Mental Health and Wellbeing

Workshop Activity

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Table of Contents

1. Introduction ............................................................................................... 3

2. Communication skills, Engagement and Therapeutic alliance ............... 3

2.1. Therapeutic relationship and Engagement ...................................... 3

2.2. Communication skills .................................................................... 4-6

3. “Bucket” and Timeline assessment ........................................................... 6

4. Reflection on communication skills during the assessment ...................... 6

5. Incorporate the knowledge of the assessment tools and communication

skills in my future nursing practice. ........................................................... 7

6. Conclusion ................................................................................................ 7

7. References ........................................................................................... 8-10

Appendix I ...................................................................................................... 10

Appendix II ................................................................................................ 11-14

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1. Introduction

Communication is a fundamental principle in the evolution of therapeutic nurse-

patient relationship by utilising effective interpersonal communication techniques

(Juvé-Udina et al., 2014). This essay will first discuss the therapeutic relationship,

engagement and communication skills; followed by completing the “Bucket” list and

Timeline through interviewing Blanca; then reflect on my communication skills

throughout the interview. Lastly, it will incorporate the knowledge of the assessment

tools and communication skills in my future nursing practice.

2. Communication skills, Engagement and Therapeutic alliance

2.1. Therapeutic relationship and Engagement

One of the core mental health assessment tools is mini-Mental State Examination

(MMSE), which is appropriate for assessing client’s mental health condition by using

therapeutic communication to build-up therapeutic relationship with the client

(Zelonis, 2006). It provides a positive outcome to establish a diagnosis or judgement,

as all interventions and management plans are depending on the facts collected

throughout assessment (Martin & Street, 2003).

Therapeutic rapport comforts and relaxes a patient’s state of mind. A strong

therapeutic rapport cultivates a calming environment to create ease, thereby

reducing the level of anxiety (Gardner, 2010). Trust is greatly vital in maintaining

communication. If clients do not have confidence in the health professionals, it is

possible that they will not disclose all information that can be significantly important

and helpful to their nursing care plan and future management. Nurses should show

care for their patients by being available and present, actively listening to patients

and maintaining confidentiality during trust development (Stickley, 2011). By

providing resources and suggestions, a therapeutic alliance empowers the patient to

make appropriate decision for themselves. For instance, this would prevent them

from resorting to negative coping strategies such as alcoholism, drug abuse, self-

harm or violence. Empathy is another important therapeutic feature that nurses must

practice repeatedly. A compassionate understanding of the individuals’ awareness of

his/her struggles is essential to the development of rapport. It is crucial to have the

skills to enter the patient’s “own world” and understand their feelings and thoughts

without judgement (Casella, 2015). Moreover, genuineness is beneficial to both client

and nurse for building successful therapeutic rapport. Juvé-Udina et al. (2014)

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pointed out that it is important for nurses to be honest and approachable instead of

being rigid and controlling. In addition, respect is part of the holistic care in nursing

practice. It is the duty of a Registered Nurse never to be stereotypical (Martin &

Street, 2003). If patients are respected, they will feel less anxious and more involved

in the process of assessment. Additionally, nurses should continually show positive

regard to patients while conducting the assessment. According to Williams and Irurita

(2004), health professionals should demonstrate acceptance sincerely rather than

superficially. Casella (2015) also points out that it is important for the health

professionals to be capable of isolating their opinions from the clients. With this,

clients should be able to get involved without worry of being disregarded, so as to

build-up self-confidence. Therefore, nurses must possess these basic skills to avoid

subjective biases, and provide an accepting and safe atmosphere for the client.

2.2. Communication skills

Registered Nurses should implement their knowledge of cultural diversity to

establish a racially ingenious nursing practice, as cultural sensitivity, competence

and awareness play a crucial role in nursing practice (Rasheed, 2015). This allows

Registered Nurses to be more efficient in carrying on assessments and delivering

care. For instance, nurses should hire an interpreter to eliminate the issue of

language barriers during assessment, which would gain the patient’s trust and gather

accurate data despite cultural differences.

