continuation of the nursing process

NCM 105PSYCHIATRIC-MENTAL HEALTH NURSING-PART 2Psychiatric Nursing Practice – The Nursing Process

Lectured by Leila T. Salera, RN, MD, DPSP

ECT – ELECTROCONVULSIVE THERAPY

ECT

Has been used continuously for more than 50 years The induction of a grand mal seizure through the

application of electrical current to the brain Duration of seizure should be at least 25 seconds

(Sadock and Sadock) Most clients require an average of 6 to 12

treatments Some may require up to 20 treatments Administered usually every other day, three times

per week Performed on an inpatient basis for those that

require close observation and care (suicidal, agitated, delusional, catatonic, or acutely manic)

( Townsend Chapter 22; Student Guide, pages 53 to 56)

ECT Indications:a. Major depression – not often the treatment of

choice but is considered only after a trial of therapy with antidepressant medication has proven ineffective

b. Mania – rarely used for this purpose; for those who do not tolerate or fail to respond to lithium or other drug treatment, or when life is threatened by dangerous behavior or exhaustion

c. Schizophrenia – can induce remission in some clients with acute schizophrenia, particularly if it is accompanied by catatonic or affective symptomatology; no value among clients with chronic shizophrenia


ECT

Other conditions it is being used:a. Neurosesb. OCD – obsessive compulsive disorderc. Personality disorderd. Postpartum psychoses Mechanism of action (theories)a. Electrical stimulation results in significant

increases in the circulating levels of several neurotransmitters (serotonin, NE, and dopamine) which are affected by antidepressant drugs

b. May also result in increases in glutamate and GABA


ECT

Side effectsa. Temporary memory loss and confusion

(most common)b. Permanent memory loss (?)c. Occasional cardiac dysrhythmiasd. Brain damage – 2 per 100,000 treatments


ECT

Nursing interventions prior to ECTa. Explain the procedureb. NPO for 8 hours (after midnight)c. Have consent signedd. Ensure labs and diagnostic examinations are

all done results available: CBC, urinalysis, X-ray

e. Empty bowel and bladderf. Take vital and record signs approximately 1

hour prior to treatment is scheduledg. Client should remain in bed with side rails up( Townsend Chapter 22; Student Guide, pages 53 to 56)

ECT

Nursing interventions prior to ECTh. Client should be changed into a hospital gowni. Administer premedications 30 minutes prior to

treatment – atropine or glycopyrolate (anticholinergics) IM

j. Remove anything conductivek. Stay with client to allay fears and anxietyl. Maintain a positive attitudem. Encourage verbalization of feelingsn. Ensure airway patencyo. Restraints as necessary( Townsend Chapter 22; Student Guide, pages 53 to 56)

ECT

Nursing interventions during ECTa. Provide suctioning as neededb. Assist anesthesiologist with oxygenation as

requiredc. Observe readouts on machines monitoring

vital signs and cardiac functioningd. Provide support to the client’s arms and

legs during the seizuree. Observe and record the type and amount of

movement induced by the seizure( Townsend Chapter 22; Student Guide, pages 53 to 56)

ECT

Nursing interventions after ECTf. Allow the client to verbalize fears and

anxieties related to receiving ECTg. Stay with the client until he or she is fully

awake, oriented, and able to perform self-care activities without assistance

h. Provide the client with a highly structured schedule of routine activities in order to minimize confusion


PSYCHOTHERAPY

PSYCHOTHERAPY

Any procedure that promotes the development of courage, inner security and self confidence making the person more functional

Most important element is trust and communication

A form of mental exploration that should be individualized

( Student Guide, pages 58 to 60)

INDIVIDUAL PSYCHOTHERAPY

Method of bringing about change in a person by exploring his or her feelings, attitudes, thinking, and behavior

Involves one-to-one relationship between the therapist and the client

Therapist’s theoretical beliefs strongly influence his or her style of therapy

Nurse or other health care provider who is familiar with the client may be in a position to recommend a therapist or a choice of therapists

