Early nursing theorists wrote about how the “therapeutic use of self” helps us to forge close working relationships with our patients. Today we talk about authenticity, and it’s been noted that “the essence of nursing care comes from bringing our authentic selves to the nurse-patient relationship.” We each develop a nursing “style,” weaving our own identities into the way we relate to patients and families. But where do the parts of ourselves that are very much “us” but not immediately evident to others come into the picture?
To disclose or not to disclose?In this month’s Reflections column, “A Lie by Omission?“, nurse practitioner Charles Yingling takes a thoughtful look at what we choose to share with our patients, and what it means to them and to us when we do so. Can a nurse refrain from disclosing key parts of his or her identity and still be “authentic” as a giver of care? If we keep a very important part of who we are out of the interaction, do we rob ourselves and our patients of a chance to deepen this therapeutic relationship? A matter of context and judgment.Of course this is not a question of nurses blurting out the facts of their personal lives to every patient. The encounter, after all, is about them and not us. But in the right context, sharing our humanity can be deeply meaningful to another single mom considering adoption, or to a patient dealing with grief after losing a partner, or to a gay or transgender teen. Read Yingling’s nuanced thoughts on “the power of these human connections” in nursing practice in the January issue of AJN. The article will be free until February 7. RelatedESTABLISHING THE THERAPEUTIC RELATIONSHIP The nurse who has self-confidence rooted in self- awareness is ready to establish appropriate therapeutic relationships with clients. Because personal growth is ongoing over one’s lifetime, the nurse cannot expect to have complete self-knowledge. Awareness of his or her strengths and limita-tions at any particular moment, however, is a good start. PhasesPeplau studied and wrote about the interpersonal pro-cesses and the phases of the nurse–client relationship for 35 years. Her work provides the nursing profession with a model that can be used to understand and document prog-ress with interpersonal interactions. Peplau’s model (1952) has three phases: orientation, working, and resolution or termination (Table 5.2). In real life, these phases are not that clear-cut; they overlap and interlock. Orientation The orientation phase begins when the nurse and client meet and ends when the client begins to identify problems to examine. During the orientation phase, the nurse estab-lishes roles, the purpose of meeting, and the parameters of subsequent meetings; identifies the client’s problems; and clarifies expectations. Before meeting the client, the nurse has important work to do. The nurse reads background materials available on the client, becomes familiar with any medications the cli-ent is taking, gathers necessary paperwork, and arranges for a quiet, private, and comfortable setting. This is the time for self-assessment. The nurse should consider his or her personal strengths and limitations in working with this client. Are there any areas that might signal difficulty because of past experiences? For example, if this client is a spouse batterer and the nurse’s father was also one, the nurse needs to consider the situation: How does it make him or her feel? What memories does it prompt, and can he or she work with the client without these memories interfering? The nurse must examine preconceptions about the client and ensure that he or she can put them aside and get to know the real person. The nurse must come to each client without preconceptions or prejudices. It may be useful for the nurse to discuss all potential prob-lem areas with the instructor. During the orientation phase, the nurse begins to build trust with the client. It is the nurse’s responsibility to establish a therapeutic environment that fosters trust and understanding (Table 5.3). The nurse should share appropriate information about himself or herself at this time, including name, reason for being on the unit, and level of schooling: For example, “Hello, James. My name is Miss Ames and I will be your nurse for the next six Tuesdays. I am a senior nursing student at the University of Mississippi.” The nurse needs to listen closely to the client’s history, perceptions, and misconceptions. He or she needs to con-vey empathy and understanding. If the relationship gets off to a positive start, it is more likely to succeed and to meet established goals. At the first meeting, the client may be distrustful if pre-vious relationships with nurses have been unsatisfactory. The client may use rambling speech, act out, or exaggerate episodes as ploys to avoid discussing the real problems. It may take several sessions until the client believes that he or she can trust the nurse. Nurse–Client Contracts. Although many clients have had prior experiences in the mental health system, the nurse must once again outline the responsibilities of the nurse and the client. At the outset, both nurse and client should agree on these responsibilities in an informal or verbal contract. In some instances, a formal or written contract may be appropriate; examples include if a written contract has been necessary in the past with the client or if the cli-ent “forgets” the agreed-on verbal contract. The contract should state the following: · Time, place, and length of sessions · When sessions will terminate · Who will be involved in the treatment plan (family members or health team members) · Client responsibilities (arrive on time and end on time) · Nurse’s responsibilities (arrive on time, end on time, maintain confidentiality at all times, evaluate progress with client, and document sessions). Confidentiality. Confidentiality