Therapeutic communication in the interaction between health workers and hypertensive patients in the family health strategy

Abstract

OBJECTIVE

To analyze the therapeutic communication in the interaction between health professionals and hypertensive patients in the Family Health Strategy.

METHODS

Descriptive study with qualitative approach. The sample consisted of 14 hypertensive patients and two health professionals of the Family Health Strategy (ESF - “Estratégia Saúde Família”) in a city of the state of Ceará, Brazil, in 2016. In the data collection, a checklist was used for non-participant systematic observation containing the strategies of therapeutic communication, namely: expression, clarity, validation, and a field diary, being these subjected to content analysis.

RESULTS

It was noted that ESF professionals do not adequately use therapeutic communication, indicating the need of investment in this device, which acts as a bridge for users, enhances care practices and opens paths that instrumentalize interpersonal relationships.

CONCLUSIONS

It was realized that health professionals are not fully exploring therapeutic communication strategies, therefore being necessary to develop skills to use these techniques correctly when caring for hypertensive patients.

Keywords:
Therapeutic Communication; Interpersonal relations; Hypertension; Primary health care

Resumo

OBJETIVO

Analisar a comunicação terapêutica na interação entre profissional de saúde e paciente hipertenso na Estratégia Saúde da Família.

MÉTODOS

Estudo descritivo com abordagem qualitativa. A amostra constituiu-se de 14 pacientes hipertensos e dois profissionais da ESF em um município do Estado do Ceará, Brasil, em 2016. Na coleta de dados, utilizou-se um checklist para observação sistemática não participante contendo as estratégias de comunicação terapêutica: expressão, clarificação, validação e um diário de campo, sendo tratados pela análise de conteúdo.

RESULTADOS

Verificou-se que os profissionais da ESF não utilizam de forma adequada a comunicação terapêutica, reconhecendo a necessidade de investimento nesse dispositivo, que atua como ponte de acesso aos usuários, potencializa as práticas assistenciais e abre caminhos que instrumentalizam as relações interpessoais.

CONCLUSÕES

Desvelou-se que as estratégias de comunicação terapêutica são pouco exploradas pelos profissionais de saúde, sendo necessário, portanto, desenvolver habilidades para empregá-las adequadamente no cuidado ao hipertenso.

Palavras-chave:
Comunicação Terapêutica; Relações interpessoais; Hipertensão; Atenção primária à saúde

Resumen

OBJETIVO

Analizar la comunicación terapéutica entre el profesional de la salud y pacientes hipertensos en la Estrategia de Salud de la familia.

MÉTODOS

Estudio descriptivo con enfoque cualitativo. La muestra estuvo constituida por 14 pacientes hipertensos y dos profesionales del Estrategia de Salud de la Familia (ESF - “Estratégia Saúde Família”) de un municipio del estado de Ceará, Brasil, en 2016. En la recopilación de datos, seutilizó una lista de verificación para la observación sistemática no participante la cual contiene las estrategias de comunicación terapéutica: expresión, claridad, validación y un diario de campo que trata del análisis de contenido.

RESULTADOS

Se comprobó que los profesionales del ESF no utilizan de manera adecuada la comunicación terapéutica, reconociéndose la necesidad de inversión en este dispositivo que actúa como puente para el acceso a los usuarios, realza las prácticas asistenciales y abre caminos que instrumentalizan las relaciones interpersonales.

CONCLUSIONES

Se reveló que las estrategias de comunicación terapéutica son poco aplicadas por los profesionales de la salud que las requieren, por lo tanto, se hace necesario desarrollar destrezas para utilizarla correctamente en el cuidado de los pacientes hipertensos.

Palabras clave:
Comunicación Terapéutica; Relaciones interpersonales; Hipertensión; Atención primaria de la salud

INTRODUCTION

The Family Health Strategy (“ESF”), the health locus of responsibility of users, families, and the community, reorganises primary care practices through comprehensive care, teamwork, therapeutic and preventive interventions, and health promotion in conformity with the precepts established by the Unified Health System (“SUS”).

