................................................... 1
BACKGROUND TO PRINCIPLES OF COMMUNICATION..................................................... 1
CHAPTER TWO .......................................................................................................................... 6
COMMUNICATION STYLES...................................................................................................... 6
CHAPTER THREE.................................................................................................................... 19
INTRODUCTION TO THERAPEUTIC COMMUNICATION.................................................. 19
CHAPTER FOUR....................................................................................................................... 38
VERBAL AND NON-VERBAL COMMUNICATION TECHNIQUES.................................... 38
CHAPTER FIVE ........................................................................................................................ 49
BARRIERS TO COMMUNICATION......................................................................................... 49
CHAPTER SIX ........................................................................................................................... 56
PERSONALITY CONFLICT AND MANAGEMENT ............................................................... 56
CHAPTER SEVEN..................................................................................................................... 73
DISAGREEMENT AND CONFLICT ......................................................................................... 73
CHAPTER EIGHT..................................................................................................................... 78
APPRECIATING CRITICISM .................................................................................................... 78
CHAPTER NINE........................................................................................................................ 87
BREAKING BAD NEWS............................................................................................................ 87
BIBLIOGRAPHY..................................................................................................................... 102
APPENDIX A............................................................................................................................ 107
APPENDIX B ............................................................................................................................ 108
APPENDIX C............................................................................................................................ 119

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LIST OF FIGURES
Figure 1: The Communication Process........................................................................................... 4
Figure 2: Effective Communication................................................................................................ 5
Figure 3: Space orientation........................................................................................................... 43
Figure 4a: The Four Categories of Temperaments ....................................................................... 59
Figure 4b: Personality Traits......................................................................................................... 60
Figure 4c: Eysenck’s Biological Trait Theory of Personality ...................................................... 61
Figure 5: Personality Conflict....................................................................................................... 63
Figure 6a: The conflict pyramid ................................................................................................... 65
Figure 6b: The conflict pyramid ................................................................................................... 66
Figure 7a: Conflict Management Continuum ............................................................................... 70
Figure 7b: Conflict Management Continuum............................................................................... 71
Figure 7c. The Conflict Continuum.............................................................................................. 72

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PREFACE
This handbook is primarily written for trainee nurses/midwives in our health training institutions.
It introduces the student to the basic therapeutic techniques in the care of their clients. It is prepared
in such a way to develop students’ interest in cultivating effective interviewing skills, including
attentive listening, eliciting patients’ concerns, fears and feelings, establishing rapport, and to
develop the skill in using open-and close-ended questions in deriving health history from their
clients to be able to plan the appropriate nursing care.
One of the main ways nurses establish trust with patients is through communication. Because
nurses are likely to have the most direct contact with patients, effective nurse-patient
communication is critical. Nurses can utilize proven therapeutic communication techniques that
promote quality care. More so, nurses provide patients with support and information while
maintaining a level of professional distance and objectivity.
The concept of therapeutic communication, as introduced in our study, is to allow the nurse to
consciously influence his/her client or help the client to a better understanding through verbal or
nonverbal communication. The goal thereof is to implement interventions designed to address the
client’s needs. It is not communicative and study skills in English Language studies as some
suggest, though.
This handbook has been written with the aim to equip the student nurse/midwife with the
appropriate verbal and non-verbal behaviours necessary in professional interpersonal interactions
with patients, families, health team members and the community. Although this book cannot
automatically change practice, it is hoped that by observing and thinking about ways in which we
communicate, from a cultural point of view of view, we can also begin to change our practice.
It is hoped that other allied health professionals would find this handbook a useful learning
material.
Finally, I invite and welcome suggestions from all to improve upon this book’s contents.

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CHAPTER ONE
BACKGROUND TO PRINCIPLES OF COMMUNICATION
Introduction
For any relationship to thrive, it depends upon good communication (Walsh & Crumbie, 2008).
Communication is a dynamic information-sharing process that occurs between people and their
environment. Communication occurs between and among all people in all situations and
circumstances of life. It occurs between family members, friends, and colleagues, as well as
between nurses and clients. Since communication is an essential tool for nurses, understanding
therapeutic communication is crucial (Haber, et al., 1997; Peplau, 1963). Communication is
therefore an essential prerequisite for connection and the building of a therapeutic relationship
with the patient and their family (Walsh & Crumbie, 2008).
According to Walsh (1991), communication should start with the patient’s personal system,
looking at his/her perceptions, self-concept and body image, growth and development along with
the patient’s views of space and time. The interpersonal system requires the nurse to discover the
patient’s views on roles, significant others in the person’s life, and interactions with others. Both
verbal and non-verbal communication should be assessed along with stress reactions and coping
mechanisms before moving on to see how the client feels about larger-scale social systems such
as relationships within the family. Good communication is therefore essential to understand the
patient’s perspective on their health status (Walsh & Crumbie, 2008).
Though communication may appear simple at first, as we do communicate with others every day
of our lives, indeed, communication is a complex process. Nurses may assume that they know how
to listen and respond to clients, and yet fail to develop the skills of therapeutic communication
which is a major intervention modality of nursing practice (Haber, et al., 1997). It is therefore
incumbent on nurses the need to know how to gain trust by using good communication skills to
gather information from the patient, the patient’s family, friends, and relevant social relations, and
to involve them in an effective treatment plan (Psychiatric nursing - Open access article on Mental
Health, 2013).

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To buttress the above assertion, Engard (2017) indicated that one of the main ways nurses establish
trust with patients is through communication. Because nurses are likely to have the most direct
contact with patients, effective nurse-patient communication is critical. Nurses can utilize proven
therapeutic communication techniques that promote quality care. Hence, the therapeutic
relationship that should exist between the nurse and the patient should be goal-oriented and
directed at learning and ensuring the growth promotion of the patient.
Some Definitions of Communication
a) Communication is a dynamic and complex process through which information and
personal beliefs or attitudes about the self or the environment, as well as instructions from
one person to another, are imparted (McFarland & Thomas, 1991).
b) Communication is a continuous circular process by which information, such as ideas and
feelings, is transmitted between people and their environment (Haber, et al., 1997).
c) Communication is the process that people use to exchange information. Messages are
simultaneously sent and received on two levels: verbally through the use of words and non-
verbally by behaviours that accompany the words (Balzer Riley, 2000).
d) Communication is a process of sharing information using a set of common rules.
e) Communication is a process by which information is exchanged between individuals
through a common system of symbols, signs, or behavior.
f) Communication refers to the reciprocal exchange of information, ideas, beliefs, and
attitudes between persons or among a group of persons. It is a goal-directed process; in
nursing, it is used in the nursing process (Patidar, n.d.).
g) Communication is a two-way process where the message sent by the sender should be
interpreted in the same terms by the recipient.
h) Communication is simply the act of transferring information from one place to another.
Communication Process
This is the art of transferring or exchanging information, ideas, or thoughts easily and correctly
through verbal or non-verbal language. Communication involves a series of ongoing reciprocal
events. Components of the communication process include:

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a) The referent — every encounter we have with another person, whether spontaneous
or deliberate, begins with an idea (i.e., a reason for engaging in a verbal exchange).
A referent may be one of “a wide range of objects, situations, ideas, or experiences.”
Any one of these items or a combination of them prompts the source
(sender/encoder) to initiate action to convey the message engendered by the referent
(Cherie, Mekonen, & Shimelse, 2006, p.129-30).
b) The sender of a message — s/he has a message to be shared with the receiver. The
origin of the message may be internal or external sensory input (e.g., a thought or
event). The sender selects words, sentences, and nonverbal cues to create the
intended message, a process known as encoding. Unconscious factors influence the
selection and processing of input, as well as the choice of verbal and nonverbal cues,
to create the message.
c) The Message itself — this is the translation of thoughts, purpose, and intention into
a code that is carried through a channel to the receiver.
d) The Channel — by channel is implied as the “physical bridge” or the
medium/media of communication between the sender and the receiver. It is thus the
medium through which a message is transmitted. Channels can be Interpersonal
(face-to-face communication) that may be verbal or nonverbal, or Mass media in
terms of TV, radio, printed media, etc. Every channel of communication has its
advantages and limitations. The proper selection and use of channels result in
successful communication (Abdullahi, n.d.).
There are three major communication channels:
(i) Visual – the visual channel is sight, observation, and perception.
Perception is a person’s sensing and understanding of the world. Perception of an
event or situation is unique in that it varies from person to person. Perceptions are
influenced by our culture, socialization, education, and experience. Perceptions,
thus, help an individual determine the meaning of the words and the content of the
messages being communicated.
Some congruent words associated with a visual channel are: ‘I see what you mean.’,
‘It looks perfectly clear that …’, ‘Show me where it hurts.’

