THERAPEUTIC COMMUNICATION

WHAT IS COMMUNICATION?

Communication-the process that people use to exchange information.

Messages are simultaneously sent and received on two levels: verbally through the use of words and nonverbally by behaviors that accompany the words

Verbal communication-consists of the words a person uses to speak to one or more listeners. Words-symbols used to identify the objects

and concepts being discussed. Content is verbal communication, the literal

words that a person speaks. Context is the environment in which

communication occurs ; can include the time and the physical, social, emotional, and cultural environment-includes the circumstances or parts that

clarify the meaning of the content of the message.

Nonverbal communication- behavior that accompanies verbal content such as body language, eye contact, facial expression, tone of voice, speed and hesitations in speech, grunts and groans, and distance from the listener.

It can indicate the speaker’s thoughts, feelings, needs, and values that the speaker acts out mostly unconsciously.

Process denotes all nonverbal messages that the speaker uses to give meaning and context to the message. -This component of communication requires the listener to observe the behaviors and sounds that accent the words and to interpret the speaker’s nonverbal behaviors to assess whether they agree or disagree with the verbal content.

Congruent message - when content and process agree. For example, a client says, “I know I haven’t

been myself. I need help.” She has a sad facial expression and a genuine and sincere voice tone. The process validates the content as being true.

Incongruent message- when the content and process disagree— when what the speaker says and what he or she does do not agree

What is THERAPEUTIC COMMUNICATION ?

Therapeutic communication is an interpersonal interaction between the nurse and client during which the nurse focuses on the client’s specific needs to promote an effective exchange of information.

Therapeutic use of self -TOOL

With the therapeutic use of self, nurses use themselves as a therapeutic tool to establish the therapeutic relationship with clients and to help clients grow, change, and heal.

The nurse uses aspects of his or her personality, experiences, values, feelings, intelligence, needs, coping skills, and perceptions to establish relationships with clients.

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

Needed by all nurses to effectively apply the nursing process and to meet standards of care for their clients.

Skilled use of therapeutic communication techniques

Therapeutic communication can helpnurses to accomplish many goals:

Establish a therapeutic nurse–client relationship.Identify the most important client concern at that moment

(the client-centered goal).Assess the client’s perception of the problem as it unfolded. This includes detailed actions (behaviors and messages) of the people involved and the client’s thoughts and feelings about the situation, others, and self.Facilitate the client’s expression of emotions.Teach the client and family necessary self-care skills.Recognize the client’s needs.Implement interventions designed to address the client’s needs.Guide the client toward identifying a plan of action to a satisfying and socially acceptable resolution.

To have effective therapeutic communication, the nurse also must consider:

privacy and respect of boundaries use of touch, and active listening and observation.

Privacy and Respecting Boundaries

Privacy is desirable but not always possible in therapeutic communication.

The nurse needs to evaluate if interacting in the client’s room is therapeutic. For example, if the client has difficulty

maintaining boundaries or has been making sexual comments, then the client’s room is not the best setting. A more formal setting would be desirable.

PROXEMICS

Proxemics- the study of distance zones between people during communication. People feel more comfortable with smaller distances when communicating with someone they know rather than with strangers.

People from the United States, Canada, and many Eastern European nations generally observe four distance zones:

4 distance zones

Intimate zone (0 to 18 inches between people): This amount of space is comfortable for parents with young

children, people who mutually desire personal contact, or people whispering.

Invasion of this intimate zone by anyone else is threatening and produces anxiety.

Personal zone (18 to 36 inches): This distance is comfortable between family and friends who

are talking. Social zone (4 to 12 feet):

This distance is acceptable for communication in social, work, and business settings.

Public zone (12 to 25 feet): This is an acceptable distance between a speaker and an

audience, small groups, and other informal functions.

Five types of TOUCH

As intimacy increases, the need for distance decreases.

• Functional-professional touch - used in examinations or procedures such as when the nurse touches a client to assess skin turgor or a masseuse performs a massage.

