Therapeutic Communication Strategies in Intermediate Care

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Introduction   

When a client requires transitional care, intermediate care can be important for clients whose goal it is to go from hospital to home but whose condition warrants additional treatments and/ or therapies. Due to early hospital discharge, these services are important and highly valued as a way for older persons to live in their own homes for as long as possible. Good communication is a key part of intermediate care and as clinicians it is important to ensure that you are familiar with techniques and strategies to communicate with the client and the interdisciplinary team members for successful client outcomes.   

Definition  

As people live longer and develop complex medical needs, intermediate care can offer attractive alternatives to hospital care, especially for elderly clients although it can pertain to any age client. The term intermediate care is care that is “in between” and provided to clients who are medically stable but too unstable to be treated in alternative healthcare settings or at home. The use of intermediate care, whether provided in intermediate care units or facilities or at home, can reduce pressure on acute care settings by providing a pathway for timely discharge from the hospital or by preventing hospital admission. 

Intermediate care is of particular importance in preventing the onset, progression, frailty and functional decline in adults, especially older adults, since they provide comprehensive assessment and rehabilitation aimed at optimizing independence and recovery. (1)   

Types of Clients Who Receive or Need Intermediate Care 

Most hospitals offer two types of care; inpatient units and intensive care units. Certain clients have clinical issues that require a higher level of care than standard inpatient units but really do not necessitate ICU care. These clients are considered semi-critical and appropriate for intermediate care units. Clients must have stable cardiovascular conditions such as uncomplicated arrhythmias and pacemaker implantation and respiratory conditions including respiratory failure along with some neurological conditions.   

Specific criteria exist to determine which clients are transferred to intermediate care including those recovering from ICU care, clients from a medical-surgical unit or the emergency room who are experiencing poor outcomes requiring a higher level of nursing care. (2) 

Intermediate Care Units 

Establishing intermediate care units decreases the occurrence of premature discharges, eliminates the need for transfers to other hospitals and minimizes the length of stay in the ICU while still maintaining proper level of monitoring without adversely affecting client outcomes. They were a critical asset in managing extremely complicated clients during the COVID-19 outbreak where they prevented almost 50% of critically ill clients from being admitted to ICUs and served as a multidisciplinary support for managing the client with COVID-19.  

These units can reduce the number of premature discharges by allowing clients with decreasing care needs to be transferred to the intermediate care unit for gradual care, avoiding the risk of involuntary or inappropriate discharges. (3) 

Often called a Step-Down Unit, an intermediate care unit can be a general medicine or surgical unit or be specific to certain specialties like cardiology or pulmonary and focus only on clients with those conditions. Other uses could include admitting clients directly from post-surgical recovery or the emergency room.  

A study looking at clients who had percutaneous coronary intervention found clients managed in the intermediate care unit made a significantly lower inpatient cost, even if client characteristics were similar to those in the ICU. (4) 

The Role of the Nurse in Intermediate Care  

Intermediate care units can reduce the burden on ICUs by admitting clients with lower acuity, but ICUs may have more complex pathologies and higher workloads. Providing a high-quality clinical environment requires a multidisciplinary healthcare team. Although intermediate care units may be staffed with fewer nurses, but typically staffing levels between those of general wards and ICU, research shows that they require the same level of training as ICU nurse. (5) 

One objective of an intermediate care unit is to improve the client’s environment to improve their condition. This environmental aspect is essential since satisfaction and comfort have a significant impact on the prognosis of their disease. The nurses manage the alarms and promote this culture of silence which can significantly reduce client discomfort by reducing the noise in the environment. (6) 

Intermediate Care at Home 

Intermediate care at home is an intervention delivered in someone’s own home or their usual place of residence to support recovery from illness and maximize independence while keeping them out of the hospital or moving them from an acute care stay. Following an illness or a sudden change in circumstances such as a fall, acute illness or hospitalization, this support can help a client regain independence by working with the client, family and the integrated health and social care professionals.  

