MENTAL HEALTH: CHAPTER 6: THERAPEUTIC COMMUNICATION:

Which of the following is a nontherapeutic communication technique? A. Reassuring B. Reflecting C. Focusing D. Exploring

A. Reassuring - Rationale: Reassuring is a nontherapeutic technique because it attempts to dispel the patient's feelings. o Reflecting, focusing, and exploring are examples of therapeutic communication techniques.

Using Therapeutic Communication Techniques: Giving Information:

- Making available the facts that the client needs - Ex: "My name is ...", "Visiting hours are ...", "My purpose in being hereis ..." - 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.

Using Therapeutic Communication Techniques: Giving Recognition:

- Acknowledging, indicating awareness - Ex: "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."

Agressive Communication:

- After saying nothing for several days, one nurse jumps up and yells, "You're always late! That is so rude! Why can't you be on time like everyone else?" Then the nurse stomps out of the room, leaving everyone uncomfortable.

Using Therapeutic Communication Techniques: Offering Self:

- Making oneself available - Ex: "I'll sit with you awhile.", "I'll stay here with you.", "I'm interested in what you think." - 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.

Avoiding Nontherapeutic Communication: Making Stereotyped Comments:

- offering meaningless clichés or trite comments - Ex: "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 lack the nurse's consideration or thoughtfulness.

Distance Zones: Intimate Zone:

- (0-18 in 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.

Distance Zones: Public Zone:

- (12-25 ft): This is an acceptable distance between a speaker and an audience, small groups, and other informal functions

Distance Zones: Personal Zone:

- (18-36 in): This distance is comfortable between family and friends who are talking.

Distance Zones: Social Zone:

- (4-12 ft): This distance is acceptable for communication in social, work, and business settings.

Nonverbal Communication: Body Language:

- (e.g., gestures, postures, movements, and body positions) is a nonverbal form of communication. - Closed body positions, such as crossed legs or arms folded across the chest, indicate that the interaction might threaten the listener who is defensive or not accepting. - A better, more accepting body position is to sit facing the client with both feet on the floor, knees parallel, hands at the side of the body, and legs uncrossed or crossed only at the ankle. - This open posture demonstrates unconditional positive regard, trust, care, and acceptance. - The nurse indicates interest in and acceptance of the client by facing and slightly leaning toward him or her while maintaining nonthreatening eye contact. - Hand gestures add meaning to the content. - A slight lift of the hand from the arm of a chair can punctuate or strengthen the meaning of words. - Holding both hands with palms up while shrugging the shoulders often means "I don't know." - Some people use many hand gestures to demonstrate or act out what they are saying, while others use very few gestures. - The positioning of the nurse and client in relation to each other is also important. - Sitting beside or across from the client can put the client at ease, while sitting behind a desk (creating a physical barrier) can increase the formality of the setting and may decrease the client's willingness to open up and communicate freely. - The nurse may wish to create a more formal setting with some clients, however, such as those who have difficulty maintaining boundaries

Passive-Agressive Communication:

- A coworker says to another nurse, "So nice of her to join us! Aren't we lucky?" Everyone sits in uncomfortable silence.

Using Therapeutic Communication Techniques: Silence:

- Absence of verbal communication, which provides time for the client to put thoughts or feelings into words, to regain composure, or to continue talking - Ex: 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.

Avoiding Nontherapeutic Communication: Disagreeing:

- opposing the client's ideas - Ex: "That's wrong.", "I definitely disagree with ...", "I don't believe that." - Disagreeing implies the client is "wrong." - Consequently, the client feels defensive about his or her point of view or ideas.

Using Therapeutic Communication Techniques: Broad Openings:

- Allowing the client to take the initiative in introducing the topic - Ex: "Is there something you'd like to talk about?", "Where would you like to begin?" - Broad openings make it 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.

Community Based Care:

- As community care for people with physical and mental health problems continues to expand, the nurse's role expands as well. - The nurse may become the major caregiver and resource person for increasingly high-risk clients treated in the home and their families and may become more responsible for primary prevention in wellness and health maintenance. - Therapeutic communication techniques and skills are essential to successful management of clients in the community. - Caring for older adults in the family unit and in communities today is a major nursing concern and responsibility. - It is important to assess the relationships of family members, and identifying their areas of agreement and conflict can greatly affect the care of clients. - To be responsive to the needs of these clients and their families for support and caring, the nurse must communicate and relate to clients and establish a therapeutic relationship. - When practicing in the community, the nurse needs self-awareness and knowledge about cultural differences. - When the nurse enters the home of a client, the nurse is the outsider and must learn to negotiate the cultural context of each family by understanding their beliefs, customs, and practices and not judging them according to his or her own cultural context. - Asking the family for help in learning about their culture demonstrates the nurse's unconditional positive regard and genuineness. - Families from other cultural backgrounds often respect nurses and health care professionals and are quite patient and forgiving of the cultural mistakes that nurses might make as they learn different customs and behaviors. - Another reason the nurse needs to understand the health care practices of various cultures is to make sure these practices do not hinder or alter the prescribed therapeutic regimens. - Some cultural healing practices, remedies, and even dietary practices may alter the client's immune system and may interact with prescribed medications. - The nurse in community care is a member of the health care team and must learn to collaborate with the client and family as well as with other health care providers who are involved in the client's care such as physicians, physical therapists, psychologis and home health aides. - Working with several people at one time rather than just with the client is the standard in community care. - Self-awareness and sensitivity to the beliefs, behaviors, and feelings of others are paramount to the successful care of clients in the community setting.

