NCLEX: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span: Grief/Bereavement

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

Grief is a typical reaction to the loss of a source of psychological gratification. It is a syndrome with somatic and psychological symptoms that diminish when grief is resolved. Grief processes have been extensively described by Erich Lindemann and George Engle.*

I. CONCEPTS AND PRINCIPLES RELATED TO GRIEF:

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

A.Cause of grief: reaction to loss (real or imaginary, actual or pending).
B. Healing process can be interrupted.
C. Grief is universal.
D. Uncomplicated grief is a self-limiting process.

E. Grief responses may vary in degree and kind (e.g., absence of grief, delayed grief, and unresolved grief).
F. People go through stages similar to stages of death described by Elisabeth Kübler-Ross.
G. Many factors influence successful outcome of grieving process:

  • The more dependent the person on the lost relationship, the greater the difficulty in resolving the loss.
  • A child has greater difficulty resolving loss.
  • A person with few meaningful relationships also has greater difficulty.
  • The more losses the person has had in the past, the more affected that person will be, because losses tend to be cumulative.
  • The more sudden the loss, the greater the difficulty in resolving it.
  • The more ambivalence (love-hate feelings, with guilt) there was toward the dead, the more difficult the resolution.
  • Loss of a child is harder to resolve than loss of an older person.

II. ASSESSMENT—CHARACTERISTIC STAGES OF GRIEF RESPONSES:

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

A. Shock and disbelief (initial and recurrent stage):

  • Denial of reality (“No, it can’t be.”)
  • Stunned, numb feeling.
  • Feelings of loss, helplessness, impotence.
  • Intellectual acceptance.

B. Developing awareness:

  • Anguish about loss.
    a. Somatic distress.
    b. Feelings of emptiness.
  • Anger and hostility toward person or circumstances held responsible.
  • Guilt feelings—may lead to self-destructive actions.
  • Tears (inwardly, alone; or inability to cry).

C. Restitution:

  • Funeral rituals are an aid to grief resolution by emphasizing the reality of death.
  • Expression and sharing of feelings by gathered family and friends are a source of acknowledgment of grief and support for the bereaved.

D. Resolving the loss:

  • Increased dependency on others as an attempt to deal with painful void.
  • More aware of own bodily sensations—may be identical with symptoms of the deceased.
  • Complete preoccupation with thoughts and memories of the dead person.

E. Idealization:

  • All hostile and negative feelings about the dead are repressed.
  • Mourner may assume qualities and attributes of the dead.
  • Gradual lessening of preoccupation with the dead; reinvesting in others.

III. ANALYSIS:  Analysis/Nursing Diagnosis: Altered Feeling States Related to Grief and Grief versus depression.

IV. NURSING CARE PLAN/IMPLEMENTATION IN GRIEF STAGES:

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

A. Apply crisis theory and interventions.
B. Demonstrate unconditional respect for cultural, religious, and social mourning customs.
C. Utilize knowledge of the stages of grief to anticipate reactions and facilitate the grief process.

  • Anticipate and permit expression of different manifestations of shock, disbelief, and denial.
    a. News of impending death is best communicated to a family group (rather than an individual) in a private setting.
    b. Let mourners see the dead or dying, to help them accept reality.
    c. Encourage description of circumstances and nature of loss.
  • Accept guilt, anger, and rage as common responses to coping with guilt and helplessness.
    a. Be aware of potential suicide by the bereaved.
    b. Permit crying; stay with the bereaved.
  • Mobilize social support system; promote hospital policy that allows gathering of friends and family in a private setting.
  • Allow dependency on staff for initial decision making while person is attempting to resolve loss.
  • Respond to somatic complaints.
  • Permit reminiscence.
  • Encourage mourner to relate accounts connected with the lost relationship that reflect positive and negative feelings and remembrances; place loss in
    perspective.
  • Begin to encourage and reinforce new interests and social relations with others by the end of the idealization stage; loosen bonds of attachment.
  • Identify high-risk persons for maladaptive responses.
  • Health teaching:
    a. Explain that emotional response is appropriate and common.
    b. Explain and offer hope that emotional pain will diminish with time.
    c. Describe normal grief stages.

