Self-awareness- process of developing an understanding of one’s own values, beliefs, thoughts, feelings, attitudes, motivations, prejudices, strengths and limitations and how these qualities affect others
Therapeutic Use of Self- the nurse beginning to use aspects of his or her personality, experiences, values, feelings, intelligence, needs, coping skills and perceptions to establish relationship with clients
JOHARI’S WINDOW UNKNOWN- UNDISCOVERED QUALITIES BY ONESELF AND OTHERS HIDDEN- QUALITIES KNOWN ONLY TO SELF BLIND- QUALITIES KNOWN ONLY TO THERS OPEN - QUALITIES ONE KNOWS ABOUT ONESELF AND OTHERS ALSO KNOW
If quadrant 1 is the longest list- indicates that the nurse is open to others
Smaller quadrant 1 means the nurse shares little about himself/herself with others
If quadrants 1 and 3 are both small, the person demonstrates little insight
GOAL- to work toward moving qualities from quadrants 2,3 and 4 into quadrant 1
THERAPEUTIC COMMUNICATION TECHNIQUES
“yes.”, “I follow what you said.”, Nodding
Rationale: Indicates that the nurse has heard and followed the train of thought. Does not indicate agreement but is nonjudgmental. Facial expression should also be congruent with the verbal content.
Allowing the client to take the initiative in introducing the topic
“ Is there something you’d like to talk about?”; “Where would you like to begin?”
Rationale: This makes explicit that the client has the lead in the interaction. It may stimulate the client to take the initiative.
Searching for mutual understanding, for accord on the meaning of the words
“ Tell me whether my understanding agrees with yours.”; “Are you using these words to convey that…?”
Rationale: It is essential that the words being used have the same meaning for both participants to avoid misunderstanding.
Asking that similarities and differences be noted
“ Was it something like…?”, “Have you had similar experiences?”
Rationale: Comparing ideas, experiences, or relationships brings out many recurring themes. It might also help the client recall past coping strategies
ENCOURAGING DESCRIPTION OF PERCEPTIONS
Asking the client to verbalize what she or he perceives
“ What is happening?”, “What does the voice seem to be saying?”
Rationale: This may relieve the tension the client is feeling and he or she might be less likely to take action on ideas that are harmful or frightening.
Asking the client to appraise the quality of his or her experience
“ What are your feelings on regard to…?”, “does this contribute to your distress?”
Rationale: This may encourage the client to make his or her own appraisal rather than accepting the opinion of others
Delving further into a subject or idea. (can also be thru asking for an example)
“ Tell me more about that.”, “Would you describe it more fully?”, “give me an example of you and your wife not getting along
Rationale: Any problem or concern can be better understood if explored in depth.If client is unwilling to explore, the nurse must respect.
Concentrating on a single point
“ This point seems worth looking more closely.”, “of all the concerns you’ve mentioned, which is most troublesome?”
Rationale:A useful technique when client jumps from one topic to another (flight of ideas). To avoid overwhelming the client also.
FORMULATING A PLAN OF ACTION
Asking the client to consider kinds of behavior likely to be appropriate in future situations
“ What could you do to let your anger out harmlessly?”, “Next time this comes up, what might you do to handle it?”
Rationale: Making definite plans increases the likelihood that the client will cope more effectively in similar situations.
Giving encouragement to continue
“Go on.”, “And then?”, “tell me about it.”
Rationale: Indicates that the nurse is listening and following what the client had said without taking away the initiative for the interaction.
Making available the facts that the client needs
“ My name is..”, “Visiting hours are…”, My purpose in being here is…”
Rationale: Informing the client of facts increases his or her knowledge about a topic or lets the client know what to expect. It builds trust.
Acknowledging, indicating awareness
“Good morning Mr. S”, “I’ve noticed that you’ve combed your hair today.”
Rationale: This shows that the nurse recognizes the client as a person, as an individual. It does not carry the notion of value.
Verbalizing what the nurse perceives
“You appear tense..”
“I notice that your biting your lips”
Rationale: Sometimes clients cannot verbalize or make themselves understood. Or the client may not be ready to talk.