Touch:

- As intimacy increases, the need for distance decreases. Knapp (1980) identified five types of touch: •Functional-professional touch is used in examinations or procedures such as when the nurse touches a client to assess skin turgor or a massage therapist performs a massage. •Social-polite touch is used in greeting, such as a handshake and the "air kisses" some people use to greet acquaintances, or when a gentle hand guides someone in the correct direction. •Friendship-warmth touch involves a hug in greeting, an arm thrown around the shoulder of a good friend, or the backslapping some people 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. - Touching a client can be comforting and supportive when it is welcome and permitted. - The nurse should observe the client for cues that show whether touch is desired or indicated. - For example, holding the hand of a sobbing mother whose child is ill is appropriate and therapeutic. - If the mother pulls her hand away, however, she signals to the nurse that she feels uncomfortable being touched. - The nurse can also ask the client about touching (e.g., "Would it help you to squeeze my hand?"). - The nurse must evaluate the use of touch based on the client's preferences, history, and needs. - The nurse may find touch supportive, but the client may not. - Likewise, a client may use touch too much, and again the nurse must set appropriate boundaries. - Although touch can be comforting and therapeutic, it is an invasion of intimate and personal space. - Some clients with mental illness have difficulty understanding the concept of personal boundaries or knowing when touch is or is not appropriate. - Clients with a history of abuse have had others touch them in harmful, hurtful ways, usually without their consent. - They may be hesitant or even unable to tell others when touch is uncomfortable. - Consequently, most psychiatric inpatient, outpatient, and ambulatory care units have policies against clients touching one another or staff. - Unless they need to get close to a client to perform some nursing care, staff members should serve as role models and refrain from invading clients' personal and intimate space. - When a staff member is going to touch a client while performing nursing care, he or she must verbally prepare the client before starting the procedure. - A client with paranoia may interpret being touched as a threat and may attempt to protect him or herself by striking the staff person.

Using Therapeutic Communication Techniques: Encouraging Comparison:

- Asking that similarities and differences be noted - Ex: 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.

Using Therapeutic Communication Techniques: Encouraging Expression:

- Asking the client to appraise the quality of his or her experiences - Ex: What are your feelings in regard to...?", "Does this contribute to your distress?" - 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 to accept the opinion of others.

Using Therapeutic Communication Techniques: Formulating Plan Of Action:

- Asking the client to consider kinds of behavior likely to be appropriate in future situations - Ex: "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

Using Therapeutic Communication Techniques: Encouraging Description Of Perceptions:

- Asking the client to verbalize what he or she perceives - Ex: "What is happening?", "What does the voice seem to be saying?" - To understand the client, the nurse must see things from his or her perspective. - Encouraging the client to fully describe ideas 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.

Rehearsing Responses:

- Assertive communication takes practice. It is often helpful to "rehearse" statements or responses in advance, especially if expressing feelings or discussing conflict is difficult. - Using assertive communication doesn't always produce a positive result, and others may not like the assertive communication style, especially if it is a change from a previous style. - But the speaker can feel confident that he or she communicated thoughts and feelings openly and honestly while respecting the rights of both parties.

Nonverbal Communication:

- Is the 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 listeners. - Nonverbal communication can indicate the speaker's thoughts, feelings, needs, and values that he or she acts out mostly unconsciously. - Process denotes all nonverbal messages that the speaker uses to give meaning and context to the message. - The process component of communication requires the listeners 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.

Communication:

- Is 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

Using Therapeutic Communication Techniques: Placing Event In Sequence:

- Clarifying the relationship of events in time - Ex: "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 the 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.

Overt & Covert Cues:

- Clients may use many word patterns to cue the listener to their intent. - Overt cues are clear, direct statements of intent, such as "I want to die." - The message is clear that the client is thinking of suicide or self-harm. - Covert cues are vague or indirect messages that need interpretation and exploration—for example, if a client says, "Nothing can help me." - The nurse is unsure, but it sounds as if the client might be saying he or she feels so hopeless and helpless that he or she plans to commit suicide. - The nurse can explore this covert cue to clarify the client's intent and to protect the client. - Most suicidal people are ambivalent about whether to live or die and often admit their plan when directly asked about it. - When the nurse suspects self-harm or suicide, he or she uses a yes-or-no question to elicit a clear response.

Using Therapeutic Communication Techniques: Focusing:

- Concentrating on a single point - Ex: "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. - It is also a useful technique when a client jumps from one topic to another.

Congruent & Incongruent Messages:

- Congruent Message is conveyed 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. But when the content and process disagree—when what the speaker says and what he or she does do not agree—the speaker is giving an incongruent message. - For example, if the client says, "I'm here to get help," but has a rigid posture, clenched fists, and an agitated and frowning facial expression and snarls the words through clenched teeth, the message is incongruent. - The process or observed behavior invalidates what the speaker says (content). - Nonverbal process represents a more accurate message than does verbal content. " - I'm sorry I yelled and screamed at you" is readily believable when the speaker has a slumped posture, a resigned voice tone, downcast eyes, and a shameful facial expression because the content and process are congruent. - The same sentence said in a loud voice and with raised eyebrows, a piercing gaze, an insulted facial expression, hands on hips, and outraged body language invalidates the words (incongruent message). - The message conveyed is "I'm apologizing because I think I have to. I'm not really sorry."

Verbal Communication:

- Consists of the words a person uses to speak to one or more listeners. - Words represent the objects and concepts being discussed. - Placement of words into phrases and sentences that are understandable to both speaker and listeners gives an order and a meaning to these symbols. - In verbal communication, content is the literal words that a person speaks. - Context is the environment in which communication occurs and can include time and the physical, social, emotional, and cultural environments. - Context includes the situation or circumstances that clarify the meaning of the content of the message.

