Continuation of the Nursing Process

NCM 105
PSYCHIATRIC-MENTAL HEALTH
NURSING-PART 2
Psychiatric Nursing Practice – The Nursing Process
Lectured by Leila T. Salera, RN, MD, DPSP

ECT – ELECTROCONVULSIVE THERAPY

ECT
 Has been used continuously for more than 50 years
 The induction of a grand mal seizure through the
application of electrical current to the brain
 Duration of seizure should be at least 25 seconds
(Sadock and Sadock)
 Most clients require an average of 6 to 12 treatments
 Some may require up to 20 treatments
 Administered usually every other day, three times per
week
 Performed on an inpatient basis for those that require
close observation and care (suicidal, agitated,
delusional, catatonic, or acutely manic)
( Townsend Chapter 22; Student Guide, pages 53 to 56)

ECT
 Indications:
a. Major depression – not often the treatment of choice
but is considered only after a trial of therapy with
antidepressant medication has proven ineffective
b. Mania – rarely used for this purpose; for those who do
not tolerate or fail to respond to lithium or other drug
treatment, or when life is threatened by dangerous
behavior or exhaustion
c. Schizophrenia – can induce remission in some clients
with acute schizophrenia, particularly if it is
accompanied by catatonic or affective
symptomatology; no value among clients with chronic
shizophrenia

ECT
 Other conditions it is being used:
a. Neuroses
b. OCD – obsessive compulsive disorder
c. Personality disorder
d. Postpartum psychoses
 Mechanism of action (theories)
a. Electrical stimulation results in significant increases in
the circulating levels of several neurotransmitters
(serotonin, NE, and dopamine) which are affected by
antidepressant drugs
b. May also result in increases in glutamate and GABA

ECT
 Side effects
a. Temporary memory loss and confusion (most
common)
b. Permanent memory loss (?)
c. Occasional cardiac dysrhythmias
d. Brain damage – 2 per 100,000 treatments


ECT
 Nursing interventions prior to ECT
a. Explain the procedure
b. NPO for 8 hours (after midnight)
c. Have consent signed
d. Ensure labs and diagnostic examinations are all
done results available: CBC, urinalysis, X-ray
e. Empty bowel and bladder
f. Take vital and record signs approximately 1 hour
prior to treatment is scheduled
g. Client should remain in bed with side rails up

ECT
 Nursing interventions prior to ECT
h. Client should be changed into a hospital gown
i. Administer premedications 30 minutes prior to
treatment – atropine or glycopyrolate
(anticholinergics) IM
j. Remove anything conductive
k. Stay with client to allay fears and anxiety
l. Maintain a positive attitude
m. Encourage verbalization of feelings
n. Ensure airway patency
o. Restraints as necessary

ECT
 Nursing interventions during ECT
a. Provide suctioning as needed
b. Assist anesthesiologist with oxygenation as
required
c. Observe readouts on machines monitoring vital
signs and cardiac functioning
d. Provide support to the client’s arms and legs
during the seizure
e. Observe and record the type and amount of
movement induced by the seizure

ECT
 Nursing interventions after ECT
f. Allow the client to verbalize fears and anxieties
related to receiving ECT
g. Stay with the client until he or she is fully awake,
oriented, and able to perform self-care activities
without assistance
h. Provide the client with a highly structured
schedule of routine activities in order to minimize
confusion

PSYCHOTHERAPY
 Any procedure that promotes the development of
courage, inner security and self confidence making
the person more functional
 Most important element is trust and communication

 A form of mental exploration that should be
individualized
( Student Guide, pages 58 to 60)

INDIVIDUAL PSYCHOTHERAPY
 Method of bringing about change in a person by
exploring his or her feelings, attitudes, thinking, and
behavior
 Involves one-to-one relationship between the
therapist and the client
 Therapist’s theoretical beliefs strongly influence his
or her style of therapy
 Nurse or other health care provider who is familiar
with the client may be in a position to recommend a
therapist or a choice of therapists
(Videbeck pages 56 to 61)