means respecting the client’s right to keep private any information about his or her mental and physical health and related care. It means allowing only those dealing with the client’s care to have access to the information that the client divulges. Only under precisely defined conditions can third parties have access to this information; for example, in many states the law requires that staff report suspected child and elder abuse. Adult clients can decide which family members, if any, may be involved in treatment and may have access to clinical information. Ideally, the people close to the client and responsible for his or her care are involved. The cli-ent must decide, however, who will be included. For the client to feel safe, boundaries must be clear. The nurse must clearly state information about who will have access to client assessment data and progress evaluations. He or she should tell the client that members of the mental health team share appropriate information among them-selves to provide consistent care and that only with the client’s permission will they include a family member. If the client has an appointed guardian, that person can review client information and make treatment decisions that are in the client’s best interest. For a child, the parent or appointed guardian is allowed access to information and can make treatment decisions as outlined by the health-care team. The nurse must be alert if a client asks him or her to keep a secret because this information may relate to the client’s harming himself or herself or others. The nurse must avoid any promises to keep secrets. If the nurse has promised not to tell before hearing the message, he or she could be jeopardizing the client’s trust. In most cases, even when the nurse refuses to agree to keep information secret, the client continues to relate issues anyway. The following is an example of a good response to a client who is suicidal but requests secrecy: Client: “I am going to jump off the 14th floor of my apartment building tonight, but please don’t tell anyone.” Nurse: “I cannot keep such a promise, espe-cially if it involves your safety. I sense you arefeeling frightened. The staff and I will help you stay safe.” The Tarasoff vs. Regents of the University of California (1976) decision releases professionals from privileged communication with their clients should a client make a homicidal threat. The decision requires the nurse to notify intended victims and police of such a threat. In this cir-cumstance, the nurse must report the homicidal threat tothe nursing supervisor and attending physician so that both the police and the intended victim can be notified. This is called a duty to warn. The nurse documents the client’s problems with planned interventions. The client must understand that the nurse will collect data about him or her that helps in making a diagnosis, planning health care (including medications), and protecting the client’s civil rights. The client needs to know the limits of confidentiality in nurse–client interac-tions and how the nurse will use and share this informa-tion with professionals involved in client care. Self-Disclosure. Self-disclosure means revealing per-sonal information such as biographical information and personal ideas, thoughts, and feelings about oneself to cli-ents. Traditionally, conventional wisdom held that nurses should share only their name and give a general idea about their residence, such as “I live in Ocean County.” Now, however, it is believed that some purposeful, well-planned, self-disclosure can improve rapport between the nurse and the client. The nurse can use self-disclosure to convey support, educate clients, and demonstrate that a client’s anxiety is normal and that many people deal with stress and problems in their lives. Self-disclosure may help the client feel more comfort-able and more willing to share thoughts and feelings, or help the client gain insight into his or her situation. When using self-disclosure, the nurse must also consider cultural factors. Some clients may deem self-disclosure inappropriate or too personal, causing the client discom-fort. Disclosing personal information to a client can be harmful and inappropriate, so it must be planned and considered thoughtfully in advance. Spontaneously self-disclosing personal information can have negative results. For example, when working with a client whose parents are getting a divorce, the nurse says, “My parents got a divorce when I was 12 and it was a horrible time for me.” The nurse has shifted the focus away from the client and has given the client the idea that this experience will be horrible for the client. Although the nurse may have meant to communicate empathy, the result can be quite the opposite. WorkingThe working phase of the nurse–client relationship is usually divided into two subphases: During problem identification, the client identifies the issues or concerns causing problems. During exploitation, the nurse guides the client to examine feelings and responses and to develop better coping skills and a more positive self-image; this encourages behavior change and develops independence. (Note that Peplau’s use of the word exploi-tation had a very different meaning than current usage, which involves unfairly using or taking advantage of a person or situation. For that reason, this phase is betterconceptualized as intense exploration and elaboration on earlier themes that the client discussed.) The trust estab-lished between nurse and client at this point allows them to examine the problems and to work on them within the security of the relationship. The client must believe that the nurse will not turn away or be upset when the client reveals experiences, issues, behaviors, and problems. Sometimes the client will use outrageous stories or act-ing-out behaviors to