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(ii) Auditory – the auditory channel consists of spoken words and cues. It is transmitted
by hearing and listening. Some congruent words associated with the auditory
channel are ‘I hear you’, ‘Tell me what you mean’, ‘Sounds like you’re saying …’,
‘Tell me what you mean.’
(iii) Kinesthetic – the kinesthetic channel refers to experiencing sensations. The mode
of transmission involves procedural and caring touches. Some congruent words
associated with the kinesthetic channel are: ‘How does that feel?’, Just the cold,
hard facts.’, ‘That is so touching.’
e) A Receiver of the message — this is the recipient of the message. The receiver
perceives and interprets the meaning of the communication through a process known
as decoding. The receiver responds based on personal perception and interpretation,
thereby providing feedback and becoming the sender.
f) Feedback — this occurs when the receiver responds to the sender’s message.
Feedback comprises the information received by the initiator of the interaction about
the message generated. Feedback serves a regulatory function in communication to
assure that the message sent is the message received. To be most helpful, feedback
should be given clearly and tactfully, be appropriately timed, and be relevant to the
person and context. It is worth noting that understating and consensus between
communicators are facilitated by feedback.
Figure 1: The Communication Process

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Purposes of Communication to the nurse
• To collect assessment data
• To initiate intervention
• To evaluate the outcome of an intervention
• To initiate change which helps in promoting health
• To take measures for preventing legal problems associated with nursing practice
• To analyze factors affecting the health team
Other importance of communication include:
• Information
• Education
• Motivation
• Counseling
• Reduce stress
• Health promotion
Figure 2: Effective Communication

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CHAPTER TWO
COMMUNICATION STYLES
Introduction
For every communication to be successful, it is important for one to consider the communication
style throughout the communication process. The style of communication depends on the
following three elements:
a) Self – Self refers to one’s own feelings, perceptions, and self-worth in a given
communication sequence.
b) Other – Other refers to the other person’s feelings, perceptions, and self-worth in the
same communication sequence.
c) Context – Context refers to both the context in which the communication takes place and
the content.
Styles of communication
1. Congruent Style – the interaction of self, other and context determines the communication
style. In the congruent style of communication, the context as well as the needs and feelings
of self and other are considered. The verbal and nonverbal behaviour is in synchrony and
is appropriate to the context. Self-worth is maintained and communication is effective
when a congruent style is utilized.
2. Incongruent Style – incongruent styles in which self, other or context is denied include
placating, blaming, super-reasonable and irrelevant. Examples of incongruent styles can be
recognized by the words spoken, the body language used, and their effect on the other.
a. Placating: in this style of communication, the goal is “peace at any price.” The
placatory ignores self and assumes all responsibility for the other and the context. The
placatory uses self-derogatory words and displays body language suggesting
submissiveness.
For example: Verbal pronouncements include, I’m wrong; it’s my fault; forgive me.
Body language include, Handwringing; head hung; eyes down; posture
supplication.

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Effect = Individual feels Pity.
b. Blaming: self becomes the predominant focus in the blaming style of communication.
Neither feelings and needs of the other, nor the context are taken into consideration.
The blamer uses accusatory and hostile words and displays body language that conveys
superiority.
For example: Verbal: You always/never; Why don’t you; You made me, etc.
Body language: Pointed finger; leaning forward; glaring; tight muscles.
Effect = Reverse blame.
c. Super-reasonable: in this communication style, the context is the focus of
communication, and the feelings and needs of both persons are denied. Both the verbal
and nonverbal behaviour of the person utilizing a super-reasonable style are impersonal
and devoid of feelings.
For example: Verbal: Impersonal; factual; logic; monotone
Body language: Upright posture; rigid; no eye contact, etc.
Effect = Coldness; hurt.
d. Irrelevant: the irrelevant style of communication ignores self, other, and the context.
The words spoken are unrelated to the circumstances. Feelings of self and other are
avoided. The nonverbal behaviour displays motion and distraction.
For example: Verbal: Frequent change of subject; nonsequiturs (i.e., A reply that has
no relevance to what preceded it), etc.
Body language: Laughing; jokes; gestures; looking about, etc.
Effect = Confusion; impatience; anxiety.
3. Assertive communication style – is a style in which individuals clearly state their opinions
and feelings, and firmly advocate for their rights and needs without violating the rights of
others. According to Ernstmeyer and Christman (2021), it is a way to convey information
that describes the facts, the sender’s feelings, and explanations without disrespecting the
receiver’s feelings. These individuals value themselves, their time, and their emotional,
spiritual, and physical needs and are strong advocates for themselves while being very
respectful of the rights of others. The assertive communicator sets goals, acts on those goals
decisively, and accepts responsibility for the consequences of actions taken. The person
who uses assertive communication is sensitive to the feelings and rights of self and others.

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The assertive person is gentle but firm when necessary and able to negotiate workable
outcomes. Such individual clearly indicates his/her position when making claims.
Assertive communicators will:
• state needs and wants clearly, appropriately, and respectfully
• express feelings clearly, appropriately, and respectfully
• use “I” statements
• communicate respect for others
• listen well without interrupting
• feel in control of self
• have good eye contact
• speak in a calm and clear tone of voice
• have a relaxed body posture
• feel connected to others
• feel competent and in control
• not allow others to abuse or manipulate them
• stand up for their rights
The impact of a pattern of assertive communication is that these individuals:
• feel connected to others
• feel in control of their lives
• are able to mature because they address issues and problems as they arise
• create a respectful environment for others to grow and mature
The assertive communicator will say, believe, or behave in a way that says:
• “We are equally entitled to express ourselves respectfully to one another.”
• “I am confident about who I am.”
• “I realize I have choices in my life and I consider my options.”
• “I speak clearly, honestly, and to the point.”
• “I can’t control others but I can control myself.”
• “I place a high priority on having my rights respected.”

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• “I am responsible for getting my needs met in a respectful manner.”
• “I respect the rights of others.”
• “Nobody owes me anything unless they’ve agreed to give it to me.”
• “I’m 100% responsible for my own happiness.”
Assertiveness allows us to take care of ourselves, and is fundamental for good mental
health and healthy relationships.
4. Passive communication style – is a style in which individuals have developed a pattern
of avoiding expressing their opinions or feelings, protecting their rights, and identifying
and meeting their needs. As a result, passive individuals do not respond overtly to hurtful
or anger-inducing situations. Instead, they allow grievances and annoyances to mount,
usually unaware of the buildup. But once they have reached their high tolerance threshold
for unacceptable behavior, they are prone to explosive outbursts, which are usually out of
proportion to the triggering incident. After the outburst, however, they may feel shame,
guilt, and confusion, so they return to being passive.
Passive communicators will often:
• fail to assert for themselves
• allow others to deliberately or inadvertently infringe on their rights
• fail to express their feelings, needs, or opinions
• tend to speak softly or apologetically
• exhibit poor eye contact and slumped body posture
The impact of a pattern of passive communication is that these individuals:
• often feel anxious because life seems out of their control
• often feel depressed because they feel stuck and hopeless
• often feel resentful (but are unaware of it) because their needs are not being met
• often feel confused because they ignore their own feelings
• are unable to mature because real issues are never addressed
A passive communicator will say, believe, or behave like:
• “I’m unable to stand up for my rights.”
• “I don’t know what my rights are.”

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• “I get stepped on by everyone.”
• “I’m weak and unable to take care of myself.”
• “People never consider my feelings.”
The passive communicator, therefore, seeks peace and avoids conflicts or confrontation.
His/her behaviour is passive and dependent, often reflecting a denial of his/her own
feelings and rights. Such communicators, ultimately, experience frustration, inadequacy,
and depression.
5. Aggressive communication style – is a style in which individuals express their feelings
and opinions and advocate for their needs in a way that violates the rights of others. Thus,
aggressive communicators are verbally and/or physically abusive. Thus, the aggressive
communicator ignores the rights and feelings of others in an effort to control and
manipulate them or the environment. Such an individual disavow responsibility for the
outcome of a behaviour.
Aggressive communicators will often:
• try to dominate others
• use humiliation to control others
• criticize, blame, or attack others
• be very impulsive
• have low frustration tolerance
• speak in a loud, demanding, and overbearing voice
• act threateningly and rudely
• not listen well
• interrupt frequently
• use “you” statements
• have an overbearing or intimidating posture
The impact of a pattern of aggressive communication is that these individuals:
• become alienated from others
• alienate others
• generate fear and hatred in others

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• always blame others instead of owning their issues, and thus are unable to mature
The aggressive communicator will say, believe, or behave like:
• “I’m superior and right and you’re inferior and wrong.”
• “I’m loud, bossy and pushy.”
• “I can dominate and intimidate you.”
• “I can violate your rights.”
• “I’ll get my way no matter what.”
• “You’re not worth anything.”
• “It’s all your fault.”
• “I react instantly.”
• “I’m entitled.”
• “You owe me.”
• “I own you.”
As emphasized by Ernstmeyer and Christman (2021), the aggressive communicator uses “you”
messages and the receiver of the message feels as if the sender is verbally attacking him/her
rather than dealing with the issue at hand.
When nonverbal behaviour is in synchrony with verbal messages, it may include finger-
pointing, a loud threatening tone of voice, or clenched fists.
6. Passive-aggressive communication style – is a style in which individuals appear passive
on the surface but are really acting out anger in a subtle, indirect, or behind-the-scenes way.
People who develop a pattern of passive-aggressive communication usually feel powerless,
stuck, and resentful – in other words, they feel incapable of dealing directly with the object
of their resentments. Instead, they express their anger by subtly undermining the object
(real or imagined) of their resentments.
Passive-Aggressive communicators will often:
• mutter to themselves rather than confront the person or issue
• have difficulty acknowledging their anger
• use facial expressions that don’t match how they feel - e.g., smiling when angry