The ESF is a proposal to change the healthcare model that, together with the hospital model, directs care to communities and approaches health workers to families¹. The provision of care in the current model and within the relations established in the different work spaces and stages of the process depends on communication exchanges to strengthen dialogue, receptive listening, mutual respect, and ties in the interaction between health workers and users.

The establishment of ties, empathy, and respect is essential and the elements for their formation are based on the mutual recognition between services and the community since ties cannot be created without the condition of subject and the free expression of users through speech, trial, and desires².

Communication is one of the fundamental human needs in the provision of care; without it, there would be no therapeutic interpersonal relationships between workers and users³. This device enables comprehension between the transmitter and the receiver and positive feedback between communicators⁴. Good communication requires respect for the thoughts, beliefs, and culture of the people involved⁵.

For this reason, therapeutic communication is a skill health workers, especially nurses, must acquire and a tool to obtain information on users. It is composed of several techniques used to promote well-being and satisfaction during nursing consultations by allowing users to express their feelings and ideas³. Therapeutic communication techniques - expression, clarification, and validation - are used in interpersonal relationships to provide better solutions to health problems and increase adherence of patients to their own care.

This communicative process is the basic condition to establish safe and sensitive interpersonal relationships in healthcare. A clear and appropriate communication benefits adherence to treatment and improves understanding between members of the team and between the team, the users and their families⁶. It is not easy to accomplish, but it makes people more skilful in the process of human communication³.

Empathy is essential in the care of hypertensive users given the chronic nature of the disease and the need to alter the lifestyle of sufferers and include daily care to prevent complications, when it is not properly controlled. Care⁷ constructed in the routine of health services provides hypertensive users with a life controlled by conducts, in a disciplinarian discourse, marked by constant monitoring, abstinence-based controls for the clinical reference of "living correctly”, with the medicalisation of food, physical activity, and habits in general.

Clear and appropriate communication supports adherence and treatment, as well as an understanding between the members of the multidisciplinary team⁶. The importance of communication in the ESF justifies any interest in addressing this subject. Moreover, health workers must add therapeutic communication techniques to their technical knowledge in the hope of preventing ineffective communication or exchanges that do not target follow-up of hypertensive patients.

The relevance of this study lies in learning about the therapeutic communication techniques used by the workers of the family health strategy in the care of hypertensive patients to discuss and propose ways of qualifying this practice in the ESF.

Thus, the question is: Which therapeutic communication techniques do health professionals use with hypertensive patients in the family health strategy? To answer this question, this papers analyses therapeutic communication in the interaction between health workers and hypertensive patients in the family health strategy.

METHODS

This paper is part of the results of the master’s dissertation⁸ “A comunicação terapêutica no cuidado ao paciente hipertenso na Estratégia Saúde da Família”. This is a descriptive study with a qualitative approach conducted in the ESF of a municipality in the state of Ceará, Brazil, from April to May 2016.

Fourteen hypertensive patients and two ESF workers, a doctor and a nurse, participated in this study. For the patients, the inclusion criteria were individuals registered at the health unit, residing in the ESF coverage area, and with regular follow-up for at least six consecutive months. The exclusion criteria were individuals with cognitive disorders and patients who were bedridden. For the health workers, the criteria for inclusion and exclusion were individuals working at the ESF for at least one year and individuals on holiday or on leave of absence, respectively.

Data were collected by visiting the health units to check the patient records and collect predefined information for research; observations using a checklist with the groups of therapeutic communication techniques, namely expression, clarification, and validation³; and recording information from the observations and other annotations, expressed verbally and non-verbally, in a field journal containing the following guiding questions: 1. Communication techniques used with hypertensive patient(s) when visiting the health unit for a consultation; 2. How therapeutic communication occurs in the care of hypertensive patient(s) during the consultation; 3. Facilities establishing therapeutic communication in the relationship between workers and hypertensive patients during the consultation; 4. Difficulties establishing therapeutic communication in the relationship between workers and hypertensive patients during the consultation; 5. Spoken or observed understanding in relation to the non-verbal and paraverbal communication during the consultation; and other observations related to empathy, mutual respect, trust, receptive listening, and patient follow-up in the reflections.

