THERAPEUTIC COMMUNICATION TECHNIQUES

TECHNIQUES EXAMPLES
Using silence

Accepting Yes
Hh hmm
I follow what you said
Nodding

Giving Recognition Good morning, Mr. S.

You look nice today

Offering Self I’ll sit with you a while

I’m interested in your comfort

Giving Broad Openings Is there something you would like to talk about?
Where would you like to begin?

Offering General Leads/Facilitation Go on

Tell me about it

Placing the Event in Time or Was this before or after?

Sequence When did this happen?

Making Observations You seem tense

Are you uncomfortable when you.

Encouraging Description of What is happening

Perception Tell me

Encouraging Comparisons Was this something like?

Have you had similar symptoms.

Restating Client: I can’t sleep, I stay awake all night.

Nurse: You have difficulty sleeping?

Reflecting Client: Do you think I should tell the doctor?

Nurse: Do you think you should.

Focusing This symptom seems worth discussing a little bit

more.

Exploring Tell me more about...

Would you describe it more fully?
Seeking Clarification I’m not sure that I follow....
What would you say is the main point of what
you said?

Voicing Doubt Isn’t that unusual?

Really?

Consensus Validation Tell me whether my understanding agrees with

yours?

Collaboration Perhaps together we can figure this out.

Summarizing Have I got this straight?

You’ve said that
During the past 15 minutes we’ve discussed.
 TECHNIQUES FOR COMMUNICATING WITH ELDERLY CLIENTS

I. Factors Influencing Communication with the Elderly

Client Factors

A. Anxiety:
Many elderly clients may function continually at a high level of anxiety. Thus,
the increased stress of a new situation may lead to intense arousal, impairing the elderly
person’s ability to communication effectively.

B. Sensory Deprivation:
Hearing loss is a widespread problem among the elderly. Its affects men more
than women and occurs in some 30% of all elderly. Hearing loss is potentially the
most difficult sensory loss for the elderly client. Although 80% of the elderly have
fair to adequate vision, some visual problems may occur.

C. Cautiousness:
Older clients tend to make few errors of commission but are likely to make errors
of omission. When taking a history, the nurse must be aware that elderly clients may
omit important aspects of their illnesses. Elderly clients take longer to respond to
inquires.

D. Persistent Themes:
The elderly client may concentrate on particular themes:

Somatic Concerns: Clients may spend much time complaining of ailments or

recounting detailed histories of bodily functions. At a time when friends and
loved ones have died and sensory input is decreased, the body, in many ways,
keeps the client company. It is, therefore quite usual for the elderly client to be
somatically oriented.

Loss Reactions: The elderly client may spend considerable time discussing the
many losses experienced in later life. These include loss of friends and loved
ones, loss of activities, and loss of self esteem.

Life Review: There is tendency in the elderly to reflect and reminisce. This is a
normal process brought about by disillusion and realization that death is
approaching.

Fear of Losing Control: Many elderly clients agonize over the loss of physical
and mental functions, including physical strength, bowel and bladder control,
motor functions, and especially, the ability to regulate one’s thoughts and
emotions. One of the greatest fears of late life is the fear of “going crazy”.
 Death: The elderly are not, as a rule, obsessed with approaching death. It
nevertheless, is a frequent topic of conservation. The major fear is of being alone
at the end of life.

Nurse Factors:

A. Attitudes toward the Elderly:

It is quite common to find fears of aging and death among members of our youth
oriented society. The recognition of such fears and of the nurse’s personal feelings
about these issues is of utmost importance in establishing effective communication
with the elderly.

B. Lack of Understand:
The nurse must attempt to separate myths about aging from reality. For example,
the labeling and stereotyping of the elderly may be a significant barrier to
communication. The elderly are especially sensitive to being labeled “senile”,
“mentally ill”, for “hypochondriac”. The nurse should try to empathize with the
elderly client. Putting your self in the other person’s shoes is an ability not easily
taught by text books and can only be learned through personal experiences.
II. Techniques of Effective Communication

Approach the Elderly Client with Respect:

The nurse should knock before entering the client’s room and approach the client
from the front. Greet the client by surname, (Mr. Smith, Mrs. Rose) rather than
by given name (Johnny, Mary), unless the client wishes to be addressed by a
given name.

Position Yourself Near the Elderly Client:

The nurse should be close enough to the client to be able to reach out and touch
the client if desired. The most comfortable arrangement of chairs for both parities
is at a 45 degree angle to each other. If possible, chairs should be the same height
and the nurse should not stand or walk during the conservation.

Speak Clearly and Slowly:

The elderly client may have a hearing problem or may not understand a nurses’
accent. Clarity of speech and the use of simple sentences is most effective in
communicating with an elderly client.

Inquire Actively and Systematically into the Problem Presented:

The nurse should inquire into common physical symptoms of later life (such as
visual and auditory defects, falls, and weight loss) and typical psychosocial problems
(death of a loved one, change in living arrangements, recent retirement, financial setback,
feelings of decreased self esteem, hopelessness, and anxiety).
Pace the Interview:
The elderly client must be give enough time to respond to the nurses questions.
The elderly are not, as a rule, uncomfortable with silences, which give them an
opportunity to formulate answers to questions, and to elaborate on certain points. A
slow and relaxed pace in the interview will do much to decrease anxiety.

Pay Attention to Nonverbal Communication:

The nurse should be alert for changes in facial expression, gestures, postures, and
touch as auxiliary methods of communication in the elderly. These nonverbal signs
can provide considerable information about conditions such as depression or anxiety.

Touch:
Touch may also be an effective way to relax and make contact with the elderly
client. As a rule, the elderly are less inhibited about physical touch. Holding the
client’s hand or resting your hand on his arm may be very reassuring.