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• use sarcasm
• deny there is a problem
• appear cooperative while purposely doing things to annoy and disrupt
• use subtle sabotage to get even
The impact of a pattern of passive-aggressive communication is that these individuals:
• become alienated or stay away from those around them
• remain stuck in a position of powerlessness
• discharge resentment while real issues are never addressed so they can’t mature
The passive-aggressive communicator will say, believe, or behave like:
• “I’m weak and resentful, so I sabotage, frustrate, and disrupt.”
• “I’m powerless to deal with you head on so I must use guerilla warfare.”
• “I will appear cooperative but I’m not.”
Guidelines for effective communication
Communication is a part and parcel of every good health delivery system and for that matter, it
should be free from barriers so as to be effective. Some characteristics of effective communication
include the following:
1. Clarity of Purpose: The message to be delivered must be clear in the mind of the sender.
The person to whom it is targeted and the aim of the message should be clear in the mind
of the sender.
2. Completeness: The message delivered should not be incomplete. It should be supported
by facts and observations. It should be well planned and organized. No assumptions should
be made by the receiver.
3. Conciseness: The message should be concise. It should not include any unnecessary
details. It should be short and complete.
4. Feedback: Whether the message sent by the sender is understood in same terms by the
receiver or not can be judged by the feedback or response received. The feedback should
be timely and in personal. It should be specific rather than general.
5. Empathy: Empathy with the patients is essential for effective verbal communication. The
nurse should step into the shoes of the patients and be sensitive to their needs and emotions.

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This way s/he can understand things from their perspective and make communication more
effective.
6. Modify the message according to the patients’ needs: The information requirement by
different patients in the health setting differs according to their needs. What is relevant to
the uneducated patient might not be relevant to an educated patient. Use of jargons should
be minimized because it might lead to misunderstanding and misinterpretations. The
message should be modified according to the needs and requirements of the targeted
patients.
7. Multiple Channels of communication: For effective communication multiple channels
should be used as it increases the chances of clarity of message. The message is reinforced
by using different channels and there are less chances of deformation of message.
8. Make effective use of grapevine (informal channel of communication): The nurses and
other caregivers should not always discourage grapevine. They should make effective use
of grapevine. The nurse can use grapevine to deliver formal messages and for identification
of issues which are significant for the patients. The nurse can get to know the problems
faced by the patients and can work upon it.
Skills for effective communication
• Confidence
• Critical thinker
• Analytical
• Open-mindedness
• Active listener
• Empathetic
• Honest
• Confidentiality
• Knowledgeable
• Systematic
• Tactfulness
• Cultural background
• Gender
• Needs of the patient
The Process of Interviewing the Client
An interview is a planned communication or a conversation with a purpose, for example, to get or
give information, identify problems of mutual concern, evaluate change, teach, provide support,
or provide counselling or therapy. One example of the interview is the nursing health history,
which is a part of the nursing admission assessment.

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There are two approaches to interviewing: directive and non-directive.
• Directive interview – the directive interview is highly structured and sought to seek specific
information. The nurse establishes the purpose of the interview and controls the interview,
at least at the outset. The patient responds to questions but may have limited opportunity
to ask questions or discuss concerns. Nurses frequently use directive interviews to gather
and to give information when time is limited, especially in an emergency situation.
• Non-directive interview – this is in contrast to the directive interview and involves rapport
building. During a non-directive interview, the nurse allows the patient to control the
purpose, subject matter and pacing. Rapport is an understanding between two or more
people.
To gather information by the nurse from the patient, a combination of directive and non-directive
approaches is usually appropriate during the interview process. It is incumbent on the nurse to
begin by determining areas of concern for the patient. If, for example, a patient expresses worry
about surgery, the nurse pauses to explore the patient’s worry and to provide support. Simply
noting the worry, without dealing with it, can leave the impression that the nurse does not care
about the patient’s concerns or dismisses them as unimportant.
Stages of an Interview
An interview has three major stages: the opening (introduction), the body (development), and the
closing.
• The Opening (Introduction): The opening can be the most important part of the interview
because what is said and done at that time sets the tone for the remainder of the interview.
The purpose of the opening is to establish rapport and orient the client/patient.
Establishing rapport is a process of creating goodwill and trust. It can begin with a greeting
(Good morning, Mr. Asare) or a self-introduction (Good morning. I am Kwame Asare, a
student nurse) accompanied by nonverbal gestures such as a smile, a handshake and a
friendly manner. The nurse must be careful not to overdo this stage. Too much superficial
talk can arouse anxiety about what is to follow and may appear insincere.
In orientation, the nurse explains the purpose and nature of the interview, for example,
what information is needed, how long it will take, and what is expected of the patient.

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• The Body (Development): In the body of the assessment interview, the patient
communicates what they think, feel, know and perceive in response to questions from the
nurse. Effective development of the interview demands that the nurse uses communication
techniques that make both parties feel comfortable and serve the purpose of the interview.
• The Closing: The nurse terminates the interview when the needed information has been
obtained. In some cases, however, a patient terminates it, for example, when deciding not
to give any more information or when unable to offer more information for some other
reason (e.g., fatigue). The closing is important for maintaining rapport and trust and for
facilitating future interactions. Example of closing remarks – ‘Do you have any
questions?’, ‘I would be glad to answer any questions you have.’ Be sure to allow time for
the patient to answer or the offer will be regarded as insincere. You may conclude by saying
‘Well, that’s all I need to know for now or ‘Well, those are all the questions I have now.’
The preceding remark with the word ‘well’ generally signals that the end of the interaction
is near. Thank the patient by saying that, for example, ‘Thank you for your time and help.
The questions you have answered will be helpful in planning the nursing care for you.’
The nurse continues by expressing concern for the patient’s welfare and future, e.g., ‘Take
care of yourself’ or ‘I hope all goes well for you.’ The nurse then proceeds to plan for the
next meeting or indicates what will happen next by offering the day, time, place, topic and
purpose for the future session.
Provide a summary to verify accuracy and agreement. Summarizing serves several
purposes:
− It helps to terminate the interview
− It reassures the patient that the nurse has listened
− It checks the accuracy of the nurse’s perceptions
− It clears the way for new ideas
− It helps the patient to note progress and forward direction
Guidelines for Communicating during an Interview
• Listen attentively, using all your senses, and speak slowly and clearly.
• Use language the patient understands and clarify points that are not understood.
• Plan questions to follow a logical sequence.

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• Ask only one question at a time. Double questions limit the patient to one choice and may
confuse both the nurse and the patient.
• Allow the patient the opportunity to look at things the way they appear to him/her and not
the way they appear to the nurse or someone else.
• Do not impose your (nurse’s) own values on the patient.
• Avoid using personal examples, such as saying, ‘If I were you …’
• Non-verbally convey respect, concern, interest and acceptance simply be self-aware.
• Use and accept silence to help the patient search for more thoughts or to organize them.
• Use eye contact and be calm, unhurried and sympathetic.
Planning the Interview and Setting
Every interview session is unique and has its own purpose of being conducted. Therefore before
starting any interview, the nurse should strive to review available information, for example, the
operative report, information about the current illness or literature about the patient’s health
problem. The nurse also should review the patient’s folder (as folders contain data collected from
the patients) or the nursing notes to identify what data (information) must be collected and what
data are within the nurse’s discretion to collect based on the specific patient.
Each interview is influenced by time, place, seating arrangement or distance, and language.
Time: Nurses need to plan interviews with hospitalized patients when the patient is physically
comfortable and free of pain, and when interruptions by friends, family and other health
professionals are minimal. Nurses should schedule interviews with patients in their homes at a
time selected by the patient wherever possible. The patient should be made to feel comfortable and
unhurried.
Place: A well-lit, well-ventilated, moderate-sized room that is relatively free of noise, movements
and interruptions encourages communication. In addition, a place where others cannot overhear or
see the patient is desirable. The nurse should note that curtains around a bed space in hospital are
not sound proof.
Seating arrangement: A seating arrangement with the nurse behind a desk and the patient seated
across creates a formal setting that suggests a business meeting between a superior and a

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subordinate. Far from this, a seating arrangement in which the nurse and the patient sit on two
chairs placed at right angles to a desk or table or a few feet apart, with no table between, creates a
less formal atmosphere, and the nurse and patient tend to feel on equal terms. If the interview is
among a specific groups of patients (as seen in mental health settings), a horseshoe or circular
chair arrangement is necessary to avoid a superior or head-of-the-table position.
If the nurse stands and looks down at a patient who is in bed or in a chair, s/he risks intimidating
the patient, who may perceive the nurse as having greater status. When the patient is in bed, the
nurse can sit a 45-degree angle to the bed. This position is less formal than sitting behind a table
or standing at the foot of the bed.
During an initial admission interview, a patient may feel less confronted if there is an overbed
table between the patient and the nurse. Sitting on a patient’s bed hems the patient in and makes
staring difficult to avoid. Nurses should refrain from this act since it is a poor infection control
practice.
Distance: The distance between the nurse and the patient should be neither too small nor too great,
because people feel uncomfortable when talking to someone who is too close or too far away. Most
people feel comfortable maintaining a distance of ½ to 1 metre during an interview. Some patients
require more or less personal space, depending on their cultural and personal needs.
Language: It is better for the nurse to conduct the interview session in a language that is easily
comprehensible to the patient. Failure for the nurse to communicate in a language that the patient
can understand may be seen as a form of discrimination. If the interview session is conducted in
English, the nurse must convert complicated medical terminology into a common English usage,
and where possible interpreters or translators be use in the transmission of information in situations
that the patient and the nurse do not speak the same language.
Translating medical terminology is a specialized skill because not all persons fluent in the
conversational form of the language are familiar with anatomical or other health terms.
Interpreters, however, may make judgements about precise word but also about subtle meanings
that require additional explanation or clarification according to the specific language and ethnicity.
They may edit the original source to make the meaning clearer or more culturally appropriate.