The data collection method was non-participant systematic observation. Findings were written in the form and the field journal synchronous with the observations. Each participant was observed for an average of 15 minutes, resulting in 210 recorded minutes.

The expression group consists of the techniques that describe facts and communicate feelings and ideas, such as 1. Listening reflexively; 2. Using silence therapeutically; 3. Voicing acceptance; 4. Voicing interest; 5. Using phrases open to interpretation; 6. Repeating the comment made by the patient; 7. Repeating the last words used by the patient; 8. Introducing the related problem; 9. Asking questions; 10. Asking questions related to what the patient said; 11. Returning the question; 12. Using descriptive phrases; 13. Keeping the patient in the same subject; 14. Allowing the patient to choose the subject; 15. Focusing on the main idea; 16. Verbalising doubts; 17. Saying no; 18. Encouraging the expression of underlying feelings; and 19. Using humour therapeutically³.

The clarification group is used to make explicit the messages of users and the group and includes the following techniques: 1. Encouraging comparisons; 2. Asking patients to clarify uncommon terms; 3. Asking patients to specify the agent of an action; and 4. Describing events in a logical sequence³.

In validation, the techniques allow workers to check whether the message expressed by patients was correctly understood. This group contains the following techniques: 1. Repeating the patient’s message; 2. Asking the patient to repeat what was said; and 3. Summarising the content of interaction³.

Data were collected while observing eight medical consultations and six nurses, after which the data were subjected to thematic content analysis⁹⁾ to obtain additional information for the critical reader of a message. This method was selected to attribute value to the meaning of the content according to the objectives of this research.

A reflexive analysis was conducted by carefully studying the words and phrases from the observations, using literature on the subject and comparing the results with those of other studies on the studied subject, and applying our perceptions and thoughts.

This study observed the ethical precepts established in Resolution No. 466/2012, of the National Health Council/Ministry of Health (“CNS/MS”)¹⁰. It was approved by the Research Ethics Committee of the Universidade Estadual do Ceará (UECE), with Opinion No. 1.506.165/2016 and by the Municipal Department of Health.

All participants were notified of the goals and methods used to conduct the research, after which they signed two copies of an informed consent statement to declare they understood and acknowledged the purpose of research and authorise use of the collected information for scientific purposes.

To ensure the ethical precepts of research, the names of patients were replaced by terms that symbolise feelings and emotions, such as joy, concern, lightheartedness, based on the observations. The professionals were represented by the letters P (physician) and N (nurse).

RESULTS

In all, 14 hypertensive patients participated in this investigation. Of these patients, 86% were women (n = 12). The ages ranged from 39 to 72 years with an average of 59.5 years. With regard to marital status, 57% (n = 8) were married and 21.4% were widowed (n = 3). Most of the patients were illiterate, 71.4% (n = 10), and 28.6% (n = 4) had not finished elementary school (1^st to 4^th grade). The health workers were between 20 and 30 years old, single, with a post-graduate degree. They had been working at the ESF from 2 to 4 years, which was considered sufficient to establish a bond and know the particularities of the territory and needs of the population.

The basis of content analysis from the discourses and the intersubjective communication in the exchanges were used to create the categories, thus representing the results of the category, "Therapeutic communication in hypertensive patients of the ESF".

The values identified in the checklist data portraying the strategic communication groups expression, clarification, and validation were 97, 10, and 5, respectively, represented by the information recorded in the field journal during the observations.

The most frequently used expression techniques in the communicative process were “voicing interest”, “using descriptive phrases”, and “asking questions related to what the patient said”. These technique were identified in the following statements:

You consulted a cardiologist [...] (P).

Yes, doctor (Delicacy).

That’s good! You are following the diet recommended by dietitian (P).

Yes, doctor. And I'm feeling very well [...] (Joy).

I'll explain so you can understand [...] (N).

Doctor, I'm going through things that aren't making me feel well (Concern).

What's troubling you? (P).

