Psych./ Mental Health Nursing CH. 6

· List and give examples of the most common therapeutic verbal techniques.

(Refer to PowerPoint slide 10 and Table 6.1.) Exploring- "Would you describe it more fully?" "What kind of work?" Focusing-"Of all the concerns you've mentioned, which is most troublesome?" restating-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." reflecting- 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 the nerve to ask for more." Nurse: "This causes you to feel angry?"

· List and give examples of the most common nontherapeutic techniques that nurses should avoid.

(Refer to PowerPoint slide 11 and Table 6.2.) Advising—"I think you should ..." "Why don't you ..." Belittling feelings expressed— 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." Challenging—"But how can you be president of the United States?" "If you're dead, why is your heart beating? Probing—"Now tell me about this problem. You know I have to find out." "Tell me your psychiatric history." Reassuring—"I wouldn't worry about that." "Everything will be alright." "You're coming along just fine."

Explain active listening and active observation; identify how these play a role in therapeutic communication. (Refer to PowerPoint slide 9.)

-Active listening (concentrating exclusively on what patient says) -Active observation (watching nonverbal actions as speaker communicates) These help the nurse: -Recognize the most important issue -Know what questions to ask -Use therapeutic communication techniques -Prevent jumping to conclusions -Objectively respond to message

· Discuss cultural considerations in communication. (Refer to PowerPoint slide 18.)

-Cultural assessment -Use of a translator who can retain original intent without inserting biases -Nurse must understand differences in how various cultures communicate. -Each culture has its own rules governing verbal and nonverbal communication

· Illuminate the threat of the relationship becoming social or intimate in the parent surrogate role. (Refer to Box 5.4.)

-Feelings of Sympathy and Encouraging Client Dependency -Nonacceptance and Avoidance BOX 5.4 Possible Warnings or Signals of Abuse of the Nurse-Client Relationship •Secrets; reluctance to talk to others about the work being done with clients •Sudden increase in phone calls between nurse and client or calls outside clinical hours •Nurse making more exceptions for client than normal •Inappropriate gift-giving between client and nurse •Loaning, trading, or selling goods or possessions •Nurse disclosure of personal issues or information •Inappropriate touching, comforting, or physical contact •Overdoing, overprotecting, or overidentifying with client •Change in nurse's body language, dress, or appearance (with no other satisfactory explanation) •Extended one-on-one sessions or home visits •Spending off-duty time with the client •Thinking about the client frequently when away from work •Becoming defensive if another person questions the nurse's care of the client •Ignoring agency policies

· Discuss understanding the meaning of communication; review context and spirituality. (Refer to PowerPoint slides 16 and 17.)

-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. -To clarify context, the nurse must gather information from verbal and nonverbal sources and validate findings with the client. -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. Spirituality= o Self-awareness of own spiritual beliefs o Need for objectivity and nonjudgmental attitude about client's beliefs 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

· Explain the need for interpreting signals and cues; describe and give examples of overt and covert cues. (Refer to PowerPoint slide 11.)

-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 Interpretation of signals or cues -Overt (clear, direct statements) ex."I want to die." -Covert (vague, indirect messages) ex."Nothing can help me."

· Describe the need for concrete messages; differentiate from abstract messages. (Refer to PowerPoint slide 10.)

-Need for concrete, not abstract, messages -In a concrete message, the words are explicit and need no interpretation; the speaker uses nouns instead of pronouns -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.

· List ways in which nonverbal messages accompany verbal messages.

-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.

· Discuss nonverbal communication skills such as facial expression, body language, vocal cues, eye contact, and understanding of levels of meaning and context.

-Nonverbal communication is the behavior a person exhibits while delivering verbal content. -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

· Explain how to phrase questions, ask for clarification, and guide the client in problem solving and empowerment. (Refer to PowerPoint slide 23 and Box 6.1.)

-Open-ended-elicit more descriptive information -yes-or-no questions-yield just an answer. Proper phrasing of questions o Using "think" versus "feel" -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. -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. -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. -Problem-solving is frequently used in crisis intervention but is equally effective for general use. 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. Identifying the problem involves engaging the client in therapeutic communication.

· Discuss the need for continual self-awareness and confronting any prejudices that threaten to hinder the nurse-client relationship. (Refer to Box 5.4.)

-The nurse-client relationship can be jeopardized if the nurse finds the client's behavior unacceptable or distasteful and allows those feelings to show by avoiding the client or making verbal responses or facial expressions of annoyance or turning away from the client. The nurse should be aware of the client's behavior and background before beginning the relationship; if the nurse believes there may be conflict, he or she must explore this possibility with a colleague. -It is the nurse's responsibility to treat each client with acceptance and positive regard, regardless of the client's history. Part of the nurse's responsibility is to continue to become more self-aware and to confront and resolve any prejudices that threaten to hinder the nurse-client relationship.

· Discuss boundaries in therapeutic communication with respect to distance and use of touch.

-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. -The nurse must evaluate the use of touch based on the client's preferences, history, and needs. -a Nurse may find touch supportive & the client may not.

· Explain the various possible roles of the nurse (teacher, caregiver, advocate, and parent surrogate) in the nurse-client relationship.

