PSYCHO-SOCIAL NURSING TOOLS

Intended Learning Outcome

1. Compare the different approaches you would consider when performing an assessment
with a child, an adolescent, and an older adult.
[Link] a psycho-social assessment including brief cultural and spiritual components.
[Link] a plan of care for a patient with a mental health problem.
[Link] basic nursing interventions and evaluation of care following the American
Nurses Association’s (ANA) Standards of Practice.
5. Compare and contrast Nursing Interventions Classification (NIC), Nursing Outcomes
Classification (NOC), and evidence-based practice (EBP).

[Link] Nursing Process and Standards of Care

A. Standards of Practice for Psychiatric-Mental Health Nursing: Standard 1:
Assessment
The assessment process begins with the initial patient encounter and continues
throughout the care of the patient. To develop a basis for the plan of care and in
preparation for discharge, every patient should have a thorough, formal nursing
assessment upon entering treatment.
Subsequent to the formal assessment, the nurse collects data continually and
systematically as the patient’s condition changes and—hopefully—improves. Perhaps
the patient came into treatment actively suicidal, and the initial focus of care was on
protection from injury. Through regular assessment, the nurse may determine that
although suicidal ideation has diminished, negative thinking may still be a problem.
A variety of professionals conduct assessments, including nurses, psychiatrists,
social workers, dietitians, and other therapists. Virtually all facilities have
standardized nursing assessment forms to aid in organization and consistency among
reviewers. These forms may be paper or electronic versions, according to the
resources and preferences of the institution.

Age Considerations

Assessment of Children
Although the child is the best source in determining inner feelings and
emotions, the caregivers (parents or guardians) often can best describe the
behavior, performance, and conduct of the child. Caregivers also are helpful in
interpreting the child’s words and responses, but a separate interview is
advisable when a child is reluctant to share information, especially in cases of
suspected abuse.
You should assess children through a combination of interview and
observation. Watching children at play provides important clues to their
functioning. Play is a safe area for children to act out thoughts and emotions.
Asking the child to tell a story, draw a picture, or engage in specific therapeutic
games can be useful, particularly when the child is having difficulty expressing
him- or herself in words. Usually, a clinician with special training in child and
adolescent psychiatry works with young children.

Assessment of Adolescents
Adolescents are especially concerned with confidentiality and may fear that
you will repeat what they say to their parents. This is a difficult area. In the eyes
of the law, parents must give consent for treatment and therefore have a right
to know how their child will be treated. Clinically and ethically nurses should
 understand that certain zones of privacy exist even for adolescents. Use of your
best judgment is appropriate. You may need to consult with your clinical
instructor or supervisor when in doubt.
The adolescent and the adolescent’s family should be provided with an
overview of how information sharing will work, what information will be shared,
with whom, and when. Adolescents should receive an explanation on the role of
the treatment team in providing care and the need to share certain information.
Threats of suicide, homicide, sexual abuse, or behaviors that put the patient or
others at risk for harm must be shared with other professionals, as well as with
the parents.

Assessment of Older Adults

As we get older, our five senses (taste, touch, sight, hearing, and smell) and
brain function begin to diminish, but the extent to which this affects each person
varies. Your patient may be a spry and alert 80-year-old or a frail and confused
60-year-old. Therefore it is important not to stereotype older adults and expect
them to be physically and mentally deficient.
On the other hand, many older adults need special attention. The nurse
needs to be aware of any physical limitations. They may be sensory (difficulty
seeing or hearing), motor (difficulty walking or maintaining balance), or medical
(back pain, cardiac or pulmonary deficits). All of these problems can cause
increased anxiety, stress, or physical discomfort.
It is wise to identify any physical deficits at the onset of the assessment and
make accommodations for them. If the patient is hard of hearing, speak a little
more slowly in clear, louder tones (but not too loud). Without invading his
personal space, seat the patient close to you. Often, a voice that is lower in pitch
is easier for older adults to hear.

Language Barriers
Psychiatric-mental health nurses can best serve their patients if they
understand the complex cultural and social factors that influence health and
illness. Awareness of individual cultural beliefs and healthcare practices can help
nurses minimize stereotyped assumptions that can lead to ineffective care.
There are many opportunities for misunderstandings when assessing a patient
from a different cultural or social background from your own. This is particularly
problematic when the patient does not speak the same language as the
caregiver.

B. Standards of Practice for Psychiatric-Mental Health Nursing: Standard 2:

Diagnosis

Diagnostic Statements
Nursing diagnostic statements are made up of the following structural
components:
1. Problem/potential problem
2. Related factors
3. Defining characteristics
The problem, or unmet need, describes the state of the patient at present.
Problems that are within the nurse’s domain to treat are termed nursing
diagnoses. The nursing diagnostic label indicates what should change.
Related factors are linked to the diagnostic label with the words related to.
Related factors are always used with problem-focused diagnoses. The related
 factors usually indicate what needs to be addressed to effect change through
nursing interventions. In the case of hopelessness related to long-term stress,
the nurse would work with the patient to reduce or prevent the negative impacts
of stress. However, in the case of hopelessness related to abandonment, there
may be nothing the nurse can do to change the abandonment. In that case, the
focus would be on symptom management by addressing the defining
characteristics.
Defining characteristics include signs (objective and measurable) and
symptoms (subjective and reported by the patient). All types of nursing
diagnoses use defining characteristics. They may be linked to the diagnosis with
the words as evidenced by. The previous example would then become:
Hopelessness related to abandonment as evidenced by stating, “Nothing will
change,” lack of involvement with family and friends, and inattention to self-care
for self.