Be Realistic but Hopeful:

Nurses who work with the elderly often deny the problems of later life. But
neither the client nor the nurse believe phrases like “You’ll live to be a hundred”, or “It’s
nothing to worry about”, and the nurse should avoid using them. The nurse should
never abandon all hope for an elderly client, but should work in the here and now.
Avoiding unrealistic expectations, three pain free days may be most rewarding to the
client dying of cancer, a fact too often overlooked.
TOPIC: TECHNIQUES FOR COMMUNICATING WITH CHILDREN

Age Group Characteristics Communication Techniques

Toddlers Limited vocabulary & Make explanations brief and clear. Use
verbal skills child’s own vocabulary words for basic
are activities (urinate = pee pee, tinkle),
learn and use self name of child. Get to
know child first before approaching
child. Show you can be a friend with
mommy.
Speaks in phases Rephrase child’s message in a simple
complete sentence: avoid baby talk.
Kinesthetic Allow ambulation when possible. Put
child in a wagon if child is not mobile.
Struggling with issues of Allow child some control. Reassure
autonomy and control child if he or she displays some
regressive behavior. (Example: If child
wets his pants, say, “We will get a dry
pair of pants and let’s find something fun
to do”). Allow child to express anger and
to protest about his care (Example: Say
“it’s OK to cry when you are angry or
hurt). Allow to sit up or walk, as often as
possible and as soon as possible after
intrusive or hurtful procedures, say, “It’s
all over and we can do something more
fun”).
Fear of Bodily Injury Show hands (free of hurtful items) and
say. “There is nothing to hurt you. I
came to play/talk.
Egocentrism Allow child to be self oriented and
accepted. Use distraction if another child
wants the same item or toy rather than
expect child to share.
Direct Questions Use non-directive approach. Sit down
and join the parallel play of child.
Separation Anxiety Accept protesting when parents leave.
Hug, rock the child, and say “You miss
mommy and daddy, They miss you too.”
Preschoolers Speaks in sentences but Use simple vocabulary; avoid lengthy
unable to comprehend explanations. Focus on the present. Use
abstract ideas. play therapy and drawings.
Unable to tolerate direct eye Use some eye contact. Sit or stoop and
to eye contact. use slow, soft tone of voice.
Short attention span and Use play therapy. Use sensory data. Use
imaginative stage music.
 Concrete sense of humor Tell corny jokes and laugh with child
Need for control Provide for many choices. “Do you want
to get dressed now or after breakfast?”
School Age Developing ability to Include child in concrete explanations
comprehend about condition, treatment, protocols.
Use draw a person. Use sensory
information in giving explanations.
Increased responsibility for Reinforce basic care activities in
health care. teaching.
Increased need for privacy. Respect privacy; knock on door before
entering room: tell client when and for
what reasons you will need to return to
his/her room.
Early Increased comprehension Verbalize issues about treatment
Adolescent about possible negative protocols requiring giving up immediate
threats to life or body gratification for long term gain. Explore
integrity, yet some difficulty alternative options.
in adhering to long term
goals.

Confidentiality Reassure about confidentiality of your

discussion, but clearly state limits of
confidentially.
Struggling to establish Allow participation in decision making.
identify and be independent Actively listen. Accept regression.
Avoid judgmental approach. Use
clarifying and qualifying approach.
Beginning to demonstrate Use abstract thinking, but look for
abstract thinking. nonverbal clues that indicate lack of
understanding.
Uses colloquial language Touch your dialogue with the use of some
of client’s own words.
Sexual Awareness and Offer self and willingness to listen.
maturation Provide value free, accurate information.

Example of a Therapeutic Conversation Expressing

Empathy
 Client: I can't believe the terrible job I did on that project.

Clinician: You seem too feel a deep sense of shame about your project.

Client: Yes, I do feel ashamed. I just always screw things up.

 Clinician: You're sounding really frustrated with yourself.

Client: Yes, I am. I mean, it's not just at my job. I screwed up my relationship with
my son. I screwed up my exercise program by stopping only two weeks into it.

Clinician: You're blaming yourself for all those things. Help me understand that
better. I wonder if you ever feel like you screwed things up in our work together.

Client: Yes, I did. Remember when I called you at home when my sister had hurt
herself again and was admitted to the hospital? I was so upset and really felt like I
needed to talk to you even though it was not a scheduled appointment.

Clinician: Sounds like you felt like that wasn't okay with me. I wonder how you
thought I reacted to the call?

Client: Well, you didn't sound annoyed. I remember you tried to help me. Still, I
felt I had done a stupid thing.

Example of a Similar Conversation, Expressing

Sympathy
 In this example, instead of the therapeutic skill of empathy, the "clinician"
expresses sympathy, which further entrenches the client in a downward spiral of
bad feelings. This example is given to show the importance of empathy in the
therapeutic alliance.

Client: I can't believe the terrible job I did on that project.

Clinician: I'm sorry you did so poorly.

Client: Yes, I am too. I guess I just don't have a good work ethic. I should just
accept that this job is above me.

Clinician: That's really a shame.

Client: Yes, I really needed this higher salary. My wife and kids are kind of
depending on me.

Clinician: How unfortunate that you might let them down like that.

Empathy is an essential part of the therapeutic conversation. Sympathy, on the

other hand, is not.
 Example of a Therapeutic Conversation
 Clinician: One thought you had was that your son was failing out of school. What
led you to have that thought?

Client: Well, he wouldn't show me his report card. It makes me think he failed
something.

Clinician: He may have. Does he have a history of failing classes?

Client: No. He usually gets "As" and "Bs."

Clinician: So this is the first time you have suspected that he may have failed a
class?

Client: Yes.

Clinician: And what is your definition of "failing out of school?"

Client: I guess it would be someone who has failed several classes so that the
person was not asked back to the school.

Clinician: And does that sound like your son?

Client: No, I guess I overreacted when I said he was failing out of school.

Clinician: And what about your thought that you are to blame for his behavior?
What led you to think that?

Client: I'm his parent. Aren't I the biggest influence in his life?

Clinician: Yes, your role certainly is an important one. How might you have
encouraged your son to fail out of school?

Client: I don't know what you mean.

Clinician: I wonder if you have failed out of school yourself.

Client: No, of course not.

Clinician: Perhaps you condone failure, or didn't try to teach him that school
success is important?
 Client: No. Just the opposite. I have very strong feelings about the importance of
education. I always tried to show my son by example how to succeed.

Clinician: I'm confused, then, about how you may have caused him to fail.

Client: I guess I was just feeling bad and wanted to find an explanation. But I can
see that I certainly never taught him to fail.

Restating
Restating what the patient has said shows him that the nurse has listened to and
understands what he has articulated. It may also give the patient a new perspective on his
situation.