Therapeutic communication skills are valuable for all health professionals while

engaging with clients. These skills include the practice of active listening, rephrasing

and reflection. Health professionals actively listen by assuring the clients that they

have heard and completely understood the issue. It is essential to observe client’s

behaviour as well as filter through the given information so that assessment is not

conducted blindly. (Xu, Staples & Shen, 2012). To ensure that the health

professional has received fully comprehensive information, rephrasing is highly

encouraged. Rephrasing is a response method used by nurses where information is

reiterated back to the patient. This helps patients elaborate on their situation so that

all aspects of the issue are thoroughly covered (Ünsal et al., 2014). Lastly, reflection

is a skill implemented across active listening which alters questions to direct the

patient’s thoughts to the subject at hand. Through this, nurses ask relevant questions

to help patients self-recognise the specific issue related to the initial problem

(Gardner, 2010).

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Registered Nurses should have the appropriate linguistic skills that encompass

confidentiality, courtesy, professionalism and reassurance. In the process of

interpersonal communication, Registered Nurses should be sensitive towards the

client instead of being apathetic (Xu et al., 2012). This can be done by maintaining a

calm manner while conducting assessments. Using a soft and warm tone with proper

facial expressions and gestures are ways to achieve a calm stance (Lima-Basto,

Gomes, Potra, Diogo & Reis, 2010). While verbal communication is essential, silence

gives clients an opportunity to reflect.

Questioning is another important tool of verbal communication as it helps in

developing trust and rapport, demonstrating empathy, recognizing patient’s

experience and bringing out necessary health information (Casella, 2015). The semi-

structured interview layout is a first choice in almost all circumstances, as the

conversation is logical without being controlled (Philpin, Jordan & Warring, 2005).

During the semi-structured interview, clients are asked a list of exploratory questions

on several topics. Their answers may create some further questions that have to be

responded prior to the next topic (Zelonis, 2006). However, nurses should not limit

the interaction based on the questions from the paper. It allows clients to provide

substantially detailed responses because they feel involved in the assessment.

Nurses have to be aware of their behaviour as it may alter the success of the

interview (Philpin et al., 2005). Primarily, nurses should start off with standard

questions, in order to bond with the client and allow them to be at ease. The

interview should commence in a relaxing and quiet environment at all times. It is also

important to encourage the client to carry through the interview accurately and fully.

Breckman (2007) explored the abbreviation SOLER of Egan’s theory. It is the non-

verbal communication that helps make a client feel cared and comfortable during the

interview. This can be done by sitting directly facing the client, keeping an open

posture, leaning towards the client to some extent, creating and maintaining eye

contact and choosing a comfortable position. These are distinct approaches that

handle communication development and encourages clients to discuss their thoughts

and feelings. Therapeutic communication should be carried out in a quiet, peaceful

and positive tone of voice to house a harmless and safe aura (Stickley, 2011). The

patient should be encouraged to practice any kinds of communication such as writing

and drawing to promote effective communication. Furthermore, MMSE helps clients

to assess his/her beliefs and explore alternatives that promote therapeutic

engagement (Lima-Basto et al., 2010).

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3. “Bucket” and Timeline assessment

I have conducted a face-to-face semi-structured interview with Blanca, who is a

29 year-old Singaporean Registered Nurse. I have utilised the Brabban and

Turkington (2002) of stress vulnerability “Bucket” model as given in Appendix I. The

timeline can be seen in Appendix II, which recognizes her stress aspects across the

lifespan and coping strategies to stressors.

