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Disarming the patient through therapeutic communication.

A neurosurgeon was asked what he thought the nurse practitioner contributed to his practice. It was a casual question, and one might have anticipated that he would say something about the nurse practitioner increasing the productivity of the office and/or relieving him of some of the more mundane aspects of patient care. However, without hesitation, he responded, "The nurse practitioner disarms the patient." He then went on to explain that for a patient, an appointment with a neurosurgeon is always a bad thing. Patients are most often going through an overwhelming, life-altering event associated with painful, debilitating treatments that too often have poor prognoses. He had observed that when the nurse practitioner delivered the results of diagnostic studies, patients were less anxious and better prepared to face what lie ahead.

Therapeutic Communication

The ability to effectively use therapeutic communication is taught in basic nurse education and refined as the nurse matures in the role. It is an essential part of nursing practice that is appreciated by patients and recognized by members of the health care team. Therapeutic communication consists of specific techniques, including the use of open-ended questions, touch, focusing, giving information, acknowledging, clarifying, reflecting, silence, and offering self (Berman & Snyder, 2012), with the goal of establishing a nurse-patient relationship based on mutual trust and respect. It is patient-centered as opposed to provider-centered.

Patient-centered communication uses open-ended questions, reflective listening, and empathy, but patient encounters take more time, especially if the conversation drifts off focus. Patient-centered communication, regardless of the provider, has been associated with better outcomes, including increased adherence to treatment plans, improved patient health, increased patient satisfaction, accurate diagnoses, and reduced malpractice risk. In contrast, provider-centered communication meets the needs of the provider; it uses closed-ended questions so patients do not get the opportunity to tell their story. Provider-centered communication reduces encounter time, but it is less accepted by the patient and is considered less desirable in relation to patient outcomes (Charlton, Dearing, Berry, & Johnson, 2008).

Nurse practitioners are frequently in positions to deliver bad news; therefore, it is imperative that they practice therapeutic, patient-centered communication. However, as the distinctions between medicine and nursing are becoming blurred and nurse practitioners are often evaluated based on productivity in terms of patients seen, the nurse practitioner communication style may be becoming more provider-centered (Berry, 2009).

To aid health care providers, including nurse practitioners, a patient-centered focus should be maintained while expediently telling bad news. The University of Texas MD Anderson Cancer Center (2013) recommends use of the SPIKES protocol. The acronym represents Setting up, Perception, Invitation, Knowledge, Emotions with Empathy, and Strategy or Summary. Information regarding the type of activities and engagement appropriate for each step is provided in video format on the University Web site (see Reference listing for link).

As a urologic nurse practitioner, I see patients who come to the office with extreme fear of the worst, and too often, the news is bad. In these instances, I reflect on the SPIKES protocol as a guide, but I also recruit the principles of therapeutic communication learned in basic nursing school. I sit down at eye level and look the patient directly in the eyes. If the patient's significant other is present, I include him or her in the discussion. I emphasize that the patient is not alone, but that there is a team of support, and the patient is the focus of our efforts. I use a calm, slow, and low voice while using the pathology report pictures to enhance patient understanding. I provide opportunity for questions, privacy, and silence for introspection. I touch hands, give hugs, and dry tears. By the end of our encounter, the nurse-patient relationship is intact, and the patient is "disarmed" and better prepared to make the decisions that lie ahead.

doi: 10.7257/1053-816X.2013.33.3.110


Berman, A., & Snyder, S.J. (2012). Kozier and Erb's fundamentals of nursing: Concepts, process, & practice (9th ed.). New York, NY: Pearson.

Berry, J.A. (2009). Nurse practitioner/patient communication styles in clinical practice. The Journal for Nurse Practitioners, 5(7), 508-515. doi:10.1016/j.nurpra.2009.02.019

Charlton, C.R., Dearing, K.S., Berry, J.A., & Johnson, M.J. (2008). Nurse practitioners' communication styles and their impact on patient outcome: An integrated literature review. Journal of the American Academy of Nurse Practitioners, 20(7], 382-388. doi:10.1111/j.1745-7599.2008.00336.x

University of Texas MD Anderson Cancer Center. (2013). SPIKES. Retrieved from care/complete-library-of-communication-videos/ basic-principles-spikes.html

Jo An Kleier, PhD, EdD, ACNP-BC, CURN

Urologic Nursing Editorial Board Member
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Author:Kleier, Jo Ann
Publication:Urologic Nursing
Article Type:Editorial
Geographic Code:1USA
Date:May 1, 2013
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