• Social-polite touch - used in greeting, such as a handshake and the “air kisses” some women use to greet acquaintances, or when a gentle hand guides someone in the correct direction.

Four types of touch. A—Functional–professional touch; B—Social–polite touch; C—Friendship–warmth touch;D—Love–intimacy touch.

• Friendship-warmth touch- involves a hug in greeting, an arm thrown around the shoulder of a good friend, or the back slapping some men use to greet friends and relatives.

• Love-intimacy touch involves tight hugs and kisses between lovers or close relatives.

• Sexual-arousal touch is used by lovers.

Active Listening and Observation

To receive the sender’s simultaneous messages, the nurse must use active listening and active observation.

Active listening - refraining from other internal mental activities and concentrating exclusively on what the client says.

Active observation- watching the speaker’s nonverbal actions as he or she communicates.

THERAPEUTIC COMMUNICATION TECHNIQUES

1. Accepting—

Accepting- indicating reception “Yes.” “I follow what you said.” Nodding

An accepting response indicates the nurse has heard and followed the train of thought.

Not the same as agreeing!

It does not indicate agreement but is nonjudgmental.

Facial expression, tone of voice, and so forth also must convey acceptance or the words will lose their meaning.

A nurse notes that an assigned client is lying tense in bed staring at the cardiac monitor. The client states, “There sure are a lot of wires around there. I sure hope we don’t get hit by lightning.”

A. “Would you like a mild sedative to help you relax?”

B. “Oh, don’t worry, the weather is supposed to be sunny and clear today.”

C. “Yes, all those wires must be a little scary. Did someone explain what the cardiac monitor was for?”

D. “Your family can stay tonight if they wish.”

2. Broad openings—

Broad openings— 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?”

Broad openings make explicit that the client has the lead in the interaction. For the client who is hesitant about talking, broad openings may stimulate him or her to take the initiative.

3. Consensual validation—

Consensual validation—searching for mutual understanding, for accord in the meaning of the words “Tell me whether my

understanding of it agrees with yours.”

“Are you using this word to convey that . . . ?”

For verbal communication to be meaningful, it is essential that the words being used have the same meaning for both (all) participants. Sometimes words, phrases, or slang terms have different meanings and can be easily misunderstood.

A client is admitted to the hospital with a bowel obstruction secondary to a recurrent malignancy, and the physician inserts a Miller-Abbott tube. After the procedure, the client asks the nurse, “Do you think this is worth all this trouble?” the most appropriate action or response by the nurse is:

A. To stay with the client and be silentB. “Are you wondering whether you are

going to get better?”C. “Let’s give this tube a chance.”D. “I remember a case similar to yours

and the tube relieved the obstruction.”

4. Encouraging comparison—

Encouraging comparison—

asking that similarities and differences be noted “Was it something

like . . . ?” “Have you had

similar experiences?”

Comparing ideas, experiences, or relationships brings out many recurring themes. The client benefits from making these comparisons because he or she might recall past coping strategies that were effective or remember that he or she has survived a similar situation.

5. Encouraging expression—

Encouraging expression— asking client to appraise the quality of his or her experiences “What are your feelings

in regard to . . . ?”

The nurse asks the client to consider people and events in light of his or her own values.

Doing so encourages the client to make his or her own

appraisal rather than accepting the opinion

of others.

6. Exploring—

Exploring—delving further into a subject or idea “Tell me more about

that.” “Would you describe it

more fully?” “What kind of work?”

When clients deal with topics superficially, exploring can help them examine the issue more fully.

Any problem or concern can be better understood if explored in depth.

If the client expresses an unwillingness to explore a subject, however, the nurse must respect his or her wishes.

