Therapeutic communication is defined as being “among verbal and nonverbal communications between the nursing professional and the family, interaction processes, whether intentional or unintentional, that have the effect of family intervention” [5].

Verbal communication is “communication using words” [5]. Non-verbal communication is “communication using means other than words” [5]. Verbal and non-verbal communication are “communication having the effect of both verbal and non-verbal communication” [5].

This study applied a self-administered questionnaire survey using the Delphi technique, conducted in two rounds [14]. To reach consensus on methods for therapeutic communication between nurses and families/family members, we targeted nurses working at visiting nursing stations in the local community, where they have extensive contact with families. Based on Benner’s definition of an expert nurse [15], we set the study subjects as nurses with at least five years of clinical experience.

We received information about 16 visiting nursing stations in a certain town through the Japan Visiting Nursing Station Council, and explained the purpose and methods of this study to the facility directors. After receiving consent from all 16 facility directors, we distributed questionnaires to 112 nurses having at least five years of clinical experience.

The questionnaire items were based on 23 subcategories from previous research [11]. An expert committee consisting of seven researchers specializing in family nursing reviewed the wording until unanimous agreement was reached, and the questionnaire items were determined.

For each item, participants were asked to check either “very important”, “important”, “neither important nor not”, “not very important”, or “not important”, and each was scored on a scale of 5 to 1. The percentage of respondents who replied “very important” or “important” was then used as the agreement rate. Regarding consensus building using the Delphi technique, as the numerical value is not clearly defined a wide range of results exists across studies, and no established numerical value has been established for the agreement rate [13]. Because this study was exploratory, the agreement rate indicating consensus was set at greater than 50% [13]. We graded the agreement rates into categories: greater than 50% but 70% or less as low agreement, greater than 70% but 80% or less as medium agreement, and greater than 80% as high agreement.

In Round 1, a free-text section was provided for each of the 23 items, allowing participants to freely write their opinions on each item. In addition, if therapeutic communication was practiced in addition to the 23 items, a free-text section was provided where participants could write their methods separately for verbal communication, non-verbal communication, and verbal and non-verbal communication. In order to revise or add items, seven researchers specializing in family nursing examined the content of the free-text section and continued to discuss the matter until reaching a unanimous agreement, ensuring the rigor of the analysis [16].

This study was conducted after being reviewed and approved by the institutional review board of the affiliated university (Approval Number 1201). The study objectives, significance, methods, and duration were explained to the research subjects in writing. A consent form was enclosed with the questionnaire, and participants’ filling and returning it constituted their agreement to participate in the study.

In Round 1, of the 11 verbal communication items, seven had a high agreement rate, three had a medium agreement rate, and one had a low agreement rate. In Round 2, of the 11 items modified based on the results of Round 1, 10 had a high agreement rate and one had a medium agreement rate.

“Encourage independent action by the family” had a low agreement rate of 68.6% in Round 1. Because previous research has shown that the meaning unit for this category includes participating in decision-making, this item was modified to “Encourage independent decision-making by the family”. As a result, in Round 2, the agreement rate changed to high, at 84.4%.

“Present topics to the family” had a medium agreement rate of 74.3% in Round 1. In the free-form responses in Round 1, one participant commented, “I also talk about things and people that are important to the person and their family, even if they are not directly related to their physical condition”. Furthermore, because previous research has introduced topics that are difficult to discuss in the meaning unit for this category, the item was modified to “Invoke new topics with the family”. As a result, in Round 2 the agreement rate was still 78.1%, a medium agreement rate.

“Ask questions to the family” had a high agreement rate of 85.7% in Round 1. Based on the comments in Round 1’s free-form responses, such as “It really brings out what the person thinks is important in life” and “It adjusts the family and patient’s aspirations and what they value”, the item was modified to “Ask questions to confirm what the family has valued up to now”. As a result, the high agreement rate in Round 2 rose to 96.9%.