Proxemics:

- Is 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

Cultural Considerations:

- Culture is all the socially learned behaviors, values, beliefs, and customs transmitted down to each generation. - The rules about the way in which to conduct communication vary because they arise from each culture's specific social relationship patterns - Each culture has its own rules governing verbal and nonverbal communication. - For example, in Western cultures, the handshake is a nonverbal greeting often used to size up or judge another's professional demeanor. - For women, a polite "hello" is an accepted form of greeting. - In some Asian cultures, bowing is the accepted form of greeting and departing and a method of designating social status. - Because of these differences, cultural assessment is necessary when establishing a therapeutic relationship. - The nurse must assess the client's emotional expression, beliefs, values, and behaviors; modes of emotional expression; and views about mental health and illness. - When caring for people who do not speak English, the services of a qualified translator who is skilled at obtaining accurate data are necessary. - He or she should be able to translate technical words into another language while retaining the original intent of the message and not injecting his or her own biases. - The nurse is responsible for knowing how to contact a translator, regardless of whether the setting is inpatient, outpatient, or in the community. - The nurse must understand the differences in how various cultures communicate. - It helps to see how a person from another culture acts toward and speaks with others. U.S. and many European cultures are individualistic; they value self-reliance and independence and focus on individual goals and achievements. - Other cultures, such as Chinese and Korean, are collectivistic, valuing the group and observing obligations that enhance the security of the group. - Persons from these cultures are more private and guarded when speaking to members outside the group and sometimes may even ignore outsiders until they are formally introduced.

Using Therapeutic Communication Techniques: Exploring:

- Delving further into a subject or an idea - Ex: "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.

Using Therapeutic Communication Techniques: Reflecting:

- Directing client actions, thoughts, and feelings back to client - Ex: 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.

Using Therapeutic Communication Techniques: Voicing Doubt:

- Expressing uncertainty about the reality of the client's perceptions - Ex: "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.

Nonverbal Communication: Facial Expressions:

- Facial movements connect with words to illustrate meaning; this connection demonstrates the speaker's internal dialogue. - Facial expressions can be categorized into expressive, impassive, and confusing: - A person who is verbally expressing sad or angry feelings while smiling is exhibiting a confusing facial expression. - Facial expressions often can affect the listener's response. - Strong and emotional facial expressions can persuade the listener to believe the message. - For example, by appearing perplexed and confused, a client can manipulate the nurse into staying longer than scheduled. - Facial expressions such as happy, sad, embarrassed, or angry usually have the same meaning across cultures, but the nurse should identify the facial expression and ask the client to validate the nurse's interpretation of it—for instance, "You're smiling, but I sense you are angry" - Frowns, smiles, puzzlement, relief, fear, surprise, and anger are common facial communication signals. - Looking away, not meeting the speaker's eyes, and yawning indicate that the listener is disinterested, lying, or bored. - To ensure the accuracy of information, the nurse identifies the nonverbal communication and checks its congruency with the content - An example is "Mr. Jones, you said everything is fine today, yet you frowned as you spoke. I sense that everything is not really fine" (verbalizing the implied).

Understanding Meaning Of Communication:

- Few messages in social and therapeutic communication have only one level of meaning; messages often contain more meaning than just the spoken words. - The nurse must try to discover all the meaning in the client's communication. - For example, the client with depression might say, "I'm so tired that I just can't go on." - If the nurse considers only the literal meaning of the words, he or she might assume the client is experiencing the fatigue that often accompanies depression. - However, statements such as the previous example may mean the client wishes to die. - The nurse would need to further assess the client's statement to determine whether the client is suicidal. - It is sometimes easier for clients to act out their emotions than to organize their thoughts and feelings into words to describe feelings and needs. - For example, people who outwardly appear dominating and strong and often manipulate and criticize others in reality may have low self-esteem and feel insecure. - They do not verbalize their true feelings but act them out in behavior toward others. - Insecurity and low self-esteem often translate into jealousy and mistrust of others and attempts to feel more important and strong by dominating or criticizing them.

Using Therapeutic Communication Techniques: General Leads:

- Giving encouragement to continue - Ex: "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.

Using Therapeutic Communication Techniques: Accepting:

- Indicating reception - Ex: "Yes.", "I follow what you said., Nodding\ - An accepting response indicates the nurse has heard and followed the train of thought. - It does not indicate agreement but is nonjudgmental. - Facial expression, tone of voice, and so forth also must convey acceptance or the words lose their meaning.

Therapeutic Communication:

- Is an interpersonal interaction between the nurse and the client during which the nurse focuses on the client's specific needs to promote an effective exchange of information. - Skilled use of therapeutic communication techniques helps the nurse understand and empathize with the client's experience. - All nurses need skills in therapeutic communication to effectively apply the nursing process and to meet standards of care for their clients. Therapeutic communication can help nurses 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 unfolds. 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 the 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. - Establishing a therapeutic relationship is one of the most important responsibilities of the nurse when working with clients. - Communication is the means by which a therapeutic relationship is initiated, maintained, and terminated. - To have effective therapeutic communication, the nurse must also consider privacy and respect of boundaries, use of touch, and active listening and observation.