A female victim of a sexual assault is being seen in the crisis center for a third visit. She states that although the rape occurred nearly 2 months ago, she still feels “as though the rape just happened yesterday.” the nurse would respond by stating:

A. “What can you do to alleviate some of your fears about being assaulted again?”

B. “Tell me more about those aspects of the rape that cause you to feel like the rape just occurred.”

C. “In time, our goal will be to help you move on from these strong feelings about your rape.”

D. “In reality, the rape did not just occur. It has been over two months now.”

A female victim of a sexual assault is being seen in the crisis center for a third visit. She states that although the rape occurred nearly 2 months ago, she still feels “as though the rape just happened yesterday.” the nurse would respond by stating:

A. “What can you do to alleviate some of your fears about being assaulted again?”

B. “Tell me more about those aspects of the rape that cause you to feel like the rape just occurred.”

C. “In time, our goal will be to help you move on from these strong feelings about your rape.”

D. “In reality, the rape did not just occur. It has been over two months now.”

7. Focusing—

Focusing— concentrating on a single point “This point seems

worth looking at more closely.”

“Of all the concerns you’ve mentioned, which is most troublesome?”

The nurse encourages the client to concentrate his or her energies on a single point, which may prevent a multitude of factors or problems from overwhelming the client.

a useful technique when a client jumps from one topic to another.

8. Formulating a plan of action—

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?”

It may be helpful for the client to plan in advance what he or she might do in future similar situations.

Making definite plans increases the likelihood that the client will cope more effectively in a similar situation.

9. General leads—

General leads— giving encouragement to continue “Go on.” “And then?” “Tell me about it.”

General leads indicate that the nurse is listening and following what the client is saying without taking away the initiative for the interaction.

They also encourage the client to continue if he or she is hesitant or uncomfortable about the topic.

10. Giving information—

Giving information— making available the facts that the client needs “My name is . . .” “Visiting hours are . . .” “My purpose in being

here is . . .”

Informing the client of facts increases his or her knowledge about a topic or lets the client know what to expect.

The nurse is functioning as a resource person

Giving information also builds trust with the client.

A 4-year-old child who was recently hospitalized is brought to the clinic by his mother for a follow-up visit. The mother tells the nurse that the child has begun to wet the bed ever since the child was brought home from the hospital. The mother is concerned and asks the nurse what to do. The appropriate nursing response wuld be:

A. “You need to discipline the child.”B. “This is a normal occurrence following

hospitalization.”C. “We need to discuss this behavior with the

physician.”D. “The child probably has developed a

urinary tract infection.”

A 4-year-old child who was recently hospitalized is brought to the clinic by his mother for a follow-up visit. The mother tells the nurse that the child has begun to wet the bed ever since the child was brought home from the hospital. The mother is concerned and asks the nurse what to do. The appropriate nursing response wuld be:

A. “You need to discipline the child.”B. “This is a normal occurrence following

hospitalization.”C. “We need to discuss this behavior with the

physician.”D. “The child probably has developed a

urinary tract infection.”

11. Giving recognition—

Giving recognition— acknowledging, indicating awareness “Good morning, Mr. S . . .” “You’ve finished your list

of things to do.” “I notice that you’ve

combed your hair.”

Greeting the client by name, indicating awareness of change, or noting efforts the client has made all show that the nurse recognizes the client as a person, as an individual.

Such recognition does not carry the notion of value, that is, of being “good” or “bad.”

12. Making observations—

Making observations—verbalizing what the nurse perceives “You appear tense.” “Are you

uncomfortable when . . . ?”

“I notice that you’re biting your lip.”

Sometimes clients cannot verbalize or make themselves understood. Or the client may not be ready to talk.

