_,i CHAPTER 10t I can become a definite barrier to communication. To

q \. avoid overuse of restating, the nurse can combineI .}. restatements with direct questions that encourage

^. S vt descriptions: "What does yo:ur life lack?" 'vVhat kiid? \ S of meaning is missing?" "Descdbe a day in your lifed\R \ thatappearsemptytoyou.")t i $ Reflecting. Reflection is a means of assisting peo,ple1} \ .g to better understand their own thoughts and feelings.S , J \,' Reflecting may take the form of a question or a sim-\

.\ X ple statement that conveys the nurse's observations of\\ il the patient when sensitive issues are being discussed.

\P .$ S The nurse might then describe briefly to the patient the. > .n \ g apparent meaning of the emotional tone of the patient's\D S \\rverbal and nonverbal behavior. For examplg to reflect*i F.t} patient's feelings about his or her [t[e, a good begin-- \\ gning might be, "You sound as if you have had many

.

-o- d {dirJrrolr,t*"n t ."\ 6 ! \l sf'ri"i"g observations with a patimt shows accep-

tf.il h $ pta.,ce ,rrJ tl,ut the patient has^ your full attention.,,j...N)ffiJ"#."ffi;*xH#*r#r:mffm:l* $ X S::"fftT:"T:f:ff H",Tffil-:'"iH,*f;,li$r{N t .[usfinxg"#trmt"#:ffiT#

"ff f":H:l l:S t P $ $ technique (Amold & Boggs, 2007). For example:-

'\ ( \ Patient "Nurse, do you think I really need to behospitalized?"

Nurse: "What do you think, Jane?"Patient "I don't know; thafs why I'm asking you."Nurse: "I'll be willing to share my impression with

you at the end of this first session. Howevel,you've probably thought about hospitalizationand have some feelings about it. I wonder whatthey are."

Communication and the Clinical lnterview 181

Exploring. A technique that enables the nurse toexamine important.ideas, experiences, or relationshipsmore fully is exploring. For example, if a patient tellsyou he does not get along well with his wife, you willwant to further explore this area. Possible openersindude:

"Tell me msre abaut your relationship with yourwife."

"Describe your relationship with your wiJe."" Giae me an example of how you and your wife don't

get along."A"ki"g for an example can greatly claily a vague or

generic statement made by a patient.Patient "No one likes me."Nurss "Give me an example of one person who

doesn't like you."ofPatienh "Everything I do is wrong."Nurge: "Give me an example of one thing you do

that you think is wrong."Table 10-2 lisb more examples of therapeutic com-

munication techniques.

Asking Ouestions and Eliciting PatientResponsesOpen-Ended Ouestions. Many of the examplesabove and in Table 70-2 arc open-mded. fli.:er-i*end*dqalclrf,i+m* and commerrts encourage l*gthy rcsponsesand information about ercperiences, perrcqptions, orresponses to a situation- For example:

o "What do you perceive as your biggest problemright now?"

. "Give me an example of some of the stresses youare under right now"

. "Tell me more about your relationship with yourwrte?"

Text continued on page 184

$

N

Using silence Gives the person time to collect thoughts or Encouraging a person to talk by waiting for thethink through a point. answers.

Accepting lndicates that the person has been "Yes."understood. An accepting statement "Uh-huh."does not necessarily indicate agreement " l follow what you sayl'but is noniudgmental. (Nurse should notimply understanding when (slhe does notunderstand.)

Giving recognition lndicates awareness of change and personal "Good morning, Mr. JamesJ'efforts. Does not imply good or bad, right or "You've combed your hair todayl'wrong. "l see you've eaten your whole lunch."

Offers presence, interest, and a desire tounderstand. ls not offered to get the personto talk or behave in a specific way.

"l would like to spend time with youl'"l'll stay here and sit with you awhilel'

Continued

182 Unit 3 Psychosocial Nursing Tools

Offering general leads Allows the other person to take direction "Go on."in the discussion. lndicates that the nurse is 'And then7"interested in what comes next. "Tell me about itl'

Clarifies that the lead is to be taken by thepatient. However, the nurse discouragespleasantries and small talk.