GROUP THERAPY
 Clients participate in sessions with a group of
people
 The members share a common purpose and are
expected to contribute to the group to benefit others
and receive benefit from others in return
 Group rules are established, which all members
must observe, which vary according to the type of
group

GROUP THERAPY
 The therapeutic results of group therapy include the
following:
a. Gaining new information, or learning
b. Gaining inspiration or hope
c. Interacting with others
d. Feeling acceptance and belonging
e. Becoming aware that one is not alone and that others
share the same problems
f. Gaining insight into one’s problems and behaviors and
how they affect others
g. Giving of oneself for the benefit of others (altruism)

GROUP THERAPY
 Psychotherapy groups
1. Family therapy
2. Family education
3. Education groups
4. Support groups
5. Self-help groups


PSYCHOTHERAPY GROUPS
 Goal: for members to learn about their behavior and to
make positive changes in their behavior by interacting
and communicating with others as a member of a group
 Often formal in structure, with one or two therapists as
the group leaders
 Two types
a. Open groups – ongoing and run indefinitely, allowing
members to join or leave the group as they need to
b. Closed groups – structured to keep the same
members in the group for a specified number of
sessions; members decide how to handle members
who wish to leave the group and the possible
admission of new group members

PSYCHOTHERAPY GROUPS-FAMILY THERAPY
 A form of group in which the client and his or her
own family members participate
 The goals include understanding how family
dynamics contribute to the client’s psychopathology,
mobilizing the family’s inherent strengths and
functional resources, restructuring maladaptive
family behavioral styles, and strengthening family
behavioral styles, and strengthening family
problem-solving behaviors
 Can be used both to assess and to treat various
psychiatric disorders

PSYCHOTHERAPY GROUPS-FAMILY
EDUCATION
 A unique 12-week Family-to-Family Education
Course developed by the National Alliance for the
Mentally Ill (NAMI)
 Taught by trained family members, the curriculum
focuses on schizophrenia, bipolar disorder, clinical
depression, panic disorder, and obsessive-
compulsive disorder
 Discusses clinical treatment of these illnesses and
teaches knowledge and skills that family members
need to cope more effectively

PSYCHOTHERAPY GROUPS-EDUCATION
GROUPS
 Goal is to provide information to members on a
specific issue-for instance, stress management,
medication management, or assertiveness training
 The group leader has expertise in the subject area
and may be a nurse, therapist, or other health
professional
 Usually scheduled for a specific number of sessions
and retain the same members for the duration of
the group

PSYCHOTHERAPY GROUPS-SUPPORT
GROUPS
 Organized to help members who share a common
problem to cope with it
 The group leader explores members’ thoughts and
feelings and creates an atmosphere of acceptance
so that members feel comfortable expressing
themselves
 Often provide a safe place for members to express
their feelings of frustration, boredom, or
unhappiness and also discuss common problems
and potential solutions

PSYCHOTHERAPY GROUPS-SELF-HELP
GROUPS
 Members share a common experience, but the
group is not a formal or structured therapy group
 Professionals organize some self-help groups,
many are run by members and do not have a
formally identified leader
 Examples: Alcoholics Anonymous (AA), Parents
Without Partners, Gamblers Anonymous, and Al-
Anon (a group of spouses and partners of
alcoholics)
 Some have national headquarters and Internet
websites
 Most have a rule of confidentiality

COMPLEMENTARY AND ALTERNATIVE
THERAPIES
 Alternative medical systems – yoga, herbal medicines,
acupuncture, etc…
 Mind-body interventions – meditation, prayer. Mental
healing, and creative therapies that use art or music
 Biologically based therapies – use substances found in
nature, such as herbs, food, vitamins
 Manipulative and body-based therapies – therapeutic
massage and chiropractic or osteopathic manipulations
 Energy therapies – two types: a) biofield therapies,
intended to affect energy fields that are believed to
surround and penetrate the body (therapeutic touch, qi
gong, Reiki) and b) bioelectric-based therapies,
involving use of electromagnetic fields, such as pulse
fields, magnetic fields, and AC or DC fields
(Videbeck, pages 56 to 61)