Types of Nursing Diagnoses

In problem-focused diagnoses, we make a judgment about undesirable
human responses to a health condition or life process. This category of nursing
diagnosis is accompanied by related factors and evidence.
In a health promotion diagnosis, a motivation and desire to improve is
diagnosed. Related factors are not used in this problem statement because they
would always be the same, that is, motivated to improve health standing. Defining
characteristics support this type of diagnosis.
Risk diagnoses pertain to vulnerability that carries a high probability of
developing problematic experiences or responses. Common problems in this category
include preventable occurrences such as falls, self-injury, pressure ulcers, and
infection. These problems are directly linked with quality improvement and patient
safety

C. Standards of Practice for Psychiatric-Mental Health Nursing: Standard 3:

Outcomes Identification
Outcome criteria are the hoped-for outcomes that reflect the maximum level
of patient health that the patient can realistically achieve through nursing
interventions. Whereas nursing diagnoses identify nursing problems, outcomes
reflect the desired change. The expected outcomes provide direction for
continuity of care.

[Link] of Practice for Psychiatric-Mental Health Nursing: Standard 4:

Planning
Once you have done an assessment and formulated nursing diagnoses, it is
time to prioritize them. Maslow’s hierarchy of needs provides a useful
framework for doing so. Physiological needs and safety always come first
because they have the potential for the most serious harm. Then the higher
order needs can be addressed including love and belonging and selfesteem can
be the focus. For each nursing diagnosis, measurable goals are set and
interventions for attaining the goals are selected.
The nurse considers the following specific principles when planning interventions:
• Safe: Interventions must be safe for the patient, as well as for other
patients, staff, and family.
 • Compatible and appropriate: Interventions must be compatible with
other therapies and with the patient’s personal goals and cultural values, as well as
with institutional rules.
• Realistic and individualized: Interventions should be
(1) within the patient’s capabilities, given the patient’s age, physical
strength, condition, and willingness to change;
(2) based on the number of staff available;
(3) reflective of the actual available community resources; and
(4) within the student’s or nurse’s capabilities.
• Evidence-based: Interventions should be based on scientific
evidence and principles when available.

D. Standards of Practice for Psychiatric-Mental Health Nursing: Standard 5:

Implementation

Standard 5A. Coordination of Care

One of the most important jobs that a registered nurse does is to coordinate
care. The nurse is generally in the most contact with the patient and
communicates patient status, needs, and goals with the interprofessional team.
Nurses also tend to be the families’ advocates and help them to navigate an
often-bewildering healthcare system at a difficult time in their lives.
Documentation of the coordination of care is an essential aspect of this standard.
Standard 5B. Health Teaching and Health Promotion
Psychiatric-mental health nurses use a variety of health teaching methods
adaptive to the patient’s special needs (age, culture, ability to learn, readiness)
and recovery goals. Healthcare teaching includes coping skills, self-care activities,
stress management, problem-solving skills, relapse prevention, conflict
management, and interpersonal relationships. A vital part of health promotion is
identifying resources for services in the community.
Standard 5C. Consultation
Consultation is an advanced practice role. Consultation involves assisting
other registered nurses and members of the inter-professional team in
addressing complex clinical and other situations. Evidence-based information,
clinical data, and theoretical frameworks provide the foundation nurse
consultants.
Standard 5D. Prescriptive Authority and Treatment
Another advanced practice role, prescribing is accomplished by using
evidence-based treatments, procedures, and therapies for healthcare consumers.
Medication is prescribed in collaboration with the patient based on clinical
symptoms and the results of diagnostic and laboratory tests. Evaluation of the
therapeutic benefit and adverse effects of pharmacology is assisted by using
standard symptom measurements along with the healthcare consumer’s
appraisal.
Standard 5E. Pharmacological, Biological, and Integrative Therapies
Nurses are knowledgeable regarding the current research findings, intended
action, therapeutic dosage, adverse reactions, and safe blood levels of
medications being administered. Monitoring the patient for any negative effects
protects the patient from unnecessary harm. The nurse communicates this
assessment of the patient’s response to psycho-biological interventions to other
members of the mental health team.
Standard 5F. Milieu Therapy
Milieu refers to a physical and social environment. Milieu therapy is a
psychiatric philosophy that involves a secure environment including people,
settings, structure, and emotional climate to effect positive change. Milieu
therapy takes naturally occurring events in the environment and uses them as
rich learning opportunities for patients. A consistent routine and structure is
maintained to provide predictability and trust.
Milieu management includes orienting patients to their rights and
responsibilities. Milieu management takes into consideration the need for
culturally sensitive care. The nurse selects activities (both individual and group)
that meet the patient’s physical and mental health needs. The nurse always
maintains patients in the least restrictive environment.

Standard 5G. Therapeutic Relationship and Counseling

The therapeutic relationship is the basis of interactions between the nurse
and patient. While medications and other treatments are important for recovery
from a psychiatric disorder, nurses are vital in providing presence and being a
sounding board. In an individual or group setting, you can reinforce healthy
behavior and help the patient to recognize maladaptive behaviors, identify
positive coping methods, and try out the new coping methods.

Standard 5H. Psychotherapy

The practice of psychotherapy is an advanced practice skill that is built upon
principles of therapeutic communication. Evidence-based therapies are chosen in
order to meet the needs of healthcare consumers who are encouraged to be
active participants in treatment. When possible, standardized tools are used to
evaluate effectiveness of interventions.

[Link] of Practice for Psychiatric-Mental Health Nursing: Standard 6:

Evaluation
Unfortunately, nurses often neglect evaluation of patient outcomes during
the nursing process. Evaluation of the individual’s response to treatment should
be systematic, ongoing, and criteria based. You should include supporting data
to clarify the evaluation. Ongoing assessment of data allows for revisions of
nursing diagnoses, changes to more realistic outcomes, or identification of more
appropriate interventions when outcomes are not met.