4. Reflection on communication skills during the assessment

I utilised the first stage of Egan’s model in my interview to explore Blanca’s life

story (Breckman, 2007). I actually used active listening techniques during the

interview with Blanca. I clarified what she said to me and made sure I understood the

initial meaning of her messages. Additionally, I maintained eye contact, relaxed body

language and showed interest in her responses as well as sent proper messages to

her through calming gestures. Therefore, she felt comfortable to do the interview with

me. During the interview, I tried to sound compassionate and encouraging when I

started my opinion by saying, “I understood it was hard for you to fail academics and

face disappointment from family, but you have done an excellent job of coping with it

by seeking help from friends and teachers.” (Appendix II) Blanca was feeling

supported after hearing my response as she felt my empathy, genuineness and had

faith in me. This enhanced a stronger bonding of therapeutic relationship between

us. However, I did not adapt summarising techniques while interacting with Blanca.

According to Ünsal et al. (2014), nurses should summarise the patients’ response to

confirm the truthfulness of their thoughts and feelings. In the future, I will ask patients

to summarize the topics, ideas, learning and problem-solving methods made

throughout the engagement. It also assists patients to gain confidence and self-

awareness of their improvement as the nurse is concentrating on them during the

communication (Lima-Basto et al., 2010). Moreover, I did not apply the leading

techniques well during the interview with Blanca. However, due to the high comfort

level between Blanca and I, she sometimes drifted off from the question. This

resulted in unnecessary information as she lost focus of the purpose of the

assessment. For example, while we were discussing the relationship with Daniel, she

started to digress to Daniel’s family, instead of concentrating on her feelings and

thoughts towards the cheating problem (Appendix II). It is important for the health

professional to lead the conversation as they can target the patient’s emotions to

better understand their situation (Rasheed, 2015). In the future, I will develop my

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skills in leading by politely redirecting clients to the main subject of the interview

which will only collect important data for recognising his/her problem, as well as

enabling them to share his/her feelings and ideas through the assessment.

5. Incorporate the knowledge of the assessment tools and communication

skills in my future nursing practice.

In future nursing practices, I will apply therapeutic communication skills into the

stress vulnerability assessment to build up a therapeutic interpersonal relationship,

which will readily recognize initial patient’s life stress events and adverse coping

strategies that highly likely induce their vulnerability to experience mental health

illness (Williams & Irurita, 2004). In Blanca’s case, she was comfortable to openly tell

me about dealing with Daniel by binge eating and drinking which did not help her

unhappiness and increased her low self-esteem. Furthermore, this assessment

provides a complete picture of the clients’ life to health professionals by using

effective communication skills, which enhance the patient-focused care and support

the acceptance of prolonging care (Williams & Irurita, 2004). In the future, I will

strengthen my therapeutic communication skills by including verbal and non-verbal

language, active listening, compassion, fair-mindedness and honesty. The rapport

enables patients to feel comfortable and have faith in receiving adequate nursing

care. For instance, when comforting patients receiving bad news, nurses should let

them know we would be there to support and listen to them. These nursing

techniques allow the best quality of care for every patient. Lastly, I will remember to

take my time to reflect on how I think the interview went and how I could do better

next time. I will make sure that the patient’s problem is not misunderstood after

interpretation and ensure that the patient does not deviate from the topic.

6. Conclusion

To sum up, the main points that have been explained in this paper are the factors

of therapeutic communication skills, my strengths and weaknesses of communication

techniques, as well as implementing these skills and tools in my future nursing

practice. As a nurse, I should deliver comprehensive care for each patient with

compassionate understanding. In addition, I should be fair-minded regardless of the

patient’s crisis or culture differences. In general, nurses use positive and therapeutic

communication skills while engaging with clients, which can help to develop a

therapeutic relationship for my future nursing practice.