PSYCHIATRIC REHABILITATION
 Involves providing services to people with severe
and persistent mental illness to help them to live in
the community
 Often called community support programs

 Focuses on the client’s strengths, not just on the
illness
 Client actively participates in program planning

 Programs are designed to help the client manage
the illness and symptoms, gain access to needed
services, and live successfully in the community

PSYCHOSOCIAL INTERVENTIONS
 Nursing activities that help enhance the client’s
social and psychological functioning and improve
social skills, interpersonal relationships, and
communication

(Videbeck, pages 56 to 61; Student Guide, pages 58 to 59 and
72 to 82)

COMMUNITY-BASED CARE – WHO/DOH
 Mental Health Sub-Programs
A. Wellness of Daily Living
B. Extreme Life Experiences
C. Mental Disorder
D. Substance Abuse Disorder

(Public Health Nursing in the Philippines, 2007, pages 231)

COMMUNITY-BASED CARE – WHO/DOH
 Home care is advocated
 Acute cases are referred to the National Center for
Mental Health (NCMH) or hospitals with psychiatric
facilities for proper management
 They are screened and after a few days they are
assessed and discharged if they can be managed at
home
 Cases needing continuing supervision and care may
be confined
 A team from the NCMH follow up their discharged
patients in the provinces
(Public Health Nursing in the Philippines, 2007, pages 231)

COMMUNITY-BASED CARE- WELLNESS OF
DAILY LIVING

 Wellness of Daily Living – The process of attaining
and maintaining mental well-being across the life
cycle through the promotion of healthy lifestyle with
emphasis on coping with psychosocial issues
 Objectives:
1. To increase awareness among the population on
mental health and psychosocial issues
2. To ensure access of preventive and promotive
mental health services
 (Public Health Nursing in the Philippines, 2007, pages 231)

COMMUNITY-BASED CARE- EXTREME LIFE
EXPERIENCES

 Objectives:
1. To differentiate between critical incident and extreme
life experiences
2. To identify situations which may be extreme life
experiences
3. To categorize/prioritize the extreme life experience
which may be the concern of mental health
4. To identify programs that could address psychosocial
consequences and mental health issues of persons
with extreme life experiences

COMMUNITY-BASED CARE- MENTAL DISORDER
 Objectives:
1. Promotion of mental health and prevention of
mental illness across the lifespan and across
sectors (children and adolescents, adults elderly,
and special population such as military, OFWs,
refugees, persons with disabilities)

COMMUNITY-BASED CARE- NURSING
RESPONSIBILITIES
 In mental health promotion
1. Participate in the promotion of mental health among
families and the community
2. Utilize opportunities in his/her everyday contacts with
other members of the community to extend the general
knowledge on mental hygiene
3. Help people in the community understand basic
emotional needs and the factors that promote mental
well being
4. Teach parents the importance of providing emotional
support to their children during critical periods in their
lives like first day in school graduation, etc…

RESPONSIBILITIES
 In prevention and control
1. Recognize mental health hazards and stress situations
as unemployment, divorce or abandonment of
children, vices, long standing physical illness, all of
which make heavy demands on the emotional
resources of the persons concerned
2. Recognize pathological deviations from normal in
terms of acting, thinking and feeling and make early
referral so that diagnosis and treatment could be done
early.
3. Be aware of potential causes of breakdown and when
necessary take some possible preventive action.