[Link]
Documentation has been called the seventh step in the nursing process. Keep in
mind that medical records are legal documents and may be used in a court of law.
Besides the evaluation of stated outcomes, the medical record should include
changes in patient condition, informed consents (for medications and treatments),
reaction to medication, documentation of symptoms (verbatim when appropriate),
concerns of the patient, and any problematic incidents in the healthcare setting.
Documentation of patient progress is the responsibility of the entire mental health
team.

Documentation of “Non-adherence”
When patients do not follow medication and treatment plans, they are often
labeled as “non-compliant.” Applied to patients, the term non-compliant often has
negative connotations because compliance traditionally referred to the extent that a
patient obediently and faithfully followed healthcare providers’ instructions. “That
patient is non-compliant” often translates into the patient being bad or lazy,
subjecting the patient to blame and criticism. The term non-compliant is invariably
judgmental. A much more useful term is non adherent. This term encourages
healthcare providers to find out what is going on in the patient’s life and explore
barriers to taking the medication.

[Link] Relationships
Concepts of the Nurse-Patient Relationship
The healthcare community accepts the concept of patient-centered care as
the gold standard. The core concepts of patient- and family-centered care
consist of
(1) dignity and respect,
(2) information sharing,
(3) patient and family participation, and
(4) collaboration in policy and program development.
These tenets are familiar to members of the nursing profession as the
nurse-patient relationship.

Importance of Talk Therapy

A formalized approach to talk therapy that is based on theoretical models is
called psychotherapy. Healthcare providers with advanced degrees and
specialized knowledge, including psychiatric mental health advanced practice
registered nurses, psychiatrists, and psychologists, are licensed to practice
psychotherapy. Evidence suggests that psychotherapy within a therapeutic
partnership actually changes brain chemistry in much the same way as
medication. Thus the best treatment for most psychiatric problems (less so with
psychotic disorders) is a combination of medication and psychotherapy.
Basic level psychiatric-mental health nurses do not practice psychotherapy
as this is an advanced skill. They do, however, use counseling techniques in the
context of the therapeutic relationship. Counseling is a supportive face-to-face
process that helps individuals problem-solve, resolve personal conflicts, and feel
supported.
Goals and Functions
The nurse-patient relationship is often loosely defined, but a therapeutic
nurse-patient relationship has specific goals and functions including the following:
• Facilitating communication of distressing thoughts and feelings
• Assisting patients with problem solving to help facilitate activities of
daily living
• Helping patients examine self-defeating behaviors and test
alternatives
• Promoting self-care and independence
• Providing education about medications and symptom management
• Promoting recovery

Social Versus Therapeutic

Social Relationships
A social relationship is primarily initiated for the purpose of friendship,
socialization, enjoyment, or accomplishment of a task. Mutual needs are met
during social interaction (e.g., participants share ideas, feelings, and
experiences). Communication skills may include giving advice and sometimes
meeting basic dependency needs such as lending money and helping with jobs.
Often, the content of the communication is superficial.
 In a therapeutic relationship, the nurse maximizes communication skills,
understanding of human behaviors, and personal strengths to enhance the
patient’s growth. Patients more easily engage in the relationship when the
clinician’s interactions address their concerns, respect patients as partners in
decision making, and use straightforward language. These interactions are
evidence that the focus of the relationship is on the patient’s ideas, experiences,
and feelings.

Relationship Boundaries and Roles

Establishing Boundaries
Professional boundaries exist to protect patients. Boundaries are the
expected and accepted social, physical, and psychological boundaries that
separate nurses from patients. This separation is essential considering the power
differential between the nurse and the patient. This differential also exists
between you and the patient, even if you do not feel powerful. You have read
the patient’s chart, you are there to help, you are close to becoming a registered
nurse, and you are not a patient.
Blurring of Boundaries
Boundaries are always at risk for becoming blurred. Two common
circumstances in which boundaries are blurred are (1) when the relationship
slips into a social context and (2) when the nurse’s needs (for attention,
affection, and emotional support) are met at the expense of the patient’s needs.
Blurring of Roles
Blurring of roles in the nurse-patient relationship is often a result of
unrecognized transference or counter transference.
■Transference
Transference occurs when the patient unconsciously and inappropriately
displaces (transfers) onto the nurse feelings and behaviors related to significant
figures in the patient’s past.
■Counter transference
Countertransference is transference in reverse. It occurs when the nurse
unconsciously displaces feelings related to significant figures in the nurse’s past
onto the patient. Frequently, the intense emotions of transference on the part of
the patient bring out countertransference in the nurse. For example, you remind
your patient of his much loved older sister and he works very hard to please you.
In response to this idealization and caring, you experience feelings of tenderness
toward the patient and spend extra time with him each day.

Peplau’s Model of the Nurse-Patient Relationship

Hildegard Peplau introduced the concept of the nurse-patient relationship
in 1952 in her groundbreaking book Interpersonal Relations in Nursing. This
model of the nurse-patient relationship is well accepted in the United States and
Canada as an important tool for all nursing practice. A professional nurse-patient
relationship consists of a nurse who has skills and expertise and a patient who
wants to alleviate suffering, find solutions to problems, explore different avenues
to increased quality of life, or find an advocate.
Peplau proposed that the nurse-patient relationship “facilitates forward
movement” for both the nurse and the patient. This interactive nurse-patient
process is designed to facilitate the patient’s boundary management,
independent problem solving, and decision making that promotes autonomy.
1. Preorientation Phase
The pre-orientation phase begins with preparing for your assignment. The
chart is a rich source of information including mental and physical evaluation,
progress notes, and patient orders. You will probably be required to research
your patient’s condition, learn about prescribed medications, and understand
laboratory results. Staff may be available to share more anecdotal information or
provide you with tips on how to best interact with your patient.