“Use family language” had a medium agreement rate of 71.4% in Round 1. Based on the comments in the free-form responses, such as “Repeat what the family says exactly” and “Speak to family members with an awareness of their developmental challenges”, the item was modified to “Use words the family uses daily and that are important to the family”. As a result, the agreement rate in Round 2 was high, at 84.4%.

“Summarize family interviews” had a medium agreement rate of 77.1% in Round 1. In previous research, the meaning unit for this category has included summarizing the content of the interaction, and enabling the establishment of a common meaning of what is expressed. Therefore, this item was modified to “Summarize the discussion and review it with the family”. This resulted in a high agreement rate of 90.6% in Round 2.

In Round 1, all five items in the non-verbal communication showed high agreement rates. In Round 2, of the six items that were modified or added based on the results of Round 1, four showed high agreement rates, one showed medium agreement, and one showed low agreement.

“Be present with the family holistically” had a high agreement rate of 85.7% in Round 1 and a medium agreement rate of 78.1% in Round 2.

“Observe changes in what the family talks about” had a high agreement rate of 94.3% in Round 1. However, the free-form responses included “I value changes in the words and facial expressions of the patient and their family” and “I try to create an environment where they feel comfortable talking by noticing subtle changes and communicating them”. Therefore, we modified the item to “Note changes in the family”, which is not limited solely to family talk. As a result, the agreement rate in Round 2 was even higher, at 100.0%.

In addition, free-form responses included “Depending on the situation, touch the person by placing my hands on their back, etc.” and “Provide a massage”, so we added “Use touching and massaging with the family”. However, in Round 2, the agreement rate was low at 53.1%.

In Round 1, six of the seven verbal and non-verbal communication items had high agreement rates, with one having a low agreement rate. In Round 2, of the nine items, which were modified or added based on the results of Round 1, eight had a high agreement rate and one a medium agreement rate.

“Make the family aware of their assumptions” had a low agreement rate of 51.4% in Round 1. In the free-form comments, one comment was, “Conversations that help families become aware of their own problems”. Furthermore, because previous research has included raising awareness of negative thinking held by the family as a meaning unit for this category, this item was modified to “Raise awareness of negative thinking held by the family”. As a result, in Round 2, a medium agreement rate of 71.9% was realized.

In Round 1, one free-form response read “Acting as a mediator between the patient and family, I build relationships where I can be on both sides”, leading to the addition of “Maintain a neutral stance with each family member”. As a result, in Round 2, a high agreement rate of 84.4% was realized.

In Round 1, one free-form response read “Even if something feels off, I don’t point it out right away, but instead try to build a relationship with them” and another, “For the time being, I do the same thing as the family does, but if it would be better to change the method, I listen to what the family thinks and respond accordingly”, leading to addition of “Respect the family’s style and schedule support”. As a result, in Round 2, a high agreement rate of 96.9% was realized.

In this study, visiting nurses with extensive experience working with families in the community served as study participants. Given their years of clinical experience, we believe we were able to gather opinions from visiting nurses who have engaged in a variety of family nursing practices.

The Delphi technique requires a wide range of sample sizes, from 10 to 100 people; however, a sample size of around 20 is acceptable if strict participant criteria are met to ensure participant quality [17]. Good results can be obtained with a sample size of 10 - 15 people, as long as the sample is homogeneous [18]. In this study, 35 participants responded in Round 1 and 32 in Round 2, which we believe were appropriate sample sizes.

In Round 2, only one item, “Use touching and massaging with the family”, had a low agreement rate among the 26 items. Omitting this item, we believe that the remaining 25 items are effective therapeutic communication methods.

In the Calgary Family Assessment and Intervention Model (CFAM/CFIM) [19], therapeutic conversation is defined as intentional verbal communication aimed at relieving the other person’s emotions, promoting understanding and aiding in problem-solving. Meanwhile, therapeutic communication as a method of family assessment/intervention is a term coined by Hohashi in the field of family nursing [5]. We believe that therapeutic communication is superior to therapeutic conversation in that it encompasses not only conversation but also nonverbal interactions. The therapeutic communication method items identified in this study have potential as methods for family assessment/intervention. We believe it is important for nurses to conduct family interviews/meetings by maintaining intentions and with each item in mind. To ensure family interviews/meetings become reliable family support techniques, nurses who work with families need to be trained in these skills.