RESPONSIBILITIES
4. Help the family to understand and accept the patient’s
health status and behavior sp that all its members may
offer as much support in the readjustments to home
and community
5. Help patient assess his/her capacities and his/her
handicaps in working towards a solution of his/her
problem
6. Encourage feeling of achievement by setting health
goals that patient can attain
7. Encourage the patient to express his/her anxieties so
that fears and misconceptions can be cleared up

RESPONSIBILITIES

8. Impart information and guidance about the
treatment scheme of the patients, the desired and
undesirable effect of the tranquilizers, psychiatric
emergency management and other nursing care

RESPONSIBILITIES
 Rehabilitation
1. Initiate patient participation in occupational activities
best suited to patient’s capabilities, education,
experience and training, capacities and interest
2. Encourage and initiate patients to partake in activities
of CIVIC organization in the community through the
cooperation of the patient’s family
3. Advise the family about the importance of regular
follow-up at the clinic
4. Make regular home visits to observe patients’
conditions during conversation and follow-up of
medication

RESPONSIBILITIES

 In research and epidemiology
1. Participate actively in epidemiological survey to be
aware of the size and extent of mental health
problems in the community and to organize a
program for better preventive, curative and
rehabilitative measures.

STANDARD 6 - EVALUATION
 The psychiatric-mental health nurse evaluates
progress toward attainment of expected outcomes
 The continuous or ongoing phase of nursing
process is evaluation.
 Nursing care is a dynamic process involving
change in the patient’s health status over time,
giving rise to the need of new data, different
diagnosis, and modifications in the plan of care.

(Videbeck, page 10; The Internet)

STANDARD 6 - EVALUATION
 When evaluating care the nurse should review all
previous phases of the nursing process and determine
whether expected outcome for the patient have been
met.
 This can be done checking:
1. Have I done everything for my patient?
2. Is my patient better after the planned care?
 Evaluation is a feed back mechanism for judging the
quality of care given.
 Evaluation of the patient’s progress indicates what
problems of the patient have been solved, which need to
be assessed again, replanted, implemented and re-
evaluated.

(Videbeck, page 10; The Internet)

AREAS OF PRACTICE
 Basic-Level Functions
a. Counseling
b. Milieu therapy
c. Self-care activities
d. Psychobiologic interventions
e. Health teaching
f. Case management
g. Health promotion and maintenance
 Advanced-Level Functions
a. Psychotherapy
b. Prescriptive authority for drugs (US)
c. Consultation and liaison
d. Evaluation
e. Program development
f. And management
g. Clinical supervision

STUDENT CONCERNS
 Student concerns are normal
 Usually do not persist once the students have initial
contacts with clients
 Some common concerns and helpful hints for
beginning students:
“What is I say the wrong thing?”
- No one magic phrase can solve a client’s problems;
likewise, no single statement can significantly
worsen them
- Listening carefully, showing genuine interest, and
caring about the client are extremely important

STUDENT CONCERNS
 Some common concerns and helpful hints for beginning
students:
“What will I be doing?”
- In the mental health setting, many familiar tasks and
responsibilities are minimal
- Physical care skills or diagnostic tests and procedures
are fewer than those conducted in a busy medical-
surgical setting
- The student must deal with his or her own anxiety about
approaching a stranger to talk about very sensitive and
personal issues
- Development of the therapeutic nurse-client relationship
takes time and patience

STUDENT CONCERNS
beginning students:
“What if no one will talk to me?”
- Students sometimes fear that they will be rejected
by the client
- Some clients may not want to talk, or are reclusive,
but may show that same behavior with experienced
staff
- Students should not see such behavior as a
personal insult or failure

STUDENT CONCERNS
beginning students:
“Am I prying when I ask personal questions?”
- Personal questions should not be the first thing a
student says to the client
- These issues usually arise after some trust and
rapport have been established
- Ask sincere questions


STUDENT CONCERNS
beginning students:
“Ho will I handle bizarre or inappropriate behavior?”
- It is important to monitor one’s facial expressions
and emotional responses so that clients do not feel
rejected or ridiculed
- The nursing student instructor and staff are always
available to assist the student in such situations
- Students should never feel as if they have to handle
situations alone

STUDENT CONCERNS
beginning students:
“What happens if a client asks me for a date or
displays sexually aggressive or inappropriate
behavior?”
- Some clients have difficulty recognizing or
maintaining interpersonal boundaries
- When client seeks contact of any type outside the
nurse-client relationship, it is important for the
student (with the assistance of the instructor or
staff) to clarify the boundaries of the professional
relationship