18
If giving written documents to patients, the nurse must determine that the patient can read in his/her
native language. If live translation is available, that should be the preferred choice because the
patient can then ask questions for clarification. The idea of asking patient family members, patient
visitors or nonprofessional health staff at the facility to assist with translations should cautiously
be considered.
It is worth noting that among patients who speak the English language, there are differences in
understanding terminology. More so, patients from different parts of the country may have strong
accents; less well-educated and teenage patients may assign different meanings to words. For
instance, ‘cool’ may imply something ‘good’ to one patient and something ‘not warm’ to another.
The nurse must always confirm accurate understandings.

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CHAPTER THREE
INTRODUCTION TO THERAPEUTIC COMMUNICATION
What is therapeutic communication?
The concept of “therapeutic communication” refers to the process in which the nurse consciously
influences a client (patient) or helps the client to a better understanding through verbal or nonverbal
communication. Therapeutic communication involves the use of specific strategies that encourage
the patient to express feelings and ideas and that convey acceptance and respect (Sherko, et al.
2013). From Engard (2017), therapeutic communication is a collection of techniques that prioritize
the physical, mental, and emotional well-being of patients. It is described further as the purposeful,
interpersonal information transmitting process through words and behaviours based on both
parties’ knowledge, attitudes, and skills, which leads to patient understanding and participation
(Ernstmeyer & Christman, 2021).
However, the concept has been defined furthermore by different scholars analyzing the terms
separately, in terms of word structure and meaning. Therapeutic and communication are two
complex words each of which containing different meanings. However the term gains quite
another meaning when referring to medical terminology and when considered as a compound
noun.
Therapeutic – refers to the science and art of healing (Miller & Keane, 1972); of or pertaining to
a treatment or beneficial act (Potter & 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.
Healing – is the process of recovery from illness, accident, or disability. This return to an optimum
level of functioning may occur rapidly or gradually. Healing encompasses the physical, emotional,
and spiritual domains of individuals. Nursing and caring are essential components in the healing
process.
Communication – has a number of definitions that tend to emphasize either 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

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information, ideas or attitudes between or among people. De Vito (1991) 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 is therefore an interpersonal interaction between the nurse and client
during which the nurse focuses on the client’s specific needs to promote an effective exchange of
information (Videbeck, 2008). Here, nurses provide clients with support and information while
maintaining a level of professional distance and objectivity. With therapeutic communication,
nurses often use open-ended statements and questions, repeat information, or use silence to prompt
patients to work through problems on their own.
Goals of Therapeutic Communication
• To Establish a therapeutic nurse-client relationship
• To Identify the most important client concern that moment (i.e., client-centered goal)
• To Assess the client’s perception of the problems as it unfolds
• To Facilitate the client’s expression of emotions
• To Teach the client and family necessary self-care skills
• To Recognise the client’s needs
• To Implement interventions designed to address the client’s needs
• To Guide the client toward identifying a plan of action to a satisfying and socially
acceptable resolution.
Levels of Therapeutic communication
1. Interpersonal communication – Face to face interaction between the nurse and another
person.
2. Transpersonal communication – interaction that occurs within a person’s spiritual domain.
3. Small-group communication – interaction that occurs when a small number of people meet
and share a common goal.
4. Intrapersonal communication – Powerful form of communication that occurs within an
individual.

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5. Public communication – interaction with an audience (nurses are required to use eye
contact, gestures, etc.).
Therapeutic Communication Techniques
These are strategies that are used to promote efficiency in communicating with the client. They
are techniques that encourage patients to express feelings, problem solve, and cope with response
to medical conditions and life events (Ernstmeyer & Christman, 2021). There are a variety of
therapeutic communication techniques nurses can incorporate into practice.
• Asking relevant questions – Ask questions one at a time, to explore the topic before going
on. When the intent is to engage the client in conversation, it is best to use open-ended
questions, and when the goal is to obtain factual information, closed-ended questions are
useful.
a) Open-ended questions focus on the topic, but allow multiple options for response.
They allow the client to clarify, elaborate, describe or compare experiences,
thoughts, and feelings. With open-ended questions, the client is allowed the
freedom to structure the conversation. These questions often begin with such
words as how, what, and when. For example, “How were you feeling when …?”;
“What was happening that …?”; “When you were …, what were you thinking and
feeling?” Questions beginning with “why” should be used with caution because
such questions often place the client on the defensive and are difficult to answer.
For instance, “Why do you refuse your medications?”
b) Closed-ended questions are worded so that they can be answered with very few
words or merely a ‘yes’ or ‘no’. These should be used sparingly, as they limit
therapeutic exploration of client’s health problems, and lead to interrogative tone.
However, closed-ended questions are useful in obtaining factual information when
a client rambles or is has difficulty expressing him/herself. For example, “Were
you feeling angry when your wife said that?” “How many times have you been on
admission to the medical block?”; “Do you feel less anxious after taking the
medication?” Thus, closed questions often begin with ‘when’, ‘where’, ‘who’,
‘what’, ‘do (did, does)’ or ‘is (are, was)’.

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c) Neutral question is a question the patient can answer without direction or pressure
from the nurse, is open ended, and used in non-directive interviews. Examples are;
‘How do you feel about that?’ and ‘Why do you think you had the
operation/surgery?’
d) Leading question is usually closed-ended used in directive interviews, and thus
directs the patient’s answer. Examples are: ‘You’re stressed about surgery
tomorrow, aren’t you?’ and ‘You will take your medicine, won’t you?’ The
leading gives the patient less opportunity to decide whether the answer is true or
not. Leading questions create problems if the patient, in an effort to please the
nurse, gives inaccurate responses. This can result in inaccurate data.
• Providing information – Provide information that the patient needs to know.
• Offering Self – Hospital stays can be lonely, stressful times; when nurses offer their time,
it shows they value patients and that someone is willing to give them time and attention.
Offering to stay for lunch, watch a TV show, or simply sit with patients for a while can
help boost their mood.
• Self-disclosing – It is a way of showing the patient that the information is understood and
shows respect for the patient.
• Confronting – Helps the patient realize his/her inconsistencies in feelings, attitudes, or
beliefs.
• Paraphrasing – Restating the patient’s message so that s/he knows that the nurse is
listening.
• Using Silence – At times, it’s useful to not speak at all. Deliberate silence can give both
nurses and patients an opportunity to think through and process what comes next in the
conversation. It may give patients the time and space they need to broach a new topic.
Nurses should always let patients break the silence.
• Accepting – Sometimes it’s necessary to acknowledge what patients say and affirm that
they’ve been heard. Acceptance isn’t necessarily the same thing as agreement; it can be
enough to simply make eye contact and say “Yes, I understand.” Patients who feel their
nurses are listening to them and taking them seriously are more likely to be receptive to
care.

23
• Giving Recognition – Recognition acknowledges a patient’s behavior and highlights it
without giving an overt compliment. A compliment can sometimes be taken as
condescending, especially when it concerns a routine task like making the bed. However,
saying something like “I noticed you took all of your medications” draws attention to the
action and encourages it without requiring a compliment.
• Giving Broad Openings – Therapeutic communication is often most effective when
patients direct the flow of conversation and decide what to talk about. To that end, giving
patients a broad opening such as “What’s on your mind today?” or “What would you like
to talk about?” can be a good way to allow patients an opportunity to discuss what’s on
their mind.
• Active Listening – By using nonverbal and verbal cues such as nodding and saying “I
see,” nurses can encourage patients to continue talking. Active listening involves showing
interest in what patients have to say, acknowledging that you’re listening and
understanding, and engaging with them throughout the conversation. Nurses can offer
general leads such as “What happened next?” to guide the conversation or propel it
forward.
Active listening involves three elements of communication: (1) the verbal, (2) paraverbal,
and (3) nonverbal communication techniques. The verbal is what is said. Paraverbal
communication (also referred to as paralinguistic) is the way in which a person speaks,
including voice tone, pitch; speed, inflection, and volume; and the nonverbal message is
body language. The nonverbal language can include facial expressions, eye contact,
standing or sitting posture. Other features are physical gestures and positioning of hands.
The active listener pays attention to all three aspects to hear the true intent of the client.
• Seeking Clarification – Similar to active listening, asking patients for clarification when
they say something confusing or ambiguous is important. Saying something like “I’m not
sure I understand. Can you explain it to me?” helps nurses ensure they understand what’s
actually being said and can help patients process their ideas more thoroughly.
• Placing the Event in Time or Sequence – Asking questions about when certain events
occurred in relation to other events can help patients (and nurses) get a clearer sense of
the whole picture. It forces patients to think about the sequence of events and may prompt
them to remember something they otherwise would not.