test the nurse. Testing behavior chal-lenges the nurse to stay focused and not to react or to be distracted. Often when the client becomes uncomfortable because he or she is getting too close to the truth, he or she will use testing behaviors to avoid the subject. The nurse may respond by saying, “It seems as if we have hit an uncomfortable spot for you. Would you like to let it go for now?” This statement focuses on the issue at hand and diverts attention from the testing behavior. The nurse must remember that it is the client who examines and explores problem situations and relation-ships. The nurse must be nonjudgmental and refrain from giving advice; the nurse should allow the client to analyze situations. The nurse can guide the client to observe pat-terns of behavior and whether or not the expected response occurs. For example, a client who suffers from depression complains to the nurse about the lack of concern her chil-dren show her. With the assistance and guidance of the nurse, the client can explore how she communicates with her children and may discover that her communication involves complaining and criticizing. The nurse can then help the client explore more effective ways of communi-cating in the future. The specific tasks of the working phase include the following: · Maintaining the relationship · Gathering more data · Exploring perceptions of reality · Developing positive coping mechanisms · Promoting a positive self-concept · Encouraging verbalization of feelings · Facilitating behavior change · Working through resistance · Evaluating progress and redefining goals as appropriate · Providing opportunities for the client to practice new behaviors · Promoting independence. As the nurse and client work together, it is common for the client unconsciously to transfer to the nurse feelings he or she has for significant others. This is called transfer-ence. For example, if the client has had negative experi-ences with authority figures, such as a parent or teachers or principals, he or she may display similar reactions of negativity and resistance to the nurse, who also is viewed as an authority. A similar process can occur when the nurse responds to the client based on personal unconscious needs and conflicts; this is called countertransference. For example, if the nurse is the youngest in her family and often felt as if no one listened to her when she was a child, she may respond with anger to a client who does not listen or resists her help. Again, self-awareness is important so that the nurse can identify when transference and counter-transference might occur. By being aware of such “hot spots,” the nurse has a better chance of responding appro-priately rather than letting old unresolved conflicts inter-fere with the relationship. TerminationThe termination or resolution phase is the final stage in the nurse–client relationship. It begins when the prob-lems are resolved, and it ends when the relationship is ended. Both nurse and client usually have feelings about ending the relationship; the client especially may feel the termination as an impending loss. Often clients try to avoid termination by acting angry or as if the problem has not been resolved. The nurse can acknowledge the client’s angry feelings and assure the client that this response is normal to ending a relationship. If the client tries to reopen and discuss old resolved issues, the nurse must avoid feeling as if the sessions were unsuccessful; instead, he or she should identify the client’s stalling maneuvers and refocus the client on newly learned behaviors and skills to handle the problem. It is appropriate to tell the client that the nurse enjoyed the time spent with the cli-ent and will remember him or her, but it is inappropriate for the nurse to agree to see the client outside the thera-peutic relationship. Page 2AVOIDING BEHAVIORS THAT DIMINISH THE THERAPEUTIC RELATIONSHIP The nurse has power over the client by virtue of his or her professional role. That power can be abused if excessive familiarity or an intimate relationship occurs or if confi-dentiality is breached. Inappropriate BoundariesAll staff members, both new and veteran, are at risk for allowing a therapeutic relationship to expand into an inap-propriate relationship. Self-awareness is extremely important: The nurse who is in touch with his or her feelings and aware of his or her influence over others can help maintain the boundaries of the professional relationship. The nurse must maintain professional boundaries to ensure the best thera-peutic outcomes. It is the nurse’s responsibility to define the boundaries of the relationship clearly in the orientation phase and to ensure those boundaries are maintained throughout the relationship. The nurse must act warmly and empatheti-cally but must not try to be friends with the client. Social interactions that continue beyond the first few minutes of a meeting contribute to the conversation staying on the sur-face. This lack of focus on the problems that have been agreed on for discussion erodes the professional relationship. If a client is attracted to a nurse or vice versa, it is up to the nurse to maintain professional boundaries. Accepting gifts or giving a client one’s home address or phone num-ber would be considered a breach of ethical conduct. Nurses must continually assess themselves and ensure they keep their feelings in check and focus on the clients’ interests and needs. Nurses can assess their behavior by using the Nursing Boundary Index in Table 5.4. Feelings of Sympathy and Encouraging Client DependencyThe nurse must not let feelings of empathy turn into sympa-thy 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. When the nurse’s behavior is rooted in sympathy, the client finds it easier to manipulate the nurse’s feelings. This discourages the client from explor-ing his or