2. Orientation Phase
The orientation phase can last for a few meetings or extend over a longer
period. It is the first time the nurse and the patient meet and is the phase in
which the nurse conducts the initial interview. During the orientation phase, the
patient may begin to express thoughts and feelings, identify problems, and
discuss realistic goals. Specific tasks of the orientation phase follow.
■ Introductions
The first task of the orientation phase is introductions. The patient needs to
know about the nurse (who the nurse is and the nurse’s background) and the
purpose of the meetings. For example, a student might furnish the following
information:
Establishing rapport
A major emphasis during the first few encounters with the patient is on
providing an atmosphere in which trust and understanding, or rapport, can
grow. As in any relationship, you can nurture rapport by demonstrating
genuineness, empathy, and unconditional positive regard. Being consistent,
offering assistance in problem solving, and providing support are also
essential aspects of establishing and maintaining rapport.
Specifying a contract
A contract emphasizes the patient’s participation and responsibility
because it shows that the nurse does something with the patient rather than
for the patient. The contract, either stated or written, contains the place,
time, date, and duration of the meetings. You should also discuss
termination of the relationship.
Explaining confidentiality
The patient has a right to know
(1) who else will be given the information shared with the nurse and
(2) that the information may be shared with specific people such as a
clinical supervisor, the physician, the staff, or other students in conference.
The patient also needs to know that the information will not be shared with
relatives, friends, or others outside the treatment team, except in extreme
situations. Extreme situations include child or elder abuse and threats of
self-harm or harm to others
(3)
3. Termination Phase
The termination phase is the final, integral phase of the nurse-patient
relationship. You discuss termination during the first interview and again
during the working stage at appropriate times. Termination may occur when
the patient is discharged or when the student’s clinical rotation ends.
Basically, the tasks of termination include the following:
• Summarizing the goals and objectives achieved in the
relationship
• Discussing ways for the patient to incorporate into daily life
any new coping strategies learned
 • Reviewing situations that occurred during the nurse-patient
relationship
• Exchanging memories, which can help validate the
experience for both nurse and patient and facilitate closure of that relationship
Termination often awakens strong feelings in both the nurse and patient.
Termination of the relationship signifies a loss for both, although the
intensity and meaning of termination may be different for each. If a patient
has unresolved feelings of abandonment, loneliness, or rejection, these
feelings may be reawakened during the termination process. This process
can be an opportunity for the patient to express these feelings, perhaps for
the first time.

[Link] Communication
The Communication Process
Communication is an interactive process between two or more persons who
send and receive messages to one another. The following is a simplified model
of communication:
1. Stimulus. One person has a need to communicate with another for
information, comfort, or advice.
2. Sender. The person sending the message initiates interpersonal
contact.
3. Message. The message is the information sent or expressed to
another. The clearest messages are those that are well-organized and
expressed in a manner familiar to the receiver.
4. Channel. The message can be sent through a variety of channels,
including auditory (hearing), visual (seeing), tactile (touch), olfactory
(smell), or any combination of these.
5. Receiver. The person receiving the message then interprets the
message and responds to the sender by providing feedback.

Factors that Affect Communication

Personal Factors
Personal factors can impede accurate transmission or interpretation of
messages. Patients may have difficulty communicating due to a psychiatric
disorder. For example, depression may result in slow thinking and reduced
communication, anxiety can cause lack of concentration, and mania creates
an inability to focus for any length of time.
Environmental Factors
Environmental factors within a healthcare setting that may affect
communication include physical factors. Background noise, lack of privacy,
and uncomfortable accommodations are not conducive to a smooth flow of
communication. While units are not as crowded and noisy as they once were,
it may still be difficult to carry on a private conversation in the day hall or
other common area.
Relationship Factors
For the purpose of this discussion, relationship factors refer to the level
of equality within the relationship. When the two participants are equal,
such as friends or colleagues, the relationship is symmetrical. However,
when there is a difference in status or power, such as between nurse and
patient or teacher and student, the relationship is characterized by
inequality. One participant has more control. This is called a complementary
 relationship. Usually, the inequality decreases as the patient recovers and as
the student progresses and graduates. Complementary relationships also
exist based on social status, age or developmental differences, gender
differences, and educational differences.

Verbal and Nonverbal Communication

Verbal Communication
Verbal communication consists of all the words a person speaks. We live
in a society of symbols, and our main social symbols are words. Words are
the symbols for emotions and mental images. Talking is our link to one
another and the primary instrument of instruction. Talking is a need, an art,
and one of the most personal aspects of our private lives. When we speak,
we:
• Communicate our beliefs and values
• Communicate perceptions and meanings
• Convey interest and understanding or insult and
judgment
• Convey messages clearly or convey conflicting or
implied messages
• Convey clear, honest feelings or disguised, distorted
feelings
Nonverbal Communication
It is said, “It’s not what you say but how you say it.” In other words, it
is the nonverbal behaviors that may be sending the real message through.
The tone of voice, emphasis on certain words, and the manner in which a
person paces speech are examples of nonverbal communication. Other
common examples of nonverbal communication are physical appearance,
body posture, eye contact, hand gestures, sighs, fidgeting, and yawning.
Table 9.1 identifies examples of nonverbal behaviors.
Facial expression is extremely important in terms of nonverbal
communication. The eyes and the mouth seem to hold the biggest clues into
how people are feeling through emotional decoding.

Therapeutic Communication Techniques

Using Silence
Silence may provide meaningful moments of reflection for both
participants. It provides an opportunity to contemplate thoughtfully what
has been said and felt, weigh alternatives, formulate new ideas, and gain a
new perspective. If the nurse waits to speak and allows the patient to break
the silence, the patient may share thoughts and feelings that would
otherwise have been withheld. It is crucial to recognize that some
psychiatric disorders, such as major depression and schizophrenia, and
medications may cause an overall slowing of thought processes. This
slowing may be so severe that it may seem like an eternity before the
patient responds. Patience and gentle prompting can help patients gather
their thoughts. For example, “You were saying that you would like to get a
pass this weekend to visit your niece.”
Conversely, silence is not always therapeutic. Prolonged and frequent
silences by the nurse may hinder an interview that requires verbal
articulation. Although a less-talkative nurse may be comfortable with silence,
this mode of communication may make the patient feel uncomfortable and
 withhold information. Moreover, without feedback, patients have no way of
knowing whether what they said was understood. It is important to point
out that children and adolescents in particular tend to feel uncomfortable
with silence.
Active Listening
People want more than just a physical presence in human
communication. Most people want the other person to be there for them
psychologically, socially, and emotionally. In active listening, nurses fully
concentrate, understand, respond, and remember what the patient is saying
verbally and non-verbally.

