Chapter 1 – Introduction to Communication and Communication Theory in Nursing
It is important for nurses to engage in communication from a trauma-informed approach, which involves integrating an understanding of the need for:
- physical and emotional safety
- choice and control
(Trauma-Informed Practice Guide, 2013, p. 12).
A trauma-informed approach can be used as one part of therapeutic communication. It involves emphasizing confidentiality, identifying the interview purpose, letting the client set the pace of the interview and shaping it based on their needs, and engaging in collaborative intervention so that the client is in control and empowered. As you apply this approach, you should always be thinking about how you can promote safety, control, and choice for the client.
Given how pervasive trauma is in clinical practice, a trauma-informed approach makes sense to incorporate into your communication and with clients. This kind of approach is especially useful because you will often not know who has experienced trauma or the circumstances of their trauma. Trauma includes the emotional consequences of a distressing event (Centre for Addiction and Mental Health [CAMH], n.d.). Many circumstances can lead to trauma, including child abuse and neglect, sexual assault and intimate personal violence, bullying and harassment, as well as events such as car accidents, a death of someone close to you, natural disaster, and war.
Among Indigenous populations, historical and intergenerational trauma caused by Canada’s oppressive colonial policies and practices as well as the destructive effects of residential school systems takes the form of unresolved grief and trauma passed from one generation to the next (O’Neil et al., 2016; Mash et al., 2015). It has also led to a silencing of experiences (O’Neil et al., 2016), impacts on Indigenous identity (Lavallee & Poole, 2010), and has caused feelings of worthlessness, self-hatred, fear, and powerlessness (Chrisjohn & Young, 2006; Health Council of Canada, 2012), as well as mental health issues including anxiety, depression, post-traumatic stress disorder, and substance use and addictions (Assembly of First Nations, 1994; Brave Heart, 2003; Chrisjohn & Young, 2006; Mash et al., 2015; O’Neil et al., 2016).
Because the trauma-informed communication approach assumes the presence of trauma, it does not require the client to disclose their experience and thereby risk re-traumatizing them through repeated disclosure (Trauma-Informed Practice Guide, 2013).
See Case Study 1 for an example of a trauma-informed approach to interviewing.
Case Study 1
A 19-year-old client presents alone at urgent care. The reason for seeking care noted on the client’s chart is: pain, swelling, and bruising on index and middle digits of the left hand, suspected fracture. Upon entry into the examination room, the nurse observes healed bruising under the client’s right eye and contusions on the client’s neck.
RN: Hello Franco Alonso, my name is Pita Kora, I will be your registered nurse today. You can call me Pita and my pronouns are she/her. What would you like me to call you and what pronouns do you use?
Client: Franco and he/him is fine.
Rationale: Introduce self using first and last name and explains designation – this action promotes accountability for your actions, as it demonstrates that you are taking responsibility through disclosure. Asking what the client would like to be called and their pronouns contributes to the client’s sense of control and wellbeing. It also conveys respect for their chosen identity.
RN: Everything we talk about will remain confidential and will only be discussed among healthcare team members involved in your care.
Rationale: This emphasizes confidentiality, including the parameters of who will be privy to the information. This is important to disclose and does not mislead the client to believe that any information they provide will end with you. Indeed, as a nurse you are required to report the data you collect. This honesty is especially important in a trauma-informed approach to build trust and ensure safety.
Rationale: In this case, you wait for the client to acknowledge your statements, which conveys respect.
RN: Today I will ask you some questions related to your injury and then I will conduct a physical assessment. I will explain all steps as I go along. It will take about 15 or 20 minutes. Does that work for you?
Client: I think so…
Rationale: By proving the client with the purpose and general plan of the interview, you share control and minimize unpredictability. By asking the client if it works for them, you include them in the process and convey collaboration. Certainty and control are important parts of creating a safe space for dialogue.
RN: Can you tell me about what happened to your fingers, Franco?
Client: They were crushed in a car door. It really hurts. I think it may be broken.
Rationale: In this case, you ask an without assumptions. This approach is better to begin with than a series of directed by you. In this case, it is important to allow the client to share their story in their own words.
RN: Ok. I’m sorry to hear. That sounds painful. We will assess for any fractures. How long ago did this happen?
Rationale: You express empathy by responding to what the client said, instead of how the fingers look. It is important to respond to what the client is telling you to build trust. Also, the statement “we will assess for any fractures” offers the client reassurance that the injury will be attended and also acknowledges the initial concern that “it may be broken.” It is important to acknowledge the client’s concern and not dismiss their concern.
Client: Last week. I didn’t think much of it at first, but the swelling hasn’t gone away and the bruising seems to be getting worse. I wasn’t sure if I should come.
RN: Ok, sure, I can understand that. I noticed some other bruises under your right eye and on your neck. Are they related to your finger injury?
Rationale: You convey empathy by stating that you can understand the client’s choices/decisions without judgement. You ask a about other injuries but should allow the client to respond at their pace.
Client: Not really. I mean it happened around the same time but they aren’t related.
RN: Ok [allow for silent pause].
Rationale: Silence can be a powerful form of communication. It works in two ways in a trauma-informed approach: first, it conveys to the client that you are unhurried and invested in what they are saying; second, it can give the client an opportunity to think through their responses, which can alleviate pressure on the client and promote their self-determination.
Client: It’s kind of a long story. I’m sure you’re busy.
RN: I’ll make time. Tell me more.
Rationale: The client may be testing your interest and investment to gauge the level of trust. It is important to foster trust within the client and let them know you are reliable. If this isn’t possible at that moment, explain to the client why you may not have the time but when you will have the time. For example, “I have an urgent matter down the hall, but I will return in 5 minutes to discuss further.” In such cases, it is important to follow up on your promise and not let the client down, because this is likely to damage any trust built.
A trauma-informed approach creates a safe space for clients to engage in conversation and fosters control and choice. It does not require the client to disclose trauma. However, it creates a space in which the client may feel safe to speak about trauma, if relevant, at their own pace.
Activity: Check Your Understanding
A statement that refers to how someone behaves and acts and encompasses both verbal and non-verbal communication.
A type of question that invites the client to share descriptive answers, open up about their experience, and let them answer in a way that is most relevant or comfortable from their perspective.
A direct question that is asked when you are seeking precise information.
A direct question that is asked when you are seeking precise information.