"Where would you like to begin?""What are you thinking aboutT""What would you like to discuss?"

Puts events and actions in befter perspective.Notes cause-and-effect relationshipsand identifies patterns of interpersonaldifficulties.

"What happened before?""When did this happen?"

Making observations Calls attention to the person's behavior (e.9., "You appear tensel'trembling, nail biting, restless mannerisms). "l notice you're biting your lipsl'Encourages patient to notice the behav- "You appear nervous whenever John entersior and describe thoughts and feelings for the room."mutual understanding. Helpful with muteand withdrawn people.

Encouraging description of lncreases the nurse's understanding of the "What do these voices seem to be saying?"perception patient's perceptions. Talking about feelings "What is happening now?"and difficulties can lesssn the need to act "Tell me when you feel anxious."them out inappropriately.

Brings out recurring themes in experiencesor interpersonal relationships. Helps the per-son clarify similarities and differences.

"Has this ever happened before?"" ls this how you felt when... ?""Was it something like... 7"

Restating Flepeats the main idea expressed. Gives Patient: "1 can't sleep. I stay awake all nightl'the patient an idea of what has been Nurse; "You have difficulty sleeping?"communicated. lf the message has been ormisunderstood, the patient can clarify it. Patient: " l don't know. . . he always has some

excuse for not coming over or keeping ourappointments."

Nurse: "You think he no longer wants to seeyou?"

Reflecting Directs questions. feelings. and ideas bac{< Patient: "What should I do about my hus-to the patient. Encourages the patient to band's affair.?"accept his or her own ideas and feelings. Nurse; "What do you think you should do?"Acknowledges the patient's right to orhave opinions and make decisions and Patient: "My brother spends all of my moneyencourages the patient to think of self as a and then has the nerve to ask for more."capable person. Nurse: "You feel angry when this happens?"

Focusing Concentrates attention on a single point. "This point you are making about leav-It is especially useful when the patient ing school seems worth looking at morejumps from topic to topic" lf a person is closely."experiencing a severe or panic level of "You've mentioned many things. Let's go backanxiety, the nurse should not persist until to your thinking o{ ending it alll'the anxiety lessens.

Examines certain ideas, experiences, or "Tell me more about that."relationships more fully. ll the patient "Would you describe it more fully?"chooses not to elaborate by answering no, "Could you talk about how it was that youthe nurse does not probe or pry. ln sudr learned your mom was dying of cancer?"a case, the nurse respects the patient'swishes.

CHAPTER 1O Communication and the Clinical lnterview 183

Makes facts the person needs available.Supplies knowledge from which decisionscan be made or conclusions drawn. Forexample, the patient needs to know therole of the nurse; the purpose o{ thenurse-patient relationship; and the time,place, and duration of the meetings.

"My purpose for being here is... ""This medication is for... ""The test wlll determine.. . "

Seeking clarification Helps patients clarify their own thoughts and "l am not sure I follow youl'maximize mutual understanding between "What would you say is the main point ofnurse and patient. what you just said?"

"Give an example of a time you thoughteveryone hated youl'

Presenting reality lndicates what is real. The nurse does not "That was Dr. Todd, not a man from theargue or try to convince the patient, just Mafia."describes personal perceptions or facts in "That was the sound of a car backfiringl'the situation. "Your mother is not here; I am a nurse."

Voicing doubt Undermines the patient's beliefs by not "lsn't that unusual?"reinforcing the exaggerated or false "Really7"perceptions. "Thats hard to believe."

Seeking consensual Clarifies that both the nurse and patient share "Tell me whether my understanding agreesvalidation mutual understanding of communications- with yours."

Helps the patient become clearer aboutwhat he or she is thinking.

Verbalizing the implied Puts into concrete terms what the Patient: "1 can't talk to you or anyone else. lt'spatient implies, making the patient's a waste of time."communication more explicit. Nurse: "Do you feel that no one understands?"