her problems, thoughts, and feelings; discourages client growth; and often leads to client dependency. The client may make increased requests of the nurse for help and assistance or may regress and act as if he or she cannot carry out tasks previously done. These can be sig-nals that the nurse has been “overdoing” for the client and may be contributing to the client’s dependency. Clients often test the nurse to see how much the nurse is willing to do. If the client cooperates only when the nurse is in attendance and does not carry out agreed-on behavior in the nurse’s absence, the client has become too dependent. In any of these instances, the nurse needs to reassess his or her professional behavior and refocus on the client’s needs and therapeutic goals. Nonacceptance and AvoidanceThe nurse–client relationship can be jeopardized if the nurse finds the client’s behavior unacceptable or distaste-ful and allows those feelings to show by avoiding the cli-ent 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 possi-bility with a colleague. If the nurse is aware of a prejudice that would place the client in an unfavorable light, he or she must explore this issue as well. Sometimes by talking about and confronting these feelings, the nurse can accept the client and not let a prejudice hinder the relationship. If the nurse cannot resolve such negative feelings, how-ever, he or she should consider requesting another assign-ment. It is the nurse’s responsibility to treat each client with acceptance and positive regard, regardless of the cli-ent’s history. Part of the nurse’s responsibility is to con-tinue to become more self-aware and to confront and resolve any prejudices that threaten to hinder the nurse– client relationship. Page 3ROLES OF THE NURSE IN A THERAPEUTIC RELATIONSHIP As when working with clients in any other nursing setting, the psychiatric nurse uses various roles to provide needed care to the client. The nurse understands the importance of assuming the appropriate role for the work that he or she is doing with the client. Teacher 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. He or she may instruct about themedication regimen and available community resources. To be a good teacher, the nurse must feel confident about the knowledge he or she has and must know the limita-tions of that knowledge base. The nurse should be familiar with the resources in the health-care setting and commu-nity and on the Internet, which can provide needed infor-mation for clients. The nurse must be honest about what information he or she can provide and when and where to refer clients for further information. This behavior and honesty build trust in clients. Caregiver The 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. If the client also requires physical nursing care, the nurse may need to explain to the client the need for touch while per-forming physical care. Some clients may confuse physical care with intimacy and sexual interest, which can erode the therapeutic relationship. The nurse must consider the relationship boundaries and parameters that have been established and must repeat the goals that were established together at the beginning of the relationship. Advocate In the advocate role, the nurse informs the client and then supports him or her in whatever decision he or she makes (Edd, Fox, & Burns, 2005). In psychiatric–mental health nursing, advocacy is a bit different from medical-surgical set-tings because of the nature of the client’s illness. For example, the nurse cannot support a client’s decision to hurt himself or herself or another person. Advocacy is the process of acting on the client’s behalf when he or she cannot do so. This includes ensuring privacy and dignity, promoting informed consent, preventing unnecessary examinations and proce-dures, accessing needed services and benefits, and ensuringsafety from abuse and exploitation by a health professional or authority figure. For example, if a physician begins to exam-ine a client without closing the curtains and the nurse steps in and properly drapes the client and closes the curtains, the nurse has just acted as the client’s advocate. Being an advocate has risks. In the previous example, the physician may be embarrassed and angry and make a comment to the nurse. The nurse needs to stay focused on the appropriateness of his or her behavior and not be intimidated. The role of advocate also requires the nurse to be obser-vant of other health-care professionals. At times, staff mem-bers may be reluctant to see what is happening or become involved when a colleague violates the boundaries of a pro-fessional relationship. Nurses must take action by talking to the colleague or a supervisor when they observe boundary violations. State nurse practice acts include the nurse’s legal responsibility to report boundary violations and unethical conduct on the part of other health-care providers. There is debate about the role of nurse as advocate. There are times when the nurse does not advocate for the client’s autonomy or right to self-determination, such as by supporting involuntary hospitalization for a suicidal client. At these times, acting in the client’s best interest (keeping the client safe) is in direct opposition to the cli-ent’s wishes. Some critics view this as paternalism and interference with the true role of advocacy. In addition, they do not see advocacy as a role exclusive to nursing but also relevant to the domains of physicians, social workers, and other health-care professionals. Parent Surrogate When a client exhibits child-like 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 com-munication. The nurse may begin to sound authoritative with an attitude of “I know what’s best for you.” Often, the client responds by acting more child-like and stubborn. Neither party realizes they have fallen from adult–adult communication to parent–child communication. It is easy for the client to view the nurse in such circumstances as a parent surrogate. In such situations, the nurse must be clear and firm and set limits or reiterate the previously set limits. By retaining an open, easygoing, nonjudgmental attitude, the nurse can continue to nurture the client while establishing boundaries. The nurse must ensure the rela-tionship remains therapeutic and does not become social or intimate. Page 4Therapeutic Communication 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 (DeVito, 2008). 