Patient: "I won't ever be able to use this electric wheelchair!" Nurse: "You're concerned
that you won't be able to use the devices on your new wheelchair."

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Open-Ended Question
In this scenario, the psychiatrist asks the patient an open-ended question to facilitate the
opportunity for a broad response. As opposed to a closed-ended question, this type of
communication avoids the perception of judgment and allows the patient to speak what is
truly on his mind regarding the topic.

Psychiatrist: "What kind of relationship did you have with your mother?" Patient: "She
was horrible to me but good to my brother and I was the one who tried to please her."

A closed-ended question may be non-therapeutic in this circumstance:

Psychiatrist: "Did you have a good relationship with your mother?" Patient: "It was all
right."

Stating Observations
The therapist may make an observation when he notices that the patient isn't talking about
how he feels. This may help the patient verbalize his feelings, explains NurseReview.org.

Therapist: "You seemed angry with your son today." Patient: "Yes, he really hurt my
feelings by telling people that I'm crazy. Who does he think he is? I worked 12 hours a
day putting him through school and now he treats me like this."
Acceptance
The doctor may use verbal and nonverbal cues to convey unconditional acceptance of the
patient's feelings. This allows the patient to feel understood and comfortable to continue
to explain her feelings. Not arguing with the patient's point of view gives her the
opportunity to fully consider the issue without feeling defensive.

Patient: "I am so disappointed that my husband put me in this nursing home." Doctor: "I
understand." The doctor makes eye contact with the patient and nods his head. Patient: "I
guess I can sort of understand it. His arthritis keeps him in a lot of pain, making it hard
for him to take care of me."

Silence
Being silent gives the patient an opportunity to consider his thoughts, explains Michael
Zychowicz, a Mount Saint Mary College faculty member. The psychologist shows the
patient her support by sitting quietly with him as he collects his thoughts, fostering the
therapeutic relationship.

The psychiatrist is silent or says, "I will sit quietly with you; I can tell you have
something serious on your mind."

Therapeutic Technique

1. Offering Self

 making self-available and showing interest and concern.

 “I will walk with you”

2. Active listening

 paying close attention to what the patient is saying by observing both verbal and
non-verbal cues.
 Maintaining eye contact and making verbal remarks to clarify and encourage
further communication.

3. Exploring

 “Tell me more about your son”

4. Giving broad openings

 What do you want to talk about today?

5. Silence
  Planned absence of verbal remarks to allow patient and nurse to think over what is
being discussed and to say more.

6. Stating the observed

 verbalizing what is observed in the patient to, for validation and to encourage
discussion
 “You sound angry”

7. Encouraging comparisons

  asking to describe similarities and differences among feelings, behaviors, and

events.
  “Can you tell me what makes you more comfortable, working by yourself or
working as a member of a team?”

8. Identifying themes

 asking to identify recurring thoughts, feelings, and behaviors.

 “When do you always feel the need to check the locks and doors?”

9. Summarizing

 reviewing the main points of discussions and making appropriate conclusions.

 “During this meeting, we discussed about what you will do when you feel the
urge to hurt your self again and this include…”

10. Placing the event in time or sequence

 asking for relationship among events.

 “When do you begin to experience this ticks? Before or after you entered grade
school?”

11. Voicing doubt

 voicing uncertainty about the reality of patient’s statements, perceptions and

conclusions.
 “I find it hard to believe…”

12. Encouraging descriptions of perceptions

 asking the patients to describe feelings, perceptions and views of their situations.
 “What are these voices telling you to do?”

13. Presenting reality or confronting

  stating what is real and what is not without arguing with the patient.
 “I know you hear these voices but I do not hear them”.
 “I am Lhynnelli, your nurse, and this is a hospital and not a beach resort.

14. Seeking clarification

 asking patient to restate, elaborate, or give examples of ideas or feelings to seek

clarification of what is unclear.
 “I am not familiar with your work, can you describe it further for me”.
 “I don’t think I understand what you are saying”.

15. Verbalizing the implied

 rephrasing patient’s words to highlight an underlying message to clarify

statements.
 Patient: I wont be bothering you anymore soon.
 Nurse: Are you thinking of killing yourself?

16. Reflecting

 throwing back the patient’s statement in a form of question helps the patient
identify feelings.
 Patient: I think I should leave now.
 Nurse: Do you think you should leave now?

17. Restating

 repeating the exact words of patients to remind them of what they said and to let
them know they are heard.
 Patient: I can’t sleep. I stay awake all night.
 Nurse: You can’t sleep at night?

18. General leads

 using neutral expressions to encourage patients to continue talking.

 “Go on…”
 “You were saying…”

19. Asking question

 using open-ended questions to achieve relevance and depth in discussion.

 “How did you feel when the doctor told you that you are ready for discharge
soon?”

20. Empathy
  recognizing and acknowledging patient’s feelings.
 “It’s hard to begin to live alone when you have been married for more than thirty
years”.

21. Focusing

 pursuing a topic until its meaning or importance is clear.

 “Let us talk more about your best friend in college”
 “You were saying…”

22. Interpreting

 providing a view of the meaning or importance of something.

 Patient: I always take this towel wherever I go.
 Nurse: That towel must always be with you.

23. Encouraging evaluation

 asking for patients views of the meaning or importance of something.

 “What do you think led the court to commit you here?”
 “Can you tell me the reasons you don’t want to be discharged?

24. Suggesting collaboration

 offering to help patients solve problems.

 “Perhaps you can discuss this with your children so they will know how you feel
and what you want”.

25. Encouraging goal setting

 asking patient to decide on the type of change needed.

 “What do you think about the things you have to change in your self?”

26. Encouraging formulation of a plan of action

 probing for step by step actions that will be needed.

 “If you decide to leave home when your husband beat you again what will you do
next?”

27. Encouraging decisions

 asking patients to make a choice among options.

 “Given all these choices, what would you prefer to do.

28. Encouraging consideration of options

  asking patients to consider the pros and cons of possible options.
 “Have you thought of the possible effects of your decision to you and your
family?”

29. Giving information

 providing information that will help patients make better choices.

 “Nobody deserves to be beaten and there are people who can help and places to
go when you do not feel safe at home anymore”.