STUDENT CONCERNS
beginning students:
behavior?”
- Likewise, setting limits and maintaining boundaries
are needed when a client’s behavior is sexually
inappropriate
- Initially, the student might be uncomfortable dealing
with such behavior, but with practice and the
assistance of the instructor and staff, it becomes
easier to manage

STUDENT CONCERNS
beginning students:
behavior?”
- It is also important to protect the client’s privacy and
dignity when he or she cannot do so

STUDENT CONCERNS
beginning students:
“Is my physical safety in jeopardy?”
- Actually, clients hurt themselves more often than
they harm others
- Staff members usually closely monitor clients with a
potential for violence for clues of an impending
outburst
- When physical aggression does occur, staff
members are specially trained to handle aggressive
clients in a safe manner

STUDENT CONCERNS
beginning students:
“What if I encounter someone I know being treated in
the unit?”
- It is essential that the client’s identity and treatment
be kept confidential
- If the student recognizes someone he or she
knows, the instructor must be notified, and the
instructor will decide on the situation
- Always reassure client that all will be kept
confidential and the student will be reassigned

STUDENT CONCERNS
beginning students:
“What if I recognize that I share problems or
backgrounds with clients?”
- No easy way to answer this question

- We do not always know why some people have
serious emotional problems, while others do not,
and yet they have similar life experiences
- Self-awareness is key


SELF-AWARENESS
 The process by which the nurse gains recognition
of his or her own feelings, beliefs, and attitudes
 In nursing, being aware of one’s feelings, thoughts,
and values is a primary focus
 What would you do if you were assigned to a client
who just had an abortion, and you are strong
believer of anti-abortion?
 Will your personal feelings and beliefs interfere with
your work?
 The nurse needs to discover him/herself and what
he/she believes before trying to help others with
different views

SELF-AWARENESS- POINTS TO CONSIDER
 Keep a dairy or journal that focuses on experiences and
related feelings
 Talk with someone you trust about your experiences and
feelings
 Engage in formal clinical supervision. Even experienced
clinicians have a supervisor with whom they discuss
personal feelings and challenging client situations to
gain insight and new approaches
 Seek alternative points of view. Put yourself in the
client’s situation and think about his or her feelings,
thoughts, and actions


SELF-AWARENESS- POINTS TO CONSIDER
 Do not be critical of yourself (or others) for having
certain values or beliefs. Accept them as a part of
yourself, or work to change those values and
beliefs you wish to be different


THERAPEUTIC RELATIONSHIPS
 The ability to establish therapeutic relationships
with clients is one of the most important skills a
nurse can develop
 The therapeutic relationship is especially crucial to
the success of interventions with clients requiring
psychiatric care because the therapeutic
relationship and the communication within it serve
as the underpinning for treatment and success

(Student Guide pages 59 to 69)

COMPONENTS OF A THERAPEUTIC
RELATIONSHIPS

 Trust
 Genuine interest
 Empathy
 Acceptance
 Positive regard
 Self awareness and Therapeutic use of self


RELATIONSHIPS
 Trust
1. Trust is built in the nurse-client relationship when the nurse exhibits the following
behaviors:
a. Caring
b. Openness
c. Objectivity
d. Respect
e. Interest
f. Understanding
g. Consistency
h. Treating the client as a human being
i. Suggesting without telling
j. Approachability
k. Listening
l. Keeping promises
m. Honesty

RELATIONSHIPS

 Trust
2. Congruence – occurs when words and actions
match
1. The client perceives this when the nurse is
comfortable with him/herself and is aware of his
strengths and limitations, and is focused
2. A client with mental illness can detect when
someone is exhibiting dishonest or artificial
behavior

RELATIONSHIPS

 Empathy
1. The ability to perceive the meanings of feelings of the
client and to communicate that understanding to the
client
2. Being able to put him/herself in the client’s shoes
 Acceptance

1. The nurse does not become upset or respond
negatively to a client’s outbursts, anger, or acting out
2. Avoiding judgment

RELATIONSHIPS

 Positive regard
1. The nurse is able to appreciate the client as a
unique worthwhile human being
2. The nurse can respect the client regardless of his
or her own behavior
3. Unconditional nonjudgmental attitude
 Self-awareness
1. The nurse must first know him/herself before he or
she can attend to a client
2. What are your values, attitudes, and beliefs?