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 sen-tences 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 the 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. Nonverbal communication is the behavior that accompanies verbal con-tent 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 ofcommunication requires the listeners to observe the behav-iors 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. A 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 exam-ple, if the client says, “I’m here to get help,” but has a rigid posture, clenched fists, 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 lan-guage invalidates the words (incongruent message). The message conveyed is “I’m apologizing because I think I have to. I’m not really sorry.” Page 5WHAT IS THERAPEUTIC COMMUNICATION? 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 com-munication techniques helps the nurse understand and empathize with the client’s experience. All nurses need skills in therapeutic communication to effectively apply the nurs-ing process and to meet standards of care for their clients. Therapeutic communication can help nurses to accom-plish many goals: · Establish a therapeutic nurse–client relationship. · Identify the most important client concern at that mo-ment (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 feel-ings about the situation, others, and self. · Facilitate the client’s expression of emotions. · Teach the client and family necessary self-care skills. · Recognize the client’s needs. · Implement interventions designed to address the client’s needs. Guide the client toward identifying a plan of action to a satisfying and socially acceptable resolution. Establishing a therapeutic relationship is one of the most important responsibilities of the nurse when work-ing with clients. Communication is the means by which a therapeutic relationship is initiated, maintained, and ter-minated. To have effective therapeutic communication, the nurse also must consider privacy and respect of boundaries, use of touch, and active listening and observation. Privacy and Respecting BoundariesPrivacy is desirable but not always possible in therapeutic communication. An interview or a conference room is optimal if the nurse believes this setting is not too isolative for the interaction. The nurse also can 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 cli-ent’s room is therapeutic. For example, if the client has difficulty maintaining boundaries or has been making sex-ual comments, then the client’s room is not the best set-ting. A more formal setting would be desirable. Proxemics is the study of distance zones between peo-ple during communication. People feel more comfortable with smaller distances when communicating with some-one they know rather than with strangers (DeVito, 2008). People from the United States, Canada, and many Eastern European nations generally observe four distance zones: · Intimate zone (0 to 18 inches between people): This amount of space is comfortable for parents with young children, people who mutually desire personal contact, or people whispering. Invasion of this intimate zone by anyone else is threatening and produces anxiety. · Personal zone (18 to 36 inches): This distance is com-fortable between family and friends who are talking. · Social zone (4 to 12 feet): This distance is acceptable for communication in social, work, and business settings. · Public zone (12 to 25 feet): This is an acceptable dis-tance between a speaker and an audience, small groups, and other informal functions (Hall, 1963). People from some cultures (e.g., Hispanic, Mediterra-nean, East Indian, Asian, and Middle Eastern) are more comfortable with less than 4 to 12 feet of space between them while talking. The nurse of European American or African American heritage may feel uncomfortable if cli-ents from these cultures stand close when talking. Con-versely, clients from these backgrounds may perceive the nurse as remote and indifferent (Andrews & Boyle, 2007). 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 always should 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/no format so the client’s response is clear. This is one of the times when yes/no questions are appropriate. The therapeutic communication interaction is most comfortable when the nurse and client are 3 to 6 feet apart. If a client invades the nurse’s intimate space (0 to 18 inches), the nurse should set limits gradually, depend-ing on how often the client has invaded the nurse’s space and the safety of the situation. TouchAs 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 masseuse performs a massage. · Social-polite touch is used in greeting, such as a hand-shake and the “air kisses” some women 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 men use to greet friends and relatives. · Love-intimacy touch involves tight hugs and kisses between lovers or close relatives. · Sexual-arousal touch is used by lovers. 