Assertive Communication:

- Is the ability to express positive and negative ideas and feelings in an open, honest, and direct way. - It recognizes the rights of both parties and is useful in various situations, such as resolving conflicts, solving problems, and expressing feelings or thoughts that are difficult for some people to express. - Assertive communication can help a person deal with issues with coworkers, family, or friends. - It is particularly helpful for people who have difficulty refusing another's request, expressing emotions of anger or frustration, or dealing with persons of authority. - Nurses can assist clients in learning and practicing assertive communication skills, as well as using assertive communication to communicate with other nurses and members of the health care team. - It can be used in both personal and professional situations. - Assertive communication works best when the speaker is calm; makes specific, factual statements; and focuses on "I" statements. - For example, one of the nurses on your unit is always a few minutes late to work, arriving in a rush and disrupting change-of-shift report. - Ex: After report, one nurse says, "When you are late, report is disrupted, and I don't like having to repeat information that was already discussed." This nurse has communicated feelings about the specific situation in a calm manner with no accusations or inflammatory comments. - Using assertive communication does not guarantee that the situation will change, but it does allow the speaker to express honest feelings in an open and direct way that is still respectful of the other person. - This lets the speaker feel good about expressing the feelings and may lead to a discussion about how to resolve this problem. - Sometimes, people have difficulty saying no or refusing requests from others. - Later, the person may regret saying yes and feel overburdened or even resentful. - Using assertive communication can help the person say no politely but firmly, even when the person making the request is persistent in the request.

Guiding the Client in Problem-Solving and Empowering the Client to Change:

- Many therapeutic situations involve problem-solving. - The nurse is not expected to be an expert or to tell the client what to do to fix his or her problem. - Rather, the nurse should help the client explore possibilities and find solutions to his or her problem. - Often just helping the client discuss and explore his or her perceptions of a problem stimulates potential solutions in the client's mind. - The nurse should introduce the concept of problem-solving and offer him or herself in this process. - Satir (1967) explained how important the client's participation is to finding effective and meaningful solutions to problems. - If someone else tells the client how to solve his or her problems and does not allow the client to participate and develop problem-solving skills and paths for change, the client may fear growth and change. - The nurse who gives advice or directions about the way to fix a problem does not allow the client to play a role in the process and implies that the client is less than competent. - This process makes the client feel helpless and not in control and lowers self-esteem. - The client may even resist the directives in an attempt to regain a sense of control. - When a client is more involved in the problem-solving process, he or she is more likely to follow through on the solutions. - The nurse who guides the client to solve his or her own problems helps the client develop new coping strategies, maintains or increases the client's self-esteem, and demonstrates the belief that the client is capable of change. - These goals encourage the client to expand his or her repertoire of skills and to feel competent; feeling effective and in control is a comfortable state for any client. - Problem-solving is frequently used in crisis intervention but is equally effective for general use. - The problem-solving process is used when the client has difficulty finding ways to solve the problem or when working with a group of people whose divergent viewpoints hinder finding solutions. It involves several steps: 1.Identify the problem. 2.Brainstorm all possible solutions. 3.Select the best alternative. 4.Implement the selected alternative. 5.Evaluate the situation. 6.If dissatisfied with results, select another alternative and continue the process. - It is important to remember that the nurse is facilitating the client's problem-solving abilities. - The nurse may not believe the client is choosing the best or the most effective solution, but it is essential that the nurse supports the client's choice and assists him or her with implementing the chosen alternative. - If the client makes a mistake or the selected alternative isn't successful, the nurse can support the client's efforts and assist the client in trying again. - Effective problem-solving involves helping the client resolve his or her own problems as independently as possible.

Nonverbal Communication Skills:

- Nonverbal communication is the behavior a person exhibits while delivering verbal content. - It includes facial expression, eye contact, space, time, boundaries, and body movements. - Nonverbal communication is as important as verbal communication, if not more so. - It is estimated that one-third of meaning is transmitted by words and two-thirds is communicated nonverbally. - The speaker may verbalize what he or she believes the listener wants to hear, while nonverbal communication conveys the speaker's actual meaning. - Nonverbal communication involves the unconscious mind acting out emotions related to the verbal content, the situation, the environment, and the relationship between the speaker and the listener. - Nonverbal communication is often more accurate than verbal communication when the two are incongruent. - People can readily change what they say but are less likely to be able to control nonverbal communication. - Nonverbal behaviors are used with verbal messages to convey meaning. - Some people use hand gestures to emphasize the words they are saying. - A nod may indicate agreement, while a quizzical look conveys confusion. - It is important to validate the meaning of nonverbal behaviors because misinterpretation or assumptions can lead to misunderstanding.

Avoiding Nontherapeutic Communication: Probing:

- persistent questioning of the client - Ex:"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.

Asking For Clarification:

- Nurses often believe they should always be able to understand what the client is saying. - This is not always possible; the client's thoughts and communications may be unclear. - The nurse should never assume that he or she understands; rather, the nurse should ask for clarification if there is doubt. - Asking for clarification to confirm the nurse's understanding of what the client intends to convey is paramount to accurate data collection. - If the nurse needs more information or clarification on a previously discussed issue, he or she may need to return to that issue. - The nurse may also need to ask questions in some areas to clarify information. - The nurse can then use the therapeutic technique of consensual validation or repeating his or her understanding of the event that the client just described to see whether their perceptions agree. - It is important to go back and clarify rather than to work from assumptions.

Using Therapeutic Communication Techniques: Presenting Reality:

- Offering for consideration that which is real - Ex: "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 his or her 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.

Using Therapeutic Communication Techniques: Suggesting Collaboration:

- Offering to share, to strive, and to work with the client for his or her benefit - Ex: "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.

Passive Communication:

- One nurse doesn't say anything at the time, but later tells coworkers, "She's always late. I had to tell her what she missed. I have so much work of my own to do." But this nurse doesn't say anything to the nurse who was late.