Clarifying Techniques
Understanding depends on clear communication, which is aided by verifying
the nurse’s interpretation of the patient’s messages. The nurse can request
feedback on the accuracy of the message received from verbal and nonverbal
cues.
■Paraphrasing
Paraphrasing occurs when you restate the basic content of a
patient’s message in different, usually fewer, words. Using simple,
precise, and culturally relevant terms, the nurse may confirm an
interpretation of the patient’s message before the interview continues.
Prefacing statements with a phrase such as “I’m not sure I understand”
or “You seem to be saying…” helps the nurse to understand the
message in what may be a bewildering mass of details. It helps the
patient to feel heard and may provide greater focus. The patient may
confirm or deny the perceptions non-verbally by nodding or looking
bewildered, or by direct responses, “Yes, that is what I was trying to
say” or “No, I meant…
■Restating
Restating is an active listening strategy that helps the nurse to
understand what the patient is saying. It also lets the patient know he is
being heard. Restating differs from paraphrasing in that it involves
repeating the same key words the patient has just spoken. If a patient
remarks, “My life is empty…it has no meaning,” additional information
may be gained by restating, “Your life has no meaning?”
■Reflecting
Reflection is a means of assisting patients to better understand
their own thoughts and feelings. Reflecting may take the form of a
question or a simple statement that conveys the nurse’s observations of
the patient when discussing sensitive issues. The nurse might then
describe briefly to the patient the apparent meaning of the emotional
tone of the patient’s verbal and nonverbal behaviors. For example, to
reflect a patient’s feelings about his or her life, a good beginning might
be, “You sound as if you have had many disappointments.”
■Exploring
A technique that enables the nurse to examine important ideas,
experiences, or relationships more fully is exploring. For example, if a
patient tells you he does not get along well with his wife, you will want
to further explore this area. Possible openers include the following:
“Tell me more about your relationship with your
wife.”
“Describe your relationship with your wife.”
 “Give me an example of how you and your wife
don’t get along.”
Asking for an example can greatly clarify a vague or generic statement
made by a patient.

Questions
■Open-ended questions
Open-ended questions encourage patients to share information
about experiences, perceptions, or responses to a situation. For
example:
• “What do you perceive as your biggest problem right now?”
• “What is an example of some of the stresses
you are under right now?”
• “How would you describe your relationship with your wife?”
Because open-ended questions are not intrusive and do not put the
patient on the defensive, they help the clinician elicit information. This
technique is especially useful in the beginning of an interview or when a
patient is guarded or resistant to answering questions. They are
particularly useful when establishing rapport with a person.

■Closed-ended questions
Nurses are usually urged to ask open-ended questions to elicit more
than a “yes” or “no” response. However, closed-ended questions, when
used sparingly, can give you specific and needed information. Closed-
ended questions are most useful during an initial assessment or intake
interview or to ascertain results as in “Are the medications helping
you?” “When did you start hearing voices?” “Did you seek therapy after
your first suicide attempt?”
■Projective questions
Projective questions usually start with a “what if” to help people
articulate, explore, and identify thoughts and feelings. They are
surprisingly strong in their ability to facilitate a patient’s thinking about
problems differently and to identify priorities. Projective questions can
also help people imagine thoughts, feelings, and behaviors they might
have in certain situations.
■The miracle question
The miracle question is a goal-setting question that helps patients
to see what the future would look like if a particular problem were to
vanish. The question should be asked deliberately and dramatically.

Non-therapeutic Communication Techniques

Excessive Questioning
Excessive questioning—asking multiple questions (particularly closed-
ended) consecutively or rapidly—casts the nurse in the role of interrogator
who demands information without respect for the patient’s willingness or
readiness to respond. This approach conveys a lack of respect for and
sensitivity to the patient’s needs. Excessive questioning controls the range
and nature of the responses, can easily result in a therapeutic stall, or may
completely shut down an interview. It is a controlling tactic and may reflect
the interviewer’s lack of security in letting the patient tell his or her own
story.
Giving Approval or Disapproval
“You look great in that dress.” “I’m proud of the way you controlled
your temper at lunch.” What could be bad about giving someone a pat on
the back once in a while? Nothing, if it is done without conveying a positive
or negative judgment. We often give our friends and family approval when
they do something well, but giving praise and approval becomes much more
complex in a nurse patient relationship.
A patient may be feeling overwhelmed, experiencing low self-esteem,
feeling unsure of where his or her life is going, and desperate for
recognition, approval, and attention. Yet when people are feeling vulnerable,
a value comment might be misinterpreted.
Giving Advice
We ask for and give advice all the time. Yet, when a nurse gives advice
to a patient, the nurse is interfering with the patient’s ability to make
personal decisions. When a nurse offers the patient solutions, the patient
eventually begins to think the nurse does not view him or her as capable of
making effective decisions. People often feel inadequate when they are
given no choices over decisions in their lives. Giving advice to patients also
can foster dependency (“I’ll have to ask the nurse what to do about…”) and
undermine the patient’s sense of competence and adequacy.
Asking “Why” Questions
“Why” demands an explanation and implies wrong doing. Think of the
last time someone asked you why: “Why did you come late?” “Why didn’t
you go to the funeral?” “Why didn’t you study for the exam?” Such
questions imply criticism. We may ask our friends or family such questions,
and in the context of a solid relationship, the why may be understood more
as “What happened?” With people we do not know—especially those who
may be anxious or overwhelmed—a why question from a person in authority
(e.g., nurse, physician, and teacher) can be experienced as intrusive and
judgmental, which serves only to make the person defensive.

