Therapeutic Listening
Shigeaki Watanuki
Mary Fran Tracy
Ruth Lindquist
Listening is an active and dynamic process of interaction with a client that requires intentional effort to attend to a client’s verbal and nonverbal cues. Listening is an integral part and foundation of nurse-client relationships, and one of the most effective therapeutic techniques available to nurses. The theoretical underpinnings of listening can be traced back to counseling psychology and psychotherapy. Rogers (1957) used counseling and listening to foster independence and promote growth and development of clients. Rogers also emphasized that empathy, warmth, and genuineness with clients were necessary and sufficient for therapeutic changes to occur. Listening has been identified as a significant component of therapeutic communication with patients and therefore fundamental to a therapeutic relationship between the nurse and patient (Foy & Timmins, 2004). Listening is also a key to improving health professionals’ teamwork effectiveness and patient safety in complex clinical settings (Denham et al., 2008).
DEFINITION
Many modifiers are used with the word listening—active, attentive, empathic, therapeutic, and holistic. The choice of modifier seems to depend more on an author’s paradigm than on differences in the descriptions of listening (Fredriksson, 1999). Unless active listening was explicitly used by researchers in the articles reviewed in this chapter, the term
therapeutic listening is used here to focus on the formal, deliberate actions of listening for therapeutic purposes (Lekander, Lehmann, & Lindquist, 1993). Therapeutic listening is defined as “an interpersonal, confirmation process involving all the senses in which the therapist attends with empathy to the client’s verbal and nonverbal messages to facilitate the understanding, synthesis, and interpretation of the client’s situation” (Kemper, 1992, p. 22). Beyond the therapist, this empathetic attending pertains to nurses and to other care providers.
therapeutic listening is used here to focus on the formal, deliberate actions of listening for therapeutic purposes (Lekander, Lehmann, & Lindquist, 1993). Therapeutic listening is defined as “an interpersonal, confirmation process involving all the senses in which the therapist attends with empathy to the client’s verbal and nonverbal messages to facilitate the understanding, synthesis, and interpretation of the client’s situation” (Kemper, 1992, p. 22). Beyond the therapist, this empathetic attending pertains to nurses and to other care providers.
SCIENTIFIC BASIS
Therapeutic listening is a topic of interest and concern to a variety of disciplines. A number of qualitative and quantitative studies provide a scientific basis of intervention effects in relation to process—behavioral changes of providers that foster communication—and outcomes: client satisfaction, improved clinical indicators.
A systematic review of 20 intervention studies that aimed at improving patient-doctor communication revealed the effectiveness of interventions that typically increased patient participation and clarification (Harrington, Noble, & Newman, 2004). Although few improvements in patient satisfaction were found, significant improvements in perceptions of control over health, preferences for an active role in health care, adherence to recommendations, and clinical outcomes were achieved. Likewise, preferable client outcomes were found in another study in nursing. A survey of 195 parents of hospitalized pediatric patients demonstrated that health care providers’ use of immediacy and perceived listening were positively associated with satisfaction, care, and communication (Wanzer, Booth-Butterfield, & Gruber, 2004).
Qualitative studies provide rich understanding of the nature of therapeutic listening and explore the meaning and experience of being listened to in the context of real-world settings. Self-expression opportunities that enable clients to be listened to and understood can promote clients’ self-discovery—meaning reconstruction and healing (Sandelowski, 1994). A discourse analysis of 20 nurse-patient pairs at community hospitals, however, indicated insufficient active listening skills on the part of nurses (Barrere, 2007). The study results showed that nurses often missed cues that patients needed nurses to listen to their concerns, or overlooked potential opportunities for health teaching, especially in “asymmetrical” communication patterns (dominance of nurse or patient) as compared to “symmetrical” patterns (nurse-patient communication involving active listening).