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7. References

Brabban, A., & Turkington, D. (2002). Search for meaning: Detecting congruence between life events underlying schema and psychotic symptoms. In A.P. Morrison (Ed.), Casebook of cognitive therapy for psychosis ch. 5 (pp. 59-75). Retrieved from http://link.library.curtin.edu.au/p?pid=CUR_ALMA51113460380001951

Breckman, B. (2007). Egan's skilled helper model - developments and applications in counselling. Nursing Standard, 21, 30. Retrieved from http://search.proquest.com/docview/219863104?accountid=10382

Casella, S. M. (2015). Therapeutic rapport: The forgotten intervention. Journal of Emergency Nursing, 41, 252-254. http://dx.doi.org/10.1016/j.jen.2014.12.017

Gardner, A. (2010). Therapeutic friendliness and the development of therapeutic leverage by mental health nurses in community rehabilitation settings. Contemporary Nurse: A Journal for the Australian Nursing Profession, 34, 140-148. Retrieved from http://search.proquest.com/docview/374988030?accountid=10382

Juvé-Udina, M., Pérez, E. Z., Padrés, N. F., Samartino, M. G., García, M. R., Creus, M., . . . Calvo, C. M. (2014). Basic nursing care: Retrospective evaluation of communication and psychosocial interventions documented by nurses in the acute care setting. Journal of Nursing Scholarship, 46, 65-72. Retrieved from http://search.proquest.com/docview/1537382722?accountid=10382

Lima-Basto, M. B., Gomes, I., Potra, T., Diogo, P., & Reis, A. (2010). Therapeutic instruments used in therapeutic interventions: Is there evidence in nursing care? A systematic review of the literature. International Journal of Caring Sciences, 3, 12-21. Retrieved from http://search.proquest.com/docview/1114167663?accountid=10382

Martin, T., & Street, A. F. (2003). Exploring evidence of the therapeutic relationship in forensic psychiatric nursing. Journal of Psychiatric and Mental Health Nursing, 10, 543-551. Retrieved from http://search.proquest.com/docview/198657333?accountid=10382

Philpin, S. M., Jordan, S. E., & Warring, J. (2005). Giving people a voice: Reflections on conducting interviews with participants experiencing communication impairment. Journal of Advanced Nursing, 50, 299-306. Retrieved from http://search.proquest.com/docview/232499908?accountid=10382

Rasheed, S. P. (2015). Self-awareness as a therapeutic tool for Nurse/Client relationship. International Journal of Caring Sciences, 8, 211-216. Retrieved from http://search.proquest.com/docview/1648623531?accountid=10382

Stickley, T. (2011). From SOLER to SURETY for effective non-verbal communication. Nurse Education in Practice, 11, 395-398. http://dx.doi.org/10.1016/j.nepr.2011.03.021

Ünsal, G., Karaca, S., Arnik, M., Oz, Y., Asik, E., Kizilkaya, M., . . . Sipkin, S. (2014). The opinions of nurses who work in psychiatry clinics related to the roles of psychiatry nurses. Marmara Üniversitesi Saglik Bilimleri Enstitüsü Dergisi, 4, 90. http://dx.doi.org/10.5455/musbed.20140527033928

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Williams, A. M., & Irurita, V. F. (2004). Therapeutic and non-therapeutic interpersonal interactions: The patient's perspective. Journal of Clinical Nursing, 13, 806-815. Retrieved from http://search.proquest.com/docview/235001002?accountid=10382

Xu, Y., Staples, S., & Shen, J. J. (2012). Nonverbal communication behaviors of internationally educated nurses and patient care. Research and Theory for Nursing Practice, 26, 290-308. Retrieved from http://search.proquest.com/docview/1315303317?accountid=10382

Zelonis, J. I. (2006). Therapeutic interaction in nursing. The Journal of Continuing Education in Nursing, 37, 280. Retrieved from http://search.proquest.com/docview/223321187?accountid=10382

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Appendix I

Lack  of  family  attention  after  younger  brother  was  born  

Poor  academic  performance  

Parental  disappointment  

Didn’t  fit  into  social  group  at  school  

Parents  argued  in  front  of  her  most  of  the  time  

Failed  to  get  into  university  

Mother  stopped  caring  

Worst  break  up  

Caught  boyfriend  (Daniel)  cheating  Binge  eating  and  drinking  alcohol    

Got  tutoring  

Went  clubbing;  smoking  and  drinking  heavily;  loss  of  appetite      

Hangout  more  with  a  friend  

(Jane)    

Got  into  Nursing  School    

Listened  to  best  friend  (Nico

lle)  

Positive  Coping  Strategies  

Negative  Coping  Strategies  

(Brabban & Turkington, 2002) – Bucket Filling Analogy  

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Appendix II Timeline

Date Significant Events Mental Health Issues Born 1986 Happy early childhood

Good memories

1990 Started Kindergarten. Enjoyed seeing friends at school. Felt love overflow from parents

She said “parents and grandparents always gave me hugs and kisses regardless where we were.”