A nurse observes an anxious client blocking the hallway, walking three steps forward and then two steps backward.Other clients are agitated trying to get past. The nurse intervenes by:

A. Standing alongside the client and saying, “You’re very anxious today.”

B. Stopping the behavior and saying: “You’re going to get exhausted.”

C. Taking the client to the TV lounge and saying, “Relax and watch television now.”

D. Walking alongside the client and saying, “ You’re not going to get anywhere very fast doing this.”

A nurse observes an anxious client blocking the hallway, walking three steps forward and then two steps backward.Other clients are agitated trying to get past. The nurse intervenes by:

A. Standing alongside the client and saying, “You’re very anxious today.”

B. Stopping the behavior and saying: “You’re going to get exhausted.”

C. Taking the client to the TV lounge and saying, “Relax and watch television now.”

D. Walking alongside the client and saying, “ You’re not going to get anywhere very fast doing this.”

13. Offering self—

Offering self— making oneself available “I’ll sit with you awhile.” “I’ll stay here with you.” “I’m interested in what

you think.” “You must have

misplaced it in your room. Let’s go and look for it together.”

The nurse can offer his or her presence, interest, and desire to understand. It is important that this offer is unconditional, that is, the client does not have to respond verbally to get the nurse’s attention.

A male client diagnosed with catatonic stupor demonstrates severe withdrawal by lying on the bed with the body pulled into a fetal position. The nurse plans to:

A. Leave the client alone and intermittently check on him.

B. Take the client into the day room with other clients so they can help watch him.

C. Sit beside the client in silence and occasionally ask open-ended questions.

D. Ask direct questions to encourage talking.

A male client diagnosed with catatonic stupor demonstrates severe withdrawal by lying on the bed with the body pulled into a fetal position. The nurse plans to:

A. Leave the client alone and intermittently check on him.

B. Take the client into the day room with other clients so they can help watch him.

C. Sit beside the client in silence and occasionally ask open-ended questions.

D. Ask direct questions to encourage talking.

14. Placing event in time or sequence— Placing event in

time or sequence— clarifying the relationship of events in time “What seemed to

lead up to . . . ?” “Was this before or

after . . . ?” “When did this

happen?”

Putting events in proper sequence helps both the nurse and client to see them in perspective.

The client may gain insight into cause-and effect behavior and consequences, or the client may be able to see that perhaps some things are not related.

The nurse may gain information about recurrent patterns or themes in the client’s behavior or relationships.

15. Presenting reality—

Presenting reality— offering for consideration that which is real “I see no one else

in the room.” “That sound was

a car backfiring.” “Your mother is

not here; I am a nurse.”

When it is obvious that the client is misinterpreting reality, the nurse can indicate what is real.

The nurse does this by calmly and quietly expressing the nurse’s perceptions or the facts not by way of arguing with the client or belittling his or her experience.

The intent is to indicate an alternative line of thought for the client to consider, not to “convince” the client that he or she is wrong.

“I know you re frightened, however, I do not see spiders and ants you are talking about.”

The nurse uses the Therapeutic Communication Technique of Presenting reality—offering for consideration that which is real.

The intent is to indicate an alternative line of thought for the client to consider, not to “convince” the client that he or she is wrong.

Auditory hallucinations, the most common type, involve hearing sounds, most often voices, talking to or about the client. There may be one or multiple voices; a familiar or unfamiliar person’s voice may be speaking. Command hallucinations are voices demanding that the client take action, often to harm self or others, and are considered dangerous.

The nurse reorients the patient to reality and assesses for the presence of such hallucinations to ensure safety.

Address him by name to ask him if he is hearing voices again

“I do not hear the voice you say you hear.”

16. Reflecting—

Reflecting—directing client actions, thoughts, and feelings back to client Client: “Do you think I should

tell the doctor . . . ?” Nurse: “Do you think you should?”Client: “My brother spends all my money and then has nerve to ask for more.”Nurse: “This causes you to feel angry?”

Reflection 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 that the client has the right to have opinions, make decisions, and think independently.

A client says to the nurse, “I’m going to die and I wish my family would stop hoping for a cure! I get so angry when they carry on like this! After all, I’m the one who’s dying.” the nurse makes which therapeutic response to the client?