 

Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

 

 

 

V. EVALUATION/OUTCOME CRITERIA: outcome may take 1 year or more—can remember comfortably and realistically both pleasurable and disappointing
aspects of the lost relationship.

  • Can express feelings of sorrow caused by loss.
  • Can describe ambivalence (love, anger) toward lost person, relationship.
  • Able to review relationship, including pleasures, regrets, etc.
  • Bonds of attachment are loosened and new object relationships are established.

Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span: Mental Status Assessment

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

I. COMPONENTS OF MENTAL STATUS EXAMINATION:

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

A. Appearance—appropriate dress, piercings, tattoos, hair color/texture, grooming, facial expression, eye contact, stereotyped movements, tremors, tics, gestures, gait, mannerisms, rigidity, height and weight.

B. Behavior—anxiety level, congruence with situation, impulse control (aggression, sexual), cooperativeness, openness, hostility, reaction to interview (guarded, defensive, apathetic), consistency.

C. Speech characteristics—relevance, coherence, meaning, repetitiveness, qualitative (what is said), quantitative (how much is said), abnormalities,
inflections, affectations, congruence with level of education, impediments (e.g., stutter), tone quality.

D. Mood—appropriateness, intensity, hostility turned inward or toward others, swings, guilty, despairing, irritable, sad, depressed, anxious, fearful.

E. Thought content—delusions, hallucinations, obsessive ideas, suicidal, homicidal, paranoid, religiosity, magical, phobic ideas, themes, areas of concern, self-concept.

F. Thought processes—organization and association of ideas, coherence, ability to abstract and understand symbols.

G. Sensorium:

  • Orientation to person, time and place, situation.
  • Memory—immediate, rote, remote, and recent.
  • Attention and concentration—susceptibility to distraction.
  • Information and intelligence—account of general knowledge, history, and reasoning powers.
  • Comprehension—concrete and abstract.
  • Stage of consciousness—alert/awake, somnolent, lethargic, delirious, stuporous, comatose.

H. Insight and judgment:

  • Extent to which client sees self as having problems, needing treatment.
  • Client awareness of intrapsychic nature of own difficulties.
  • Soundness of judgment, problem-solving, decision making.

I. Spiritual.

II. INDIVIDUAL ASSESSMENT—consider the following (Individual Assessment ):

  • Physical and intellectual factors.
  • Socioeconomic factors.
  • Personal values and goals.
  • Adaptive functioning and response to present involvement.
  • Developmental factors.

III. CULTURAL ASSESSMENT:

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

A. Knowledge of ethnic beliefs and cultural practices can assist the nurse in the planning and implementation of holistic care.

B. Consider the following:

  • Demographic data: is this an “ethnic neighborhood”?
  • Socioeconomic status: occupation, education (formal and informal), income level; who is employed?
  • Ethnic/racial orientation: ethnic identity, value orientation.
  • Country of immigration: date of immigration; where were the family members born? Where has the family lived?
  • Languages spoken: does family speak English? Language and dialect preferences.
  • Family relationships: what are the formal roles? Who makes the decisions within the family? What is the family lifestyle and living arrangements?
  • Degree of acculturation of family members: how are the family customs and beliefs similar to or different from the dominant culture?
  • Communication patterns: social customs, nonverbal behaviors.
  • Religious preferences: what role do beliefs, rituals, and taboos play in health and illness? Is there a significant religious person? Are there any dietary symbolisms or preferences or restrictions due to religious beliefs?
  • Cultural practices related to health and illness: does the family use folk medicine practices or a folk healer? Are there specific dietary practices related to health and illness?
  • Support systems: do extended family members provide support?
  • Health beliefs: response to pain and hospitalization; disease predisposition and resistance.
  • Other significant factors related to ethnic identity: what health-care facilities does the family use?
  • Communication barriers:
    a. Differences in language.
    b. Technical languages.
    c. Inappropriate place for discussion.
    d. Personality or gender of the nurse.
    e. Distrust of the nurse.
    f. Time-orientation differences.
    g. Differences in pain perception and expression.
    h. Variable attitudes toward death and dying.

Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span: Interviewing

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

I. DEFINITION: a goal-directed method of communicating facts, feelings, and meanings. For interviewing to be successful, interaction between two persons involved must be effective.

II. NINE PRINCIPLES OF VERBAL INTERACTION:

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

  • Client’s initiative begins the discussion.
  • Indirect approach, moving from the periphery to the core.
  • Open-ended statements, using incomplete forms of statements such as “You were saying . . .” to prompt rather than close off an exchange.
  • Minimal verbal activity in order not to obstruct thought process and client’s responses.
  • Spontaneity, rather than fixed interview topics, may bring out much more relevant data.
  • Facilitate expression of feelings to help assess events and reactions by asking, for example, “What was that like for you?”
  • Focus on emotional areas about which client may be in conflict, as noted by repetitive themes.
  • Pick up cues, clues, and signals from client, such as facial expressions and gestures, behavior, emphatic tones, and flushed face.
  • Introduce material related to content already brought up by client; do not bring in a tangential focus from “left field.”

III. PURPOSE AND GOALS OF INTERVIEWING:

  • Initiate and maintain a positive nurse-client relationship, which can decrease symptoms, lessen demands, and move client toward optimum health when
    nurse demonstrates understanding and sharing of client’s concerns.
  • Determine client’s view of nurse’s role in order to utilize it or change it.
  • Collect information on emotional crisis to plan goals and approaches in order to increase effectiveness of nursing interventions.
  • Identify and resolve crisis; the act of eliciting cause or antecedent event may in itself be therapeutic.
  • Channel feelings directly by exploring interrelated events, feelings, and behaviors in order to discourage displacement of feelings onto somatic and behavioral symptoms.
  • Channel communication and transfer significant information to the physician and other team members.
  • Prepare for health teaching in order to help the client function as effectively as possible.

Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span: General Principles of Health Teaching

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

One key nursing function is to promote and restore health. This involves teaching clients new psychomotor skills, general knowledge, coping attitudes, and social skills related to health and illness (e.g., proper diet, exercises, colostomy care, wound care, insulin injections, urine testing). The teaching function of the nurse is vital in assisting normal development and helping clients meet health-related needs.

I. PURPOSE OF HEALTH TEACHING:

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

A. General goal: motivate health-oriented behavior.

B. Nursing interventions:

  • Fill in gaps in information.
  • Clarify misinformation.
  • Teach necessary skills.
  • Modify attitudes.

II. EDUCATIONAL THEORIES on which effective health teaching is based:

A. Motivation theory:

  • Health-oriented behavior is determined by the degree to which person sees health problem as threatening, with serious consequences, high probability of occurrence, and belief in availability of effective course of action.
  • Non–health-related motives may supersede health-related motives.
  • Health-related motives may not always give rise to health-related behavior, and vice versa.
  • Motivation may be influenced by:
    a. Phases of adaptation to crisis (poor motivation in early phase).
    b. Anxiety and awareness of need to learn. (Mild anxiety is highly motivating.)
    c. Mutual versus externally imposed goal setting.
    d. Perceived meaningfulness of information and material. (If within client’s frame of reference, both meaningfulness and motivation increase.)

B. Theory of planned change:

  • Unfreeze present level of behavior—develop awareness of problem.
  • Establish need for change and relationship of trust and respect.
  • Move toward change—examine alternatives, develop intentions into real efforts.
  • Freeze on a new level—generalize behavior,stabilize change.

