Communication, documentation, and culture
Clear communication keeps patients safe. Respectful, culturally aware care builds trust. For study only, not clinical guidance: always follow your programme, current local protocols, and supervising clinicians.
Therapeutic communication
Therapeutic communication is purposeful communication that supports patients' wellbeing. Techniques include active listening, open-ended questions ('How have you been feeling?'), reflecting, clarifying, summarising, and silence. Non-therapeutic responses include false reassurance ('Everything will be fine'), giving advice, changing the subject, and asking 'why' questions that can feel accusatory.
SBAR handoffs
SBAR is a structured format for communicating about a patient, especially in handoffs and calls to providers: Situation (what is happening now), Background (relevant history), Assessment (what the nurse thinks is going on), and Recommendation (what the nurse suggests). Structured handoffs reduce errors when care passes between staff.
Documentation principles
Documentation records care for continuity, legal protection, and quality monitoring. It should be accurate, timely, objective, concise, and complete, written only by the person who performed or observed care. A widely taught principle is 'if it wasn't documented, it wasn't done.' Late entries must be clearly marked.
Electronic health records
Most hospitals use electronic health records (EHRs), which improve legibility and access but bring risks such as copy-and-paste errors and alert fatigue. Nurses must protect passwords, log out, and access only records needed for their work.
Health literacy and teaching
Many patients have limited health literacy. Use plain language, avoid jargon, focus on a few key points, and use the teach-back method: ask patients to explain in their own words what they need to do. This checks understanding rather than assuming it.
Cultural humility
Cultural humility means recognising your own biases, learning from each patient about their beliefs and preferences, and addressing power imbalances. Culture may shape views on illness, family decision-making, diet, modesty, pain expression, and end-of-life care. Avoid stereotypes: ask, don't assume.
Interpreters
Patients with limited English proficiency should be offered qualified medical interpreters, not family members, especially children, for important conversations such as consent. Federal rules in the US require meaningful language access in programmes receiving federal funding.
Worked example
SBAR call: 'Situation: Mr Lee in room 12 has a new oxygen saturation of 88% on room air. Background: he is day 2 after abdominal surgery with a history of COPD. Assessment: his breathing is laboured at 26 per minute; I am concerned about possible atelectasis or pneumonia. Recommendation: I would like you to assess him, and I request an order for oxygen and a chest X-ray.'
Key takeaways
Therapeutic communication uses open questions, active listening, and reflection, avoiding false reassurance and 'why' questions. SBAR structures handoffs. Documentation must be accurate, timely, objective, and done by the caregiver. EHRs need careful privacy practices. Teach-back checks understanding. Cultural humility means asking rather than assuming. Use qualified interpreters.
Flashcard
Purposeful communication supporting wellbeing
Check your understanding
A patient says, 'I'm scared about my surgery tomorrow.' Which response is most therapeutic?