30. Limit setting

 discouraging nonproductive feelings and behaviors, and encouraging productive

ones.
 “Please stop now. If you don’t, I will ask you to leave the group and go to your
room.

31. Supportive confrontation

 acknowledging the difficulty in changing, but pushing for action.

 “I understand. You feel rejected when your children sent you here but if you look
at this way…”

32. Role playing

 practicing behaviors for specific situations, both the nurse and patient play
particular role.
 “I’ll play your mother, tell me exactly what would you say when we meet on
Sunday”.

33. Rehearsing

 asking the patient for a verbal description of what will be said or done in a
particular situation.
 “Supposing you meet these people again, how would you respond to them when
they ask you to join them for a drink?”.

34. Feedback

 pointing out specific behaviors and giving impressions of reactions.

 “I see you combed your hair today”.

35. Encouraging evaluation

 asking patients to evaluate their actions and their outcomes.

 “What did you feel after participating in the group therapy?”.
36. Reinforcement

 giving feedback on positive behaviors.

 “Everyone was able to give their options when we talked one by one and each of
waited patiently for our turn to speak”.

Avoid pitfalls:

1. Giving advise
2. Talking about your self
3. Telling client is wrong
4. Entering into hallucinations and delusions of client
5. False reassurance
6. Cliché
7. Giving approval
8. Asking WHY?
9. Changing subject
10. Defending doctors and other health team members.

Non-therapeutic Technique

1. Overloading

 talking rapidly, changing subjects too often, and asking for more information than
can be absorbed at one time.
 “What’s your name? I see you like sports. Where do you live?”

2. Value Judgments

 giving one’s own opinion, evaluating, moralizing or implying one’s values by

using words such as “nice”, “bad”, “right”, “wrong”, “should” and “ought”.
 “You shouldn’t do that, its wrong”.

3. Incongruence

 sending verbal and non-verbal messages that contradict one another.

 The nurse tells the patient “I’d like to spend time with you” and then walks away.

4. Underloading

 remaining silent and unresponsive, not picking up cues, and failing to give
feedback.
 The patient ask the nurse, simply walks away.

5. False reassurance/ agreement

  Using cliché to reassure client.
 “It’s going to be alright”.

6. Invalidation

 Ignoring or denying another’s presence, thought’s or feelings.

 Client: How are you?
 Nurse responds: I can’t talk now. I’m too busy.

7. Focusing on self

 responding in a way that focuses attention to the nurse instead of the client.
 “This sunshine is good for my roses. I have beautiful rose garden”.

8. Changing the subject

 introducing new topic

 inappropriately, a pattern that may indicate anxiety.
 The client is crying, when the nurse asks “How many children do you have?”

9. Giving advice

 telling the client what to do, giving opinions or making decisions for the client,
implies client cannot handle his or her own life decisions and that the nurse is
accepting responsibility.
 “If I were you… Or it would be better if you do it this way…”

10. Internal validation

 making an assumption about the meaning of someone else’s behavior that is not
validated by the other person (jumping into conclusion).
 The nurse sees a suicidal clients smiling and tells another nurse the patient is in
good mood.

Other ineffective behaviors and responses:

1. Defending – Your doctor is very good.

2. Requesting an explanation – Why did you do that?
3. Reflecting – You are not suppose to talk like that!
4. Literal responses – If you feel empty then you should eat more.
5. Looking too busy.
6. Appearing uncomfortable in silence.
7. Being opinionated.
8. Avoiding sensitive topics
9. Arguing and telling the client is wrong
10. Having a closed posture-crossing arms on chest
 11. Making false promises – I’ll make sure to call you when you get home.
12. Ignoring the patient – I can’t talk to you right now
13. Making sarcastic remarks
14. Laughing nervously
15. Showing disapproval – You should not do those things.

One of the most important skills of a nurse is developing the ability to establish a
therapeutic relationship with clients. For interventions to be successful with clients in a
psychiatric facility and in all nursing specialties it is crucial to build a therapeutic
relationship. Crucial components are involved in establishing a therapeutic nurse-patient
relationship and the communication within it which serves as the underpinning for
treatment and success. It is essential for a nurse to know and understand these
components as it explores the task that should be accomplish in a nurse-client
relationship and the techniques that a nurse can utilize to do so.

TRUST

Without trust a nurse-client relationship would not be established and interventions won’t
be successful. For a client to develop trust, the nurse should exhibit the following
behaviors:

 Friendliness
 Caring
 Interest
 Understanding
 Consistency
 Treating the client as human being
 Suggesting without telling
 Approachability
 Listening
 Keeping promises
 Providing schedules of activities
 Honesty

GENUINE INTEREST

Another essential factor to build a therapeutic nurse-client relationship is showing a

genuine interest to the client. For the nurse to do this, he or she should be open, honest
and display a congruent behavior. Congruence only occurs when the nurse’s words
matches with her actions.

EMPATHY

For a nurse to be successful in dealing with clients it is very essential that she empathize
with the client. Empathy is the nurse’s ability to perceive the meanings and feelings of the
client and communicate that understanding to the client. It is simply being able to put
oneself in the client’s shoes. However, it does not require that the nurse should have the
same or exact experiences as of the patient. Empathy has been shown to positively
influence client outcomes. When the nurse develops and utilizes this ability, clients tend
to feel much better about themselves and more understood.

Some people confuse empathizing with sympathizing. To establish a good nurse-patient

relationship, the nurse should use empathy not sympathy. Sympathy is defined as the
feelings of concern or compassion one shows for another. By sympathizing, the nurse
projects his or her own concerns to the client, thus, inhibiting the client’s expression of
feelings. To better understand the difference between the two, let’s take a look at the
given example.

Client’s statement:

“I am so sad today. I just got the news that my father died yesterday. I should have been
there, I feel so helpless.”

Nurse’s Sympathetic Response:

“I know how depressing that situation is. My father also died a month ago and until now I
feel so sad every time I remember that incident. I know how bad that makes you feel.”

Nurse’s Empathetic Response:

“I see you are sad. How can I help you?”

When the nurse expresses sympathy for the client, the nurse’s feelings of sadness or even
pity could influence the relationship and hinders the nurse’s abilities to focus on the
client’s needs. The emphasis is shifted from the client’s to the nurse’s feelings thereby
hindering the nurse’s ability to approach the client’s needs in an objective manner.