C. Elements of learning theory:

  • Drive must be present based on experiencing uncertainty, frustration, concern, or curiosity; hierarchy of needs exists.
  • Response is a learned behavior that is elicited when associated stimulus is present.
  • Reward and reinforcement are necessary for response (behavior) to occur and remain.
  • Extinction of response, that is, elimination of undesirable behavior, can be attained through conditioning.
  • Memorization is the easiest level of learning, but least effective in changing behavior.
  • Understanding involves the incorporation of generalizations and specific facts.
  • After introduction of new material, there is a period of floundering when assimilation and insight occur.
  • Learning is a two-way process between learner and teacher; defensive behavior in either makes both activities difficult, if not impossible.
  • Learning flourishes when client feels respected, accepted by nurse who is enthusiastic; learning occurs best when differing value systems are accepted.
  • Feedback increases learning.
  • Successful learning leads to more successes in learning.
  • Teaching and learning should take place in the area where targeted activity normally occurs.
  • Priorities for learning are dependent on client’s physical and psychological status.
  • Decreased visual and auditory perception leads to decreased readiness to learn.
  • Content, terminology, pacing, and spacing of learning must correspond to client’s capabilities, maturity level, feelings, attitudes, and experiences.

III. ASSESSMENT OF THE CLIENT-LEARNER:

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

A. Characteristics: age, sex, race, medical diagnosis, prognosis.
B. Sociocultural-economic: ethnic, religious group beliefs and practices; family situation (roles, support); job (type, history, options, stress); financial situation, living situation (facilities).
C. Psychological: own and family’s response to illness; premorbid personality; current self-image.
D. Educational:

  • Client’s perception of current situation: what is wrong? Cause? How will lifestyle be affected?
  • Past experience: previous hospitalization and treatment; past compliance.
  • Level of knowledge: what has client been told? From what source? How accurate? Known others with the same illness?
  • Goals: what client wants to know.
  • Needs: what nurse thinks client should know for self-care.
  • Readiness for learning.
  • Educational background; ability to read and learn.

IV. ANALYSIS OF FACTORS INFLUENCING LEARNING:

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

A. Internal:

  • Physical condition.
  • Senses (sight, hearing, touch).
  • Age.
  • Anxiety.
  • Motivation.
  • Experience.
  • Values (cultural, religious, personal).
  • Comprehension.
  • Education and language deficiency.

B. External:

  • Physical environment (heat, light, noise, comfort).
  • Timing, duration, interval.
  • Teaching methods and aids.
  • Content, vocabulary.

V. TEACHING PLAN must be:

A. Compatible with the three domains of learning:

  • Cognitive (knowledge, concepts): use written and audiovisual materials, discussion.
  • Psychomotor (skills): use demonstrations, illustrations, role models.
  • Affective (attitudes): use discussions, maintain atmosphere conducive to change; use role models.

B. Appropriate to educational material.
C. Related to client’s abilities and perceptions.
D. Related to objectives of teaching.

VI. IMPLEMENTATIONteaching guidelines to use with clients:

  • Select conducive environment and best timing for activity.
  • Assess the client’s needs, interests, perceptions, motivations, and readiness for learning.
  • State purpose and realistic goals of planned teaching/learning activity.
  • Actually involve the client by giving him or her the opportunity to do, react, experience, and ask questions.
  • Make sure that the client views the activity as useful and worthwhile and that it is within the client’s grasp.
  • Use comprehensible terminology.
  • Proceed from the known to the unknown, from specific to general information.
  • Provide opportunity for client to see results and progress.
  • Give feedback and positive reinforcement.
  • Provide opportunities to achieve success.
  • Offer repeated practice in real-life situations.
  • Space and distribute learning sessions over a period of time.

VII. EVALUATION/OUTCOME CRITERIA:

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life SpanFocus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

  • Client’s deficit of knowledge is lessened.
  • Increased compliance with treatment.
  • Length of hospital stay is reduced.
  • Rate of readmission to hospital is reduced.
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Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span: The Therapeutic Nursing Process*

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

A therapeutic nursing process involves an interaction between the nurse and client in which the nurse offers a series of planned, goal-directed activities that are useful to a particular client in relieving discomfort, promoting growth, and satisfying interpersonal relationships.