Making oneself available
“ I’ll sit with you awhile”
“ I’ll stay here with you”
“ I’m interested in what you think”
Rationale: It is important that this offer is unconditional, that is the client does not have to respond verbally to get the nurse’s attention
Placing Event in Time or Sequence
Clarifying the relationship of events in time
“ What seemed to lead up to…?
“ Was this before or after?”
Rationale: It helps both the nurse and client to see them in perspective.Client may gain insight in cause-and-effect behavior and consequences
Offering for consideration that which is real
“ I see no one else in the room.”
“ Your mother is not here; I am a nurse.”
Rationale: The nurse indicates what is real through not arguing with the client. The intent is to indicate an alternative line of thought for the client to consider and not to ‘convince” the client that he/she is wrong.
Directing client actions, thoughts, and feelings back to client
Client: “Do you think I should tell the doctor…? Nurse: “Do you think you should?”
Rationale: Encourages the client to recognize and accept his or her own feelings. The nurse indicates that the client’s point of view has value and has the right to air opinions, ideas
Repeating the main idea expressed
Client: I can’t sleep. I stay awake all night.”
Nurse:You have difficulty sleeping.”
Client:”I’m really mad, and upset”
Nurse: You’re really mad and upset.”
Rationale: Nurse repeats what the client has said in approximately or nearly the same words the client had used to let the client know that he/she communicated the idea effectively
Seeking to make clear that which is not meaningful or that which is vague
“ I’m not sure that I follow.”
“ Have I heard you correctly?”
Rationale: This helps the nurse to avoid making assumptions that understanding has occurred when it has not.Also for the client to articulate feelings.
Absence of verbal communication, which provides time for for the client to put thoughts or feelings into words, regain composure, or continue talking
Nurses says nothing but continues to maintain eye contact and conveys interest.
Rationale: Gives time for the client to organize thoughts, direct the topic of interaction or focus on issues that are most important.
Offering to share , to strive, to work with the client for his or her benefit
“ Perhaps you and I can discuss and discover the triggers for your anxiety”
Rationale: The nurse offers to do things with, rather than for the client.
Organizing and summing up that which has gone before
“ Have I got this straight?”, “You’ve said that…”,”During the past hour, you and I have discussed..”
Rationale: This seeks to bring out the important points of the discussion and to increase the awareness and understanding of both participants.
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?”
Rationale:To understand, the nurse must concentrate on what the client might be feeling to express himself/herself this way.
Verbalizing the Implied
Voicing what the client has hinted at or suggested
Client: I cant’ talk to you or anyone. It’s a waste of time.” Nurse: “Do you feel that no one understands”
Rationale: The client may have difficulty communicating directly. The nurse should take care to express only what is fairly obvious.
Expressing uncertainty about the reality of the client’s perceptions
“ Isn’t that unusual?”,“Really?”,“That’s hard to believe.”
Rationale: Such permits the client to become aware that others do not necessarily perceive events in the same way or draw the same conclusions
Allow client to express feelings more often than possible without being judgmental in order to understand what is going on with the client. This would facilitate better action in dealing with client’s concerns thus helping him arrive at solutions at his own pace.
Nontherapeutic Communication Techniques
D-iscourages expression of feelings
O-verwhelming the patient/client
R-eassuring the client
S-ympathizing with the client
A-rguing with the client
L-limiting the ideas, opinions, of the client
T-hreatening the client
Advising-telling the client what to do
Agreeing- indicating accord with the client
“I think you should..”,“That’s right”
Rationale: Implies that only the nurse knows what is best for the client
Indicating accord with the client
“ that’s right.” “I agree”
Rationale: approval indicates the client is “right” rather than “wrong’ which gives him/her the impression that he or she is right because of agreement with the nurse. There is no opportunity for the client to change his or her mind.
Belittling Feelings expressed
Misjudging the degree of the client’s comfort
Client: “I have nothing to live for..I wish I was dead”
Nurse: “Everybody gets down in the dumps.”
Rationale: When the client tries to equate the intense and overwhelming feelings the client has expressed to “everybody’, the nurse implies that the discomfort is temporary, mild, self-limiting or not very important.
Demanding proof from the client
“But how can you be President of the Philippines?”
Rationale: This causes the client to defend the delusions or misperceptions more strongly than before
Attempting to protect someone or something from verbal attack
“This hospital has a fine reputation.”