You said you would stop taking the medication [...] (N).

The observations reveal a relationship process in which the professionals express interest and concern with the problems of the hypertensive patients and try to calm them by providing guidelines regarding their health conditions while respecting their singularities in order to improve the quality of care.

These techniques help patients share their feelings and thoughts and allow the health workers to correctly explore the health problems and needs, which is fundamental for the provision of joint care in medical and nursing consultations at the ESF.

In these consultations, other techniques were used in the therapeutic relationship, such as "listening reflexively", "voicing acceptance", and "returning the question". The use of these technique was observed in the following statements:

The doctor listens to me [...] (Lightheartedness).

You can only leave when you finished when you started [...] (N).

The doctor loves listening to my jokes [...] (Friendliness).

You can continue [...] (N).

Doctor, can you take a look at my test results? (Charisma).

Yes, I can [...]. They are fine. Congratulations! I wish you lots of health (N).

What are you feeling? (N).

Doctor, can I take this medicine? (Anxiety).

Why do you want to take this medication? (P).

Doctor, I have not had that test done (Lightheartedness).

Why haven’t you had it done? (N).

The statements reveal beneficial attitudes in the interaction between the workers and the hypertensive patients. Furthermore, in the interface established in the nursing consultations, some users call the nurses doctors due to respect they have for them and the belief they are the leaders of the ESF team.

The observations also revealed the need to bridge the gaps in this communication by focusing on non-verbal language. Health workers should read between the lines to prevent misunderstandings, especially considering that verbal and non-verbal modalities support and complement each other.

In the observations, the techniques “focusing on the main idea”, “verbalising doubts”, “saying no”, and “using humour therapeutically” were identified, as shown in the statements below:

My blood pressure is high today (Peace).

Is there a problem? Would you like to tell me what happened? (N).

Does everyone take care of you? (P).

No. Only my daughter mostly [...] (Loneliness).

I want to have that test done [...], doctor (Curiosity).

No. There’s no need to have that test done now. It's not urgent [...] (P).

I like to talk to the doctor [...], I forget what I'm feeling [...] (Charisma).

According to the reports, the information was recorded clearly and concisely and the messages transmitted and received were understood. Since it was the most widely used group of techniques, the observations showed the workers were qualified to deal with hypertensive patients but lacked the means to deal with issues alluding to therapeutic communication.

Other strategies considered important, such as "using phrases open to interpretation", "repeating the comment made by the patient", "introducing the related problem", "repeating the last words used by the patient", "keeping the patient in the same subject", "allowing the patient to choose the subject", and "encouraging the expression of underlying feelings” were not identified during the observations.

In the clarification group consisting of four techniques, “asking patients to specify the agent of an action", and "encouraging comparisons" were identified in the medical and nursing consultations during the observations. The following statements show these situations in the communication process:

When they fight I feel ill, I get this tightness in my chest, my pressure goes up [...] (Hope).

Who are they? (P).

My son-in-law and my daughter (Hope).

We take the medicine properly, every day [...] (Tranquillity).

We. Who are you referring to? (P).

Me and my old lady (laughter) [...] (Tranquillity).

Can you tell me about another situation in your life that is similar to the one you just told me about? (P).

The statements show the workers have the skills needed to conduct the messages transmitted by the hypertensive patients. The ideas that were not clearly expressed in the communication exchange, however, must also be clarified appropriately by correcting the incorrect or ambiguous information in order to provide individualised care and meet the multidimensional needs of these users.

In the validation group, with three techniques, the observations only identified the strategy “summarising the content of interaction”, as illustrated in the following statements:

You were given the guidelines on how to treat high blood pressure, how to take your medications correctly, the right diet, and the importance of walking to improve your health (P).

Peace - Does not speak and listens to the doctor (Peace).

You said your daughter came to the unit? (N).

Loneliness - Yes, doctor, she is outside [...] (Loneliness).

According to the observations, use of the validation strategies, which are important to verify the accurate comprehension of messages transmitted and received during communication, was restricted. Given the excessive demand of the studied unit, the health workers do not validate the messages transmitted by the hypertensive patients and are therefore unable to establish fully effective and efficient communication.