I. CHARACTERISTICS of therapeutic nursing:

A. Movement from first contact through final outcome:

  • Eight general phases occur in a typical unfolding of a natural process of problem-solving.
  • Stages are not always in the same sequence.
  • Not all stages are present in a relationship.

B. Phases†

  • Beginning the relationship. Goal: build trust.
  • Formulating and clarifying a problem and concern. Goal: clarify client’s statements.
  • Setting a contract or working agreement. Goal: decide on terms of the relationship.
  • Building the relationship. Goal: increase depth of relationship and degree of commitment.
  • Exploring goals and solutions, gathering data, expressing feelings. Goals: (a) maintain and enhance relationship (trust and safety), (b) explore blocks to goal, (c) expand self-awareness, and (d) learn skills necessary to reach goal.
  • Developing action plan. Goals: (a) clarify feelings, (b) focus on and choose between alternative courses of action, and (c) practice new skills.
  • Working through conflicts or disturbing feelings. Goals: (a) channel earlier discussions into specific course of action and (b) work through unresolved
    feelings.
  • Ending the relationship. Goals: (a) evaluation of goal attainment; (b) pointing out assets and gains; and (c) leave-taking reactions (repression, regression, anger, withdrawal, acting out).

II. THERAPEUTIC NURSE-CLIENT INTERACTIONS:

Focus topic: Psychosocial Integrity: Behavioral/Mental Health Care Throughout the Life Span

A. Plans/goals:

  • Demonstrate unconditional acceptance, interest, concern, and respect.
  • Develop trust—be consistent and congruent.
  • Make frequent contacts with the client.
  • Be honest and direct, authentic and spontaneous.
  • Offer support, security, and empathy, not sympathy.
  • Focus comments on concerns of client (client centered), not self (social responses). Refocus when client changes subject.
  • Encourage expression of feelings; focus on feelings and here-and-now behavior.
  • Give attention to a client who complains.
  • Give information at client’s level of understanding, at appropriate time and place.
  • Use open-ended questions; ask how, what, where, who, and when questions; avoid why questions; avoid questions that can be answered by yes or no.
  • Use feedback or reflective listening.
  • Maintain hope, but avoid false reassurances, clichés, and pat responses.
  • Avoid verbalizing value judgments, giving personal opinions, or moralizing.
  • Do not change the subject unless the client is redundant or focusing on physical illness.
  • Point out reality; help the client leave “inner world.”
  • Set limits on behavior when client is acting out unacceptable behavior that is self-destructive or harmful to others.
  • Assist clients in arriving at their own decisions by demonstrating problem-solving or involving them in the process.
  • Do not talk if it is not indicated.
  • Approach, sit, or walk with clients who are agitated; stay with the person who is upset, if he or she can tolerate it.
  • Focus on nonverbal communication.
  • Remember the psyche has a soma! Do not neglect appropriate physical symptoms.

B. Examples of therapeutic responses as interventions:

  • Being silent—being able to sit in silence with a person can connote acceptance and acknowledgment that the person has the right to silence. (Dangers: The nurse may wrongly give the client the impression that there is a lack of interest, or the nurse may discourage verbalization if acceptance of this behavior is
    prolonged; it is not necessarily helpful with acutely psychotic behavior.)
  • Using nonverbal communication—for example, nodding head, moving closer to the client, and leaning forward; use as a way to encourage client to speak.
  • Give encouragement to continue with open ended leads—nurse’s responses: “Then what?” “Go on,” “For instance,” “Tell me more,” “Talk about that.”
  • Accepting, acknowledging—nurse’s responses: “I hear your anger,” or “I see that you are sitting in the corner.”
  • Commenting on nonverbal behavior of client— nurse’s responses: “I notice that you are swinging your leg,” “I see that you are tapping your foot,” or “I notice that you are wetting your lips.” Client may respond with, “So what?” If she or he does, the nurse needs to reply why the comment was made—for example, “It is distracting,” “I am giving the nonverbal behavior meaning,” “Swinging your leg makes it difficult for me to concentrate on what you are saying,” or “I think when people tap their feet it means they are impatient. Are you impatient?”
  • Encouraging clients to notice with their senses what is going on—nurse’s response: “What did you see (or hear)?” or “What did you notice?”
  • Encouraging recall and description of details of a particular experience—nurse’s response: “Give me an example,” “Please describe the experience further,” “Tell me more,” or “What did you say then?”
  • Giving feedback by reflecting, restating, and paraphrasing feelings and content:

Client: I cried when he didn’t come to see me.

Nurse: You cried. You were expecting him to come and he didn’t?

  • Picking up on latent content (what is implied)— nurse’s response: “You were disappointed. I think it may have hurt when he didn’t come.”
  • Focusing, pinpointing, asking “what” questions:
    Client: They didn’t come.
    Nurse: Who are “they”?
    Client: [Rambling.] Nurse: Tell it to me in a sentence or two. What is your main point? What would you say is your main concern?
  • Clarifying—nurse’s response: “What do you mean by ‘they’?” “What caused this?” or “I didn’t understand. Please say it again.”
  • Focusing on reality by expressing doubt on “unreal” perceptions:
    Client: Run! There are giant ants flying around after us.
    Nurse: That is unusual. I don’t see giant ants flying.
  • Focusing on feelings, encouraging client to be aware of and describe personal feelings:
    Client: Worms are in my head.
    Nurse: That must be a frightening feeling. What did you feel at that time? Tell me about that feeling.
  • Helping client to sort and classify impressions, make speculations, abstract and generalize by making connections, seeing common elements and similarities, making comparisons, and placing events in logical sequence—nurse’s responses: “What are the common elements in what you just told me?” “How is this similar to . . .?” “What happened just before?” or “What is the connection between this and . . .?”
  • Pointing out discrepancies between thoughts, feelings, and actions—nurse’s response: “You say you were feeling sad when she yelled at you, yet you laughed. Your feelings and actions do not seem to fit together.”
  • Checking perceptions and seeking agreement on how the issue is seen, checking with the client to see if the message sent is the same one that was received—nurse’s response: “Let me restate what I heard you say,” “Are you saying that . . .?” “Did I hear you correctly?” “Is this what you mean?” or “It seems that you were saying . . .”
  • Encouraging client to consider alternatives— nurse’s response: “What else could you say?” or “Instead of hitting him, what else might you do?”
  • Planning a course of action—nurse’s response: “Now that we have talked about your on-the job activities and you have thought of several choices, which are you going to try out?” or “What would you do next time?”
  • Imparting information—give additional data as new input to help client (e.g., state facts and reality-based data that client may lack).
  • Summing up—nurse’s response: “Today we have talked about your feelings toward your boss, how you express your anger, and about your fear of being rejected by your family.”
  • Encouraging client to appraise and evaluate the experience or outcome—nurse’s response: “How did it turn out?” “What was it like?” “What was your part in it?” “What difference did it make?” or “How will this help you later”?