4.2.1. Verbal Communication

“Confirm family perceptions and understanding” indicates the need to interpret the correct meaning of words used by family members. Furthermore, “Use words that the family uses daily and are important to the family” is a reliable way to clarify the specific meaning and image of words used by family members. Words having multiple meanings, referred to as “big words”, can lead to misunderstandings, misconceptions, and misinterpretations in communication. When such words are used, the specific meaning of the word must be confirmed with the other person [20].

“Invoke new topics with the family” is a horizontal question that elicits topics of similar importance and broadens the scope of the topic by changing the topic [21]. One reason for the moderate agreement rate for this item is that although nurses may bring up topics that are difficult to discuss with family members, they first build a relationship with the family before initiating the topic, and therefore rarely bring up or introduce the topic in an abrupt manner.

4.2.2. Non-Verbal Communication

“Be present with the family holistically” refers to a holistic relationship that involves being present rather than doing something. In other words, this involves simply being there for the person and accepting them as they are. It is believed essential for nurses to face families as professionals while also spending time with them as individuals, sharing the same hearts and minds. Furthermore, while family members may feel isolated when communication is lacking [22], it has been shown that the presence of nurses brings peace of mind and leads to family support [23].

“Note changes in the family” is necessary for engaging with families while capturing not only current family phenomena but also anticipated future family phenomena. It is important to capture changing family phenomena. Attention should be paid to facial expressions that reveal the emotions of others, such as whether their facial expressions are softening or whether their brows are furrowing [20]. When sensing someone’s anxiety or tension, words can be used to soothe them, and speaking speed, volume, and tone of voice can be changed to make them feel comfortable talking [24].

“Create an atmosphere where the family feels comfortable talking” suggests preparing a quiet environment and creating a comfortable venue for communication, implicitly conveying that this will be a time-consuming opportunity for communication and providing the family with mental preparation and space [24]. Matching the pace of the subject’s emotional expression is called pacing, which is a method of speaking by adjusting speaking speed and volume to match the other person’s. Mirroring, a method of synchronizing one’s movements and facial expressions with other persons, as if reflected in a mirror, is also said to make other persons feel more comfortable and accepted, facilitating discussion [25].

“Use touching and massaging with the family”, which was added based on the free-form responses in Round 1, received a low agreement rate in Round 2. Touching and massage are family healing methods [26]. This result revealed that utilizing family healing is not particularly important in therapeutic communication.

4.2.3. Verbal and Non-Verbal Communication

“Raise awareness of negative thinking held by the family” is a belief conversion that transforms negative family beliefs, which are unconstructive, passive, and pessimistic, into positive family beliefs [21]. Drawing out the family’s narratives of distress embedded in negative family beliefs is believed to correct and change family beliefs, leading to a conversion to positive family beliefs.

“Share the family’s strengths” praises the family’s positive qualities and motivates them to solve problems. Furthermore, focusing on family strengths deepens family bonds and allows family members to view their situation from various perspectives [27]. Identifying family strengths, communicating them to family members, and helping them recognize their own strengths have a positive impact on families [28]. Clarifying family strengths and sharing them with all family members helps nurses build rapport with the family to motivate them and foster their own willingness to solve problems [29].

“Listen actively to the family” refers to an attitude of actively listening to family members and trying to understand the details of what they are saying and their feelings [30]. Active listening is optimal communication [31]. It means being supportive to gather detailed information about family members, thereby improving trust in mutual relationships and family adherence [32].

The questionnaire response rate was low, at 31.3% in Round 1 and 28.6% in Round 2, and the findings must be interpreted with caution when making general conclusions. This study targeted visiting nurses working at visiting nursing stations, and opinions from nurses working in hospitals were not obtained. Expanding the panel would be desirable in the future. Furthermore, since using therapeutic communication methods requires understanding the intent (purpose), context, and expected effects, it would be necessary to investigate each item separately.