Therapeutic Communication: How To Phrase Questions:

- Open-ended questions elicit more descriptive information, and yes-or-no questions yield just an answer. - The nurse asks different types of questions based on the information the nurse wishes to obtain. - The nurse uses active listening to build questions based on the cues the client has given in his or her responses. - In English, people frequently substitute the word feel for the word think. - Emotions differ from the cognitive process of thinking, so using the appropriate term is important. - For example, "What do you feel about that test?" is a vague question that could elicit several types of answers. - A more specific question is, "How well do you think you did on the test?" The nurse should ask, "What did you think about...?" when discussing cognitive issues, and "How did you feel about...?" when trying to elicit the client's emotions and feelings. - Using active listening skills, asking many open-ended questions, and building on the client's responses help the nurse obtain a complete description of an issue or an event and understand the client's experience. - Some clients do not have the skill or patience to describe how an event unfolded over time without assistance from the nurse. - Clients tend to recount the beginning and the end of a story, leaving out crucial information about their own behavior. - The nurse can help the client by using techniques such as clarification and placing an event in time or sequence. - Proper phrasing of questions - Using "think" versus "feel" - Active listening skills, asking many open-ended questions, building on client's responses - Techniques include clarification and placing an event in time or sequence.

Using Therapeutic Communication Techniques: Summarizing:

- Organizing and summing up that which has gone before - Ex: "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 seeks 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.

Privacy and Respecting Boundaries:

- Privacy is desirable but not always possible in therapeutic communication. - An interview in a conference room is optimal if the nurse believes this setting is not too isolative for the interaction. - The nurse can also talk with the client at the end of the hall or in a quiet corner of the day room or lobby, depending on the physical layout of the setting - The nurse needs to evaluate whether 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. - Some people from different cultures (e.g., Hispanic, Mediterranean, East Indian, Asian, and Middle Eastern) are more comfortable with less than 4 to 12 ft of space between them while talking. - The nurse of European American or African American heritage may feel uncomfortable if clients from these cultures stand close when talking. - Conversely, clients from these backgrounds may perceive the nurse as remote and indifferent - Both the client and the nurse can feel threatened if one invades the other's personal or intimate zone, which can result in tension, irritability, fidgeting, or even flight. - When the nurse must invade the intimate or personal zone, he or she should always ask the client's permission. - For example, if a nurse performing an assessment in a community setting needs to take the client's blood pressure, he or she should say, "Mr. Smith, to take your blood pressure I will wrap this cuff around your arm and listen with my stethoscope. Is this acceptable to you?" He or she should ask permission in a yes-or-no format so the client's response is clear. - This is one of the times when yes-or-no questions are appropriate.

Using Therapeutic Communication Techniques: Restating:

- Repeating the main idea expressed - Ex: Client: "I can't sleep. I stay awake all night." Nurse: "You have difficulty sleeping." Client: "I'm really mad, I'm really upset." Nurse: "You're really mad and upset." - 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.

Avoiding Nontherapeutic Communication: Giving Approval:

- Sanctioning the client's behavior or ideas - Ex: "That's good.", "I'm glad that ..." - Saying what the client thinks or feels is "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.

Using Therapeutic Communication Techniques: Consensual Validation:

- Searching for mutual understanding, for accord in the meaning of the words - Ex: 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 or all participants. - Sometimes, words, phrases, or slang terms have different meanings to different people and can be easily misunderstood.

Using Therapeutic Communication Techniques: Seeking Information:

- Seeking to make clear that which is not meaningful or that which is vague - Ex: "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 articulate thoughts, feelings, and ideas more clearly.

Using Therapeutic Communication Techniques: Translating Into Feelings:

- Seeking to verbalize client's feelings that he or she expresses only indirectly - Ex: Client: "I'm dead.", Nurse: "Are you suggesting that you feel lifeless?" - 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 him or herself this way.

Nonverbal Communication: Silence:

- Silence or long pauses in communication may indicate many different things. - The client may be depressed and struggling to find the energy to talk. - Sometimes, pauses indicate the client is thoughtfully considering the question before responding. - At times, the client may seem to be "lost in his or her own thoughts" and not paying attention to the nurse. - It is important to allow the client sufficient time to respond, even if it seems like a long time. - It may confuse the client if the nurse "jumps in" with another question or tries to restate the question differently. - Also, in some cultures, verbal communication takes a slower cadence with many pauses, and the client may believe the nurse is impatient or disrespectful if he or she does not wait for the client's response.

Client's Avoidance Of Anxiety-Producing Topic:

- Sometimes, clients begin discussing a topic of minimal importance because it is less threatening than the issue that is increasing the client's anxiety. - The client is discussing a topic but seems to be focused elsewhere. - Active listening and observing changes in the intensity of the nonverbal process help give the nurse a sense of what is going on. - Many options can help the nurse determine which topic is more important: 1.Ask the client which issue is more important at this time. 2.Go with the new topic because the client has given nonverbal messages that this is the issue that needs to be discussed. 3.Reflect the client's behavior, signaling there is a more important issue to be discussed. 4.Mentally file the other topic away for later exploration. 5.Ignore the new topic because it seems that the client is trying to avoid the original topic.