A. You’re feeling angry that your family continues to hope for you to be cured?”

B. “I think we should talk more about your anger at your family.”

C. “Well, it sounds like you’re being pretty pessimistic. After all, years ago, people died of pneumonia.”

D. “Have you shared your feelings with your family?

A client says to the nurse, “I’m going to die and I wish my family would stop hoping for a cure! I get so angry when they carry on like this! After all, I’m the one who’s dying.” the nurse makes which therapeutic response to the client?

A. You’re feeling angry that your family continues to hope for you to be cured?”

B. “I think we should talk more about your anger at your family.”

C. “Well, it sounds like you’re being pretty pessimistic. After all, years ago, people died of pneumonia.”

D. “Have you shared your feelings with your family?

17. Restating—

Restating— repeating the main idea expressed Client: “I can’t sleep. I

stay awake all night.” Nurse: “You have

difficulty sleeping.”

The nurse repeats what the client has said in approximately or nearly the same words the client has used.

This restatement lets the client know that he or she communicated the idea effectively.

This encourages the client to continue. Or if the client has been misunderstood, he or she can clarify his or her thoughts.

A client with a diagnosis of major depression says to the nurse, “I should have died. I’ve always been a failure. The nurse makes which therapeutic response to the nurse?

A. “I see a lot of positive things in you.”

B. “Feeling like a failure is part of your illness.”

C. “You’ve been failing like a failure for some time now.

D. You still have a great deal to live for.”

18. Seeking information—

Seeking information— 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?”

The nurse should seek clarification throughout interactions with clients.

Doing so can help the nurse to avoid making assumptions that understanding has occurred when it has not.

It helps the client to articulate thoughts, feelings, and ideas more clearly.

A client who is experiencing suicidal thoughts greets the nurse with the following statement: “It just doesn’t seem worth it anymore. Why not just end it all?” the nurse would further assess the client by making which of the following responses?

A. “I’m sure your family is worried about you.”

B. “I know you have had a stressful night.”

C. “Did you sleep at al last night?”

D. “Tell me what you mean by that.”

A client who is experiencing suicidal thoughts greets the nurse with the following statement: “It just doesn’t seem worth it anymore. Why not just end it all?” the nurse would further assess the client by making which of the following responses?

A. “I’m sure your family is worried about you.”

B. “I know you have had a stressful night.”

C. “Did you sleep at al last night?”

D. “Tell me what you mean by that.”

19. Silence— Silence— absence

of verbal communication, which provides time for the client to put thoughts or feelings into words, regain composure, or continue talking Nurse says nothing

but continues to maintain eye contact and conveys interest.

Silence often encourages the client to verbalize, provided that it is interested and expectant.

Silence gives the client time to organize thoughts, direct the topic of interaction, or focus on issues that are most important.

Much nonverbal behavior takes place during silence, and the nurse needs to be aware of the client and his or her own nonverbal behavior.

20. Suggesting collaboration— Suggesting

collaboration—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.”

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

The nurse seeks to offer a relationship in which the client can identify problems in living with others, grow emotionally, and improve the ability to form satisfactory relationships.

The nurse offers to do things with, rather than for, the client.

21. Summarizing— Summarizing—

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 . . .”

Summarization seeks to bring out the important points of the discussion and to increase the awareness and understanding of both participants.

It omits the irrelevant and organizes the pertinent aspects of the interaction.

It allows both client and nurse to depart with the same ideas and provides a sense of closure at the completion of each discussion.

22. Translating into feelings—

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?” Client: “I’m way out in the

ocean.” Nurse: “You seem to feel

lonely or deserted.”

Often what the client says, when taken literally, seems meaningless or far removed from reality.

To understand, the nurse must concentrate on what the client might be feeling to express himself or herself this way.

23. Verbalizing the implied—

Verbalizing the implied— voicing what the client has hinted at or suggested Client: “I can’t talk

to you or anyone. It’s a waste of time.”

Nurse: “Do you feel that no one understands?”

Putting into words what the client has implied or said indirectly tends to make the discussion less obscure.