Rationale: this implies that the client has no right to express impressions, opinions or feelings.
Opposing the client’s ideas
“That’s wrong”, “I definitely disagree with..”
Rationale: Implies that the client is ‘wrong” which may make the client defensive
Denouncing the client’s behavior or ideas
“That’s bad”, “I’d rather you wouldn’t”
Rationale: This implies that the nurse has the right to pass judgment on the client’s thoughts or actions
Sanctioning the client’s behavior or ideas
“ That’s good.” “I’m glad that..”
Rationale: this tends to limit the client’s freedom to think, speak or act in a certain way.
Giving Literal Responses
Responding to a figurative comment as though it were a statement of fact
Client: “They’re looking in my head with television camera.”
Nurse: “Try not to watch television
Rationale: Often the client is at loss to describe his/her feelings, so such comments are the best he or she can do.The nurse should focus on the feelings of the nurse.
Indicating the existence of an external source
“What makes you say that?”, “What made you do that?”, “Who told you that you are a prophet?”
Rationale: This implies that the client was compelled to think in a certain way.
Asking to make conscious that which is unconscious
“ What you really mean is..”, “Unconsciously you’re saying that..”
Rationale: The client’s thoughts and feelings are his or her own, not to be interpreted by the nurse or for hidden meaning.
Introducing an unrelated topic
Changing the subject
Client: “I’d like to die.”
Nurse: “did you have visitors last night?”
Rationale: This would make the nurse take away the initiative away from the client. This may mean that the nurse does not know how to respond or is uncomfortable with the topic.
Making stereotyped comments
Offering meaningless cliches or trite comments
“ Keep your chin up.”,“Just have a positive outlook.”
Rationale:such comments has no value to the NPR
Persistent questioning of the client
“Now tell me about this problem. I need to know.”
Rationale: This tends to make the client feel used or invaded.
Indicating there is no reason for anxiety
“Everything will be alright.”
Rationale: attempts to dispel the client’s anxiety by implying that there is not sufficient reason for concern completely devalue the client’s feelings
Refusing to consider or showing contempt for the client’s behavior, ideas
“Let’s not discuss..”
Rationale: This close the topic off from exploration which may in turn make the client feel rejected.
Requesting an explanation
Asking the client to provide reasons for thoughts, feelings, behaviors, events
‘ Why do you think that?”, “ Why do you feel that way?”
Rationale: “Why” question is intimidating
Appraising the client’s degree of insight
“Do you know what kind of hospital this is?”
Rationale: This can force the client to try to recognize his/her problems which may in turn meet the nurse’s needs but not helpful to the client
Refusing to admit that a problem exists
Client: “I am nothing.”
Nurse: “Of course, you’re something.”
Rationale: This dismisses the client’s comments without attempting to discover the feelings or meaning behind them.
RECOGNIZING THERAPEUTIC FROM NON-THERAPEUTIC COMMUNICATION TECHNIQUES
1.Situation: Carlo, a depressed client is admitted in the psychiatric ward. He will undergo Electroconvulsive therapy.
He states “I’m afraid because my roommate told me I”ll forget everything and my memory will never return”. What is the best response?
A. “There’s a money-back guarantee if you lose your memory.
B. “There will be no memory loss, you will just forget who you are”
C . “There is memory loss but it’s only temporary.”
D. “ What you don’t know wont hurt you.”
2. One afternoon, after visiting hours, Vince becomes agitated and talkative. The nurse using collaboration technique of communication will ask him;
A. “What would you like to discuss?”
B. “Perhaps you and I can discover what causes your anxiety”
C. “What are you thinking about?
D. “Has this ever happened before?”
3. In a nurse-patient interaction, John says “I don’t want to talk today. “ The nurse responds therapeutically by saying:
A. “What made you say that?”
B. “I’ll sit with you for a while.”
C. “Are you not feeling well today?”
D. “Why are you reluctant to talk?”
4.In a therapeutic communication, one of the techniques being used is validation. Which of the following statements is an example?
A. “Are you sure of what you said?”
B. “Is that really what you believe?”
C. “Something seems to be bothering you. Would you like to talk about it?”
D. “What proof do you have that someone is out to harm you?”
5. As the nurse stands near the window in the client’s room, the client shouts, “Come away from the window! They’ll see you!” Which of the following responses by the nurse would be best?