C. Examples of nontherapeutic responses:

  • Changing the subject, tangential response, moving away from problem or focusing on incidental, superficial content:
    Client: I hate you.
    Nurse: Would you like to take your shower now? Suggested responses: use reflection: “You hate me; tell me about this,” or “You hate me; what does hate mean to you?”
    Client: I want to kill myself today.
    Nurse: Isn’t today the day your mother is supposed to come?
    Suggested responses: (a) give open-ended lead, (b) give feedback: “I hear you saying today that you want to kill yourself,” or (c) clarifying: “Tell me more about this feeling of wanting to kill yourself.”
  • Moralizing: saying with approval or disapproval that the person’s behavior is good or bad, right or wrong; arguing with stated belief of person; directly opposing the person:
    Nurse: That’s good. It’s wrong to shoot yourself.
    Client: I have nothing to live for.
  • Agreeing with client’s autistic inventions:
    Client: The eggs are flying saucers.
    Nurse: Yes, I see. Go on.
    Suggested response: use clarifying response first: “I don’t understand,” and then, depending on client’s response, use either accepting and acknowledging, focusing on reality, or focusing on feelings.
  • Agreeing with client’s negative view of self:
    Client: I have made a mess of my life.
    Nurse: Yes, you have.
    Suggested response: use clarifying response about “mess of my life”—“Give me an example of one time where you feel you messed up in your life.”
  • Complimenting, flattering:
    Client: I have made a mess of my life.
    Nurse: How could you? You are such an attractive, intelligent, generous person.
    Suggested response: same as in C. 4.
  • Giving opinions and advice concerning client’s life situation—examples of poor responses include: “In my opinion . . .” “I think you should . . .” or “Why not?”
    Suggested responses: (a) encourage the client to consider alternatives (“What else do you think you could try?”); (b) encourage the client to appraise and evaluate for himself or herself (“What is it like for you?”).
  • Seeking agreement from client with nurse’s personal opinion—examples of poor responses include: “I think . . . don’t you?” and “Isn’t that right?”
    Suggested responses: (a) it is best to keep personal opinion to oneself and only give information that would aid the client’s orientation to reality; (b) if you give an opinion as a model of orienting to reality, ask client to state his or her opinion (“My opinion is . . . what is your opinion?”).
  • Probing or offering premature solutions and interpretations; jumping to conclusions:
    Client: I can’t find a job.
    Nurse: You could go to an employment agency.
    Client: I’d rather not talk about it.
    Nurse: What are you unconsciously doing when you say that? What you really mean is . . .
    Client: I don’t want to live alone.
    Nurse: Are you afraid of starting to drink again?
    Suggested responses: use responses that seek clarification and elicit more data.
  • Changing client’s words without prior validation:
    Client: I am not feeling well today.
    Nurse: What makes you feel so depressed?

Suggested response: “In what way are you not feeling well?” Use the same language as the client.

  • Following vague content as if understood or using vague global pronouns, adverbs, and adjectives:
    Client: People are so unfair.
    Nurse: I know what you mean.
    Suggested response: clarify vague referents such as “people” and “unfair.”
    Client: I feel sad.
    Nurse: Everyone feels that way at one time or another.
    Suggested response: “What are you sad about?”
  • Questioning on different topics without waiting for a reply:
    Client: [Remains silent.] Nurse: What makes you so silent? Are you angry? Would you like to be alone?
    Suggested response: choose one of the above and wait for a response before asking the next question.
  • Ignoring client’s questions or comments:
    Client: Am I crazy, nurse?
    Nurse: [Walking away as if he or she did not hear the client.] Suggested responses: “I can’t understand what makes you bring this up at this time,” or “Tell me what makes you bring this up at
    this time.” Ignoring questions or comments usually implies that the nurse is feeling uncomfortable. It is important not to “run away” from the client.
  • Closing off exploration with questions that can be answered by yes or no:
    Client: I’ll never get better.
    Nurse: Is something making you feel that way?
    Suggested response: “What makes you feel that way?” Use open-ended questions that start with what, who, when, where, etc.
  • Using clichés or stereotyped expressions:
    Client: The doctor took away my weekend pass.
    Nurse: The doctor is only doing what’s best for you. Doctor knows best. [Comment: also an example of moralizing.] Suggested response: “Tell me what happened when the doctor took away your weekend pass.”
  • Overloading: giving too much information at one time:
    Nurse: Hello, I’m Mr. Brown. I’m a nurse here. I’ll be here today, but I’m off tomorrow. Ms. Anderson will assign you another nurse
    tomorrow. This unit has five RNs, three LVNs, and students from three nursing schools who will all be taking care of you at some time.