The nurse should be as direct as possible without being unfeelingly blunt or obtuse. The client may have difficulty communicating directly.

The nurse should take care to express only what is fairly obvious; otherwise the nurse may be jumping to conclusions or interpreting the client’s communication.

24. Voicing doubt—

Voicing doubt— expressing uncertainty about the reality of the client’s perceptions “Isn’t that

unusual?” “Really?” “That’s hard to

believe.”

Another means of responding to distortions of reality is to express doubt.

Such expression permits the client to become aware that others do not necessarily perceive events in the same way or draw the same conclusions. This does not mean the client will alter his or her point of view, but at least the nurse will encourage the client to reconsider or reevaluate what has happened.

The nurse neither agreed nor disagreed; however, he or she has not let the misperceptions and distortions pass without comment.

NON-THERAPEUTIC COMMUNICATION TECHNIQUES

1. Advising—

Advising— telling the client what to do “I think you should . . .” “Why don’t you . . .”

Giving advice implies that only the nurse knows what is best for the client.

2. Agreeing—

Agreeing— indicating accord with the client “That’s right.” “I agree.”

Approval indicates the client is “right” rather than “wrong.”

This gives the client the impression that he or she is “right” because of agreement with the nurse.

Opinions and conclusions should be exclusively the client’s. When the nurse agrees with the client, there is no opportunity for the client to change his or her mind without being “wrong.”

3. Belittling feelings expressed—

Belittling feelings expressed— Misjudging the degree of the client’s discomfort Client: “I have nothing

to live for . . . I wish I was dead.”

Nurse: “Everybody gets down in the dumps.” OR

“I’ve felt that way myself.”

When the nurse tries to equate the intense and overwhelming feelings the client has expressed to “everybody” or to the nurse’s own feelings, the nurse implies that the discomfort is temporary, mild, self-limiting, or not very important.

The client is focused on his or her own worries and feelings; hearing the problems or feelings of others is not helpful.

When it is obvious that the client is misinterpreting reality, the nurse can indicate what is real. The nurse does this by calmly and quietly expressing the nurse’s perceptions or the facts not by way of arguing with the client or belittling his or her experience.

4. Challenging—

Challenging— demanding proof from the client “But how can you

be President of the

United States?” “If you’re dead,

why is your heart beating?”

Often the nurse believes that if he or she can challenge the client to prove unrealistic ideas, the client will realize there is no “proof” and then will recognize reality.

Actually challenging causes the client to defend the delusions or misperceptions more strongly

than before.

5. Defending—

Defending—attempting to protect someone or something from verbal attack “This hospital has a

fine reputation.” “I’m sure your

doctor has your best interests in mind.”

Defending what the client has criticized implies that he or she has no right to express impressions, opinions, or feelings.

Telling the client that his or her criticism is unjust or unfounded does not change the client’s feelings but only serves to block further communication.

Arguing with the patient about routine activities in the hospital

Arguing with the patient about routine activities in the hospital will only increase agitation.

6. Disagreeing—

Disagreeing—opposing the client’s ideas “That’s wrong.” “I definitely

disagree with . . .”

Disagreeing implies the client is “wrong.”

Consequently the client feels defensive about his or her point of view or ideas.

7. Disapproving—

Disapproving—denouncing the client’s behavior or ideas “That’s bad.” “I’d rather you

wouldn’t . . .”

Disapproval implies that the nurse has the right to pass judgment on the client’s thoughts or actions.

It further implies that the client is expected to please the nurse.

Refraining from moralizing and chastising him for his drug abuse

A nonjudgmental attitude is neither condemning nor approving. Through tone of voice and manner the nurse conveys to the patient a helpful attitude without morally judging his behavior.

A nonjudgmental attitude toward the behavior of a mentally ill patient implies that the nurse recognizes that the behavior, like the physical symptoms, displayed by physically ill patients, is neither good or bad nor right or wrong but rather an expression of emotional need.