(Videbeck pages 56 to 61)

GROUP THERAPY

Clients participate in sessions with a group of people

The members share a common purpose and are expected to contribute to the group to benefit others and receive benefit from others in return

Group rules are established, which all members must observe, which vary according to the type of group


GROUP THERAPY

The therapeutic results of group therapy include the following:

a. Gaining new information, or learningb. Gaining inspiration or hopec. Interacting with othersd. Feeling acceptance and belonginge. Becoming aware that one is not alone and that

others share the same problemsf. Gaining insight into one’s problems and

behaviors and how they affect othersg. Giving of oneself for the benefit of others

(altruism)(Videbeck pages 56 to 61)

GROUP THERAPY

Psychotherapy groups1. Family therapy2. Family education3. Education groups4. Support groups5. Self-help groups


PSYCHOTHERAPY GROUPS Goal: for members to learn about their behavior and to

make positive changes in their behavior by interacting and communicating with others as a member of a group

Often formal in structure, with one or two therapists as the group leaders

Two typesa. Open groups – ongoing and run indefinitely, allowing

members to join or leave the group as they need tob. Closed groups – structured to keep the same

members in the group for a specified number of sessions; members decide how to handle members who wish to leave the group and the possible admission of new group members


PSYCHOTHERAPY GROUPS-FAMILY THERAPY

A form of group in which the client and his or her own family members participate

The goals include understanding how family dynamics contribute to the client’s psychopathology, mobilizing the family’s inherent strengths and functional resources, restructuring maladaptive family behavioral styles, and strengthening family behavioral styles, and strengthening family problem-solving behaviors

Can be used both to assess and to treat various psychiatric disorders


PSYCHOTHERAPY GROUPS-FAMILY EDUCATION

A unique 12-week Family-to-Family Education Course developed by the National Alliance for the Mentally Ill (NAMI)

Taught by trained family members, the curriculum focuses on schizophrenia, bipolar disorder, clinical depression, panic disorder, and obsessive-compulsive disorder

Discusses clinical treatment of these illnesses and teaches knowledge and skills that family members need to cope more effectively


PSYCHOTHERAPY GROUPS-EDUCATION GROUPS

Goal is to provide information to members on a specific issue-for instance, stress management, medication management, or assertiveness training

The group leader has expertise in the subject area and may be a nurse, therapist, or other health professional

Usually scheduled for a specific number of sessions and retain the same members for the duration of the group


PSYCHOTHERAPY GROUPS-SUPPORT GROUPS

Organized to help members who share a common problem to cope with it

The group leader explores members’ thoughts and feelings and creates an atmosphere of acceptance so that members feel comfortable expressing themselves

Often provide a safe place for members to express their feelings of frustration, boredom, or unhappiness and also discuss common problems and potential solutions


PSYCHOTHERAPY GROUPS-SELF-HELP GROUPS

Members share a common experience, but the group is not a formal or structured therapy group

Professionals organize some self-help groups, many are run by members and do not have a formally identified leader

Examples: Alcoholics Anonymous (AA), Parents Without Partners, Gamblers Anonymous, and Al-Anon (a group of spouses and partners of alcoholics)

Some have national headquarters and Internet websites

Most have a rule of confidentiality(Videbeck pages 56 to 61)

COMPLEMENTARY AND ALTERNATIVE THERAPIES Alternative medical systems – yoga, herbal medicines,

acupuncture, etc… Mind-body interventions – meditation, prayer. Mental

healing, and creative therapies that use art or music Biologically based therapies – use substances found in

nature, such as herbs, food, vitamins Manipulative and body-based therapies – therapeutic

massage and chiropractic or osteopathic manipulations Energy therapies – two types: a) biofield therapies,

intended to affect energy fields that are believed to surround and penetrate the body (therapeutic touch, qi gong, Reiki) and b) bioelectric-based therapies, involving use of electromagnetic fields, such as pulse fields, magnetic fields, and AC or DC fields