The involvement of skilled nursing, physical and occupational therapy, social workers, home health aides, dieticians and pastoral care can bring a multi-faceted look at the client’s condition, living environment and support system to assure the staying at home will be a successful option for the client.  

Therapeutic Communication Strategies  

Therapeutic communication prioritizes the physical, mental and emotional well-being of the client and is the process of using verbal and nonverbal communication to connect and correspond with clients and family members each day to ensure that health care concerns and needs are addressed. If communication breaks down, information exchange stops and needs go unidentified. 

Nurses provide support and information while maintaining a level of professional distance and objectivity. The nurse ensures that sharing of information occurs within the multidisciplinary team. With therapeutic communication, nurses often use open-ended statements and questions, repeat information or use silence to prompt clients to work through problems on their own. It is also an essential part of interdisciplinary relationships, promoting effective and efficient collaboration among team members to promote positive client outcomes.  

Therapeutic Communication Strategies for Nurses 

• Using Silence: at times it is useful to not speak at all. Deliberate silence can give both the nurses, clients, family members and other team members to think through and process what comes next in the conversation. It can give the client the time and space needed to bring up a new topic. Nurses should always let clients break the silence.  

• Accepting: Often, it’s necessary to acknowledge what clients say and affirm that they’ve been heard. Acceptance isn’t always the same thing as agreement. It can be simply enough to make eye contact and say “Yes, I understand.” Clients who feel their nurses are listening to them and taking them seriously are more likely to be receptive to care.  

• Giving Recognition: Recognition acknowledges a client’s behavior and highlights it without giving an overt compliment. Sometimes a compliment can be taken as condescending, especially when it concerns routine tasks such as making the bed. Saying something like, “I noticed you took all of your medications” draws attention to the action and encourages it without requiring a compliment.  

• Offering Self: Any type of stay, regardless of length of time, can be lonely and stressful so when nurses offer their time, it shows they value the clients and that someone is willing to give them time and attention. Simply sitting with a client for a while can help boost their mood. 

• Giving Broad Openings: Therapeutic communication is often most effective when clients direct the flow of conversation and decide what to talk about. Giving clients 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 clients an opportunity to discuss what’s on their mind. 

• Active Listening: Nonverbal and verbal cues such as nodding and saying “I see,” gives nurses the ability to encourage the client to continue talking. Active listening involves showing interest in what clients 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 move it forward.  

• Seeking Clarification: similar to active listening, asking clients for clarification when they say something confusing or ambiguous is important. Often saying something like “I’m not sure I understand. Can you explain it to me?” helps the nurse ensure they understand what’s actually being said and can help clients 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 clients (and nurses) get a clearer sense of the whole picture. It forces clients to think about the sequence of events and may prompt them to remember something they otherwise wouldn’t.  

• Making Observations: Observations about the appearance, demeanor, or behavior of clients can help draw attention to areas that might pose a problem for them. Observing that they look tired may prompt clients 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 clients 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 clients a prompt to explain what they’re perceiving without casting their perceptions in a negative light.  

• Encouraging Comparisons: Often clients can draw upon experience to deal with current problems. By encouraging them to make comparisons, nurses can help clients discover solutions to their problems.  

• Summarizing: It’s frequently useful for nurses to summarize what clients have said after the fact. This demonstrates to clients that the nurse was listening and allows the nurse to document conversations. Ending a summary with a phrase like “Does that sound correct?” gives clients explicit permission to make corrections if they’re necessary.  

• Reflecting: Clients often ask nurses for advice about what they should do about particular problems or in specific situations. Nurses can ask clients what they think they should do, which encourages clients to be accountable for their own actions and helps them come up with solutions themselves.  

• Focusing: Sometimes during a conversation, clients mention something particularly important. When this happens, nurses can focus on their statement, prompting clients to discuss it further. Clients 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 clients to disagree with them, present them with reality, or challenge their assumptions. Confrontation, when used correctly, can help clients break destructive routines or understand the state of their situation. 

• Voicing Doubt: Voicing doubt can be a gentler way to call attention to the incorrect or delusional ideas and perceptions of clients. By expressing doubt, nurses can force clients to examine their assumptions.  