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, how-ever, she signals to the nurse that she feels uncomfort-able being touched. The nurse also can ask the client about touching (e.g., “Would it help you to squeeze my hand?”). Although touch can be comforting and therapeutic, it is an invasion of intimate and personal space. Some cli-ents with mental illness have difficulty understanding the concept of personal boundaries or knowing when touch is or is not appropriate. Consequently, most psy-chiatric 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 ver-bally prepare the client before starting the procedure. A client with paranoia may interpret being touched as a threat and may attempt to protect himself or herself by striking the staff person. Active Listening and ObservationTo receive the sender’s simultaneous messages, the nurse must use active listening and active observation. Active listening means refraining from other internal mentalactivities 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 infor-mation obtained, determines the underlying needs that relate to the behavior, and connects pieces of informa-tion (makes links between various sections of the conversation). A common misconception by students learning the art of therapeutic communication is that they always must 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 frustrat-ing to both participants. When a superficial conversa-tion 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 impossi-ble 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 com-munication, the nurse must ask specific questions to get the entire story from the client’s perspective, to clarify assumptions, and to 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 pos-sible 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 to · 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. Page 6VERBAL COMMUNICATION SKILLS Using Concrete MessagesWhen speaking to the client the nurse should use words that are as clear as possible so that 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, from different cul-tures, cognitively impaired, or suffering from some mental disorders often function at a concrete level of comprehen-sion and have difficulty answering abstract questions. The nurse must be sure that statements and questions are clear and concrete. The following are examples of abstract and concrete messages: Abstract (unclear): “Get the stuff from him.” Concrete (clear): “John will be home today at 5 pm, and you can pick up your clothes at that time.” Abstract (unclear): “Your clinical perfor-mance has to improve.” Concrete (clear): “To administer medications tomorrow, you’ll have to be able to calculate dosages correctly by the end of today’s class.” Using Therapeutic Communication TechniquesThe nurse can use many therapeutic communication tech-niques to interact with clients. The choice of technique depends on the intent of the interaction and the client’s ability to communicate verbally. Overall, the nurse selects techniques that facilitate the interaction and enhance com-munication between client and nurse. Table 6.1 lists these techniques and gives examples. Techniques such asexploring, focusing, restating, and reflecting encourage the client to discuss his or her feelings or concerns in more depth. Other techniques help focus or clarify what is being said. The nurse may give the client feedback using tech-niques such as making an observation or presenting reality. Avoiding Nontherapeutic CommunicationIn contrast, there are many nontherapeutic techniques that nurses should avoid (Table 6.2). These responses cut off communication and make it more difficult for the inter-action to continue. Responses such as “Everything will work out” or “Maybe tomorrow will be a better day” may be intended to comfort the client, but instead may impede the communication process. Asking “why” questions (in an effort to gain information) may be perceived as criti-cism by the client, conveying a negative judgment from the nurse. Many of these responses are common in social interaction. Therefore, it takes practice for the nurse to avoid making these types of comments. Interpreting Signals or CuesTo understand what a client means, the nurse watches and listens carefully for cues. Cues (overt and covert) are ver-bal 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 to know what to ask next or how to respond to the client. The nurse builds his or her responses on these cue words or con-cepts. Understanding this can relieve pressure on students who are worried and anxious about what question to ask next. The following example illustrates questions the nurse might ask when responding to a client’s cue: Client: “I had a boyfriend when I was younger.” Nurse: “You had a boyfriend?” (reflecting) “Tell me about you and your boyfriend.”(encouraging description) “How old were you when you had this boy-friend?” (placing events in time or sequence) If a client has difficulty attending to a conversation and drifts into a rambling discussion or a flight of ideas, the nurse listens carefully for a theme or a topic around which the client composes his or her words. Using the theme, the nurse can assess the nonverbal behaviors that accompany the client’s words and build responses based on these cues. In the following examples, the underlined words are themes and cues to help the nurse formulate further communication. Theme of sadness: Client: “Oh, hi, nurse.” (face is sad; eyes look teary; voice is low, with little inflection) Nurse: “You seem sad today, Mrs. Venezia.” Client: “Yes, it is the anniversary of my husband’s death.” Nurse: “How long ago did your husband die?” (Or the nurse can use the other cue.) Nurse: “Tell me about your husband’s death, Mrs. Venezia.” Theme of loss of control: Client: “I had a fender bender this morning. I’m okay. I lost my wallet, and I have to go to the bank to cover a check I wrote last night. I can’t get in contact with my husband at work. I don’t know where to start.” Nurse: “I sense you feel out of control” (translating into feelings). 