Understanding Spirituality:

- Spirituality is a client's belief about life, health, illness, death, and one's relationship to the universe. - It differs from religion, which is an organized system of beliefs about one or more all-powerful, all-knowing forces that govern the universe and offer guidelines for living in harmony with the universe and others - Spiritual and religious beliefs are usually supported by others who share them and follow the same rules and rituals for daily living. - Spirituality and religion often provide comfort and hope to people and can greatly affect a person's health and health care practices. - The nurse must first assess his or her own spiritual and religious beliefs. - Religion and spirituality are highly subjective and can be vastly different among people. - The nurse must remain objective and nonjudgmental regarding the client's beliefs and must not allow them to alter nursing care. - The nurse must assess the client's spiritual and religious needs and guard against imposing his or her own on the client. - The nurse must ensure that the client is not ignored or ridiculed because his or her beliefs and values differ from those of the staff. - As the therapeutic relationship develops, the nurse must be aware of and respect the client's religious and spiritual beliefs. - Ignoring or being judgmental will quickly erode trust and could stall the relationship. - For example, a nurse working with a Native American client could find him looking up at the sky and talking to "Grandmother Moon." - If the nurse did not realize that the client's beliefs embody all things with spirit, including the sun, moon, earth, and trees, the nurse might misinterpret the client's actions as inappropriate.

Avoiding Nontherapeutic Communication: Advising:

- Telling the client what to do - Ex:"I think you should ...", "Why don't you ..." - Giving advice implies that only the nurse knows what is best for the client.

Nonverbal Communication: Eye Contact:

- The eyes have been called the mirror of the soul because they often reflect our emotions. - Messages that the eyes give include humor, interest, puzzlement, hatred, happiness, sadness, horror, warning, and pleading. - Eye contact, looking into the other person's eyes during communication, is used to assess the other person and the environment and to indicate whose turn it is to speak; it increases during listening but decreases while speaking - Although maintaining good eye contact is usually desirable, it is important that the nurse doesn't "stare" at the client.

Avoiding Nontherapeutic Communication: Using Denial:

- refusing to admit that a problem exists - Ex: 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.

Nurse Patient Distance:

- The therapeutic communication interaction is most comfortable when the nurse and client are 3 to 6 ft apart. - If a client invades the nurse's intimate space (0-18 in), the nurse should set limits gradually, depending on how often the client has invaded the nurse's space and the safety of the situation.

Self-Awareness Issues:

- Therapeutic communication is the primary vehicle that nurses use to apply the nursing process in mental health settings. - The nurse's skill in therapeutic communication influences the effectiveness of many interventions. - Therefore, the nurse must evaluate and improve his or her communication skills on an ongoing basis. - When the nurse examines his or her personal beliefs, attitudes, and values as they relate to communication, he or she is gaining awareness of the factors influencing communication. - Gaining awareness of how one communicates is the first step toward improving communication. - The nurse will experience many different emotional reactions to clients, such as sadness, anger, frustration, and discomfort. - The nurse must reflect on these experiences to determine how emotional responses affect both verbal and nonverbal communication. - When working with clients from different cultural or ethnic backgrounds, the nurse needs to know or find out what communication styles are comfortable for the client in terms of eye contact, touch, proximity, and so forth. - The nurse can then adapt his or her communication style in ways that are beneficial to the nurse-client relationship.

Broken-Record Technique:

- This is called the "broken record technique." Instead of responding to additional information, such as concert tickets, not having plans, or emotional pleas, the speaker simply repeats the response without justifying or explaining the response. - In time, the person can become quite comfortable refusing a request without feeling guilty or compelled to explain the refusal. - This can allow the person to avoid stress from being overcommitted or resentful from agreeing to a request that is later resented.

Active Listening & Observing:

- To receive the sender's simultaneous messages, the nurse must use active listening and active observation. - Active listening means refraining from other internal mental activities and concentrating exclusively on what the client says. - Active observation means watching the speaker's nonverbal actions as he or she communicates. - Peplau (1952) used observation as the first step in the therapeutic interaction. - The nurse observes the client's behavior and guides him or her in giving detailed descriptions of that behavior. - The nurse also documents these details. - To help the client develop insight into his or her interpersonal skills, the nurse analyzes the information obtained, determines the underlying needs that relate to the behavior, and connects pieces of information (makes links between various sections of the conversation). - A common misconception by students learning the art of therapeutic communication is that they must always be ready with questions the instant the client has finished speaking. - Hence, they are constantly thinking ahead regarding the next question rather than actively listening to what the client is saying. - The result can be that the nurse does not understand the client's concerns, and the conversation is vague, superficial, and frustrating to both participants. - When a superficial conversation occurs, the nurse may complain that the client is not cooperating, is repeating things, or is not taking responsibility for getting better. - Superficiality, however, can be the result of the nurse's failure to listen to cues in the client's responses and repeatedly asking the same question. - The nurse does not get details and works from his or her assumptions rather than from the client's true situation. - While listening to a client's story, it is almost impossible for the nurse not to make assumptions. - A person's life experiences, knowledge base, values, and prejudices often color the interpretation of a message. - In therapeutic communication, the nurse must ask specific questions to get the entire story from the client's perspective, clarify assumptions, and develop empathy with the client. - Empathy is the ability to place oneself into the experience of another for a moment in time. - Nurses develop empathy by gathering as much information about an issue as possible directly from the client to avoid interjecting their personal experiences and interpretations of the situation. - The nurse asks as many questions as needed to gain a clear understanding of the client's perceptions of an event or issue. Active listening and observation help the nurse: •Recognize the issue that is most important to the client at this time •Know what further questions to ask the client •Use additional therapeutic communication techniques to guide the client to describe his or her perceptions fully •Understand the client's perceptions of the issue instead of jumping to conclusions •Interpret and respond to the message objectively

Interpreting Signals & Cues:

- To understand what a client means, the nurse watches and listens carefully for cues. - Cues (overt and covert) are verbal or nonverbal messages that signal key words or issues for the client. Finding cues is a function of active listening. - Cues can be buried in what a client says or can be acted out in the process of communication. - Often, cue words introduced by the client can help the nurse know what to ask next or how to respond to the client. - The nurse builds his or her responses on these cue words or concepts. - Understanding this can relieve pressure on students who are worried and anxious about what question to ask next.