According to the observations and field journals, the use of therapeutic communication strategies by the ESF workers is deficient, which compromises the quality of the care offered to hypertensive patients. This finding may be explained by the limited knowledge these workers have on this device, consequently affecting their use of relationship technologies. These techniques were more frequently used in the medical consultations due to the greater demand for physicians during the observations.

The need to invest in communication strategies was evident in various stages of research since they can enable user access to services and instrumentalise interpersonal relations that ensure positive practices and actions in the care of hypertensive patients.

DISCUSSION

The observations revealed the use of therapeutic communication strategies. The techniques of expression “voicing interest”, “using descriptive phrases”, “asking questions related to what the patient said”, “listening reflexively”, “voicing acceptance”, “asking questions”, “returning the question”, “focusing on the main idea”, “verbalising doubts”, “saying no”, and “using humour therapeutically” were the most common techniques used with the hypertensive patients in the medical and nursing consultations.

The techniques that were not identified could encourage greater and better interactions since they facilitate the description of experiences, feelings, and thoughts so workers can understand users and direct interpersonal relationship more effectively³.

According to literature, group expression techniques can be used to voice and describe thoughts and feelings and explore problem areas of patients¹¹. Health workers should use their skills to help people solve their problems, relate better to themselves and with others, and adapt to their health condition and living context¹².

This tool should be used by all health professionals whether they have a common goal or not. When used correctly, it can improve the psychological well-being of users by ensuring a welcoming reception in an environment that is not conductive to nursing or medical evaluation errors and adherence of patients to this health service¹³. The ESF workers must know the communication mechanisms needed to improve their performance with users and strengthen their relationship with other members of their team¹¹.

The clarification strategies, consisting of four techniques, identified in the medical and nursing consultations were “asking patients to specify the agents of an action" and "encouraging comparisons". The technique of this group are used to understand or clarify messages transmitted by patients when part or all of these messages are ambiguous³. Health workers must acquire skills that help them recognise and offer relational technologies to communicate effectively, provide the appropriate care, and establish a bond with users and the team.

These observations reveal the need to acquire the fundamental knowledge of therapeutic communication in order to help⁴ others discover and solve their problems. Moreover, these workers can use these skills and capabilities to help patients resolve conflicts, recognise their own limitations, accept that which cannot be changed, and confront their difficulties while pursuing a healthier lifestyle and finding a sense of purpose to live with autonomy. Based on this capability¹⁴, workers identify and understand the problems of users and their families and help them solve these problems.

The validation group is used to validate the patient's message and verify whether they understood the guidelines of the health workers³. In this study, these were the least frequent techniques identified in the observations. The only technique of this group was “summarising the contents of interactions”, revealing gaps in the communication process and highlighting the need to learn more about these techniques for a more effective therapeutic communication.

These gaps also show the complexity and multidimensional nature of human communication and the need to acquire competencies, skills, and attitudes to instrumentalise this communication¹⁵. According to literature, health workers must use their knowledge of human communication to establish a care relationship with others and discover and use their capacity to cope with challenges and adapt to what cannot be changed³.

It is part of the lives of people and, in healthcare, it is essential to obtain valuable information for therapy despite the difficulties people have expressing themselves or interpreting the language of communication in their everyday lives¹⁶.

Consequently, these techniques must be used by the ESF workers to ensure significant gains in the interaction with users, increase the quality of care, and offer services capable of solving their problems.

The groups of therapeutic communication techniques favour the establishment of two-way communication and the continuity of care, resulting in comprehensive and humanised assistance based on individualised interventions that meet and satisfy the real healthcare needs of users.

Therapeutic communication makes users feel welcome. It creates a relationship of trust and favours the revelation of the other. In this moment of communication, effective actions toward treatments are established through the individualisation of care³. It is in this interaction with others that human beings are constructed¹⁷.

Interaction facilitates the provision of quality care in the healthcare services⁴ and increases the possibilities of effective, resolute, and efficient care permeated by open and productive dialogue. It should not, however, focus solely on verbal aspects since the non-verbal is also part of human relations.