Studies evaluating training of health care providers in therapeutic communication skills have shown that training can be effective in
improving therapeutic communication skills. A randomized controlled study tested the efficacy of 25-hour training sessions in self-control techniques and communication skills with 61 nurse volunteers. The participating nurses were presented with simulated encounters with relatives of seriously ill patients and their role-plays were evaluated by blinded raters. The results showed significant improvements in the skills of listening, empathizing, not interrupting, and coping with emotions after controlling for baseline performance scores (Garcia de Lucio, Garcia Lopez, Marin Lopez, Mas Hesse, & Caamano Vaz, 2000).
improving therapeutic communication skills. A randomized controlled study tested the efficacy of 25-hour training sessions in self-control techniques and communication skills with 61 nurse volunteers. The participating nurses were presented with simulated encounters with relatives of seriously ill patients and their role-plays were evaluated by blinded raters. The results showed significant improvements in the skills of listening, empathizing, not interrupting, and coping with emotions after controlling for baseline performance scores (Garcia de Lucio, Garcia Lopez, Marin Lopez, Mas Hesse, & Caamano Vaz, 2000).
A combination of learning sessions (cognitive interventions), administrative support, and coaching activities (affective and behavioral interventions) enables long-term improvement in communication styles of nurses. A quasiexperimental study was undertaken to test the effectiveness of an integrated communication skills training program for 129 oncology nurses at a hospital in China. Continued significant improvements in overall basic communication skills, self-efficacy, outcome expectancy beliefs, and perceived support in the training group were observed after 1 and 6 months of training intervention. No significant improvements were found in the control group (Liu, Mok, Wong, Xue, & Xu, 2007).
These studies attempted to identify complex relationships among multiple phenomena and variables, including the immediate and long-term effects of training interventions, clinical supervision and support, and cognitive and behavioral changes on the part of nurses. Further systematic studies are needed to enhance knowledge related to intervention effectiveness, especially the link between client characteristics, client satisfaction, and type of interventions. This is particularly important in light of today’s health care emphasis and reimbursement aligned with patient satisfaction, patient engagement, and symptom management such as alleviation of pain.
INTERVENTION
Therapeutic listening enables clients to better understand their feelings and to experience being understood by another caring person. Effective engagement in therapeutic listening requires nurses to be aware of verbal and nonverbal communication that conveys explicit and implicit messages. When verbalized words contradict nonverbal messages, communicators rely more often on nonverbal cues; facial expression, tone of voice, and silence become as important as words in determining the meaning of a message (Kacperek, 1997). Nonverbal communication is inextricably linked to verbal communication and can change, emphasize, or distract from the words that are spoken (Bush, 2001).
Guidelines
Listening is an active process, incorporating explicit behaviors as well as attention to choice of words, quality of voice (pitch, timing, and volume), and full engagement in the process (Burnard, 1997). Therapeutic listening requires a listener to tune in to the client and to use all the senses in analyzing, inferring, and evaluating the stated and underlying meaning of the client’s message. As providers feel increasing time pressures, it can be easy to attempt to guide or limit the conversation rather than allowing the patient to fully express concerns. However, to be fully heard without interruption can be viewed as supportive by the patient (Bryant, 2009), and may ultimately strengthen the therapeutic relationship. Therapeutic listening requires concentration and an ability to differentiate between what is actually being said and what one wants or expects to hear. It may be difficult to listen accurately and interpret messages that one finds difficult to relate to, or to listen to information that one may not want to hear. Therapeutic listening is both a cognitive and an emotional process (Arnold & Underman Boggs, 2007). When not fully engaged, it can be easy to become distracted or to start formulating a response rather than to stay focused on the message. Three components have been identified as being foundational to therapeutic listening:
1. Rephrasing the patient’s words and thoughts to ensure clarity and accuracy
2. Conveying an understanding of the speaker’s perceptions
3. Asking questions and prompting to clarify (De Vito, 2006)
These and other techniques for therapeutic listening intervention are presented in Exhibit 4.1.
Therapeutic listening with children can be even more complex because it frequently involves the presence or participation of more parties: the nurse, the child, parents, and/or other family members. This may take particular skill on the part of the nurse as he or she attends to both the spoken messages as well as the nonverbal communication/reactions of two, three, or more persons simultaneously. In addition, the nurse must be sensitive to the clarification of information and cues in front of either the child or the caregiver, depending on the child’s age and developmental stage.