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• Making Observations – Observations about the appearance, demeanor, or behavior of
patients can help draw attention to areas that might pose a problem for them. Observing
that they look tired may prompt patients to explain why they haven’t been getting much
sleep lately; making an observation that they haven’t been eating much may lead to the
discovery of a new symptom.
• Encouraging Descriptions of Perception – For patients experiencing sensory issues or
hallucinations, it can be helpful to ask about them in an encouraging, non-judgmental way.
Phrases like “What do you hear now?” or “What does that look like to you?” give patients
a prompt to explain what they’re perceiving without casting their perceptions in a negative
light.
• Encouraging Comparisons – Often, patients can draw upon experience to deal with current
problems. By encouraging them to make comparisons, nurses can help patients discover
solutions to their problems.
• Summarizing – It’s frequently useful for nurses to summarize what patients have said after
the fact. This demonstrates to patients that the nurse was listening and allows the nurse to
document conversations. Ending a summary with a phrase like “Does that sound correct?”
gives patients explicit permission to make corrections if they’re necessary.
• Reflecting – Patients often ask nurses for advice about what they should do about
particular problems or in specific situations. Nurses can ask patients what they think they
should do, which encourages patients to be accountable for their own actions and helps
them come up with solutions themselves.
• Focusing – Sometimes during a conversation, patients mention something particularly
important. When this happens, nurses can focus on their statement, prompting patients to
discuss it further. Patients don’t always have an objective perspective on what is relevant
to their case; as impartial observers, nurses can more easily pick out the topics to focus
on.
• Confronting – Nurses should only apply this technique after they have established trust.
It can be vital to the care of patients to disagree with them, present them with reality, or
challenge their assumptions. Confrontation, when used correctly, can help patients break
destructive routines or understand the state of their situation.

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• Voicing Doubt – Voicing doubt can be a gentler way to call attention to the incorrect or
delusional ideas and perceptions of patients. By expressing doubt, nurses can force
patients to examine their assumptions.
• Offering Hope and Humor – Because hospitals can be stressful places for patients, sharing
hope that they can persevere through their current situation and lightening the mood with
humor can help nurses establish rapport quickly. This technique can keep patients in a
more positive state of mind. Through the use of humor, clients may be able to “jokingly”
express feelings of fear or embarrassment.
• Non-judgemental approach – Non-judgemental behaviour must be used if nursing
interventions are to be therapeutic. Non-judgemental means acting without biases,
preconceptions, or stereotypes. Non-judgemental nurses do not evaluate the client’s moral
values nor tell the client what to do; these nurses accept people as they are. Nurses using
this approach do not stereotype people, nor expect others to behave in certain ways
because they belong to a certain group.
Selected Advantages and Disadvantages of Open-Ended and Closed Questions
Open-Ended Questions – Advantages
1) They let client do the talking
2) The nurse is able to listen and observe
3) They are easy to answer and non-threatening
4) They may reveal the patient’s lack of information, misunderstanding of words, frame of
reference, prejudices or stereotypes
5) They reveal what the patient think
6) They can provide information the nurse may not ask for
7) They reveal the patient’s degree of feeling about his/her health problem
8) They can convey interest and trust because of the freedom they provide
Open-Ended Questions – Disadvantages
1) They take more time
2) Only brief answers may be given
3) Valuable information may be withheld

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4) Responses are difficult to document and require skill in recording
5) They often elicit more information than necessary
6) The nurse requires skill in controlling an open-ended interview
7) Responses require psychological insight and sensitivity from the nurse
Closed Questions – Advantages
1) Questions and answers can be controlled more effectively
2) They require less effort from the patient
3) They may be less threatening since they do not require explanations or justifications
4) They take less time
5) Information can be asked for sooner than it would be volunteered
6) Responses are easily documented
7) Questions are easy to use and can be handled by unskilled nurses
Closed Questions – Disadvantages
1) They may provide too little information and require follow-up questions
2) They may not reveal how the patient feels
3) They do not allow the client to volunteer possibly valuable information
4) They may inhibit communication and convey a lack of interest by the interviewer
5) The nurse may dominate the interview with questions
[Source: Adapted from Kozier, et al. (2008). Fundamentals of nursing: Concepts, process and practice.
Harlow, England: Pearson Education. (p.150)]
Non-therapeutic communication techniques
While therapeutic techniques promote efficiency, non-therapeutic ones might have a contrary
effect. They are “blocks” to communication of feelings and ideas. They might inhibit
communication with the patient. The nurse needs to be well trained in order to prevent using non-
therapeutic techniques. Nontherapeutic communication techniques include:
1. Giving false or bland reassurance – This negates patient’s fears; feels not taken seriously,
and may discourage client from further expression of feelings if client believes the feelings

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will only be downplayed or ridiculed. False reassurance which is not supported by facts
may do more harm than good. For example: “Don’t worry, everything will be all right.” 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
patient is reaching for understanding these phrases that are not based on fact or based on
reality can do more harm than good.
The nurse may be trying to be kind and think s/he is helping, but these comments tend to
block conversation and discourage further expressions of feelings. A better response would
be “It must be difficult not to know what the surgeon will find. What can I do to help?”
2. Failing to listen – do not receive message from the client
3. Rejecting – refusing to consider client’s ideas or behavior.
4. Parroting – irritates client who comes to doubt your competence.
5. Automatic responses show that the nurse is not taking the situation seriously. For example:
“Administration doesn’t care about the staff,” or “Older adults are always confused.” These
are generalizations and stereotypes that reflect poor nursing judgment and threaten nurse-
client or team relationships.
6. Patronizing – insults and devalues patient.
7. Approving or disapproving - implies that the nurse has the right to pass judgment on the
“goodness” or “badness” of client’s behavior. Approval or disapproval may send the
message that the nurse has the right to make judgments.
For example: “You shouldn’t even think about assisted suicide, it’s just not right.” Nurses
must not impose their own attitudes, values, beliefs, and moral standards on others, while
in the professional helping role. Judgmental responses by the nurse often contain terms
such as should, ought, good, bad, right or wrong.
Approving implies that the behavior being praised is the only acceptable one. Disapproving
implies that the client must meet the nurse’s expectations or standards.
Instead the nurse should help clients explore their own beliefs and decisions.
Agreeing or disagreeing – implies that the nurse has the right to pass judgment on whether
client’s ideas or opinions are “right” or “wrong”. Agreeing or disagreeing sends the subtle
message that nurses have the right to make value judgments about the client’s decisions.

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8. Being judgemental – suggests you have a right that you do not: the right to judge the client.
This prevents establishment of good relationship with patient.
9. Giving advice – implies that the nurse knows what is best for client and that client is
incapable of any self-direction.
10. Probing – pushing for answers to issues the client does not wish to discuss causes client to
feel used and valued only for what is shared with the nurse. Failure to probe leads to
inadequate data collection.
11. Defending – to defend what client has criticized implies that client has no right to express
ideas, opinions, or feelings. Defensive responses indicate that the patient might feel that
s/he has no rights to an opinion.
12. Requesting an explanation – asking “why” implies that client must defend his or her
behavior or feelings. Asking for explanation questions can cause resentment.
13. Indicating the existence of an external source of power – encourages client to project blame
for his or her thoughts or behaviors on others.
14. Belittling feelings expressed – causes client to feel insignificant or unimportant.
15. Making stereotyped comments, clichés, and trite expressions - these are meaningless in a
nurse-client relationship.
16. Using denial – blocks discussion with client and avoids helping client identify and explore
areas of difficulty.
17. Interpreting – results in the therapist’s telling client the meaning of his or her experience
18. Introducing an unrelated topic - causes the nurse to take over the direction of the discussion.
19. Changing topics – tells patient that the nurse is in charge and sets the agenda rather than
discuss the topics the client wants to talk about.
20. Refusing to discuss topics – client feels personally rejected
21. Changing the subject tends to block further communication. For example: “Let’s not talk
about your insurance problems it’s time for your walk.” Changing the subject when
someone is trying to communicate with you is rude and shows a lack of empathy. It ends
to block further communication, and seems to say that you don’t really care about what
they are sharing. “After your walk let’s talk some more about what’s going on with your
insurance company.”