RELATIONSHIPS

 Therapeutic use of self
1. Self-awareness has been developed

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

RELATIONSHIPS

Client: “I’m so confused! My son just visited and
wants to know where the safety deposit box key
is.”
Nurse: “You’re confused because your son asked for
the safety deposit box key?” (using reflection)
or
Nurse: “Are you confused about the purpose of your
son’s visit?” (using clarification)

RELATIONSHIPS

 Acceptance
Client: puts his arm around the nurse’s waist
Appropriate response conveying acceptance but not
allowing the inappropriate behavior of the client to
continue:
“ Sir, do not place your hand on me. We are working
on your relationship with your girlfriend and that
does not require you to touch me. Now, let’s
continue.”
Inappropriate response:
“ Sir, stop that! What’s wrong with you? I am leaving,
and maybe I’ll return tomorrow.”

RELATIONSHIPS

 Positive regard
Client: I was so mad, I yelled and screamed at my
mother for an hour.”
Which conveys positive regard or are appropriate
responses by the nurse?
a. “Well that didn’t help did it?”

b. “I can’t believe you did that.”

c. “What happened then?”

d. “You must really be upset.”

RELATIONSHIPS
 Therapeutic use of self
- Johari Window
1. A “words portrait” of a person in four areas
2. Each area indicates how well that person knows
him/herself and communicated with others
 Patterns of knowing
- Nurse theorist Hildegard Peplau (1952) identified
preconceptions, or ways one person expects another
person to behave or speak, as a roadblock to the
formation of an authentic relationship


TYPES OF RELATIONSHIPS
 Social relationship – primarily initiated for the
purpose of friendship, socialization, companionship,
or accomplishment of a task
 Intimate relationship – involves two people who are
emotionally committed to each other
 Therapeutic relationship – focuses on needs,
experiences, feelings, and ideas of the client only

ESTABLISHING THE THERAPEUTIC
RELATIONSHIP

 Phases:
1. Orientation phase

2. Working phase

a. Problem identification subphase

b. Exploitation subphase

3. Termination phase

(Videbeck pages 87 to91)

RELATIONSHIP

 Phases:
1. Orientation phase
a. Begins when then nurse and client meet and ends
when the client begins to identify problems to
examine
b. The nurse establishes the roles, the purpose of
meeting, and the parameters of subsequent
meetings
c. Identifies client’s problems
d. Clarifies expectations

RELATIONSHIP

 Phases:
2. Working phase

a. Problem identification subphase – the client
identifies the issues or concerns causing problems
b. Exploitation subphase – the nurse guides the
client to examine feelings and responses and
develop better coping skills and a more positive
self-image, to encourage behavior change and
develop independence

RELATIONSHIP

 Phases:
3. Termination phase

a. Also known as the resolution phase

b. The final stage of the nurse-client relationship

c. It begins when the problem is resolved

d. Ends when the relationship is ended


THERAPEUTIC AND NON-THERAPEUTIC FORMS
OF 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
- Helps the nurse understand and empathize with the
client’s experience

(Videbeck, page 98 to 116)

OF COMMUNICATION

- Goals:

1. Establish a therapeutic nurse-client relationship
2. Identify the most important client concern at that
moment (the client-centered goal)
3. Assess the client’s detailed actions as it unfolds
4. Facilitate the client’s expression of emotions
5. Teach the client and family necessary self-care skills
6. Recognize the client’s needs
7. Guide the client toward identifying a plan of action to a
satisfying and socially acceptable resolution