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 interpretationand 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 feels so hopeless and helpless that he 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/no question to elicit a clear response. Theme of hopelessness and suicidal ideation: Client: “Life is hard. I want it to be done. There is no rest. Sleep, sleep is good . . . forever.” Nurse: “I hear you saying things seem hope-less. I wonder if you are planning to kill your-self” (verbalizing the implied). Other word patterns that need further clarification for meaning include metaphors, proverbs, and clichés. When a client uses these figures of speech, the nurse must follow up with questions to clarify what the client is trying to say. A metaphor is a phrase that describes an object or a situation by comparing it to something else familiar. Client: “My son’s bedroom looks like a bomb went off.” Nurse: “You’re saying your son is not very neat” (verbalizing the implied). Client: “My mind is like mashed potatoes.” Nurse: “I sense you find it difficult to put thoughts together” (translating into feelings). Proverbs are old accepted sayings with generally accepted meanings. Client: “People who live in glass houses shouldn’t throw stones.” Nurse: “Who do you believe is criticizing you but actually has similar problems?” (encourag-ing description of perception) A cliché is an expression that has become trite and gen-erally conveys a stereotype. For example, if a client says, “she has more guts than brains,” the implication is that the speaker believes the woman to whom he or she refers is not smart, acts before thinking, or has no common sense. The nurse can clarify what the client means by saying, “Give me one example of how you see Mary as having more guts than brains” (focusing). Page 7NONVERBAL 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, if not more so than, verbal communication. It is estimated that one third of meaning is transmitted by words and twothirds is communicated nonverbally. The speaker may ver-balize what he or she believes the listener wants to hear, whereas nonverbal communication conveys the speaker’s actual meaning. Nonverbal communication involves the unconscious mind acting out emotions related to the ver-bal content, the situation, the environment, and the rela-tionship between the speaker and the listener. Knapp and Hall (2009) listed the ways in which non-verbal messages accompany verbal messages: · Accent: using flashing eyes or hand movements · Complement: giving quizzical looks, nodding · Contradict: rolling eyes to demonstrate that the mean-ing is the opposite of what one is saying · Regulate: taking a deep breath to demonstrate readiness to speak, using “and uh” to signal the wish to continue speaking · Repeat: using nonverbal behaviors to augment the ver-bal message, such as shrugging after saying “Who knows?” · Substitute: using culturally determined body move-ments that stand in for words, such as pumping the arm up and down with a closed fist to indicate success Facial ExpressionThe human face produces the most visible, complex, and sometimes confusing nonverbal messages. Facial move-ments connect with words to illustrate meaning; this con-nection demonstrates the speaker’s internal dialogue. Facial expressions can be categorized into expressive, impassive, and confusing: · An expressive face portrays the person’s moment-by-moment thoughts, feelings, and needs. These expres-sions may be evident even when the person does not want to reveal his or her emotions. · An impassive face is frozen into an emotionless deadpan expression similar to a mask. · A confusing facial expression is one that is the opposite of what the person wants to convey. 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 could 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 very angry” (Sheldon, 2008). 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 non-verbal communication and checks its congruency with the content (Sheldon, 2008). 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). Body LanguageBody language (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, whereas 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, whereas sitting behind a desk (creating a physical barrier) can increase the for-mality of the setting and may decrease the client’s willing-ness 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. Vocal CuesVocal cues are nonverbal sound signals transmitted along with the content: voice volume, tone, pitch, intensity, emphasis, speed, and pauses augment the sender’s mes-sage. 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 spo-ken 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 impor-tant 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?”). Eye ContactThe 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, happi-ness, sadness, horror, warning, and pleading. Eye contact, looking into the other person’s eyes during communica-tion, is used to assess the other person and the environ-ment and to indicate whose turn it is to speak; it increases during listening but decreases while speaking (DeVito, 2008). Although maintaining good eye contact is usually desirable, it is important that the nurse doesn’t “stare” at the client. SilenceSilence 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 is slow 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. Page 8UNDERSTANDING THE 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 (DeVito, 2008). The nurse must try to discover all the meaning in the cli-ent’s communication. For example, the client with depres-sion 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 often mean the client wishes to die. The nurse would need to further assess the client’sstatement to determine whether or not the client is suicidal. It is sometimes easier for clients to act out their emo-tions 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. |