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22. Asking personal questions – Asking personal questions that are not relevant to the situation,
is not professional or appropriate. Don’t ask questions just to satisfy your curiosity. “Why
aren’t you married to Mary?” is not appropriate. What might be asked is “How would you
describe your relationship to Mary?
23. Giving personal opinions – Giving personal opinions, takes away decision-making from
the client. Remember the problem and the solution belongs to the patient and not the nurse.
“If I were you I’d put your father in a nursing home” can be reframed to say,” Let’s talk
about what options are available to your father.”
24. Sympathy is subjective. It prevents a clear picture of the patient’s situation. Sympathy
focuses on the nurse’s feelings rather than the client’s. Saying “I’m so sorry about your
amputation, it must be terrible to lose a leg.” A more empathetic approach would be “The
loss of your leg is a major change, how do you think this will affect your life?”
25. This shows concern but more sorrow and pity than trying to understand how the client
feels.
26. Passive or aggressive responses. Passive responses avoid the issues and aggressive
responses maybe confrontational.
27. Arguing. It might imply that the patient is lying or misinformed. For example: “How can
you say you didn’t sleep a wink when I heard you snoring all night long!!” Challenging or
arguing again perceptions denies that they are real and valid to the other person. They
imply that the other person is lying, misinformed, or uneducated.
The skillful nurse can provide information or present reality in a way that avoids argument:
“You feel like you didn’t get any rest at all last night, even though I thought you slept well
since I heard you snoring.”
As an inexperience nurse, learn to avoid these non-therapeutic techniques.
Therapeutic Nurse-Client Relationship
The relationship between nurses and the people they care for has changed. In the past, recipients
of care were called patients. The word patient comes from the word patience which means “to
wait.” Patients were expected to play a passive role, allow others to make decisions for them, and
submit to treatments without question or protest. Nurses now encourage individuals for whom they
care to become actively involved, to communicate, to question, to assist in planning their care, and

30
to over all, to retain as much independence as possible. To reflect this philosophic change in role
relationships, it is now common for nurses to refer to their partners in care as clients. Today, instead
of doing things to patients who are sick, nurses do things with clients who are both sick and well.
For those who are sick, the nurse helps them resolve and cope with illness. For those who are well,
the nurse implements measures that prevent disease and promote health and well-being (Scherer
& Timby, 1995). Nursing practice, therefore, occurs within the relationship of nurse and a client.
A relationship is defined as a of being related or a state of affinity between two individuals.
Hence, the nurse and client interact with each other in the health care system, with the goals of
assisting the client to use personal resources to meet his/her unique needs. The contribution of each
partner in the nurse-client relationship is more important than the individual contribution of either
the nurse or the client. In nursing, relationship refers to connectedness in interaction where each
person has an effect upon the other (Basavanthappa, 2007). There are three possible types of
relationship – social, intimate and therapeutic.
i. Social relationship: It is the most common kind between individuals in everyday life. Both
individuals are equally involved in this relationship and are concerned with meeting their
own needs through the relationship and the continuation of the relationship is not determined
at the onset, e.g., work colleagues.
ii. Intimate relationship: It is a relationship between two individuals committed to one another,
caring for and respecting each other. Intimacy is usually exclusive to those involved and
implies that they love each other, e.g., by marriage or partner type.
iii. Therapeutic relationship: In this type of relationship, the nurse and client work together
toward the goal of assisting the client to regain the inner resources to meet life challenges
and facilitate growth. The interaction is purposefully established maintained, carried out with
the anticipated outcomes of helping the client gain new coping and adaptation skills. There
are basic assumptions underlying the therapeutic relationships:
− The client’s difficulties are expressed in the relationships.
− The previous, learned difficulties of former relationships are amenable to change in this
relationship.
Therapeutic relationships are goal-oriented and directed at learning and promoting growth. It deals
with therapeutic use of self (i.e., ability to use one’s personality consciously and in full awareness

31
in an attempt to establish relatedness and to structure nursing interventions). Nurses, therefore,
must possess self-awareness, self-understanding, and a philosophical belief about life, death, and
the overall human condition for effective therapeutic use of self. As a goal-oriented activity which
is aim at helping the client in promoting growth, the nurse-client relationship has the following
levels (McFarland & Thomas, 1991):
1. Care contract – the goal of nursing intervention is care, not cure. The client may lack the
ability or motivation for change, and the contract may be actually be with a third party such
as the parents and/or significant others. At this level 1 stage, the nurse provides needed
physical care, assists in activities of daily living and attempt to minimize negative
outcomes.
2. Social control contract – this is level 2 stage of the nurse-client relationship. The client
seeks help because of a developmental life change or stressor that has precipitated a life
crisis. The nursing interventions are usually short-term and pragmatically directed toward
solving the immediate problem.
3. Relationship contracts – this level 3 stage focuses on the repetitive or cyclical nature of
the client’s relationship problems. The client and nurse work together to make the
connection between the client’s early life decisions and current relationships and life-style.
Relationship contracts often include helping client to have insight into his/her problems,
cognitive restructuring by having positive mindset of issues, and having marital, family or
relationship counselling.
4. Structural change contract – this is level 4 stage of the contracts and it involves intensive,
usually long-term, psychotherapy intended to affect pathologic structure as well as current
relationship issues.
Components of a Therapeutic Relationship
These are requirements for therapeutic relationship as many factors enhance the nurse-client
relationship. It is the nurse’s responsibility to develop them as these factors promote
communication and enhance relationships in all aspects of the nurse’s life (Videbeck, 2008). These
factors or components are qualities that the nurse brings to the relationships with clients. These
qualities include:

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• Rapport: This is a bond or connection between two people that is based on mutual trust. It
involves setting rules for the relationship, use courtesy by introducing yourselves as nurses,
make eye contacts, smile, knock on doors, saying hello and goodbye, etc.
Establishment of Rapport
- Requirement: No specific requirement is needed but a calm environment and
knowledge of client’s name is very important.
- Procedure
1. Welcome client and introduce yourself.
2. Explain to client what s/he should expect from you as a nurse.
3. Offer seat and sit near him/her.
4. Find out client’s name and use when addressing him/her.
5. Speak using simple clear language.
6. Encourage the client to talk and express his/her feelings and listen mostly.
7. Help client think through his/her problems in a logical manner using
appropriate cues [words] and questions.
8. Show consistency in approaching the client.
9. Demonstrate firmness in dealing with inappropriate request and behaviour
by client.
10. Explain to client the support and assistant s/he could expect from you
(nurse).
11. Maintain a relax attitude when dealing with client to show patience – a sign
that you have time for him/her.
• Confidentiality: This deals with safeguarding the client’s rights to privacy. Confidentiality
means respecting the client’s right to keep private any information about his/her mental
and physical health and related care. Confidentiality means allowing only those dealing
with the client’s care to have access to the information that the client divulges (Videbeck,
2008; Ernstmeyer & Christman, 2021). The nurse cannot reveal client’s information
publicly without the informed consent of the client. Only under precisely defined
conditions can third parties have access to this information.
• Respect: This indicates showing high esteem and regard for the client. It involves having
consideration for client’s individuality and uniqueness, and having concern for his/her

33
welfare. The nurse must take into consideration the background, age, religion,
socioeconomic status and race. Respect is communicated through active listening to what
is the client is saying.
• Genuineness: This is being “real” in the relationship. There is congruence (when words
and actions match) between what the nurse believes or feels and what is expressed. This
congruence is basic to establishment of interpersonal trust. For example, the nurse would
say “I’m glad to see you” to a client only if that is an expression of a sincere sentiment.
NB: nurses are at times asked to disclose information that they do not wish to share. In
such situations, being genuine may mean responding honestly, e.g., “It makes me
uncomfortable when you ask me about my personal life.”
• Empathy: This deals with understanding the patient’s perception of the situation. It is the
experience of accurately getting the meaning of or comprehending what the client is
experiencing. Empathy is the ability to hear what another person is saying and be able to
borrow temporarily the other person’s feelings but still maintain our own feelings (Barry,
1994). Empathy is the ability to assume the role of another and, by imagining the world as
the other sees it, predict accurately the motives, attitudes, feelings, and needs of the other
(Samovar, Porter, & McDaniel, 2010). The nurse maintains his/her objectivity in order to
be able to assess client’s information accurately. The process is complex and involves
observing the client’s physical demeanor and listening to the content and style of what is
said. It is not just a cognitive understanding that is gained, but also a spontaneous,
emotional awareness. Empathy is “a particular mode of gathering data about the internal
experiences of another.” It requires the ability to alternate between emotionally
participating with the client and intellectually observing the client. “It is the sensing of the
client’s inner world of private personal meanings ‘as if’ it were the nurse’s own, but without
ever losing the ‘as if’ quality. Hence, being empathic is the ability to communicate about
the client’s inner and experience in such a way that the client feels understood and soothed.
Unlike empathy, sympathy is losing our objectivity by adopting the same feelings as the
client, and in this case the nurse will not be able to assess the client’s status. For example,
ongoing for fishing in a lake with friends and one accidentally falls into the water body,
we can only throw him/her a life-jacket or life preserver and pull him/her to safety

34
(empathic therapeutic intervention) or jump into the lake when we do not know how to
swim (sympathy) (Barry, 1994).
• Hope: This means anticipating the future by helping clients look realistically at their
potential. And this is what Peplau termed as “a bias of optimism.” It is an assumption that
all clients have the potential for learning and change. The nurse who is hopeful recognizes
small changes and successes and communicates them to the client. This assists the client
in seeing the self as confronting problems, rather than as being overwhelmed by them. To
be hopeful about potential for change does not mean that clients should be forced to change.
Rather, the nurse’s hope or optimism provides the client with the experience of knowing
that another person believes that change is possible.
• Trust: The nurse-client relationship requires mutual trust and this should be established at
the beginning of the relationship. Trust builds when the client is confident in the nurse and
when the nurse’s presence conveys integrity and reliability. Trust develops when the client
believes that the nurse will be consistent in his/her words and actions, and can be relied on
to do what s/he says. For example, if you promise to visit a client daily, arrive at the
appointed time, stay the length of time promised, and leave when time is up. Should
something unavoidably cause a delay or prevent a visit, notify the client. This is the way
to build trust. Trust is built in the nurse-client relationship when the nurse exhibits
behaviours such as friendliness, caring, interest, understanding, and consistency. Others
include treating the client as a human being, suggesting without telling, approachability,
listening, keeping promises, providing schedules of activities, and honesty.
• Positive regard: The nurse who appreciates the client as a unique worthwhile human being
can respect the client regardless of his/her behaviour, background, or lifestyle. This
unconditional non-judgemental attitude is known as positive regard and implies respect.
Calling the client by name spending time with the client, and listening and responding to
openly are measures by which the nurse conveys respect and positive regard by considering
the client’s ideas and preferences when planning care.
• Authenticity: The nurse allows him/herself to be known to the client. This is also called
transparency or genuineness.