OF COMMUNICATION
- Privacy and Respecting Boundaries
1. Privacy is desirable, but not always possible in a therapeutic
communication
2. Proxemics – the study of distance zones between people
during communication
a. Intimate zone – 0 to 18 inches between people; parents and
young children, people who mutually desire personal contact
b. Personal zone – 19 to 36 inches; between family and friends
who are talking
c. Social zone – 4 to 12 feet; acceptable for communication in
social, work, and business settings
d. Public zone – 12 to 25 feet; speaker and audience, small
groups, and other informal functions

OF COMMUNICATION

1. Verbal communication – uses concrete messages
and abstract messages
2. Non-verbal communication – body language, eye
contact, facial expression, tone of voice, speed
and hesitations in speech, grunts and groans, and
distance from the listeners


OF COMMUNICATION

1. Touch
a. Functional-professional touch
b. Social-polite touch
c. Friendship-warmth touch
d. Love-intimacy touch


OF COMMUNICATION

1. Concrete messages – the words are explicit and
need no interpretation
2. Abstract messages – requires interpretation by the
listener like figure of speeches


OF COMMUNICATION

Concrete messages
“What health problems caused you to come to the
hospital today?”
Abstract messages
“How did you get here?”
The terms “how” and “here” are vague. To an anxious
client who is not thinking clearly:
“Where am I?” or “The ambulance brought me here?”

OF COMMUNICATION

Therapeutic communication
Abstract (unclear): “Get the stuff from him.”
Concrete (clear): “He’ll be home today at 5pm, and
you can pick up your clothes at that time.”

Abstract (unclear): “Your clinical performance has
improved.”
Concrete (clear): “To administer medications
tomorrow, you’ll have to be able to calculate
dosages correctly by the end of today’s class.”

OF COMMUNICATION

 Non-Therapeutic communication
a. Should be avoided

b. These responses cut off the communication and
make it more difficult for the interaction to continue
c. Asking “why” questions may be perceived as
criticism by the client, conveying a negative
judgment from the nurse

THERAPEUTIC COMMUNICATION TECHNIQUES
 Accepting – indicating reception, you are listening
and you have followed the train of thought
“Yes” or “I follow what you said” or simply nodding
 Broad opening – allowing the client to take the
initiative in introducing the topic, makes the client
feel that he or she has the lead interaction
“Is there something you’d like to talk about?”
 Consensual validation – searching for mutual
understanding, for accord in the meaning of the
words; to avoid any misunderstanding
“Tell me whether my understanding of it agrees with
yours.”

 Encouraging comparison – asking that similarities
and differences be noted
“ Was it something like…?”
 Encouraging description of perception – asking the
client to verbalize what he or she perceives
“What is happening?’
 Encouraging expression – asking the client to
appraise the quality of his or her experiences
“Tell me more about that.”
 Focusing – concentrating on a single point
“Of all you’ve mentioned, which is the most
troublesome?”

 Formulating a plan of action – asking the client to
consider kinds of behavior likely to be appropriate
in the future
 General leads – giving encouragement to continue

 Giving information – making available the facts that
the client needs
 Giving recognition – acknowledging, indicating
awareness
“Good morning, sir.”
“I noticed that you’ve combed your hair.”

 Making observations – verbalizing what the nurse
perceives
“You appear tense.”
 Offering self – making oneself available

“I’ll stay here with you for a while.”
 Placing event in time or sequence – clarifying the
relationship of events in time
“When did this happen?”
 Presenting reality – offering for consideration that
which is real
“I see no one else in the room.”

 Reflecting – directing the client actions, thoughts,
and feelings back to the client
Client: “Do you think I should tell the doctor…?”
Nurse: “Do you think you should?”
 Restating – repeating the main idea expressed

Client: “I can’t sleep. I stay awake all night.”
Nurse: “You have difficulty sleeping.”
 Seeking information – seeking to make clear that
which is not meaningful or that which is vague
Nurse: “I’m not sure I follow.”
Nurse: “Have I heard you correctly.”