-The teacher role is inherent in most aspects of client care. During the working phase of the nurse-client relationship, the nurse may teach the client new methods of coping and solving problems. -primary caregiving role in mental health settings is the implementation of the therapeutic relationship to build trust, explore feelings, assist the client in problem-solving, and help the client meet psychosocial needs. -the advocate role, the nurse informs the client and then supports him or her in whatever decision he or she makes. In psychiatric-mental health nursing, advocacy is a bit different from medical-surgical settings because of the nature of the client's illness -Parent Surrogate- When a client exhibits childlike behavior or when a nurse is required to provide personal care such as feeding or bathing, the nurse may be tempted to assume the parental role as evidenced in choice of words and nonverbal communication. Often, the client responds by acting more childlike and stubborn. Neither party realizes they have fallen from adult-adult communication to parent-child communication.

· Identify therapeutic and nontherapeutic verbal communication skills

-Therapeutic Techniques (see Table 6.1) -Exploring, focusing, restating, reflecting, etc. -Some promote discussion of feelings or concerns in more depth -Other techniques useful in focusing or clarifying what is being said -Feedback via making an observation or presenting reality

Explain how communication is the means by which a therapeutic relationship is initiated, maintained, and terminated.

-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. -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.

· Distinguish and define between concrete and abstract messages and give examples of each.

-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- 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."

· Identify the forms of nonverbal communication, and explore multiple meanings conveyed by each. (Refer to PowerPoint slides 12 and 13.)

-facial expression- -Body language- a nonverbal form of communication o Closed body position-such as crossed legs or arms folded across the chest, indicating that the interaction might threaten the listener who is defensive or not accepting. o Open posture-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. -Vocal cues- -Eye contact -Silence

describe the process component of communication

-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.

explain congruent and incongruent messages; give examples

A congruent message is conveyed when content and process agree. ex. 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 incongruent message is when the content and process disagree ex. 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.

· Identify therapeutic and nontherapeutic verbal communication skills

AVOID DOING THESE: Nontherapeutic techniques (see Table 6.2) o Advising, belittling, challenging, probing, reassuring

· Explain the nondirective and directive roles. (Refer to PowerPoint slide 22.)

Nondirective Role-using broad openings and open-ended questions to collect information and to help the client identify and discuss the topic of concern. -The client does most of the talking. -The nurse guides the client through the interaction, facilitating the client's expression of feelings and identification of issues. -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. -used when the client is suicidal, experiencing a crisis, or out of touch with reality.

· List the five types of touch, and discuss their appropriate uses. (Refer to PowerPoint slide 6.)

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.

· Review the goals of a therapeutic communication session. (Refer to PowerPoint slide 21.)

Goals of Therapeutic communication session: o Establishing rapport o Actively listening o Gaining in-depth understanding of client's perception of issue o Being empathetic o Exploring client's thoughts and feelings o Facilitating client's expression of thoughts and feelings o Guiding client in developing problem-solving skills o Promoting client's evaluation of solutions

Review the goals of therapeutic communication outlined in the chapter, and relate how they are part of the therapeutic relationship. (Refer to PowerPoint slide 4.)

Goals of therapeutic communication -Establish a therapeutic nurse-client relationship -Identify the most important client's concerns; assess client's perceptions -Facilitate client's expression of emotions -Teach client and family the necessary self-care skills -Recognize client's needs -Implement interventions to address client's needs -Guide client toward acceptable solutions -All nurses need skills in therapeutic communication to effectively apply the nursing process and to meet standards of care for their clients.

· List the roles that a nurse may assume during the nurse-client relationship. (Refer to PowerPoint slide 23.)

Parent Surrogate Advocate Caregiver Teacher

· Explain proxemics; describe how the personal and intimate zones can affect therapeutic communication. (Refer to PowerPoint slide 5.)

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. -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. 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.

· Explain the likely consequences of inappropriate boundaries, feelings of sympathy, non-acceptance, and avoidance on the nurse-client relationship.

This is in CH. 5. -Boundary violations often begin unintentionally, or may even be well-intentioned, such as the nurse sharing personal relationship problems, thinking it might help the client. Once personal information has been shared, it cannot be retracted. The harm to the therapeutic relationship cannot be undone. -The nurse must not let feelings of empathy turn into sympathy for the client. Unlike the therapeutic use of empathy, the nurse who feels sorry for the client often tries to compensate by trying to please him or her.

define communication (PowerPoint slide 2) & differentiate between verbal and nonverbal communication

communication: Exchange of information through verbal and nonverbal messages. Verbal -Content: literal words spoken -Context: environment, circumstances, situation in which communication occurs Nonverbal -Process: all messages used to give meaning, context to message -Congruent or incongruent messages

explain the content and context of communication

content- the literal words a person speaks context-the environment in which communication occurs

· List the four distance zones, and demonstrate their appropriate uses.

o Distance zones Intimate (0-18 in)-his 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 (18-36 in)-This distance is comfortable between family and friends who are talking. Social (4-12 ft)-This distance is acceptable for communication in social, work, and business settings. Public (12-25 ft)-This is an acceptable distance between a speaker and an audience, small groups, and other informal functions.

· Review the three categories of facial expressions: expressive, impassive, and confusing.

o 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. o Impassive face- is frozen into an emotionless deadpan expression similar to a mask. o Confusing facial expression- is one that is the opposite of what the person wants to convey.

· Describe the role of privacy and boundaries in therapeutic communication. (Refer to PowerPoint slide 5.)

o Therapeutic communication: most comfortable when nurse and patient are 3 to 6 ft apart