1992 Started first year of private primary school. Felt like a princess in the family as they all “spoiled” her as she was the only child in the family tree

1993 Brother born. He took away all the attention from adults because he is the first baby boy. Didn’t like young brother very much. Made loads of friends at school. Couldn’t keep up with schoolwork and had loads of tutoring after school time.

She stated “feeling like an idiot for not being able to understand stuff at school.”

1996 Ended primary school. Mother was disappointed that her daughter couldn’t get into private school with her average grades.

She said “I’m such a loser and ruining my family’s reputation.” “Don’t know how to behave in the family gathering!”

1997 Started public secondary school. Overwhelmed with the transition from single-sex to coeducational school. Didn’t fit into group in relation to her geeky look. Had a few friends only.

Low self-esteem

1999-2001 Parents started to fight a lot every day. Felt annoyed and didn’t like to stay home. Became closer to a friend

She said ”I hated when I starting to hear them shout or yell at each other no matter what time it was ”

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(Jane) who taught her the way to “fit into” the school.

2002 1st relationship. Treated “boyfriend” like a step-brother rather than having real boyfriend-girlfriend feelings. Wanted to try what is like to be in a “relationship”. Didn’t feel that was a special thing as it was boring.

2003-2004 Senior year- Mutual break up with the “boyfriend”. Felt fine with it. Failed the examination and didn’t get into college. Mother didn’t care about her as much afterwards.

She stated “I’m used to being a disappointment to the family, and it’s not the first time being neglected anyway.”

2005 Started Diploma of Enrolled Nurse, due to insufficient points to get into school of education. Always wanted to become a teacher.

Had poor appetite. Loss weight rapidly. Started to go clubbing, drinking and smoking, as she didn’t want to stay home and watch her parents fight.

2006-2009 2nd relationship – with Daniel who was a bartender but became unemployed once the relationship started. Smoked at least 2 packs a day due to negative influence from him. Fully supported his finances. Felt so in love with him and couldn’t live without him. Lost her virginity under Daniel’s pressure. Low self-image because Daniel called her “fat” and “obese”. Broke up after caught him

Overthinking and worried that he would cheat again. She said “I was too paranoid that a random girl from the street was able to take him away from me.” Started binge eating and drinking alcohol everyday after 1st break up Ran away from home to stay with boyfriend multiple times Extremely heartbroken after 2nd break up

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cheating. Patched back after he swore to change. She consistently imagined him cheated everyday again. She caught him cheating the 2nd time. Stopped working and studying for weeks and just stayed at home.

2010 Her nursing school best friend (Nicolle) suggested further studies as a distraction from the heart breaking experience. She decided to complete a nursing degree in America. Felt like a turning point in life.

She stated “I think Nicolle’s idea wasn’t bad. Changing the environment would help me move on.”

2011 Started college in America. Found a part-time carer job and made some friends at work and university. 3rd relationship – with Ayman who was a medical student in the same college. He made her feel happy and confident. She had never felt this happy to be in a relationship before.

She said “Ayman makes me feel like I’m living in a dream, as I haven’t felt this happy since I was little. I’m glad that my life has turned away from darkness ”

2012-2014 Finished nursing degree with honours. Became a Registered Nurse in a private hospital.

Present Engaged to Ayman. Planning the wedding. Feeling happy and excited.

She said “I want to be a good housewife and mother. I especially want my kids to feel loved and cared for at all times.”