[Link] Response and Stress Management

Responses to and Effects of Stress

Early Stress Response Theories

Fight-or-Flight Response
The earliest research into the stress response began as a result of
observations that stressors increased the incidence of physical disorders and
made existing conditions worse. Stressors are any psychological or physical
stimuli or events that provoke a stress response in an organism. Stressors
can be acute or chronic and may be external or internal.
General Adaptation Syndrome
Hans Selye was another pioneer in stress research who introduced the
concept of stress into both the scientific and popular literature. Selye
defined stress as “a nonspecific response of the body to any demand for
change.” He incorporated Cannon’s fight or flight response into an expanded
theory of stress known as the general adaptation syndrome (GAS).

1. The alarm stage is the initial, brief, and adaptive response (fight or flight) to
the stressor.
 It begins with the eyes or ears sending information such as a car running a light
or the sound of a fire alarm to the brain’s amygdala. If the amygdala, which
processes emotional data, interprets the event as dangerous, it sounds the alarm to
the hypothalamus, which responds in two ways:

1. [Link].
The hypothalamus signals through the autonomic nerves to the adrenal
glands. The adrenals then pump the catecholamine epinephrine (also known
as adrenaline) into the blood stream, thereby activating the sympathetic
nervous system. This results in a faster heart rate and increased blood
pressure that pushes blood to muscles and the heart. Breathing becomes
more rapid and the lungs expand more fully. Extra oxygen is sent to the
brain to aid in cognitive processing. All senses including sight (pupils dilate
for a broad view of the environment) and hearing become sharper. Glucose
is dumped in the bloodstream to supply additional energy. Blood is shunted
away from the digestive tract (resulting in a dry mouth) and kidneys to
more essential organs.
All of this happens so quickly that most people are not aware of the full
scope of the threat. This is why you can jump out of the way of oncoming
car before you really realize what is happening.

1. b. Hypothalamic-Pituitary-Adrenal (HPA) Axis.

As the initial surge of epinephrine subsides, the HPA axis, which is
comprised of the hypothalamus, the pituitary, and the adrenal gland, is
activated. You can conceptualize this axis as the gas pedal of the system
that keeps the system on high alert.

2. The resistance stage could also be called the adaptation stage because it is
during this time sustained and optimal resistance to the stressor occurs.
Usually, stressors are successfully overcome. Recovery, repair, and renewal
may occur. At this point individuals have used up valuable resources and
have reduced defenses and adaptive energy. If stressors continue, the body
remains in a state of arousal and may transition to the final stage of the
syndrome.
[Link] exhaustion stage occurs when attempts to resist the stressor prove futile.
At this point, resources are depleted, and the stress may become chronic.
The impact of long-term overexposure to cortisol renders people more
vulnerable to all kinds of illness.

Bad Stress Versus Good Stress?

• Distress is a negative draining energy that results in anxiety, depression,
confusion, helplessness, hopelessness, and fatigue. Stressors such as a death in the
family, financial overload, or school/work demands may cause distress.
• Eustress (“eu” is Greek for well or good) is a positive beneficial energy that
motivates and results in feelings of happiness, hopefulness, and purposeful
movement. Eustress is the result of a positive perception toward a stressor.
Examples of eustress are a much-needed vacation, playing a favorite sport, the birth
of a baby, or the challenge of a new job. Because the same physiological responses
are in play with stress and eustress, eustress can still tax the system, and downtime
is important.
 Mediators of the Stress Response
Stressors
Many situations such as emotional arousal, fatigue, fear, humiliation, loss of
blood, extreme happiness, or unexpected success are capable of producing stress
and triggering the stress response. Stressors can be divided into two broad
categories: physiological and psychological.

Physiological stressors include environmental conditions (e.g., trauma and

excessive cold or heat) and physical conditions (e.g., infection, hemorrhage, hunger,
and pain). Psychological stressors include such events as divorce, loss of a job,
unmanageable debt, the death of a loved one, retirement, and fear of a terrorist
attack. Psychological stressors also include changes we consider positive such as
marriage, the arrival of a new baby,
or unexpected success.

Perception
The way that we perceive
stressors is affected by factors
such as age, gender, culture, life
experience, and lifestyle. All of
these factors may work to either
lessen or increase the degree of
emotional or physical influence and
the sequelae (consequence or
result) of stress. For example, a
man in his 40s who has a new
baby, a new home, and gets laid
off may feel more stress than a
man in his 60s who is financially
secure and is asked to take an
early retirement.

Individual Temperament
As mentioned earlier, part of
the response to stressors is based
on our own individual perceptions.
These perceptions are colored by a variety of factors including genetic structure and
vulnerability, childhood experiences, coping strategies, and personal outlook on life
and the world. All these factors combine to form a unique personality with specific
strengths and vulnerabilities.

Social Support
The benefit of social support cannot be emphasized enough, whether it is for
you or for your patients. Humans once lived in close communities with extended
family sharing the same living quarters. Essentially, neighbors were the therapists of
the past. Suburban life often results in isolated living spaces where neighbors
interact sporadically. In fact, you may not even know your neighbors. People in
crowded cities may also live in isolation where eye contact and communication may
be considered an invasion of privacy.
Support Groups
The proliferation of self-help groups attests to the need for social supports.
Many of the support groups currently available are for people going through similar
stressful life events: Alcoholics Anonymous (a prototype for 12-step programs),
Gamblers Anonymous, Reach for Recovery (for cancer patients), and Parents Without
Partners to note a few. Online support groups provide cost effective, anonymous,
and easily accessible self-help for people with every disorder imaginable.