Suggested response: “Hello, I’m Mr. Brown, your nurse today.” Keep your initial orienting information simple and brief.

  • Under loading: not giving enough information, so that meaning is not clear; withholding information:
    Client: What are visiting hours like here?
    Nurse: They are flexible and liberal.
    Suggested response: “They are flexible and liberal, from 10 a.m. to 12 noon and from 6 to 8 p.m.” Use specific terms and give specific information.
  • Saying no without saying no:
    Client: Can we go for a walk soon?
    Nurse: We’ll see. Perhaps. Maybe. Later.
    Suggested response: “I will check the schedule in the nursing office and let you know within an hour.” Vague, ambiguous responses can be seen as “putting the client off.” It is best to be clear, specific, and direct.
  • Using double-bind communication: sending conflicting messages that do not have “mutual fit,” or are incongruent:
    Nurse: [Continuing to stay and talk with the client.] It’s time for you to rest.
    Suggested response: “It’s time for you to rest and for me to leave [proceeding to leave].”
  • Protecting: defending someone else while talking with client; implying client has no right to personal opinions and feelings:
    Client: This hospital is no good. No one cares here.
    Nurse: This is an excellent hospital. All the staff were chosen for their warmth and concern for people.
    Suggested response: focus on feeling tone or on clarifying information.
  • Asking “why” questions implies that the person has immediate conscious awareness of the reasons for his or her feelings and behaviors. Examples of this include: “Why don’t you?” “Why did you do that?” or “Why do you feel this way?”
    Suggested response: ask clarifying questions using how, what, etc.
  • Coercion: using the interaction between people to force someone to do your will, with the implication that if he or she does not “do it for your sake,” you will not love or stay with himor her:
    Client: I refuse to talk with him.
    Nurse: Do it for my sake, before it’s too late.
    Suggested response: “Something keeps you from wanting to talk with him?”
  • Focusing on negative feelings, thoughts, actions:
    Client: I can’t sleep; I can’t eat; I can’t think; I can’t do anything.

Nurse: How long have you not been sleeping, eating, or thinking well?
Suggested response: “What do you do?”

  • Rejecting client’s behavior or ideas:
    Client: Let’s talk about incest.
    Nurse: Incest is a bad thing to talk about; I don’t want to.
    Suggested response: “What do you want to say about incest?”
  • Accusing, belittling:
    Client: I’ve had to wait five minutes for you to change my dressing.
    Nurse: Don’t be so demanding. Don’t you see that I have several people who need me?
    Suggested response: “It must have been hard to wait for me to come when you wanted it to be right away.”
  • Evading a response by asking a question in return:
    Client: I want to know your opinion, nurse. Am I crazy?
    Nurse: Do you think you are crazy?
    Suggested response: “I don’t know. What do you mean by ‘crazy’?”
  • Circumstantiality: communicating in such a way that the main point is reached only after many side comments, details, and additions:
    Client: Will you go out on a date with me?
    Nurse: I work every evening. On my day off I usually go out of town. I have a steady boyfriend. Besides that, I am a nurse and you are a client. Thank you for asking me, but no, I will not date you.
    Suggested response: abbreviate your response to: “Thank you for asking me, but no, I will not date you.”
  • Making assumptions without checking them:
    Client: [Standing in the kitchen by the sink, peeling onions, with tears in the eyes.] Nurse: What’s making you so sad?
    Client: I’m not sad. Peeling onions always makes my eyes water.
    Suggested response: use simple acknowledgment and acceptance initially, such as “I notice you have tears in your eyes.”
  • Giving false, premature reassurance:
    Client: I’m scared.
    Nurse: Don’t worry; everything will be all right. There’s nothing to be afraid of.
    Suggested response: “I’d like to hear about what you’re afraid of, so that together we can see what could be done to help you.” Open the way for clarification and exploration, and offer yourself as a helping person—not someone with magic answers.
[/sociallocker]

FURTHER READING/STUDY:

Resources:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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