(Videbeck, pages 56 to 61)

PSYCHIATRIC REHABILITATION

Involves providing services to people with severe and persistent mental illness to help them to live in the community

Often called community support programs Focuses on the client’s strengths, not just on

the illness Client actively participates in program planning Programs are designed to help the client

manage the illness and symptoms, gain access to needed services, and live successfully in the community


PSYCHOSOCIAL INTERVENTIONS

Nursing activities that help enhance the client’s social and psychological functioning and improve social skills, interpersonal relationships, and communication

(Videbeck, pages 56 to 61; Student Guide, pages 58 to 59 and 72 to 82)

COMMUNITY-BASED CARE – WHO/DOH

Mental Health Sub-ProgramsA. Wellness of Daily LivingB. Extreme Life Experiences C. Mental DisorderD. Substance Abuse Disorder

(Public Health Nursing in the Philippines, 2007, pages 231)

COMMUNITY-BASED CARE – WHO/DOH

Home care is advocated Acute cases are referred to the National Center for

Mental Health (NCMH) or hospitals with psychiatric facilities for proper management

They are screened and after a few days they are assessed and discharged if they can be managed at home

Cases needing continuing supervision and care may be confined

A team from the NCMH follow up their discharged patients in the provinces


COMMUNITY-BASED CARE- WELLNESS OF DAILY LIVING

Wellness of Daily Living – The process of attaining and maintaining mental well-being across the life cycle through the promotion of healthy lifestyle with emphasis on coping with psychosocial issues

Objectives:1. To increase awareness among the population

on mental health and psychosocial issues2. To ensure access of preventive and promotive

mental health services (Public Health Nursing in the Philippines, 2007, pages 231)

COMMUNITY-BASED CARE- EXTREME LIFE EXPERIENCES

Objectives:1. To differentiate between critical incident and

extreme life experiences2. To identify situations which may be extreme life

experiences3. To categorize/prioritize the extreme life

experience which may be the concern of mental health

4. To identify programs that could address psychosocial consequences and mental health issues of persons with extreme life experiences


COMMUNITY-BASED CARE- MENTAL DISORDER

Objectives:1. Promotion of mental health and prevention

of mental illness across the lifespan and across sectors (children and adolescents, adults elderly, and special population such as military, OFWs, refugees, persons with disabilities)


COMMUNITY-BASED CARE- NURSING RESPONSIBILITIES In mental health promotion1. Participate in the promotion of mental health among

families and the community2. Utilize opportunities in his/her everyday contacts with

other members of the community to extend the general knowledge on mental hygiene

3. Help people in the community understand basic emotional needs and the factors that promote mental well being

4. Teach parents the importance of providing emotional support to their children during critical periods in their lives like first day in school graduation, etc…


COMMUNITY-BASED CARE- NURSING RESPONSIBILITIES In prevention and control1. Recognize mental health hazards and stress

situations as unemployment, divorce or abandonment of children, vices, long standing physical illness, all of which make heavy demands on the emotional resources of the persons concerned

2. Recognize pathological deviations from normal in terms of acting, thinking and feeling and make early referral so that diagnosis and treatment could be done early.

3. Be aware of potential causes of breakdown and when necessary take some possible preventive action.


COMMUNITY-BASED CARE- NURSING RESPONSIBILITIES In prevention and control4. Help the family to understand and accept the

patient’s health status and behavior sp that all its members may offer as much support in the readjustments to home and community

5. Help patient assess his/her capacities and his/her handicaps in working towards a solution of his/her problem

6. Encourage feeling of achievement by setting health goals that patient can attain

7. Encourage the patient to express his/her anxieties so that fears and misconceptions can be cleared up


COMMUNITY-BASED CARE- NURSING RESPONSIBILITIES

In prevention and control8. Impart information and guidance about the

treatment scheme of the patients, the desired and undesirable effect of the tranquilizers, psychiatric emergency management and other nursing care