Understanding Context:

- Understanding the context of communication is extremely important in accurately identifying the meaning of a message. - Think of the difference in the meaning of "I'm going to kill you!" when stated in two different contexts: anger during an argument and when one friend discovers another is planning a surprise party for him or her. - Understanding the context of a situation gives the nurse more information and reduces the risk for assumptions. - To clarify context, the nurse must gather information from verbal and nonverbal sources and validate findings with the client. - For example, if a client says, "I collapsed," she may mean she fainted or felt weak and had to sit down. - Or she could mean she was tired and went to bed.

Using Therapeutic Communication Techniques: Making Observations:

- Verbalizing what the nurse perceives - Ex: "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.

Avoiding Nontherapeutic Communication: Rejecting:

- refusing to consider or showing contempt for the client's ideas or behaviors - Ex: "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.

Nonverbal Communication: Vocal Cues:

- Vocal cues are nonverbal sound signals transmitted along with the content: voice volume, tone, pitch, intensity, emphasis, speed, and pauses augment the sender's message. - Volume, the loudness of the voice, can indicate anger, fear, happiness, or deafness. - Tone can indicate whether someone is relaxed, agitated, or bored. - Pitch varies from shrill and high to low and threatening. Intensity is the power, severity, and strength behind the words, indicating the importance of the message. - Emphasis refers to accents on words or phrases that highlight the subject or give insight into the topic. - Speed is the number of words spoken per minute. - Pauses also contribute to the message, often adding emphasis or feeling. - The high-pitched rapid delivery of a message often indicates anxiety. - The use of extraneous words with long, tedious descriptions is called circumstantiality. - It can indicate the client is confused about what is important or is a poor historian. - Slow, hesitant responses can indicate that the person is depressed, confused, and searching for the correct words, having difficulty finding the right words to describe an incident, or reminiscing. - It is important for the nurse to validate these nonverbal indicators rather than to assume that he or she knows what the client is thinking or feeling (e.g., "Mr. Smith, you sound anxious. Is that how you're feeling?").

Using Therapeutic Communication Techniques: Verbalizing The Implied:

- Voicing what the client has hinted at or suggested - Ex: 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.

Therapeutic Communication Session: Nondirective Role:

- When beginning therapeutic interaction with a client, it is often the client (not the nurse) who identifies the problem he or she wants to discuss. - The nurse uses active listening skills to identify the topic of concern. - The client identifies the goal, and information-gathering about this topic focuses on the client. - The nurse acts as a guide in this conversation. - The therapeutic communication centers on achieving the goal within the time limits of the conversation. The following are examples of client-centered goals: •The client will discuss her concerns about her 16-year-old daughter who is having trouble in school. •The client will describe the difficulty she has with side effects of her medication. •The client will share his distress about his son's drug abuse. •The client will identify the greatest concerns she has about being a single parent.

VERBAL COMMUNICATION SKILLS: Using Concrete Messages:

- When speaking to the client, the nurse should use words that are as clear as possible so the client can understand the message. - Anxious people lose cognitive processing skills—the higher the anxiety, the less the ability to process concepts—so concrete messages are important for accurate information exchange. - In a concrete message, the words are explicit and need no interpretation; the speaker uses nouns instead of pronouns—for example, "What health symptoms caused you to come to the hospital today?" or "When was the last time you took your antidepressant medications?" - Concrete questions are clear, direct, and easy to understand. They elicit more accurate responses and avoid the need to go back and rephrase unclear questions, which interrupts the flow of a therapeutic interaction. - Abstract messages, in contrast, are unclear patterns of words that often contain figures of speech that are difficult to interpret. - They require the listener to interpret what the speaker is asking. - For example, a nurse who wants to know why a client was admitted to the unit asks, "How did you get here?" - This is an abstract message: the terms how and here are vague. - An anxious client might not be aware of where he or she is and might reply, "Where am I?" or might interpret this as a question about how he or she was conveyed to the hospital and respond, "The ambulance brought me." - Clients who are anxious, experiencing language barriers, cognitively impaired, or suffering from some mental disorders often function at a concrete level of comprehension and have difficulty answering abstract questions. - The nurse must be sure that statements and questions are clear and concrete.

Therapeutic Communication Session: Directive Role:

- When the client is suicidal, experiencing a crisis, or out of touch with reality, the nurse uses a directive role, asking direct yes-or-no questions and using problem-solving to help the client develop new coping mechanisms to deal with present issues

Avoiding Nontherapeutic Communication: Giving Literal Response:

- responding to a figurative comment as though it were a statement of fact - Ex: 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.

Avoiding Nontherapeutic Communication: Testing:

- appraising the client's degree of insight - Ex: "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 acknowledgment that he or she doesn't know these things may meet the nurse's needs but is not helpful for the client.

Avoiding Nontherapeutic Communication: Requesting A Explanation:

- asking the client to provide reasons for thoughts, feelings, behaviors, and events - Ex: "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 or her 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 him or herself.

Avoiding Nontherapeutic Communication: Interpreting:

- asking to make conscious that which is unconscious; telling the client the meaning of his or her experience - Ex: "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 for hidden meaning. - Only the client can identify or confirm the presence of feelings.

Avoiding Nontherapeutic Communication: Defending:

- attempting to protect someone or something from verbal attack - Ex: "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.

Avoiding Nontherapeutic Communication: Indicating The Existence Of External Source:

- attributing the source of thoughts, feelings, and behaviors to others or to outside influences - Ex: "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?" - However, 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.