35
Phases of Therapeutic Nurse-Client Relationship
The therapeutic nurse-client relationship can be divided into three phases: Orientation, Working
and Termination. Besides, it is useful to consider the pre-interaction and post-termination periods.
The phases of the nurse-client relationship actually overlap one another, especially if the time
period is short (McFarland & Thomas, 1991).
• Pre-interaction period: During this period, the nurse is aware that there will be meetings
with a particular client and prepares for those meetings. The nurse discovers what has been
learned by others by reviewing assessment data collected on the client by others. As the
nurse reviews these data, s/he builds his expectations and fathoms certain behaviours that
may be evoked by the client and the interventions to be given in that respect, both for
planning purposes and as a means of reducing anxiety. It is important to give consideration
in handling difficult situations, and if possible seek help from another nurse, consultants,
or review literature. Note that before the interaction, the client also has certain expectations.
• Orientation (Introductory) phase: Being the initial interaction, the nurse and the client
who are strangers get acquainted to each other with each having his/her own expectations
(Scherer & Timby, 1995). Goals for the relationship are discussed and set, and the nurse
arranges ways in which they can work collaboratively. The nurse initiates meetings with
the client and gathers assessment data (information) which are the health problems. Based
on the data collected, nursing diagnoses are formulated for the health problems. In addition
to clarifying the goals and how they will be attained, the treatment contract which include
the frequency, length, and place of meetings are also highlighted at this period. For
example, the nurse might summarize a discussion of roles and responsibilities by saying:
“Then we’ll meet here in this office at 12:30 pm every Thursday and Friday as long as you
are in this hospital. You’ll bring up any problems you are having with getting angry with
your family and I’ll discuss them with you.” Termination of the relationship is discussed
at this phase of the nurse-client relationship. This is done when the client’s health problems
have improved. It is important for the nurse to demonstrate courtesy and respect, active
listening, empathy, competency, genuineness, and appropriate communication skills to
ensure that the relationship begins positively.

36
• Working phase: The working phase involves mutually planning the client’s care and
putting the plan into action. Nursing diagnoses are refined and new health problems are
identified. Both the nurse and the client participate. Each shares in the performing those
tasks that will lead to the desired outcomes identified by the client. During the working
phase, the nurse tries not to retard the client’s independence. Doing too much can be as
harmful as doing too little. In addition, it is good for the nurse to identify patterns of
behaviour, such as lateness or unwillingness to participate in the relationship – a situation
that indicates client’s anxiety about the relationship. It is incumbent on the nurse to evaluate
client’s progress towards the goals set at the beginning of the relationship, and to consider
his/her own thoughts and feelings in response to the client.
• Termination phase: Termination of the nurse-client relationship is done when there is
mutual agreement that the client’s immediate health problems have improved. Thus,
termination is directly related to achieving the goals defined for the nurse-client
relationship. It may also be in response to factors such as the client’s discharge from the
hospital or the nursing student’s completion of clinical experience. The task of this phase
is to bring a therapeutic end to the relationship and this is fulfilled acknowledging the forth-
coming termination and by evaluating what has been learned during the relationship. The
relationship is weakened by decreasing the frequency and intensity of the sessions and by
encouraging the client to increase participation in other relationships. The nurse therefore
uses a caring attitude and compassion in facilitating the client’s transition of care to other
health care services or independent living. Though reaction to termination may be difficult
for both client and the nurse, the nurse should encourage the client to share thoughts and
feelings about the forthcoming termination, and genuinely share his/her reactions to
termination in a way that is appropriate to the client.
• Post-termination period: At this period, it is useful for nurses to review their part in the
relationship. An honest appraisal of what was helpful to the client and what could be
improved upon can assist nurses to grow in clinical skills.

37
Social and Therapeutic Relationships – Compared
Social Relationship
• Is spontaneous
• Is mutually beneficial
• Often has no planned agenda
• Is based on mutual interest
• Each participant expects to be liked by the other
• Problems are shared
• Communication is spontaneous
Therapeutic Relationship
• Is planned and goal-directed
• Seeks to meet client’s needs
• Is based on theory
• Privileged information is available to health care provider
• Client is emotionally vulnerable
• Client must be accepted as s/he is.
• Communication is planned
• Has clear-cut boundaries

38
CHAPTER FOUR
VERBAL AND NON-VERBAL COMMUNICATION TECHNIQUES
Introduction
Human spoken and picture languages can be described as a system of symbols (sometimes known
as lexemes) and the grammars (rules) by which the symbols are manipulated. The word “language”
also refers to common properties of languages. Language learning normally occurs most
intensively during human childhood. Most of the thousands of human languages use patterns of
sound or gesture for symbols which enable communication with others around them. Languages
seem to share certain properties although many of these include exceptions. There is no defined
line between a language and a dialect. However, a variety of verbal and non-verbal means of
communicating exists such as body language, eye contact, sign language, paralanguage, haptic
communication, chronemics, and media such as pictures, graphics, sound, and writing.
Verbal communication
By definition, verbal communication is the exchange of information using words understood by
the receiver (Ernstmeyer & Christman, 2021). It refers to spoken (oral) or written words that
comprise the symbols of language (Haber, et al., 1997). It is that communication that uses words.
It includes speaking, reading, and writing. In verbal communication, the meanings of the words
are derived not only from the words themselves but also from their order in phrases, sentences,
and paragraphs. Some groups of words convey special meanings: these groups include figure of
speech, jokes, proverbs, clichés, and mottos. Such messages may have both an abstract and
concrete (real) interpretation. For example, “A stitch in time saves nine” which is a proverb can
be interpreted abstractly to mean that preventive health measures may forestall bigger health
problems in the future. However, nurses should remember that expressions such as proverbs may
be culturally relevant; clients from diverse cultures may lack familiarity with them and how to
interpret them.
As verbal communication is used by both the nurse and the client to gather facts, it is also used to
instruct, clarify, and exchange ideas. The ability of the nurse to encourage communication is
extremely important, especially when exploring problems with the client or encouraging the

39
expression of feelings. In situations where clients are quiet and non-communicative, the nurse must
never assume that it indicates the client has no problems or understands everything. It is never
appropriate to probe and pry (force) to press an unwilling client to communicate. Rather, it may
be advantageous to wait and be patient. It is not unusual for reticent (unwilling) clients to share
their feelings and concerns after they feel that the nurse is sincere and trustworthy. For instance,
when clients are angry or cry, the best nursing approach is to allow them to express their emotions.
Allowing clients to display their feelings without fear of retaliation or censure contributes to a
therapeutic relationship.
Verbal communication becomes even more difficult when an interaction involves people who
speak different languages. Both clients and nurses experience frustration when they are unable to
communicate verbally with each other. For the client whose language is not the same as that of the
nurse, an intermediary may be necessary. A translator converts written material from one
language into another. An interpreter is an individual who mediates spoken communication
between people speaking different languages without adding, omitting, distorting meaning or
editorializing (Kozier, et al., 2008).
Strategies for effective verbal communication
• Focus on the issue, not the person. Try not to take everything personally, and similarly,
express your own needs and opinions in terms of the job at hand. Solve problems rather
than attempt to control others. For example, rather than ignoring a student who routinely
answers questions in class with inappropriate tangents, speak with the student outside of
class about how this might disrupt the class and distract other students.
• Be genuine rather than manipulative. Be yourself, honestly and openly. Be honest with
yourself, and focus on working well with the people around you, and acting with integrity.
• Empathize rather than remain detached. Although professional relationships entail
some boundaries when it comes to interaction with colleagues, it is important to
demonstrate sensitivity, and to really care about the people you work with. If you do not
care about them, it will be difficult for them to care about you when it comes to working
together.
• Be flexible towards others. Allow for other points of view, and be open to other ways of
doing things. Diversity brings creativity and innovation.