COMMUNITY-BASED CARE- NURSING RESPONSIBILITIES Rehabilitation1. Initiate patient participation in occupational activities

best suited to patient’s capabilities, education, experience and training, capacities and interest

2. Encourage and initiate patients to partake in activities of CIVIC organization in the community through the cooperation of the patient’s family

3. Advise the family about the importance of regular follow-up at the clinic

4. Make regular home visits to observe patients’ conditions during conversation and follow-up of medication


COMMUNITY-BASED CARE- NURSING RESPONSIBILITIES

In research and epidemiology1. Participate actively in epidemiological

survey to be aware of the size and extent of mental health problems in the community and to organize a program for better preventive, curative and rehabilitative measures.


STANDARD 6 - EVALUATION

The psychiatric-mental health nurse evaluates progress toward attainment of expected outcomes

The continuous or ongoing phase of nursing process is evaluation.

Nursing care is a dynamic process involving change in the patient’s health status over time, giving rise to the need of new data, different diagnosis, and modifications in the plan of care.

(Videbeck, page 10; The Internet)

STANDARD 6 - EVALUATION When evaluating care the nurse should review all

previous phases of the nursing process and determine whether expected outcome for the patient have been met.

This can be done checking: 1. Have I done everything for my patient? 2. Is my patient better after the planned care? Evaluation is a feed back mechanism for judging the

quality of care given. Evaluation of the patient’s progress indicates what

problems of the patient have been solved, which need to be assessed again, replanted, implemented and re-evaluated.

(Videbeck, page 10; The Internet)

AREAS OF PRACTICE Basic-Level Functionsa. Counselingb. Milieu therapyc. Self-care activitiesd. Psychobiologic interventionse. Health teachingf. Case managementg. Health promotion and maintenance Advanced-Level Functionsa. Psychotherapyb. Prescriptive authority for drugs (US)c. Consultation and liaisond. Evaluatione. Program developmentf. And managementg. Clinical supervision(Videbeck, pages 11 to 12)

STUDENT CONCERNS

Student concerns are normal Usually do not persist once the students have

initial contacts with clients Some common concerns and helpful hints for

beginning students:“What is I say the wrong thing?”- No one magic phrase can solve a client’s

problems; likewise, no single statement can significantly worsen them

- Listening carefully, showing genuine interest, and caring about the client are extremely important


STUDENT CONCERNS

Some common concerns and helpful hints for beginning students:

“What will I be doing?”- In the mental health setting, many familiar tasks

and responsibilities are minimal- Physical care skills or diagnostic tests and

procedures are fewer than those conducted in a busy medical-surgical setting

- The student must deal with his or her own anxiety about approaching a stranger to talk about very sensitive and personal issues

- Development of the therapeutic nurse-client relationship takes time and patience


STUDENT CONCERNS


“What if no one will talk to me?”- Students sometimes fear that they will be

rejected by the client- Some clients may not want to talk, or are

reclusive, but may show that same behavior with experienced staff

- Students should not see such behavior as a personal insult or failure


STUDENT CONCERNS


“Am I prying when I ask personal questions?”- Personal questions should not be the first

thing a student says to the client- These issues usually arise after some trust

and rapport have been established- Ask sincere questions(Videbeck, pages 11 to 12)

STUDENT CONCERNS


“Ho will I handle bizarre or inappropriate behavior?”

- It is important to monitor one’s facial expressions and emotional responses so that clients do not feel rejected or ridiculed

- The nursing student instructor and staff are always available to assist the student in such situations

- Students should never feel as if they have to handle situations alone


STUDENT CONCERNS


“What happens if a client asks me for a date or displays sexually aggressive or inappropriate behavior?”