 Silence – nurse says nothing but maintains eye
contact
 Suggesting collaboration – offering to share, to
strive, and to work with the client to his or her
benefit
Nurse: “Let’s go to your room, and I’ll help you find
what you’re looking for.”
 Summarizing – organizing and summing up that
which has gone before
Nurse: “Have I got this straight.”
Nurse: “You’ve said that…”

 Translating into feelings – seeking to verbalize client’s
feelings that he or she expresses only indirectly
Client: “I’m dead.”
Nurse: “Are you suggesting that you feel lifeless?”
 Verbalizing the implied – voicing what the client has
hinted or suggested
Client: “I can’t talk to you or anyone. It’s a waste of time.”
Nurse: “Do you feel that no one understands?”
 Voicing doubt – expressing uncertainty about the reality
of the client’s perceptions
Nurse: “Really?”

NON-THERAPEUTIC COMMUNICATION
TECHNIQUES

 Advising – telling client what to do
Nurse: “I think you should….” or “Why don’t you…?”
 Agreeing – indicating accord with the client
 Belittling feelings expressed – misjudging the
degree of the client’s discomfort
 Challenging – demanding proof from the client
 Defending – attempting to protect someone or
something from verbal attack
Nurse: “This hospital has a fine reputation.” or “I am
sure your doctor has your best interests in mind.”

TECHNIQUES

 Disagreeing – opposing the client’s ideas
 Disapproving – denouncing the client’s behavior or
ideas; implies that the nurse has the right to pass
judgment
 Giving approval – sanctioning the client’s behavior or
ideas; tends to limit the client’s freedom to think, speak,
or act in a certain way, which could lead to the client
acting a certain way just to please the nurse
 Giving literal responses – responding to a figurative
comment as though it were a statement of fact
Client: “They’re looking in my head with a TV camera.”
Nurse: “Try not to watch TV.” or “What channel?”

TECHNIQUES
 Indicating an existence of an external source –
attributing the source of thoughts, feelings, and behavior
to others or to outside influences
Nurse: “What made you say that?” – implies that the client
is compelled to think a certain way
 Interpreting – asking to make conscious that which is
unconscious, telling the client the meaning of his or her
experience. The client’s thoughts and feelings are his
own, hidden meaning are not meant for the nurse to
discover, only the client knows.
Nurse: “What you really mean is…” or “Unconsciously,
you’re saying…”
 Introducing an unrelated topic – changing the subject
Client: “I’d like to die.”
Nurse: “Did you have visitors this evening?”

TECHNIQUES

 Making stereotyped comments – offering
meaningless clichés or trite comments
Nurse: “It’s for your own good.” or “Just have a
positive attitude and you’ll be better in no time.”
 Probing – persistent questioning of the client

Nurse: “Tell me about this problem. You know I have
to find out.” or “Tell me your psychiatric history.”
 Reassuring – indicating there is no reason for
anxiety or other feelings of discomfort
Nurse: “Everything will be alright.”

TECHNIQUES

 Rejecting – refusing to consider or showing contempt for
the client’s ideas or behaviors’ This closes the chances
of exploration, and the client may feel personally
rejected along with feelings or ideas
Nurse: “Let’s not discuss….” or “I don’t want to hear
about…”
 Requesting an explanation – asking the client to provide
reasons for thoughts, feelings, behaviors, events. There
is a difference between this and asking the client to
describe what is occurring or has taken place, and
usually a “why” question is intimidating
Nurse: “Why do you think that?” or “Why do you feel that
way?”

TECHNIQUES
 Testing – appraising the client’s degree of insight, which
forces the client to recognize his or her problem. Helpful
to the nurse, but not to the client
Nurse: “Do you know what kind of hospital this is?” or “Do
you still have the idea that….?”
 Using denial – refusing to admit that a problem exists.
This implies that the nurse dismisses the seriousness of
the situation
Client: “I’m nothing.”
Nurse: “Of course you’re something – everybody’s
something.”
Client: “I’m dead.”
Nurse: “Don’t be silly.”

Continuation of the Nursing Process

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