In dealing with clients their interest should be the nurse’s greatest concern. Thus,
empathizing with them is the best technique as it acknowledges the feelings of the client
and at the same time it allows a client to talk and express his or her emotions. Here a
bond can be established that serves as a foundation for the nurse-client relationship.

Therapeutic Communication Techniques Examples

1. Using silence The client says: "We drink and smoke a lot here."
The student thinks…how can that be…drinking
alcohol in a state hospital? But says nothing…using
silence…the client then says: "yes we drink a lot of
cokes and smoke a lot."

2. Accepting "Yes" or "I follow what you said"

3. Giving Recognition "I notice you combed your hair."

4. Offering self "I'll sit with you awhile."

5. Using Broad Openings "What would you like to talk about?"

"Tell me what's bothering you."

6. Using General Leads (using neutral expressions "Go on. " Ummm..I am listening"
to encourage continued talking by the client)
"Tell me about it"

7. Placing he event in time or sequence "Was this before or after…?"

"What seemed to lead up to…?"

8. Making Observations "You appear tense"

"I notice you are biting your lips."

9. Encouraging Description of Perceptions "What do you think is happening to you right

now…?"

10. Restating Client: "I can't sleep. I stay awake all night."

Nurse: "You have difficulty sleeping"

11. Reflecting Patient: "Do you think I should tell the doctor?"

Nurse: "Do you think you should tell the doctor?"

12. Focusing "This point seems worth looking at more closely."

"You said something earlier that I want you to go

back to."

13. Exploring "Would you describe that more fully."

14. Giving Information "My name is…I am a student nurse.."

15. Seeking Clarification "What would you say is the main point of what you
said?"

16. Presenting Reality "Your mother is not here…I am a nurse."

Patient: "Did you bring my car today?"

Nurse: "No, you do not have a car. I drove my car

 here today."

17.. Voicing Doubt "That's hard to believe."

"Really?"

18. Seeking Consensual Validation

19. Verbalizing the Implied

20. Encouraging Evaluation (asking for the client's "How important is it for you to change this
view of the meaning or importance of something) behavior?"

21. Attempting to Translate Into Feelings " From what you say, I suspect you are
feeling relieved."

22. Suggested Collaboration "Let's see if we can figure this out.."

23. Summarizing " Let's see, so far you have said..."

24. Encouraging Formulation of a Plan of Action "What will it take to reach your goal of not
hitting anyone?"

25. Identifying themes ..asking client to "So what do you do each time you drink
identify recurrent patterns in thoughts, too much and it's time to go home?" What
feelings, and behaviors is the major feeling you have about all
men?"

Nursing Process in Psychiatric Nursing

Mrs. Jyoti Beck, RN, RM,DPN RINPAS, Ranchi, India

This page was last updated on March 8, 2011

Outline

 Introduction
 Assessment
 Nursing Diagnosis
 Outcome Identification
 Planning
 Implementation
 Evaluation
 Components of Assessment
 Sample of Nursing Care Plan
  References

Introduction

 The nursing process is an interactive, problem-solving

process. It is systematic and individualized way to achieve
outcome of nursing care.
 The nursing process respects the individual’s autonomy and
freedom to make decisions and be involved in nursing care.
 The nursing process is accepted by the nursing profession
as a standard
for providing ongoing nursing care that is adapted to
individual client needs.
 The nurse and the patient emerge as partner in a
relationship built on trust and directed toward maximising
the patient’s strengths, maintaining integrity, and promoting
adaptive response to stress.
 In dealing with psychiatric patients, the nursing process can
present unique challenges.
 Emotional problems may be vague, not visible like many
physiological disruptions.
 Emotional problems can also show different symptoms and
arise from a number of causes. Similarly, past events may
lead to very different form of present behaviours. Many
psychiatric patients are unable to describe their problems.
 They may be highly withdrawn, highly anxious, ,or out of
touch with reality.
 Their ability to participate in the problem solving process
may also be limited if they see themselves as powerless.

Nursing process aims at individualized care to the patient and the

care is adapted to patient’s unique needs. Nursing process the
following steps;

 Assessment
 Nursing Diagnosis

 Outcome Identification

 Planning

 Implementation and

 Evaluation
Assessment

Individualized care begins with a detailed assessment as soon as

the patient is admitted. In the Assessment phase, information is
obtained the patient in a direct and structured manner through
observation, interviews and examination. Initial interview includes
an evaluation of mental status. In such cases, where the patient is
too ill to participate in or complete the interview, the behaviour the
patient exhibits to be recorded and reports from family members if
possible, can obtained. Even when the initial assessment is
complete, each encounter with the patient involves a continuing
assessment .The ongoing assessment involves what patient is
saying or doing at that moment.

HEALTH HISTORY AND PHYSICAL ASSESSMENT

1. Client’s complaint, present symptom and focus of concern

2. Perceptions and expectations
3. Previous hospitalizations and mental health treatment
4. Family history
5. Health beliefs and practices
6. Substance use
7. Sexual history
8. Abuse
9. Spiritual
10. Basic needs (diet, exercise, sleep, elimination)
11. Sociocultural
12. Coping patterns
13. Self-esteem
14. Medical Examination
15. Diagnostic Investigations
16. Mental Status Examination

Subjective Data Objective Data

 Name and general  Physical exam
information about the  Behavior
client  Mood and affect
 Client’s perception of  Awareness
current stressor or  Thought processes
problem  Appearance
 Current occupational or  Activity
work situation  Judgment
 Any recent difficulty in  Response to
relationships environment
 Any somatic complaints
  Current or past substance
use
 Interests or activities
previously enjoyed  Perceptual ability

 Sexual activity or
difficulties

When the nurse investigates a patient’s specific behaviour, it is

valuable to explore the following,

 Situation that precipitated that behaviour

 What the patient was thinking at that moment?

 Whether that behaviour makes any sense in that context?

 Whether the behaviour was adaptive or dysfunctional?

 Whether a change is needed?