- Some clients have difficulty recognizing or maintaining interpersonal boundaries

- When client seeks contact of any type outside the nurse-client relationship, it is important for the student (with the assistance of the instructor or staff) to clarify the boundaries of the professional relationship


STUDENT CONCERNS



- Likewise, setting limits and maintaining boundaries are needed when a client’s behavior is sexually inappropriate

- Initially, the student might be uncomfortable dealing with such behavior, but with practice and the assistance of the instructor and staff, it becomes easier to manage


STUDENT CONCERNS



- It is also important to protect the client’s privacy and dignity when he or she cannot do so


STUDENT CONCERNS


“Is my physical safety in jeopardy?”- Actually, clients hurt themselves more often

than they harm others- Staff members usually closely monitor clients

with a potential for violence for clues of an impending outburst

- When physical aggression does occur, staff members are specially trained to handle aggressive clients in a safe manner


STUDENT CONCERNS


“What if I encounter someone I know being treated in the unit?”

- It is essential that the client’s identity and treatment be kept confidential

- If the student recognizes someone he or she knows, the instructor must be notified, and the instructor will decide on the situation

- Always reassure client that all will be kept confidential and the student will be reassigned


STUDENT CONCERNS


“What if I recognize that I share problems or backgrounds with clients?”

- No easy way to answer this question- We do not always know why some people

have serious emotional problems, while others do not, and yet they have similar life experiences

- Self-awareness is key(Videbeck, pages 11 to 12)

SELF-AWARENESS

The process by which the nurse gains recognition of his or her own feelings, beliefs, and attitudes

In nursing, being aware of one’s feelings, thoughts, and values is a primary focus

What would you do if you were assigned to a client who just had an abortion, and you are strong believer of anti-abortion?

Will your personal feelings and beliefs interfere with your work?

The nurse needs to discover him/herself and what he/she believes before trying to help others with different views


SELF-AWARENESS- POINTS TO CONSIDER

Keep a dairy or journal that focuses on experiences and related feelings

Talk with someone you trust about your experiences and feelings

Engage in formal clinical supervision. Even experienced clinicians have a supervisor with whom they discuss personal feelings and challenging client situations to gain insight and new approaches

Seek alternative points of view. Put yourself in the client’s situation and think about his or her feelings, thoughts, and actions


SELF-AWARENESS- POINTS TO CONSIDER

Do not be critical of yourself (or others) for having certain values or beliefs. Accept them as a part of yourself, or work to change those values and beliefs you wish to be different


THERAPEUTIC RELATIONSHIPS

The ability to establish therapeutic relationships with clients is one of the most important skills a nurse can develop

The therapeutic relationship is especially crucial to the success of interventions with clients requiring psychiatric care because the therapeutic relationship and the communication within it serve as the underpinning for treatment and success

(Videbeck pages 80 to 86)(Student Guide pages 59 to 69)

COMPONENTS OF A THERAPEUTIC RELATIONSHIPS

Trust Genuine interest Empathy Acceptance Positive regard Self awareness and Therapeutic use of self


COMPONENTS OF A THERAPEUTIC RELATIONSHIPS Trust1. Trust is built in the nurse-client relationship when the nurse exhibits

the following behaviors:a. Caringb. Opennessc. Objectivityd. Respecte. Interestf. Understandingg. Consistencyh. Treating the client as a human beingi. Suggesting without tellingj. Approachabilityk. Listeningl. Keeping promisesm. Honesty (Videbeck pages 80 to 86)(Student Guide pages 59 to 69)


Trust2. Congruence – occurs when words and

actions match Genuine interest1. The client perceives this when the nurse is

comfortable with him/herself and is aware of his strengths and limitations, and is focused

2. A client with mental illness can detect when someone is exhibiting dishonest or artificial behavior



Empathy 1. The ability to perceive the meanings of feelings

of the client and to communicate that understanding to the client

2. Being able to put him/herself in the client’s shoes

Acceptance 1. The nurse does not become upset or respond

negatively to a client’s outbursts, anger, or acting out

2. Avoiding judgment (Videbeck pages 80 to 86)(Student Guide pages 59 to 69)


Positive regard1. The nurse is able to appreciate the client as a

unique worthwhile human being2. The nurse can respect the client regardless of

his or her own behavior3. Unconditional nonjudgmental attitude Self-awareness 1. The nurse must first know him/herself before

he or she can attend to a client2. What are your values, attitudes, and beliefs?(Videbeck pages 80 to 86)(Student Guide pages 59 to 69)