The ability to hear and understand in order to communicate and interact with others is not only related to verbal language; it includes body movements known as non-verbal communication¹¹. Verbal and non-verbal communication is one of the elements used to sustain care and care actions, enable genuine exchanges between caregivers and the ones-being-cared-for, and support interaction with sensitivity and affection¹⁸. The use of verbal and non-verbal communication in the ESF is one of the pillars of healthcare and a critical instrument to enhance therapeutic relationships.

The ESF is the breeding ground of health promotion and the prevention and treatment of diseases insofar as knowledge on the verbal and non-verbal forms of communication is correctly articulated¹⁶. For the people who receive care, communication always exists, whether through the eyes, facial expression, gestures or words or in the manner it occupies the environment¹⁹. Verbal communication does not occur alone; the transmitted message is always a verbal and non-verbal interaction¹¹.

The data in this study reveal a deficit in the therapeutic communication observed during the medical and nursing consultation, which makes this form of communication a challenge for primary care. To achieve competent communication, care must be humanised and personalised by means of therapeutic techniques to identify the needs of those who receive care. The capacity to understand non-verbal communication is essential to change the way workers act, provide care, and promote the well-being of hypertensive patients.

This moment calls for changes in the way ESF workers understand the healthcare work process and the relationships established between the services, the workers, and the users²⁰. Communication is the guiding principle of encounters between people - the subjects of care and their families - acknowledged as those who think, feel, act, and react to the entire healthcare context¹⁸.

Therefore, it must be considered an ethical duty and responsibility of any health professional who works in direct contact with people as a way of ensuring the provision of care with technical, relational, and human competence. It is important to improve the education and awareness of health workers regarding the need to promote the use and potential of therapeutic communication¹³.

Given the lack of studies on this subject in primary care, we hope this study can be used by health workers to expand their knowledge of therapeutic communication and encourage them the reflect on the importance of this type of communication in their personal, social, and professional lives, thus increasing their capacity to understand, guide, and communicate effectively in a harmonious and humanised manner.

CONCLUSION

It was concluded that the health workers of the studied unit use the therapeutic communication techniques - expression, clarification, and validation, with emphasis on the use of the expression techniques. These techniques, however, were not used effectively in the observed consultations, thus compromising the relationship between these workers and the users and any possibility of making the communication process more effective and efficient.

The health workers did not recognise the importance of this tool in interpersonal interaction and failed to identify it as a human dimension in healthcare, which hinders the establishment of therapeutic relationships.

These techniques strengthen bonds, mutual respect, trust, receptive listening, and interpersonal relations and contribute to shifts in behaviour and the lifestyle of hypertensive patients. The ESF workers must learn about these techniques to strengthen their work process and the holistic range of care through involvement and integration of the team itself and toward users.

The meetings between the workers and the hypertensive patients revealed the need to increase understanding of the interposition of verbal and non-verbal communication and overcome the gaps in communication exchanges to enable changes in interpersonal relationship supported by therapeutic communication.

The consolidation of this experiment required the processing of changes in the way the ESF workers act and do their work, which is critical for the effectiveness of work, the success of therapeutic communication, and the creation of an interactional field that boosts the level of satisfaction of workers and hypertensive patients.

These workers must be qualified to apply the approaches of communication based on evidence on the benefits of interpersonal relationships and the improved quality of life and health of these users.

The limitation of this study was the use of only one unit in the municipality, which prevented the inclusion of all ESF workers and the recognition of its importance in the context of ESF, especially for the nurses who aim to provide practical and technical care as well as comprehensive and humanised quality care.

Since therapeutic communication is a tool that contributes to education and research and the provision of comprehensive care by strengthening interpersonal relationships and health promotion, further studies are needed to answer the many questions on this subject and expand this subject for all health workers, thus enabling the use of effective, mindful communication with a holistic dimension

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Publication Dates

• Publication in this collection
  2017

History

• Received
  24 Dec 2016
• Accepted
  25 Aug 2017