Culture
Each culture not only emphasizes certain problems of living more than others
but also interprets emotional problems differently. Although Western European and
North American cultures tend to subscribe to a psychophysiological view of stress
and somatic distress, this is not the dominant view in other cultures. The
overwhelming majority of Asians, Africans, and Central Americans tend to express
distress in somatic terms and actually experience it physically.

Spirituality and
Religion
Spirituality and
religious affiliation
help people cope with
stress. Studies have
demonstrated that
spiritual practices can
even enhance the
immune system and
sense of well-being.
Spiritual well-being
helps people deal with
health issues, primarily
because spiritual
beliefs help people cope with issues of living. People who include spiritual solutions
to physical or mental distress often gain a sense of comfort and support that can aid
in healing and lowering stress. Even prayer, in and of itself, can elicit the relaxation
response (discussed later in this chapter) known to reduce stress physically and
emotionally and to reduce the impact of stress on the immune system.

Managing Stress through Relaxation Techniques

Biofeedback

Through the use of sensitive instrumentation, biofeedback provides immediate

and exact information regarding muscle activity, brain waves, skin temperature,
heart rate, blood pressure, and other bodily functions. Indicators of the particular
internal physiological process are detected and amplified by a sensitive recording
device. An individual can achieve greater voluntary control over phenomena once
considered to be exclusively involuntary if he or she knows instantaneously, through
an auditory or visual signal, whether a somatic activity is increasing or decreasing.
Deep Breathing Exercises
The US Department of Health and Human Services conducted a study and found
that the most common relaxation technique used in the United States was deep
breathing exercises. About a third of respondents used this technique as a mainstay
or a quick fix to calm down. Breathing exercises are simple and easy to remember,
even when anxiety begins to escalate. This technique involves focusing on taking
slow, deep, and even breaths.
• Find a comfortable position.
• Relax your shoulders and chest; let your body relax.
• Shift to relaxed, abdominal breathing. Take a deep breath through your nose,
expanding the abdomen. Hold it for 3 seconds and then exhale slowly
through the mouth; exhale completely, telling yourself to relax.
• With every breath, turn attention to the muscular sensations that accompany
the expansion of the belly.
• As you concentrate on your breathing, you will start to feel focused.
• Repeat this exercise for 2 to 5 minutes.

Guided Imagery
Long before we learn to speak, our experience is based on mental images. With
guided imagery people are taught to focus on pleasant images to replace negative or
stressful feelings. Guided imagery may be self-directed or led by a practitioner or a
recording. Imagery techniques are a useful tool in the management of medical
conditions and are an effective means of relieving pain for some people. Inducing
muscle relaxation and focusing the mind away from the pain reduce pain. For some,
imagery techniques are healing exercises in that they not only relieve the pain but
also, in some cases, diminish the source of the pain. Cancer patients use guided
imagery to help reduce high levels of cortisol, epinephrine, and catecholamines —
which prevent the immune system from functioning effectively—and to produce β-
endorphins— which increase pain thresholds and enhance lymphocyte proliferation.
Script For Guided Imagery
• Imagine releasing all the tension in your body…letting it go.
• Now, with every breath you take, feel your body drifting down deeper and
deeper into relaxation…floating down…deeper and deeper.
• Imagine a peaceful scene. You are sitting beside a clear, blue mountain stream.
You are barefoot, and you feel the sun-warmed rock under your feet. You hear the
sound of the stream tumbling over the rocks. The sound is hypnotic, and you relax
more and more. You see the tall pine trees on the opposite shore bending in the
gentle breeze. Breathe the clean, scented air, with each breath moving you deeper
and deeper into relaxation. The sun warms your face.
• You are very comfortable. There is nothing to disturb you. You are
experiencing a feeling of well-being.
• Come back to this peaceful scene by taking time to relax. The positive feelings
can grow stronger and stronger each time you choose to relax.
• You can return to your activities now, feeling relaxed and refreshed.

Progressive Relaxation
In 1938 Edmund Jacobson, a Harvard-educated physician, developed a rather
simple procedure that elicits a relaxation response, which he coined progressive
relaxation or progressive muscle relaxation. This technique can be done without any
external gauges or feedback and can be practiced almost anywhere by anyone. The
premise behind progressive relaxation is that, because anxiety results in tense
muscles, one way to decrease anxiety is to nearly eliminate muscle contraction. This
is accomplished by deliberately tensing groups of muscles (beginning with feet and
ending with face or vice versa) as tightly as possible for about 8 seconds and then
releasing the tension you have created.
Short Progressive Muscle Relaxation
Find a quiet, comfortable place to sit. A reclining chair is ideal. Take five slow,
deep breaths before you begin. Now tense and relax each area listed below. Tighten
your muscles only until you feel tension, not pain.
• First, let’s focus on your neck and shoulders. Raise your shoulders up toward
your head . . . tighten the muscles there… hold… feel the tension there…and now
release. Let your shoulders drop to a lower, more comfortable position.
• Now let’s move to your hands. Tighten your hands into fists. Very tight…as if
you are squeezing a tennis ball tightly in each hand…hold…feel the tension in your
hands and forearms…and now release. Shake your hands gently, shaking out the
tension. Feel how much more relaxed your hands are now.
• Now, your forehead: Raise your eyebrows, feeling the tight muscles in your
forehead. Hold that tension. Now tightly lower your eyebrows and scrunch your
eyes closed, feeling the tension in your forehead and eyes. Hold it tightly. And now,
relax…let your forehead be relaxed and smooth, your eyelids gently resting.
• Your jaw is the next key area: Tightly close your mouth, clamping your jaw
shut, very tightly. Your lips will also be tight and tense across the front of your teeth.
Feel the tension in your jaws. Hold…and now relax. Release all of the tension. Let
your mouth and jaw be loose and relaxed.
• There is only one more key area to relax, and that is your breathing: Breathe
in deeply, and hold that breath. Feel the tension as you hold the air in. Hold…and
now relax. Let the air be released through your mouth. Breathe out all the air.
• Once more, breathe in…and now hold the breath. Hold…and relax. Release the
air, feeling your entire body relax. Breathe in…and out…in… and out…
• Continue to breathe regular breaths.
• You have relaxed some of the key areas where tension can build up.
Remember to relax these areas a few times each day, using this quick progressive
muscle relaxation script, to prevent stress symptoms.