Therapeutic use of self1. Self-awareness has been developed2. The nurse can use aspects of his or her

personality, experiences, values, feelings, intelligence, needs, coping skills, and perceptions to establish relationships with clients



Genuine interestClient: “I’m so confused! My son just visited and

wants to know where the safety deposit box key is.”

Nurse: “You’re confused because your son asked for the safety deposit box key?” (using reflection)

orNurse: “Are you confused about the purpose of

your son’s visit?” (using clarification)


AcceptanceClient: puts his arm around the nurse’s waistAppropriate response conveying acceptance

but not allowing the inappropriate behavior of the client to continue:

“ Sir, do not place your hand on me. We are working on your relationship with your girlfriend and that does not require you to touch me. Now, let’s continue.”

Inappropriate response:“ Sir, stop that! What’s wrong with you? I am

leaving, and maybe I’ll return tomorrow.”


Positive regardClient: I was so mad, I yelled and screamed at

my mother for an hour.”Which conveys positive regard or are

appropriate responses by the nurse?a. “Well that didn’t help did it?”b. “I can’t believe you did that.”c. “What happened then?”d. “You must really be upset.”


Therapeutic use of self- Johari Window 1. A “words portrait” of a person in four areas2. Each area indicates how well that person knows

him/herself and communicated with others Patterns of knowing- Nurse theorist Hildegard Peplau (1952) identified

preconceptions, or ways one person expects another person to behave or speak, as a roadblock to the formation of an authentic relationship


TYPES OF RELATIONSHIPS

Social relationship – primarily initiated for the purpose of friendship, socialization, companionship, or accomplishment of a task

Intimate relationship – involves two people who are emotionally committed to each other

Therapeutic relationship – focuses on needs, experiences, feelings, and ideas of the client only


ESTABLISHING THE THERAPEUTIC RELATIONSHIP

Phases:1. Orientation phase2. Working phasea. Problem identification subphaseb. Exploitation subphase3. Termination phase(Videbeck pages 87 to91)(Student Guide pages 59 to 69)


Phases:1. Orientation phasea. Begins when then nurse and client meet

and ends when the client begins to identify problems to examine

b. The nurse establishes the roles, the purpose of meeting, and the parameters of subsequent meetings

c. Identifies client’s problemsd. Clarifies expectations(Videbeck pages 87 to 91)(Student Guide pages 59 to 69)


Phases:2. Working phasea. Problem identification subphase – the client

identifies the issues or concerns causing problems

b. Exploitation subphase – the nurse guides the client to examine feelings and responses and develop better coping skills and a more positive self-image, to encourage behavior change and develop independence



Phases:3. Termination phasea. Also known as the resolution phaseb. The final stage of the nurse-client

relationshipc. It begins when the problem is resolvedd. Ends when the relationship is ended(Videbeck pages 87 to 91)(Student Guide pages 59 to 69)

THERAPEUTIC AND NON-THERAPEUTIC FORMS OF COMMUNICATION

Therapeutic communication- Is an interpersonal interaction between the

nurse and the client during which the nurse focuses on the client’s specific needs to promote an effective exchange of information

- Helps the nurse understand and empathize with the client’s experience

(Videbeck, page 98 to 116)


Therapeutic communication- Goals:1. Establish a therapeutic nurse-client relationship2. Identify the most important client concern at that

moment (the client-centered goal)3. Assess the client’s detailed actions as it unfolds4. Facilitate the client’s expression of emotions5. Teach the client and family necessary self-care

skills6. Recognize the client’s needs7. Guide the client toward identifying a plan of action

to a satisfying and socially acceptable resolution(Videbeck, page 98 to 116)