If the nurse has to interview the patient she should select a private
place, free from noise and distraction and interview should be goal
directed. Although the patient is a regarded as a source of
validation , the nurse should also be prepared to consult with
family members or other people knowledgeable about the patient.
This is particularly important when the patient is unable to provide
reliable information because the symptoms of the psychiatric
illness. She should gather Information from other information
sources, including health care records, nursing rounds, change- of
shifts, nursing care plans and evaluation of other health care
professionals.

Nursing Diagnosis

 After collecting all data, the nurse compares the

information and then analyses the data and derives a
nursing diagnosis.
 A nursing diagnosis is a statement of the patient’s nursing
problem that includes both the adaptive and maladaptive
health responses and contributing stressors.
 These nursing problems concern patient’s health aspects
that may need to be promoted or with which the patient
needs help.
 A nursing diagnosis may be an actual or potential health
problem, depending on the situation.
 The most commonly used standard is that of the North
 American Nursing Diagnosis Association (NANDA).

A nursing diagnostic statement consists of three parts:

 Health problem
 Contributing factors

 Defining characteristics

The defining characteristics are helpful because they reflect the

behaviour that are the target of nursing intervention .They also
provide specific indicators for evaluating the outcome of
psychiatric nursing interventions and for determining whether the
expected goals of the nursing care were met.

Example:

 If a patient is making statements about dying, he is

isolative, anorexic, cannot sleep and wants to die. Then the
nursing diagnosis can be-
 Helplessness, related to physical complaints, as evidenced
by decreased appetite and verbal cues indicating
despondency.

 Fatigue related to insomnia, as evidenced by an increases

in physical complaints and disinterest in surroundings.

 Social isolation , related to anxiety, as evidenced by

withdrawal and uncommunicative behaviour.

Outcome Identification

The psychiatric mental health nurse identifies expected outcomes

individualised to the patient. Within the context of providing
nursing care, the ultimate goal is to influence health outcomes and
improve the patient’s health status. Outcomes should be mutually
identified with the patient, and should be identified as clearly as
clearly and determine the effectiveness and efficiency of their
interventions.

Before defining expected outcomes, the nurse must realize that

patient often seek treatment with goals of their own. These goals
may be expressed as relieving symptoms or improving functional
ability. The nurse must understand the patient’s coping response
and the factors that influence them. Some of these difficulties in
defining goals are as follows-

 The patient may view a personal problem as someone

else’s behaviour.
 The patient may express a problem as feeling, such as “I
am lonely” or “I am so unhappy”.

Clarifying goals is an essential step in the therapeutic process.

Therefore the patient nurse relationship should be based upon
mutually agreed goals. Once the goals are a greed on they must be
stated in writing .Goals should be written in behavioural terms, and
should be realistically described what the nurse wishes to
accomplish within a specific time span. Expected outcomes and
short term goals should be developed with short tem objectives
contributing to the long term expected outcomes.

Example of short term goals:

 At the end of the two weeks patients will stay out of bed
and participate in activities
 At the end of the one week patient will sleep well at night.

 At the end of the one week patient will eat properly and
maintain weight.

Planning

As soon as the patient‘s problems are identified, nursing diagnosis

made, planning nursing care begins.

The planning consists of:

 Determining priorities
 Setting goals

 Selecting nursing actions

 Developing /writing nursing care plan

In planning the care the nurse can involve the patient, family,
members of the health team. Once the goals are chosen the next
task is to outline the plan achieving them. On the basis of an
analysis, the nurse decides which problem requires priority
attention or immediate attention. Goals stated indicates as to what
is to be achieved if the identified problem is taken care of. These
can be immediate short-term and long- term goals. The nursing
action technique chosen will enable the nurse to meet the goals or
desired objectives. For example, the short-terms for a depressed
patient is "to pursue him or her take bath”. The nursing action may
be “The nurse firmly direct the patient to get up and finish
her/his bath before 8 O’ clock. On persuasion the patient takes
bath. This is an example of selection of the nursing action. Writing
or recording of the problems, goals, and nursing actions is a
nursing care plan.

Implementation

The implementation phase of the nursing process is the actual

initiation of the nursing care plan. Patient outcome/goals are
achieved by he performance of the nursing interventions. During
the phase the nurse continues to assess the patient to determine
whether interventions are effective. An important part of this phase
is documentation. Documentation is necessary for legal reasons
because in legal dispute “if it wasn’t charted, it wasn’t done". The
nursing interventions are designed to prevent mental and physical
illness and promote, maintain, and restore mental and physical
health. The nurse may select interventions according to their level
of practice. She may select counselling, milieu therapy, self-care
activities, psychological interventions, health teaching, case
management, health promotion and health maintenance and other
approaches to meet the mental health care needs of the patient.

To implement the actions, nurses need to have intellectual,

interpersonal and technical skills.

Nursing actions are of two types-

1. Dependent nursing action: Action derived from the advice

from the psychiatrist. For example, giving medicines.
2. Independent nursing actions: This is based on nursing
diagnosis and plan of care, pursuing the patient to attend to
personal hygiene.

Evaluation

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.
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 –have I
done everything for my patient? 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.

Components of Assessment

Mental Status Examination

Appearance

 Dress, grooming, hygiene, cosmetics, apparent age,

posture, facial expression.

Behaviour/activity

 Hyperactivity or hyperactivity, rigid, relaxed, restless, or

agitated motor movements, gait and coordination, facial
grimacing, gestures, mannerisms,, passive , combative,
bizarre.

Attitude

 Interactions with interviewer: - Cooperative, resistive,

friendly, hostile, ingratiating
 Speech-Quantity: - poverty of speech, poverty of content,
volume.