Meditation
Meditation follows the basic guidelines described for the relaxation response. It
is a discipline for training the mind to develop greater calm and then using that calm
to bring penetrative insight into one’s experience. Meditation can be used to help
people to tap into their deep inner resources for healing, calm their minds, and help
them operate more efficiently in the world. It can help people develop strategies to
cope with stress, make sensible adaptive choices under pressure, and feel more
engaged in life.
Meditation elicits a relaxation response by creating a hypometabolic state of
quieting the sympathetic nervous system. Some people meditate using a visual
object or a sound to help them focus. Others may find it useful to concentrate on
their breathing while meditating. Meditation is easy to practice anywhere. Some
students find that meditating before a test helps them focus and lessens anxiety.
Keep in mind that meditation, like most other techniques, becomes better with
practice.

Mindfulness
a centuries-old form of meditation that dates back to Buddhist tradition, has
received increased attention among healthcare professionals. Mindfulness is based
on two ways our brains work. One is a default network that includes the medial
prefrontal cortex and memory regions such as the hippocampus. In this state we
operate on a sort of mental autopilot or “mind wandering.” You are thinking about
what to make for dinner or how your hair looks and are continually compiling the
narrative of your life and people you know. This type of thinking tends to be
dominant. The other network is the direct experience network that is the focus of
mindfulness. Several areas of the brain are activated in this state. The insular cortex
is active and makes us aware of bodily sensation and a sense of self.
The anterior cingulate cortex is active and is central to attention and focuses us
on what is happening around us. In this state you are in tune with your environment,
live in the moment, and take a break from planning, strategizing, and setting goals.
Being mindful includes being in the moment by paying attention to what is going on
around you —what you are seeing, feeling, hearing. Imagine how much you miss
during an ordinary walk to class if you spend it staring straight ahead as your mind
wanders from one concern to the next. You miss the pattern of sunlight filtered
through the leaves, the warmth of the sunshine on your skin, and the sounds of
birds calling out to one another. By focusing on the here and now, rather than past
and future, you are practicing mindfulness
 A Mindfulness Technique
Creating space to come down from the worried mind and back into the
present moment has been shown to be enormously helpful to people. When we
are present, we have a firmer grasp of all our options and resources that often
make us feel better. Next time you find your mind racing with stress, try the
acronym STOP.
S – Stop what you are doing; put things down for a minute.
T – Take a breath. Breathe normally and naturally and follow your breath
coming in and out of your nose. You can even say to yourself “in” as you’re
breathing in and “out” as you’re breathing out if that helps with concentration.
O – Observe your thoughts, feelings, and emotions. You can reflect about what
is on your mind and also notice that thoughts are not facts, and they are not
permanent. If the thought arises that you are inadequate, just notice the thought, let
it be, and continue on. Notice any emotions that are there and just name them. Just
naming your emotions can have a calming effect. Then notice your body. Are you
standing or sitting? How is your posture? Any aches and pains?
P – Proceed with something that is important to you in the moment, whether
that is talking with a friend, appreciating your children, or walking while paying
attention to the world.

Other Ways to Relax

Physical Exercise
Physical exercise can lead to protection from the harmful effects of stress on
both physical and mental states. Researchers have been particularly interested in
the influence exercise has over depression. Exercise is associated with a
reduction in depressive symptoms. Blumenthal and colleagues found that
patients who had either 4 months of treatment with a selective serotonin re-
uptake inhibitor antidepressant or with aerobic exercise had similar relief of
depression. Older adults who engage in regular physical activity have some
protection from anxiety and depressive disorder.

Cognitive Re-framing
Cognitive re-framing stems from an evidenced-based practice known as
cognitive-behavioral therapy. The goal of cognitive re-framing (also known as
cognitive restructuring) is to change the individual’s perceptions of stress by
reassessing a situation and replacing irrational beliefs. For example the thought
“I can’t pass this course” is replaced with a more positive self-statement, “If I
choose to study for this course, I will increase my chances of success.” We can
learn from most situations by asking ourselves the following:
• “What positive things came out of this situation or
experience?”
• “What did I learn in this situation?”
• “What would I do in a different way?”
The desired result is to reframe a disturbing event or experience as less
disturbing and to give the patient a sense of control over the situation. When the
perception of the disturbing event is changed, there is less stimulation to the
sympathetic nervous system, which in turn reduces the secretion of cortisol and
catecholamines that destroy the balance of the immune system

Journaling
Writing in a journal (journaling) is an extremely useful and surprisingly
simple method of identifying stressors. It is a technique that can ease worry and
obsession, help identify hopes and fears, increase energy levels and confidence,
and facilitate the grieving process. Keeping an informal diary of daily events and
activities can reveal surprising information on sources of daily stress. Simply
noting which activities put a strain on energy and time, which trigger anger or
anxiety, and which precipitate a negative physical experience (e.g., headache,
backache, fatigue) canbe an important first step in stress reduction. Writing
down thoughts and feelings is helpful not only in dealing with stress and
stressful events but also in healing both physically and emotionally.
Humor
The use of humor as a cognitive approach is a good example of how a
stressful situation can be “turned upside down.” The intensity attached to a
stressful thought or situation can be dissipated when it is made to appear absurd
or comical. Essentially, the bee loses its sting.