8. Giving approval—

Giving approval— sanctioning the client’s behavior or ideas “That’s good.” “I’m

glad that . . .”

Saying what the client thinks or feels if “good” implies that the opposite is “bad.”

Approval, then, tends to limit the client’s freedom to think, speak, or act in a certain way.

This can lead to the client’s acting in a particular way just to please the nurse.

9. Giving literal responses—

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 television camera.”

Nurse: “Try not to watch television.” OR “What channel?”

Often the client is at a loss to describe his or her feelings, so such comments are the best he or she can do.

Usually it is helpful for the nurse to focus on the client’s feelings in response to such statements.

10. Indicating the existence of an external source—

Indicating the existence of an external source— attributing the source of thoughts, feelings, and behavior to others or to outside influences “What makes you say

that?” “What made you do

that?” “Who told you that you

were a prophet?”

The nurse can ask, “What happened?” or “What events led you to draw such a conclusion?”

But to question “What made you think that?” implies that the client was made or compelled to think in a certain way.

Usually the nurse does not intend to suggest that the source is external but that is often what the client thinks.

11. Interpreting— Interpreting—

asking to make conscious that which is unconscious; telling the client the meaning of his or her experience “What you really

mean is . . .” “Unconsciously you’re

saying . . .”

The client’s thoughts and feelings are his or her own, not to be interpreted by the nurse or for hidden meaning.

Only the client can identify or confirm the presence of feelings.

12. Introducing an unrelated topic—

Introducing an unrelated topic— changing the subject Client: “I’d like to die.”

Nurse: “Did you have visitors last evening?”

The nurse takes the initiative for the interaction away from the client.

This usually happens because the nurse is uncomfortable, doesn’t know how to respond, or has a topic he or she would rather discuss.

13. Making stereotyped comments—

Making stereotyped comments—offering meaningless clichés or trite comments “It’s for your own good.” “Keep your chin up.” “Just have a positive

attitude and you’ll be better in no time.”

Social conversation contains many clichés and much meaningless chit-chat.

Such comments are of no value in the nurse–client relationship.

Any automatic responses will lack the nurse’s consideration or thoughtfulness.

14. Probing—

Probing—persistent questioning of the client “Now tell me about

this problem. You know I have to find out.”

“Tell me your psychiatric history.”

Probing tends to make the client feel used or invaded.

Clients have the right not to talk about issues or concerns if they choose.

Pushing and probing by the nurse will not encourage the client to talk.

15. Reassuring—

Reassuring—indicating there is no reason for anxiety or other feelings of discomfort “I wouldn’t worry about

that.” “Everything will be all

right.” “You’re coming along

just fine.”

Attempts to dispel the client’s anxiety by implying that there is not sufficient reason for concern completely devalue the client’s feelings.

Vague reassurances without accompanying facts are meaningless to the client.

16. Rejecting—

Rejecting—refusing to consider or showing contempt for the client’s ideas or behaviors “Let’s not discuss . . .” “I don’t want to hear

about . . .”

When the nurse rejects any topic, he or she closes it off from exploration.

In turn, the client may feel personally rejected along with his or her ideas.

17. Requesting an explanation—

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?”

There is a difference between asking the client to describe what is occurring or has taken place and asking him to explain why.

Usually a “why” question is intimidating. In addition, the client is unlikely to know “why” and may become defensive trying to explain himself or herself.

18. Testing—

Testing—appraising the client’s degree of insight “Do you know what

kind of hospital this is?”

“Do you still have the idea that . . . ?”

These types of questions force the client to try to recognize his or her problems.

The client’s acknowledgement that he or she doesn’t know these things may meet the nurse’s needs but is not helpful for the client.

19. Using denial—

Using denial— refusing to admit that a problem exists Client: “I’m nothing.”

Nurse: “Of course you’re something—everybody’s something.”

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

The nurse denies the client’s feelings or the seriousness of the situation by dismissing his or her comments without attempting to discover the feelings or meaning behind them.