 Quality: - articulate, congruent, monotonous, talkative,

repetitious, spontaneous, circumstantial, confabulation,
tangential and pressured

 Rate:-slowed, rapid

Mood and affect

 Mood (Intensity depth duration):- sad, fearful, depressed,

angry, anxious, ambivalent, happy, ecstatic, grandiose.
 Affect (Intensity depth duration) :- appropriate, apathetic,
constricted, blunted, flat, labile, euphoric.
Perception

 Hallucination, illusions, depersonalization, derealization,

distortions

Thoughts

 Form and content-logical vs. illogical, loose associations,

flight of ideas, autistic, blocking., broadcasting,
neologisms, word salad, obsessions, ruminations,
delusions, abstract vs. concrete

Sensorium and Cognition

 Level of consciousness, orientation, attention span, , recent

and remote memory, concentration, , ability to comprehend
and process information, intelligence

Judgment

 Ability to assess and evaluate situations makes rational

decisions, understand consequence of behaviour, and take
responsibly for actions

Insight

 Ability to perceive and understand the cause and nature of

own and other’s situatio

Reliability

 Interviewer’s impression that individual reported

information accurately and completely

Psychosocial Criteria

 Internal:-Psychiatric or medical illness, perceived loss such

as loss of self concept/self-esteem
 External:-Actual loss, e.g. death of loved ones, diverse,
lack of support systems, job or financial loss, retirement of
dysfunctional family system

Coping skills

 Adaptation to internal and external stressors, use of

functional, adaptive coping mechanisms, and techniques,
 management of activities of daily living

Relationships

 Attainment and maintenance of satisfying, interpersonal

relationships congruent with developmental stages,
including sexual relationship as appropriate for age and
status

Cultural

 Ability to adapt and conform to present norms, rules,

ethics.

Spiritual (Value-belief)

 Presence of self-satisfying value-belief system that the

individual regards as right, desirable, worthwhile, and
comforting

Occupational

 Engagement is useful, rewarding activity, congruent with

developmental stages and societal standards (work, school
and recreation)

Sample of Nursing Care Plan

Sample of Nursing Diagnoses (As per NANDA- North

American Nursing Diagnosis Association)
Nursing Diagnosis Analysis

1 Risk for injury related to Accelerated motor activity or

accelerated motor activity impulsive actions

2 Disturbed thought process Judgement impaired , mood of

related to impaired elation (patient is using
judgement associated with inappropriate dress and bizarre
manic behaviour dressing)

3 Self-care deficit (unkempt Unable to take time for self-care

appearance) related to is, dishevelled and unkempt
 hyperactivity

4 Impaired verbal Accelerated speech with flight of

communication –flight of ideas (thought speeded up
ideas related to accelerated causing rapid speech and flight of
thinking ideas, excessive planning for
activities

5 Ineffective coping related Euphoria, elation,

to elated expressive mood cheerfulness( an exaggerated
sense of well being)

6 Disturbed thought process – Grandiosity-inflation self-esteem

grandiosity related to
elevated mood

7 Ineffective coping related Emotional labiality (unstable

to emotional liability mood moves from cheerfulness
associated with manic to irritation easily with little
behaviour irritation

8 Disturbed thought process – Grandiose delusions (Belief that

related to delusion of well known political religious, or
grandeur entertainment leader)

9 Disturbed thought process Short attention span, difficulty in

decreased attention span concentrating , easily disturbed
and difficulty in
concentration related to
accelerated thinking

10 Risk for violence related to Hostile comment and complaints

hostile and angry behaviour

11 Impaired verbal Accelerated thinking, highly

communication related to responsive to environmental
pressure of speech stimuli, accompanying flight of
ideas
 Nutrition: less than
12 body requirements, Weight loss (less food intake
imbalanced associated with depression which
  Nutrition: more than
body requirements, contributes to loss of appetite
imbalanced with weight loss/weight gain
following pharmacological
 Nutrition: risk for management/possible wieght
more than body gain
requirements,
imbalanced

13 Self-care deficit-neglect of Neglect of personal hygiene

personal hygiene related to (feeling of worthlessness
depression associated with depression which
contribute to lack of interest in
personal hygiene

14 Health Maintenance, Extreme slowness in performing

ineffective –psychomotor activity
retardation related to
depression

15 Risk for violence- self- Bruises, cuts, scars, (possible

directed, related to destructive behaviour or abuse
depression by others)

16 Anxiety –neurological Extreme nervousness (possible

symptoms related to response to loss with symptoms
depression to those of anxiety)

17 Risk for violencerm Suicidal feeling (Hopelessness

contributes to total despair

18 Sensory perceptual Confusion or disorientation

alteration –disorientation
about time, place, and
person related to increased
anxiety

19 Ineffective coping – Anxiety (Increased anxiety

obsessive thinking related unapparent and discharge
to anxiety through obsessive thinking)

20 Impaired Social interactions Lacks ability to develop warm

 –inability to form warm, relationship ( has limited ability
meaningful relationships, to express emotion)
related to compulsive
behaviour

21 Ineffective coping – Excessive cleanliness (Over

compulsion related to need emphasis for cleanliness and
for excessive cleanliness) neatness)

22 Potential for self harm Poor impulse control

related to poor impulse
control associated with
substance abuse)

23 Potential for self-harm Disorientation, disorganization

related to marked and confusion (If marked ,
disorientation , patient is at high suicidal risk)
disorganization, and
confusion

24 Distarbance of self- Insecurity, oversensitive, Failure

concept-insecurity related to meet needs results in mistrust
to suspiciousness and insecurity

25 Potential for violence Anger and hostility –may become

directed towards others physically violent (Overly
related t perceived threat or concerned with protecting
injustice to himself himself from environment :
overly sensitive)

25 Ineffective individual Feeling of being misjudged ,

coping persecutory feeling conspired against, spied upon ,
related to mistrust followed , poisoned, dragged,
obstructed in achieving long term
goals.

Nursing Diagnosis: Risk for violence, self directed.

Risk factors-Chronic illness, retirement, change in marital status

Patient Outcome Nursing Intervention with Evaluation

Rationale
Patient will not Observe patient’s behaviour Patient remained
harm himself during routine patient care. safe, unharmed.
Close observation is
necessary to protect from
self harm.
Patient will refrain
from suicidal Listen carefully suicidal
threats or statements and observe for Absence of
behaviour non-verbal indications of verbalized or
gestures. suicidal intent. Such behavioural
behaviours are critical clues indications of
He will deny any regarding risk for self harm. suicidal intent by
plans for suicide the patient.

Ask direct questions to

determine suicidal intent , Patient denies
plans for suicide, and means active suicide
to commit suicide .Suicide plans
risk increases when plans
and means exists

Nursing Diagnosis: Ineffective individual coping, related to

response crisis (retirement), as evidence by isolative behaviour,
changes in mood, and decreased sense of well-being.