Adolescents especially may be willing to talk openly with an adult who is not a family member. However, they may respond quickly, abruptly, or defensively to any perceived indications of judgment, indifference, or disrespect on the part of the listener. It is extremely important with adolescents to be fully attentive, allow for complete expression of thoughts, and avoid statements or facial expressions that imply disapproval or that can be misinterpreted.
Exhibit 4.1. Therapeutic Listening Techniques
Active presence: Active presence involves focus on the client to interpret the message that he or she is trying to convey, recognition of themes, and hearing what is left unsaid. Short responses such as “yes” or “uh-huh” with appropriate timing and frequency may promote clients’ willingness to talk.
Accepting attitude: Conveying an accepting attitude is assuring, and can help clients to feel more comfortable about expressing themselves. This can be demonstrated by short affirmative responses or gestures.
Clarifying statements: Clarifying statements and summarizing can help the listener verify message interpretation and create clarity. Encourage specificity rather than vague statements to facilitate communication. Rephrasing and reflection can assist the client in self-understanding. Using phrases such as “tell me more about that” or “what was that like?” may be helpful, rather than asking “why,” which may elicit a defensive response from the client.
Use of silence: Use of silence can encourage the client to talk, facilitate the nurse’s focus on listening rather than the formulation of responses, and reduce the use of leading questions. Sensitivity toward cultural and individual variations in the seconds of silence may be developed by paying detailed attention to the patterns of client communication.
Tone: Tone of voice can express more than the actual words through empathy, judgment, or acceptance. Match the intensity of the tone to the message received to avoid minimizing or overemphasizing.
Nonverbal behaviors: Clients relaying sensitive information may be very aware of the listener’s body language and will be viewed as either accepting of the message or closed to it, judgmental, and/or disinterested. Eye contact, or a nodding head, are essential to conveying the listener’s true interest and attention. Maintaining a conversational distance and judicious use of touch may increase the client’s comfort. Cultural and social awareness are important so as to avoid undesired touch.
Environment: Distractions should be eliminated to encourage the therapeutic interchange. Therapeutic listening may require careful planning to provide time for undivided attention or may occur spontaneously. Some clients may feel very comfortable having family present; others may feel inhibited when others are present.
Because therapeutic listening involves both cognitive and emotional processes, it is important that nurses recognize the role of emotional intelligence in their therapeutic interactions. Emotional intelligence is
defined as an ability to recognize emotions in self and other, and to understand and utilize these emotions in thinking processes and interactions with others (Vitello-Cicciu, 2002). Nursing requires a significant amount of emotional labor, resulting in expectations of expressions of caring, understanding, and empathy with patients and families. Strategies such as reflection, empathizing, and skilled therapeutic listening can promote a healing environment for patients and families (Molter, 2003).
defined as an ability to recognize emotions in self and other, and to understand and utilize these emotions in thinking processes and interactions with others (Vitello-Cicciu, 2002). Nursing requires a significant amount of emotional labor, resulting in expectations of expressions of caring, understanding, and empathy with patients and families. Strategies such as reflection, empathizing, and skilled therapeutic listening can promote a healing environment for patients and families (Molter, 2003).
A listening technique referred to as change-oriented reflective listening targets behavioral change of health care providers (Strang, McCambridge, Platts, & Groves, 2004) and has a strong potential for incorporation into the repertoire of nursing interventions. This technique has been adapted from the core principles of motivational interviewing (Rollnick et al., 2002). Change-oriented reflective listening is a brief motivational enhancement intervention that encourages providers’ consideration of the quality of primary care, and then stimulates their intent to change behavior in the direction desired. This method takes the form of a brief telephone conversation (15-20 min), in which reflective listening statements are interspersed with open questions about the issue at hand. A menu of questions with the range of possible areas for discussion is constructed in advance. The technique has been successfully piloted with general practitioners to motivate them to intervene with opiate users and as part of alcohol intervention (McCambridge, Platts, Whooley, & Strang, 2004; Strang et al., 2004).
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