• Offering Hope and Humor: Because hospitals can be stressful places for clients, 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 clients in a more positive state of mind. (7) 

• Respect for the Client’s Values and Beliefs: Nurses must uphold and integrate the client’s personal values and beliefs into their care without exception. It is crucial for nurses to keep in mind, that the client is the center of care, not the nurse or other healthcare providers. 

• Honesty: It is never appropriate to lie to a client. While there may be uncomfortable subjects to discuss, there are ways to deal with those situations while practicing honesty. Dishonesty inevitably leads to severe issues with the nurse-client relationship and hinders therapeutic communication. When faced with a situation where you are uncomfortable or unsure how to answer a client, do not lie to them. Instead, tell them you need to clarify information before you answer.  

• Use Touch: Touch can be a powerful tool in developing therapeutic communication for nurses. Appropriate touch can promote a feeling of calm, ease anxiety, and be effective in providing comfort. Some clients may value having their hand held or someone placing an assuring hand on their shoulder. If, however, the client’s cultural beliefs find touch offensive, this technique should be avoided. (8) 

• Family Meetings: An important aspect of the care received in intermediate care is the participation of the client in goal setting and evaluating their progress along with active participation of the family.  Family meetings are a common part of the teamwork aspect of intermediate care involving the nurse, therapists, client and family members where they come together with the interdisciplinary team to discuss goals and interventions, including length of stay and follow-up services after discharge. It is important to start the meeting with a proper introduction and explanation of the purpose of the meeting to establish trust and to be able to successfully move to the next stage of questioning the client’s preferences, views and goals using the “what matters to you?” question.  

Successful family meetings are crucial to obtaining client participation and the first few moments of the meeting are key to establishing a trusting relationship.  An important question to ask the client is “what matters to you?” Assess the client’s point of view on their problems and goals as well as the impact that their issues have on their life situation. This can assist in uncovering hidden concerns. (9) 

The presence of family members throughout the client’s stay in an intermediate care unit provides continuous support and offers psychological benefits to the client.  

Attitude and Tone 

Research has shown that a professional’s attitude and tone of voice determine the client’s involvement and important aspects of person-centered communication include actively listening to a client’s narrative as well as being sensitive to their cues and concerns. The first few moments of an encounter or meeting are key to establishing a trusting relationship. Using open ended questions, welcoming the client’s perspective and concerns, along with explaining the purpose of the meeting to the client and attendees are crucial.  

Be empathetically present with clients to avoid missing or overlooking clients’ nonverbal cues (head-shaking, silence, ‘tell me more’, etc. referred to as ‘continuers’) subtle verbal invitations to discuss concerns but also clear empathetic communication. (10) 

Set the stage for good communication. Shared decision making helps clients take charge of their care. They need information they can understand so the nurse needs to assess and record their communication needs. If necessary, make sure the client and family know that there are medical interpreters available to help enhance communication. (11) 

The Four Habits Model 

The Four Habits Model consists for four interrelated domains of how to structure a clinical encounter where the different communication tasks around each habit are organized into groups of skills, techniques and pay-offs. 

The first habit is to invest in the beginning. (12) 

1. Quickly build trust. Explore the older person’s concerns and plan the stay or meeting.  
2. Elicit the client’s perspective, such as using the question “what matters to you?” 
3. Demonstrate empathy and being aware of the client’s cues and nonverbal signals.  
4. Invest in the end by providing information and encouraging clients to participate in the decision-making while negotiating treatment and follow-up plans. 

Conclusion

Well designed and administered intermediate care can improve client’s outcomes and satisfaction levels while reducing admissions to hospital and long-term care facilities and reduce delayed discharges.  Intermediate care consists of not only the physical care but the emotional aspect of care that involves client centered treatment and communication and includes family members and primary caregivers. The ability to communicate in a therapeutic manner to a client who has just entered into intermediate care can set the stage for a successful stay and discharge to home or other appropriate care setting.  

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