Encouraging evaluation Aids the patient in considering people and "How do you feel about...7"events from the perspecrive of the patient's "What did it mean to you when he said heown set of values. couldn't stay?"

Attempting to translate into Responds to the feelings expressed, not just Patient: "1 am dead inside."feelings the content. Often termed decoding. Nurse: ?re you saying that you feel lifeless?

Does life seem meaningless to you7"

Suggesting collaboration Emphasizes working with the patient, not "Perhaps you ahd I can discover whatdoing things for the patient. Encourages produces your anxietyl'the view that change is possible through " Perhaps by working together, we can comecollaboration. up with some ideas that might improve your

communications with your spouse."Summarizing Brings together important points of discussion "Have I got this straight?"

to enhance understanding. Also allows the "You said that. . . "opportunity to clarify communications so that "During the past hour, you and I haveboth nurse and patient leave the interview discussed... "with the same ideas in mind.

Encouraging iormulation of Allows the patient to identify alternative "What could you do to let anger outa plan of action actions for interpersonal situations the harmlessly? "

patient finds disturbing (e.9., when anger or "The next time this comes up, what might youanxiety is provoked). do to handle it?"

"What are some other ways you can approachyour boss?"

Adapted from Hays, J. S-, & Larson, K. {1963}. Interacfing with patients. New York: Macmillan.r

184 Unit 3 Psychosocial Nursing ToolsSince open-ended quesdons are not intmsive and

do not put the patient on the defensive, they help theclinician illicit information, especially in the begir,-ning of an interyiew or when a patient is guarded orresistant to answering questions. They are particuladyuseful when establishing rapport with a person.

Closed-Ended Ouestions. Nurses are usually urgedto ask open-ended questions to elicit more ttlan a "yes"ot "rto" response. Howeveq, closed-ended questions,when used sparingly, can give you specific and neededinformation. {- i *'reri *crl.*l l:'i :; ;.r l.r :,,til.id rx 5 atre most use-ful during an initial assessment or intake interyiew orto ascertain results, as ilt "Are the medications helpingyou?" "When did you start hearing yoices?" "Did you

seek therapy after your first suicide attempt?" Careneeds to be exercised with thi$ technique. Frequentuse of closed-ended questions during time spent withpatierrts can close an interview down rapidly; this isespecially true with guarded or resistant patients.

Nontherapeutic GommunicationTechniquesAlthough people may use "nontherapeutic" or inef-fective communication techniques in their daily lives,they can cause problems for nurses because they tendto impede or shut down nurse-patient interaction.Table 10-3 dgscribes ra.l.: rlr h,l n ++ p; i rlrr, r-!1 l i?ri{'t ;i.r. ;r^-ri.iiri.i:rlii:;rt',tl. and suggests more helpfuI responses.

Giving premature Assumes the nurse knows best "Get out of this situation Encouraging problem solving:advice and the patient can't think for immediately:' "What are the pros and cons of your

self. lnhibits problem solving situation?"and fosters dependency. "What were some of the actions you

thought you might take?""What are some of the ways you have

thought of to meet your goals?"Minimizing feelings lndicates that the nurse is Patient: " l wish I were dead." Empathizing and exploring:

unable to understand or Nurse; f'Everyone gets down "You must be feeling very upset. Areempathize with the patient. in the dumps." you thinking of hurting yourself?"Here the patient's feelings or " l know what you mean."experiences are being beli'ttled, "You should feel happy you'rewhich can cause the patient to getting better."feel small or insignificant. "Things get worse before

they get better."Undenates a person's feelings and

belittles a persons concems.May cause the patient to stop

sharing feelings if the patientthinks he or she will beridiculed or not taken seriously.

"l wouldn't worry about that.""Everfihing will be all rightl'"You will do just fine, you'll

see."