THERAPEUTIC AND NON-THERAPEUTIC FORMS OF COMMUNICATION Therapeutic communication- Privacy and Respecting Boundaries1. Privacy is desirable, but not always possible in a

therapeutic communication2. Proxemics – the study of distance zones between people

during communicationa. Intimate zone – 0 to 18 inches between people; parents

and young children, people who mutually desire personal contact

b. Personal zone – 19 to 36 inches; between family and friends who are talking

c. Social zone – 4 to 12 feet; acceptable for communication in social, work, and business settings

d. Public zone – 12 to 25 feet; speaker and audience, small groups, and other informal functions



Therapeutic communication1. Verbal communication – uses concrete

messages and abstract messages2. Non-verbal communication – body language,

eye contact, facial expression, tone of voice, speed and hesitations in speech, grunts and groans, and distance from the listeners



Therapeutic communication1. Toucha. Functional-professional touchb. Social-polite touchc. Friendship-warmth touchd. Love-intimacy touch



Therapeutic communication1. Concrete messages – the words are explicit

and need no interpretation2. Abstract messages – requires interpretation

by the listener like figure of speeches



Therapeutic communicationConcrete messages“What health problems caused you to come to

the hospital today?”Abstract messages“How did you get here?”The terms “how” and “here” are vague. To an

anxious client who is not thinking clearly:“Where am I?” or “The ambulance brought me

here?”(Videbeck, page 98 to 116)


Therapeutic communicationAbstract (unclear): “Get the stuff from him.”Concrete (clear): “He’ll be home today at 5pm,

and you can pick up your clothes at that time.”

Abstract (unclear): “Your clinical performance has improved.”

Concrete (clear): “To administer medications tomorrow, you’ll have to be able to calculate dosages correctly by the end of today’s class.”



Non-Therapeutic communicationa. Should be avoidedb. These responses cut off the communication

and make it more difficult for the interaction to continue

c. Asking “why” questions may be perceived as criticism by the client, conveying a negative judgment from the nurse


THERAPEUTIC COMMUNICATION TECHNIQUES

Accepting – indicating reception, you are listening and you have followed the train of thought

“Yes” or “I follow what you said” or simply nodding Broad opening – allowing the client to take the

initiative in introducing the topic, makes the client feel that he or she has the lead interaction

“Is there something you’d like to talk about?” Consensual validation – searching for mutual

understanding, for accord in the meaning of the words; to avoid any misunderstanding

“Tell me whether my understanding of it agrees with yours.”


Encouraging comparison – asking that similarities and differences be noted

“ Was it something like…?” Encouraging description of perception – asking

the client to verbalize what he or she perceives“What is happening?’ Encouraging expression – asking the client to

appraise the quality of his or her experiences“Tell me more about that.” Focusing – concentrating on a single point“Of all you’ve mentioned, which is the most

troublesome?”


Formulating a plan of action – asking the client to consider kinds of behavior likely to be appropriate in the future

General leads – giving encouragement to continue

Giving information – making available the facts that the client needs

Giving recognition – acknowledging, indicating awareness

“Good morning, sir.”“I noticed that you’ve combed your hair.”


Making observations – verbalizing what the nurse perceives

“You appear tense.” Offering self – making oneself available“I’ll stay here with you for a while.” Placing event in time or sequence – clarifying

the relationship of events in time“When did this happen?” Presenting reality – offering for consideration

that which is real“I see no one else in the room.”


Reflecting – directing the client actions, thoughts, and feelings back to the client

Client: “Do you think I should tell the doctor…?”Nurse: “Do you think you should?” Restating – repeating the main idea expressedClient: “I can’t sleep. I stay awake all night.”Nurse: “You have difficulty sleeping.” Seeking information – seeking to make clear

that which is not meaningful or that which is vague

Nurse: “I’m not sure I follow.”Nurse: “Have I heard you correctly.”