A. Who are they?
B. No one will see me.
C. You have no reason to be afraid.
D. What will happen if they do see me?
6. During the initial interview, a client with schizophrenia suddenly turns to the next chair and whispers, “Now just leave, I told you to stay home. There‘s not enough work here for both of us.” What is the nurse’s best initial response?
A. “When people are under stress, they may see or hear things that others do not. Is that what just happened?”
B. “I’m having a difficult time hearing you. Please look at me when you talk.”
C. “There is no one else in this room. What are you doing?”
D.“Who are you talking to? Are you hallucinating?”
7. A client with major depression tells the nurse, “Life’s just not worth living. I can’t stand the pain any longer.” What is the nurse’s best response?
“ Sometimes when people feel depressed and helpless, they feel like hurting themselves. Do you feel like hurting yourself?”
“ Perhaps you should discuss this in group therapy today.”
“ I think you may want to use your p.r.n. lorazepam now.”
“ You don’t feel like living?”
. A woman, age 18, highly dependent on her parents and fears leaving home to go away to college. Shortly before the next semester starts, she complains that her legs are paralyzed and is rushed to the emergency department. When physical examination rules out a physical cause for her paralysis, the physician admits her to the psychiatric unit where she is diagnosed with conversion disorder. The client asks the nurse, “Why has this happened to me?” What is the nurse’s best response?
A. “You’ve developed this paralysis so you can stay with your parents. You must deal with this conflict if you want to walk again.”
B. “It must be awful not to be able to move your legs. You may feel better if you realize the problem is psychological, not physical.”
C. “Your problem is real but there is no physical basis for it. We’ll work on what is going on in your life to find out why it’s happened.”
D. “It isn’t uncommon for someone with your personality to develop a conversion disorder during times of stress.”
9. While pacing in the hall, a client with paranoid schizophrenia runs to the nurse and says, “Why are you poisoning me? I know you work for central thought control! You can keep my thoughts. Give me back my soul!” How should the nurse respond during the early stage of the therapeutic process?
A. “I’m a nurse. I’m not poisoning you. It’s against the nursing code of ethics.”
B. “I’m a nurse, and you’re a client in the hospital. I’m not going to harm you.”
C. “I’m not poisoning you. And how could I possibly steal your soul?”
D. “I sense anger. Are you feeling angry today?”
10. A client has just begun to discuss important feelings when the time of the interview is up. The next day, when the nurse meets with the client at the agreed-upon time, the initial intervention would be to say:
A. “Good morning! How are you today?”
B. “Yesterday you were talking about some very important feelings. Let’s continue.”
C. “What would you like to talk about today?”
D. Nothing and wait for the client to open a topic.
11. A nurse observes a client sitting alone in her room crying. As the nurse approaches her, the client states, “I’m feeling sad. I don’t want to talk now.” The nurse’s best response would be:
A. “I’ll help you feel better if you talk about it.”
B. “I’ll come back when you feel like talking.”
C. “I’ll stay with you a few minutes.”
D. “Sometimes it helps to talk.”
12. Kristina is a 29 year old woman admitted to the surgical unit after an accident in a small airplane. Her husband the pilot was killed. She had some minor bruises and contusions but she is physically stable. She has a 2-year old son. The day after admission, the nurse enters the client’s room to find the shades drawn and her in bed sobbing quietly. The most therapeutic nursing response is:
A. “It’s a beautiful day outside, let’s get some sunshine here.”
B. “Obviously you are upset, let’s talk about what you’re feeling now.”
C. I”ll be back when you’re feeling better, you seem upset.”
D. “it’s not good for you to sit in here in the dark.”
13. Several days after learning of her pregnancy, a recently widowed client tells the nurse. I’m going to have an abortion. I can’t bear the thought of raising this child alone.” What is the best response?”
A. “Well, it sounds as though you already have made a decision.”
B. “you maybe acting too hastily.”
C. “Let’s talk about it.”
D. “You might be sorry in a year or two.”
14. A client says to the nurse, “Dr. Lim has surely botched my case. I can’t believe they’d let her continue to practice.” Which of the following is an appropriate response?