Cladfying the patient's message:"What specifically are you worried

about?""What do you think could go wrongT""What are you concerned might

happen?"Making value Prevents problem solving, Can " How come you still smoke Making observations:judgments make the patient feel guilty, when your wife has lung "l notice you are still smoking even

angry misunderstood, not cancer?" though your wife has lung cancer.supported, or anxious to leave. ls this a problem?"

lmplies criticism; often has theeffect of making the patientfeel defensive.

"Why did you stop takingyour medication?"

Asking open-ended guestions;giving a broad opening:

"Tell me some of the reasons thatled up to your not taking yourmedications."

Asking excessive Hesuhs in the patient's not knowing Nurse: "How's your appetite? Cladfying:questions which question to ans\ /er and Are you losing weight? Are "Tell me about your eating habits

possibly being confused about you eating enoughT" since you've been depressedJ'what is being asked. Patient: "No!'

CHAPTER 1O Communication and the Clinical lnterview 185

Giving approval. lmplies the patient is doing the "l'm proud of you for Making obsermtions:agreeing nght thing*and that not doing applying for that lob." " l noticed that you applied for that

it is wrong. "l agree with your decision." job. What factors will lead up toMay lead the patient to focus your changing your mind7"

on pleasing the nurse or Asking open-ended questions;clinician; denies the patient the giving a broad opening:opportunity to change his or "What led to that decisionT"her mind or decision.

Disapproving;disagreeing

Can make a person defensive. Exploring:"What was going through your mind

when you decided not to come toyour medication group?"

"That's one point of view How didyou arrive at that conclusion?"

"You realty should haveshown up for themedication group."

"l disagree with thatl'

Changing the May invalidate the patient's Patient: "1'd like to diel' Validating and exploringrsubject feelings and needs. Nurse: "Did you go to Patient: "ld like to diel'

Can leave the patient feeling Alcoholics Anonymous llke Nurse: "This sounds serious. Havealienated and isolated we discussed?" you thought of harming yourself?"and increase feelings ofhopelessness.

Adapted from Hays, J. S., & Larson. K.i.1963l,. lnteracting with patienls. New Yo*: Macmillan

Excessive OuestioningExcessive questioning-asking multiple questions(particularly closed-ended) consecutively or veryrapidly--casts the nurse in the role of interrogatol,who demands information without respect for thepatient's willingness or readiness to respond. Thisapproach conveys a lack of respect for and sensi-tivity to the patient's needs. Excessive questioningcontrols the range and nature of the responses, caneasily result in a therapeutic stall, or may completelyshut down an interview. It is a controlling tactic andmay reflect the interviewer's liack of security in lettingthe patient tell his or her own story. [t is better to askmore open-ended questions and follow the patient'slead. For example:

Excessive questioning: "I{hy did you leave yourwife? Did you feel angry at her? What did she doto you? Are you going back to her?"

More therapeutic apprcach: "Tell me about the sit-uation between you and your wife."

Giving Approval or Disapproval'You look great in that dress." "I'm proud of the way youcontrolled your ternper at lundu" "Thafs a great quiltyou made." What could be bad about giving s,omeone apat on the back once in a while? Nothing, if it is donewithout conveying a positive or negative judgment. We

often give our frierrds and family approval when theydo something well. Howeve4 in a nurse-patient relation-ship, giving praise and approval becomes much morecomplex.

A patient may be feeling overwhelmed, experi-encing low self-esteem, feeling unsure of where hisor her life is going, and desperate for recognition,approval, and attention. Yet when people are feelingvulnerable, a value comrnent might be misinterpreted.For example:

Giving approval: "You did a great job in grouptelling John just what you thought about howrudely he treated you."

This message implies that the nurse was pleasedby the manner in which the patimt talked to |ohn.The patient then sees such a rcsponse as a way toplease the nurse by doing the right thing. To continueto please the nurse (and get approval), the patient maycontinue the behavior. The behavior might be usefirlfor the patienf but when a behavior is being done toplease another person/ it is not coming from *re indi.vidual's own volition or conviction. Also, when theother person the patient needs to please is not around,the motivation for the new behavior might not be thereeither. Thus the new response really is not a changein behavior as much as a ploy to win approval andacceptance from another.