Patient Nursing Intervention

Evaluation
Outcome with Rationale
Patient will
identify positive Develop trusting
coping relationship with patient Patient expresses trust in
strategies, such to demonstrate caring nurse-patient
as structuring and, encourage patient to relationship.
leisure time. practice new skills in a
safe therapeutic setting.

Patient will
combine past Praise patient for Patient discusses plans
effective coping adaptive coping. Positive for use of past and
methods with feedback encourages newly learned coping
newly acquired repetition of effective methods.
coping coping by patient
strategies
Nursing Diagnosis: Self-care deficit (grooming, dressing, and
feeding) related to manic hyperactivity, difficulty in concentrating
and making decisions: as evidenced by inappropriate dress, and
dysfunctional eating habits.

Nursing
Patient Outcome Intervention with Evaluation
Rationale
Offer assistance for
selecting clothing and
grooming to provide
input and direction
for appropriateness of
dress and hygiene to
preserve self-esteem
Patient will dress Patient dresses self
and avoid
appropriately for age appropriately and
embracement.
and status. maintains hygiene.
Encourage and
remind patient to
drink fluid and to eat
food to focus the
patient on necessary
feeding activities , to
prevent dehydration
Patient will eat and Patient eats and drinks
and starvation.
drink adequately to fluids necessarily to
sustain fluid balance maintain physical
Provide recognition
and proper nutrition. health.
and positive
reinforcement for
feeding/dressing
accomplishments to
reinforce appropriate
behaviours and
enhance self-esteem.

References:

1. Ladwig, A.(1999).Nursing Diagnosis Handbook, A Guide

for Planning Care. Section 1:5
2. Kapoor, B. (1994). A Text Book for Psychiatric Nursing:
Chapter5, Page 223-224.

3. Foortinash, Hoolodey-Warrant. Psychiatric Mental Health

 Nursing, 1996: Chapter 20, page 279, 482.

4. Gail.W.Stuart, Michal T. Laraiya. Principles and Practice of

Psychiatric Nursing 1998: Chapter 10, Page 178.

5. Katherine N Fortinash, Patrica N Hooliday-Worret.

Psychiatric Nursing Care Plans 1991: Chapter 1, Page 1.

Mental Health Quiz

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 Psychiatric Nursing
History Quiz-I

 Psychiatric Nursing
History Quiz-II

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The first use of convulsive therapy for the treatment of a
psychiatric disorder in modern times is attributed to

A. Ladislaus von Meduna

B. A. E. Bennett

C. Egas Moniz

D. Kurt Schneider

Answer Key
2. The first therapeutic use of electrically induced seizures in the
treatment of mental disorders is related to

A. Harold Sackeim

B. Luigi Bini and Ugo Cerletti

C. D. Goldman

D. G. Holmberg and S. Thesieff

Answer Key
3. The sequece of administration of medications in anesthesia for
ECT is:

A. Atropine---thiopentone/methohexitol---succinylcholine

B. Succinylcholine---atropine---thiopentone/methohexitol

C. Atracurium---succinylcholine---atropine

D. Atropine--- succinylecholine---thiopentone/methohexitol

Answer Key
4. As per the current evidence, which statement is NOT correct?

A. Bilateral ECT is superior in efficacy to unilateral ECT.

B. Unilateral ECT is more likely to cause cognitive deficits.

C. Brief-pulse ECT delivery is associated with decreased

cognitive deficits.
D. Unilateral ECT is administered to the non-dominant
hemisphere

Answer Key
5. Which of the following drugs is associated with lower seizure
thresholds when administering ECT?

A. Lithium

B. Anticonvulsants

C. Benzodiazepines

D. Barbiturates

Answer Key
6. What is the minimum seizure duration required for
effectiveness of ECT?

A. 1 to 3 seconds

B. 5 to 10 seconds

C. 30 to 90 seconds

D. 180 to 200 seconds

Answer Key
7. What is the best accepted placement of electrodes in unilateral
ECT?

A. Bifrontotemporal

B. Paritotemporal

C. Occipital

D. D'Elia position

Answer Key
8. What is considered as the gold standard for confirmation of
seizure in ECT?
A. Cuff method

B. Electroencephalography (EEG)

C. Electromyogram (EMG)

D. Galvanic Skin Response (GSR)

Answer Key
9. What is the average mortality rate with ECT (modified)?

A. 3-4 per 100,000

B. 10-25 per 100,000

C. 10-20 per 10,000

D. 50-60 per 1000,00

Answer Key
10. Factors predisposing to postictal confusional state include, all
EXCEPT:

A. Sine wave ECT

B. High-dose ECT

C. Existing CNS disease

D. Multiple ECT

E. A younger age group

Answer Key
11. Which is the best unit for quantification of ECT stimuli?

A. Millicoulombs (mC)

B. Joules

C. Watts

D. Volt
 Answer Key
12. Which of the following is NOT a recommended preparation
for ECT procedure?

A. Informed consent in writing

B. Pre-ECT investigations

C. Morning bath, cleaning the oil from the head, overnight fast

D. Premedication with an anticholinergic agent

E. Administration of an anticonvulsant 30 minutes before ECT

Answer Key
13. The most common indication of ECT is:

A. Schizophrenia

B. Generalized Anxiety Disorder

C. Manic episodes

D. Major depression

Answer Key
14. rTMS is found to have antidepressant properties when
applied to

A. Temporal– parietal regions of the cortex

B. Dorsolateral prefrontal cortex (DLPFC)

C. Occipital cortex

D. Parieto-occipital cortex

Answer Key
15. The most persistent adverse effect of ECT is

A. Retrograde amnesia
B. Fractures

C. Seizures

D. Hypertension

Answer Key

ANSWER KEY
1. A 2. B 3. A 4. B 5. A
6. C 7. D 8. B 9. A 10. E
11. A 12. E 13.D 14. B 15. A
Reference

1. Andrade C. Electrical Aspects of ECT. in Handbook of

Psychiatry by Bhugra D, Ranjith G, Patel V. Byword Viva
Publishers, New Delhi, 2005.

2. Kaplan HI, Sadock BJ. Synopsis of Psychiatry , Behavioral

Sciences/ Clinical Psychiatry. 9th ed. Hong Kong :William
and Wilkinson Publishers ;1998.
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