40
• Value yourself and your own experiences. Be firm about your own rights and needs.
Undervaluing yourself encourages others to undervalue you, too. Offer your ideas and
expect to be treated well.
• Use affirming responses. Respond to other in ways that acknowledge their experiences.
Thank them for their input. Affirm their right to their feelings, even if you disagree. Ask
questions, express positive feeling; and provide positive feedback when you can.
[Source: https://uwaterloo.ca/centre-for-teaching-excellence/teaching-resources/teaching-
tips/communicating-students/telling/effective-communication-barriers-and-strategies (retrieved
January 15, 2021)]
Nonverbal communication: The Messages of Action, Space, Time and Silence
To appreciate the importance of nonverbal communication to human interaction, you should reflect
for a moment on the countless times in a day that you send and receive nonverbal messages.
Nonverbal communication is an indispensable and all-pervasive element of human behavior.
Perhaps its most obvious application is seen in infants. Babies start comprehending words at
around six months of age, yet understand nonverbal communication well before that time. Hence,
from the moment of birth to the end of life, nonverbal behavior is an important symbol system. It
is essential to note that nonverbal communication is a basic means of expressing what a person is
thinking and feeling (Samovar, Porter, & McDaniel, 2010).
Nonverbal communication is important because people use this message system to express
attitudes, feelings, and emotions. Consciously and unconsciously, intentionally and
unintentionally, people make important judgments and decisions concerning the internal states of
others – states they often express without words. If you see someone with a clenched fist and a
grim expression, you do not need words to tell you that this person is not happy. If you hear
someone’s voice quaver and see his or her hands tremble, you may infer that the person is fearful
or anxious, despite what he or she might say.
Nonverbal communication involves all those nonverbal stimuli in a communication setting that
are generated by both the source and his or her use of the environment and that have potential
message value for the source or receiver (Samovar, et al., 2010). As defined by Haber and
colleagues (1997), nonverbal communication is communication without words. It includes

41
messages created through body motion and the use of space, sound, and touch. Scherer and Timby
(1995) affirmed the statement and asserted that nonverbal communication is the exchange of
information without using words. It is what is not said.
Nonverbal communication takes place through body movements, eye contact, facial expressions,
posture, manner of dress, makeup, gesture, and physical appearance. Others include touch, silence,
volume, and voice inflections (vocal sounds). These can be said to be the components of nonverbal
communication.
It is important for the nurse to pay attention to the client’s body language since verbalized
comments are not always an accurate reflection of how clients really feel. Adults may use words
to disguise or hide their fears and anxieties, but by interpreting a client’s nonverbal
communication, it may be possible to validate comments that the client makes. Touch, space, and
silence also influence communication. “To know what people think, pay regard to what they
do, rather than what they say”—René Descartes.
Four Ways to Express Nonverbal Messages
1. Kinesics – these are body movements and gestures. The nurse must be able to understand
the specific meaning of the motor actions use by the client. The nurse should strive to bring
into congruence (agreement) her motor actions of her nonverbal behaviours and verbal
communications.

42
2. Paralanguage – it is the voice quality and use of sounds in non-language vocalizations.
For instance, the groan or scream of a client about to engage in aggressive behaviour would
be vocal nonverbal communication, whereas the smile or frown of a withdrawn client
would be non-vocal nonverbal communication.
3. Proxemics – use of space. Proxemics is the study of distance zones between people during
communication. It deals with the use of space when people are conversing. People feel
more comfortable with smaller distances when communicating with someone they know
rather than with strangers (De Vito, 2004; Videbeck, 2008) and for that matter undue
invasion into people’s privacy and not respecting one’s boundaries bring problems into the
relationship.
a. Intimate zone (0 – 18 inches) - the closest distance that individuals allow between
themselves and others. This amount of space is comfortable for parents with young
children, people who mutually desire personal contact, or people whispering.
Invasion of this intimate zone by anyone else is threatening and produces anxiety.
b. Personal zone (18 – 36 inches) - the distance for interactions that are personal in
nature, such as close conversation with friends. This distance is comfortable
between family and friends who are talking.
At the healthcare setting, however, there are times when a nurse must enter a patient’s intimate or
personal space, which can cause emotional distress for some patients. The nurse should always ask
for permission before entering a patient’s personal space and explain why and what is about to
happen. Notwithstanding, patients may also be concerned about their modesty or being exposed.
A patient may deal with the violation of their space by removing themselves from the situation,
pulling away, or closing their eyes. The nurse should recognize these cues for what they are, an
expression of cultural preference, and allow the patient to assume a position or distance that is
comfortable for them (Ernstmeyer & Christman, 2021).
c. Social zone (4 – 12 feet) - the distance for conversation with strangers or
acquaintances. This distance is acceptable for communication in social, work, and
business settings.

43
d. Public zone (12 – 25 feet) - the distance for speaking in public or yelling to someone
some distance away. This is an acceptable distance between a speaker and an
audience, smaller groups, and other informal functions.
For instance, if a nurse performing an assessment at Kotwia Health Centre needs to take the client’s
blood pressure, s/he should say “Ms. Fremah Asare, to take your blood pressure I will wrap this
cuff around your arm and listen with my stethoscope. Is this acceptable to you?”
The nurse should ask permission in a yes/no format so the client’s response is clear. It is worth
noting that if a client invades the nurse’s intimacy space (0 to 18 inches), the nurse should set
limits gradually, depending on how often the client has invaded the nurse’s space and the safety
of the situation.
It is worth noting that men of all cultures usually need more space than women (Kozier, et al.,
2008).
Figure 3. Space orientation
[Image adapted from Ernstmeyer, K., & Christman, E. (Eds.). (2021). Open RN Nursing Fundamentals by
Chippewa Valley Technical College is licensed under CC BY 4.0.]

44
4. Appearance – use of clothing and other objects to communicate a personal image.
The Use of Touch (A non-verbal technique)
As intimacy increases, the need for distance decreases thereby increases the chances of using
touch. Touch is making physical contact with, or coming in contact with another person. It is an
effective method for communicating a sense of caring. Hence, touch is a powerful way to
professionally communicate caring and empathy if done respectfully while being aware of the
patient’s cultural beliefs. Nurses commonly use professional touch when assessing, expressing
concern, or comforting patients. For example, simply holding a patient’s hand during a painful
procedure can be very effective in providing comfort (Ernstmeyer & Christman, 2021).
Nurses should note that touch is also culturally determined. This is so because it may be
inappropriate for a male nurse to provide care for a female patient and vice versa. In some cultures,
it is also considered rude to touch a person’s head without permission (Ernstmeyer & Christman,
2021). It is therefore incumbent on nurses to be culturally sensitive when it comes to touching the
client.
Videbeck (2011) identified five types of touch:
1. Functional-professional touch is used in patients’ examinations or procedures such as
when the nurse touches a client to assess skin turgor or a masseuse performs a massage.
2. Social-polite touch is used in greeting, such as a handshake and the “air kisses” some
women use to greet acquaintances, or when a gentle hand guides someone in the correct
direction.
3. Friendship-warmth touch involves a hug in greeting, an arm thrown around the shoulder
of a good friend, or the backslapping some men use to greet friends and relatives.
4. Love-intimacy touch involves tight hugs and kisses between lovers or close relatives.
5. Sexual-arousal touch is used by lovers.
Touching a client can be comforting and supportive when it is welcome and permitted. The nurse
should observe the client for cues that show whether touch is desired or indicated. For example,
holding the hand of a sobbing mother whose child is ill is appropriate and therapeutic. If the mother

45
pulls her hand away, however, she signals to the nurse that she feels uncomfortable being touched.
The nurse also can ask the client about touching (e.g., “Would it help you to squeeze my hand?”).
Touch is an invasion of intimate and personal space that one should take note of. Some clients
with mental illness have difficulty understanding the concept of personal boundaries or knowing
when touch is or is not appropriate. It is therefore incumbent on nurses to refrain from invading
clients’ personal and intimate space.
When a nurse is going to touch a client while performing nursing care, he/she must verbally
prepare the client before starting the procedure. For instance, a client with paranoia may interpret
being touched as a threat and may attempt to protect himself or herself by striking and kicking
against the nurse. Even a simple hand on the shoulder can be misinterpreted, especially between
persons of the opposite gender. Therefore, it is prudent to avoid touching clients who are
suspicious, hostile, or very confused.
Actively Listening to the Patient and Attending Behaviours
To listen actively is to be attentive to what the client is saying, both verbally and nonverbally.
Effective communication cannot exist without first listening to the patient, then conveying the
necessary information rests on the nurse’s ability to communicate. While communication is
normally a two-way process, the unequal relationship, particularly in a hospital setting, puts the
onus on the nurse to ensure patients are informed and, where necessary, feeling comforted about
their situation. The use of appropriate styles of communication also facilitates collaboration with
colleagues and, in extreme cases, poor communication has been linked to the deaths of patients.
The action of listening is fundamental to effective therapeutic communication. Being listened to is
important for patients’ quality of life, resulting in feelings of being acknowledged, valued, and
empowered (McKenna, et al., 2014). Hence, listening is obviously an important part of
communication.
There are four main types of listening:
1. Competitive (Combative) listening happens when the nurse concentrates on sharing
his/her own point of view instead of listening to the client. In other words, we are focused
on sharing our own point of view instead of listening to someone else.

THERAPEUTIC COMMUNICATION FOR THE STUDENT NURSE - RICHARD OPOKU ASARE

THERAPEUTIC COMMUNICATION FOR THE STUDENT NURSE - RICHARD OPOKU ASARE

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