Silence – nurse says nothing but maintains eye contact

Suggesting collaboration – offering to share, to strive, and to work with the client to his or her benefit

Nurse: “Let’s go to your room, and I’ll help you find what you’re looking for.”

Summarizing – organizing and summing up that which has gone before

Nurse: “Have I got this straight.”Nurse: “You’ve said that…”


Translating into feelings – seeking to verbalize client’s feelings that he or she expresses only indirectly

Client: “I’m dead.”Nurse: “Are you suggesting that you feel lifeless?” Verbalizing the implied – voicing what the client

has hinted or suggestedClient: “I can’t talk to you or anyone. It’s a waste of

time.”Nurse: “Do you feel that no one understands?” Voicing doubt – expressing uncertainty about the

reality of the client’s perceptionsNurse: “Really?”

NON-THERAPEUTIC COMMUNICATION TECHNIQUES

Advising – telling client what to doNurse: “I think you should….” or “Why don’t

you…?” Agreeing – indicating accord with the client Belittling feelings expressed – misjudging the

degree of the client’s discomfort Challenging – demanding proof from the client Defending – attempting to protect someone or

something from verbal attackNurse: “This hospital has a fine reputation.” or

“I am sure your doctor has your best interests in mind.”

NON-THERAPEUTIC COMMUNICATION TECHNIQUES Disagreeing – opposing the client’s ideas Disapproving – denouncing the client’s behavior or

ideas; implies that the nurse has the right to pass judgment

Giving approval – sanctioning the client’s behavior or ideas; tends to limit the client’s freedom to think, speak, or act in a certain way, which could lead to the client acting a certain way just to please the nurse

Giving literal responses – responding to a figurative comment as though it were a statement of fact

Client: “They’re looking in my head with a TV camera.”

Nurse: “Try not to watch TV.” or “What channel?”

NON-THERAPEUTIC COMMUNICATION TECHNIQUES Indicating an existence of an external source –

attributing the source of thoughts, feelings, and behavior to others or to outside influences

Nurse: “What made you say that?” – implies that the client is compelled to think a certain way

Interpreting – asking to make conscious that which is unconscious, telling the client the meaning of his or her experience. The client’s thoughts and feelings are his own, hidden meaning are not meant for the nurse to discover, only the client knows.

Nurse: “What you really mean is…” or “Unconsciously, you’re saying…”

Introducing an unrelated topic – changing the subjectClient: “I’d like to die.”Nurse: “Did you have visitors this evening?”


Making stereotyped comments – offering meaningless clichés or trite comments

Nurse: “It’s for your own good.” or “Just have a positive attitude and you’ll be better in no time.”

Probing – persistent questioning of the clientNurse: “Tell me about this problem. You know I

have to find out.” or “Tell me your psychiatric history.”

Reassuring – indicating there is no reason for anxiety or other feelings of discomfort

Nurse: “Everything will be alright.”

NON-THERAPEUTIC COMMUNICATION TECHNIQUES Rejecting – refusing to consider or showing

contempt for the client’s ideas or behaviors’ This closes the chances of exploration, and the client may feel personally rejected along with feelings or ideas

Nurse: “Let’s not discuss….” or “I don’t want to hear about…”

Requesting an explanation – asking the client to provide reasons for thoughts, feelings, behaviors, events. There is a difference between this and asking the client to describe what is occurring or has taken place, and usually a “why” question is intimidating

Nurse: “Why do you think that?” or “Why do you feel that way?”


Testing – appraising the client’s degree of insight, which forces the client to recognize his or her problem. Helpful to the nurse, but not to the client

Nurse: “Do you know what kind of hospital this is?” or “Do you still have the idea that….?”

Using denial – refusing to admit that a problem exists. This implies that the nurse dismisses the seriousness of the situation

Client: “I’m nothing.”Nurse: “Of course you’re something – everybody’s

something.”Client: “I’m dead.”Nurse: “Don’t be silly.”