Avoiding Nontherapeutic Communication: Introducing Unrelated Topic:

- changing the subject - Ex: 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. - The client's thoughts and feelings are his or her own, not to be interpreted by the nurse for hidden meaning. Only the client can identify or confirm the presence of feelings.

Avoiding Nontherapeutic Communication: Challenging:

- demanding proof from the client - Ex: "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.

Avoiding Nontherapeutic Communication: Disapproving:

- denouncing the client's behavior or ideas - Ex: "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.

Avoiding Nontherapeutic Communication: Agreeing:

- indicating accord with the client - Ex: "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."

Avoiding Nontherapeutic Communication: Reassuring:

- indicating there is no reason for anxiety or other feelings of discomfort - Ex: "I wouldn't worry about that.", "Everything will be alright." , "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.

Avoiding Nontherapeutic Communication: Belittling Feelings Expressed:

- misjudging the degree of the client's discomfort - Ex: 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 that important. - The client is focused on his or her own worries and feelings; hearing the problems or feelings of others is not helpful.

Is the following statement true or false? Assertive communication focuses on identifying negative feelings.

False - Rationale: Assertive communication focuses on the expression of positive and negative feelings or ideas in an open, honest, direct manner.

Is the following statement true or false? A distance of 2 ft between the nurse and patient is adequate for promoting comfortable therapeutic communication.

False - Rationale: For effective therapeutic communication, a distance of 3 to 6 ft between the nurse and patient is most appropriate.

Is the following statement true or false? Nonverbal communication is often less accurate than verbal communication.

False - Rationale: Nonverbal communication is often more accurate than verbal communication when the two are incongruent. People can readily change what they say but are less likely to be able to control nonverbal communication.

7. Which of the following is a concrete message? a."Help me put this pile of books on Marsha's desk." b."Get this out of here." c."When is she coming home?" d."They said it is too early to get in."

a."Help me put this pile of books on Marsha's desk."

Therapeutic Communication Session Goals:

The nurse uses all the therapeutic communication techniques and skills previously described to help achieve the following goals: •Establish rapport with the client by being empathetic, genuine, caring, and unconditionally accepting of the client regardless of his or her behavior or beliefs. •Actively listen to the client to identify the issues of concern and to formulate a client-centered goal for the interaction. •Gain an in-depth understanding of the client's perception of the issue and foster empathy in the nurse-client relationship. •Explore the client's thoughts and feelings. •Facilitate the client's expression of thoughts and feelings. •Guide the client in developing new skills in problem-solving. •Promote the client's evaluation of solutions. - Often the nurse can plan the time and setting for therapeutic communication, such as having an in-depth, one-on-one interaction with an assigned client. - The nurse has time to think about where to meet and what to say and will have a general idea of the topic, such as finding out what the client sees as his or her major concern or following up on interaction from a previous encounter. - At times, however, a client may approach the nurse saying, "Can I talk to you right now?" Or the nurse may see a client sitting alone, crying, and decide to approach the client for an interaction. In these situations, the nurse may know that he or she will be trying to find out what is happening with the client at that moment in time. - When meeting the client for the first time, introducing oneself and establishing a contract for the relationship is an appropriate start for therapeutic communication. - The nurse can ask the client how he or she prefers to be addressed. - A contract for the relationship includes outlining the care the nurse will give, the times the nurse will be with the client, and acceptance of these conditions by the client. - After making the introduction and establishing the contract, the nurse can engage in small talk to break the ice and help get acquainted with the client if they have not met before. - Then the nurse can use a broad opening question to guide the client toward identifying the major topic of concern. - Broad opening questions are helpful to begin the therapeutic communication session because they allow the client to focus on what he or she considers important

Nonverbal Communication Facial Expression: Confusing:

•A confusing facial expression is one that is the opposite of what the person wants to convey.

2. "Earlier today you said you were concerned that your son was still upset with you. When I stopped by your room about an hour ago, you and your son seemed relaxed and smiling as you spoke to each other. How did things go between the two of you?" This is an example of which therapeutic communication technique? a.Consensual validation b.Encouraging comparison c.Accepting d.General lead

a.Consensual validation

3. "Why do you always complain about the night nurse? She is a nice woman and a fine nurse and has five kids to support. You're wrong when you say she is noisy and uncaring." This example reflects which nontherapeutic technique? a.Requesting an explanation b.Defending c.Disagreeing d.Advising

b. Defending

5. Client: "I was so upset about my sister ignoring my pain when I broke my leg." Nurse: "When are you going to your next diabetes education program?" This is a nontherapeutic response because the nurse has a.used testing to evaluate the client's insight. b.changed the topic. c.exhibited an egocentric focus. d.advised the client what to do.

b.changed the topic.

4. "How does Jerry make you upset?" is a nontherapeutic communication technique because it a.gives a literal response. b.indicates an external source of the emotion. c.interprets what the client is saying. d.is just another stereotyped comment.

b.indicates an external source of the emotion.

Nonverbal Communication Facial Expression: Expressive:

•An expressive face portrays the person's moment-by-moment thoughts, feelings, and needs. These expressions may be evident even when the person does not want to reveal his or her emotions.

6. When the client says, "I met Joe at the dance last week," what is the best way for the nurse to ask the client to describe her relationship with Joe? a."Joe who?" b."Tell me about Joe." c."Tell me about you and Joe." d."Joe, you mean that blond guy with the dark blue eyes?"

c."Tell me about you and Joe."

1. Client: "I had an accident." Nurse: "Tell me about your accident." This is an example of which therapeutic communication technique? a.Making observations b.Offering self c.General lead d.Reflection

c.General lead

Nonverbal Communication Facial Expression: Impassive:

•An impassive face is frozen into an emotionless deadpan expression similar to a mask.