A. “Dr. Lim is a fine doctor and one worthy of respect.”
B. “Dr. Lim has been sued before and her practice is questionable.”
C. “You seem to have some concerns with Dr. Lim.”
D. “Dr. Lim usually provides good care.”
15. Mr. Levy was admitted with a diagnosis of bipolar disorder. On Mr. Levy’s admission, his daughter said to the nursing staff, “He’s been really tough to handle. I hope you can calm them down, because I sure can’t. Which of the following responses would be most helpful at this time?
A. “You must really be fed up. I’ve never seen anyone this maniacal.”
B. “Sounds like this has been very difficult for you. Hospitalization will be very helpful for both of you.”
C. “I can appreciate your embarrassment. He is really high, isn’t he?”
D. “You must wonder why your father is acting aggressively in order to gain attention.”
16. Mrs. Adam a 65 year old woman, admitted herself to the hospital after she began hearing the voices of her dead husband. She says to the nurse, “My husband says I shouldn’t talk to you.” What is the most appropriate response?
A. “you’re husband has been dead for over 10 years.”
B. ‘When did he say that.”
C. “The more you talk like this the more confused you will become.”
D. “I know that this is real to you. It would be helpful; if we talk about it.”
17. Mrs. Kravitz, a woman diagnosed with schizophrenia, says to an approaching nurse, “I don’t want to talk.” What is the best nursing response?
A. “That’s you’re choice!”
B. “Why don’t you want to talk to me?”
C. “There’s no need to talk with me.”
D. “I’ll sit with you for a while.”
18. . Mrs. Valle yells for the nurse. As the nurse arrives and enters the room, the client says, “Do you see? There! God is appearing!” Which of the following is the best nursing response?
A. “No, I don’t see him but I understand that he is real to you.”
B. “He is not there. You must be imagining things.”
C. “Show me where God appears to you.”
D. “God is appearing?”
19. Pong a 25 year old man admitted in an acute psychotic state caused by ingestion of lysergic acid di-ethylamide (LSD), sees red spiders crawling on his bed. Which of the following is the appropriate nursing response?
A. “Come on Pong, you’re putting me on.”
B. Swat the red spiders as if to kill them in the client’s presence.
C. “I understand you believe you see spiders, Pong, I am not seeing any.”
D. Discuss details of the hallucinations with him.
20. How about a pound of rye instead?” Which of the following is the most therapeutic response?
A. “Don’t you think alcohol is the last thing you need right now?”
B. “It’s a little early in a day for that, isn’t it?”
C. “It sounds as though you feel that you could use a drink.”
D. “Sorry but liquor is not allowed in the hospital.”
COMMON CLIENT BEHAVIORS & NURSE RESPONSES
WHAT TO DO IF THE CLIENT CRIES
Possible reactions by the nurse: Nurse may feel uncomfortable and experience increased anxiety or feel somehow responsible for making the person cry
Useful responses by the Nurse: Nurse should stay with the client and reinforce that its all right to cry often. It is at this time that feelings are closest to the surface and can be best identified
“ You seem ready to cry.”, “You still are upset about your brother’s death?”, “What are you thinking right now?”
Nurse offers tissues when appropriate
What to do if the client asks the nurse to keep a secret
Possible reactions by the nurse: Nurse may feel conflict because the nurse wants the client to share important information but is unsure about making such a promise
Useful responses by the nurse: Nurse cannot make such a promise. The information maybe important to the health or safety of the client and others.
“ I can not make that promise. It might be important for me to share it with other staff.”
The client then decides whether to share the information or not.
What to do if the client leaves before the session is over
Possible reactions by the nurse: Nurse may feel rejected, thinking it was something that he or she did. The nurse may experience increased anxiety or feel abandoned by the client.
Useful responses: Some clients are not able to relate for long periods of time without experiencing an increased in anxiety, On the other hand, the client maybe testing the nurse.
“ I will wait for you here for 15 minutes until our time is up.”,
During this time, the nurse does not engage in conversation with any other client or other staff.
When the time is up, the nurse approaches the client, tells him/her that the time is up and restates the day and time the nurse will see the client again.
What to do if another client interrupts during time with your selected client
Possible reactions by nurse: nurse may feel a conflict. The nurse does not want to appear rude. Sometimes the nurse tries to engage both clients in conversation
Useful responses: The time the nurse had contracted with a selected client is that client’s time.
By keeping their part of the contract, nurses demonstrate that they mean what they say and that they view the sessions are important.
“ I am with Mr. Rob for the next 20 minutes. At 10AM, after our time is up, I can talk to you for 5 minutes.”
What to do if the client says he wants to kill himself
Possible reactions by the nurse: Nurse may feel overwhelmed or responsible to “talk the client out of it”. The nurse may pick up some of the client’s feelings of hopelessness
Useful responses: Nurse tells the client that this is serious, that the nurse does not want harm to come to the client and that this information needs to be reported to other staff.
“ this is very serious Mrs. Lamb. I do not want any harm to come to you. I will have to report this to the other staff.”
The nurse can then discuss with the client the feelings and circumstances that led up to this.
What to do if the client says she does not want to talk
Possible reactions: the nurse new to this situation may feel rejected or ineffectual
Useful responses: At first, the nurse might say something to this effect: “ Its all right. I would like to spend time with you. We don’t have to talk.”
The nurse might spend short, frequent periods of time (e.g. 5 minutes) with the client throughout the day.
“ Our 5 minutes is up. I”ll be back at 10AM and stay with you for 5 more minutes.”
This gives the client the opportunity to understand that the nurse means what he/she says and is back on time consistently. This also gives the client time between visits to assess the nurse and perhaps feel less threatened.
What to do if the client seeks to prolong the interview
Possible reactions: sometimes clients will open up dynamic or ‘juicy” topics right before the interview time is up. This is often done to test or manipulate the nurse. The nurse might feel tempted to extend the scheduled time or might not want to hurt the client’s feelings.
Useful responses: The nurse sets limits and restates and reinforces the original contract.
The nurse states that they will use the issues for the next session.
“ Our time is up now, Mr. Jones. This would be a good place to start at our next sessions which is Wednesday at 10AM”
What to do if the client gives the nurse a present
Possible reactions: The nurse may feel uncomfortable when offered a gift-the meaning needs to be examined. Is the gift:
A way of getting better care
A way to maintain self-esteem
A way of making the nurse feel guilty
A sincere expression of thanks
-if the gift is expensive, the best policy is perhaps to graciously refuse
-if the gift is inexpensive and is given at the end of hospitalization in which a relationship has developed, graciously accept.
-if the gift is inexpensive and is given at the beginning of hospitalization, graciously refuse
“ Thank you, but it is our job to care for our clients. Are you concerned that some aspect of your care will be overlooked?”
If the gift is money, it maybe best to graciously refuse
TESTING BEHAVIORS USED BY CLIENTS
I. Client Behavior: shifts focus of interview to the nurse; off the client
Client example: “Do you have any children?” or “Are you married?”
Nurse’s response: “This time is for you.”
If appropriate, the nurse could add:
“ Do you have any children?” or “What about your children?”
“ Are you married?”
Rationale: Nurse sticks to the contract and refocuses back to the client and the client’s concerns.
Client Behavior: Tries to get the nurse to take care of him.
Client example: “Could you tell my doctor…”
Nurse’s response: “I’ll leave a message with the ward that you want to see him.” or “You know best what you want to say to him. I’ll be interested in what he has to say.”
Rationale: Nurse validates that the client is able to do many things for him/herself. This aids in increasing self-esteem.
Client Behavior: Makes sexual advances toward the nurse (e.g. touching the nurse’s arm, wanting to hold hands or kiss the nurse.)
Client example: “Would you go out with me…Why not?” or “Can I kiss you?…Why not?”
Nurse’s response: “I am not comfortable having you touch me.”, the nurse briefly reiterates the nurse’s role, “This time is for you to focus on your problems and concerns.” (rationale: frequently restating the nurse’s role throughout the relationship can help maintain boundaries)
If the client stops: “I wonder what this is about?”
1. Is the client afraid the nurse won’t like him/her?
2. Is the client trying to take the focus off of his/her problems?(Rationale: whenever possible, the meaning of the client’s behavior should be explored)
Nurse’s response: If the client continues:
“ If you can’t cease this behavior, I”ll have to leave. I”ll be back at (time) to spend time with you then.
Rationale: leaving gives the client time to gain control . The nurse returns at the stated time.