Chapter 7

Question 1

Nonverbal communication

Answer 1

physical appearance, body movement and posture, touch, eye behavior, facial expressions, vocal cues or paralanguage

Question 2

Using Silence

Answer 2

Silence encourages the patient to organize thoughts and put them into words and allows the patient time to think about the significance of events, thoughts, and feelings. Allowing the patient to break the silence often provides the nurse with important information about the patient’s foremost concerns.

Patient: “My husband divorced me so I must be undesirable.”

Nurse: (silence)

Patient: “You know, when I think about it, no matter what my husband does I always assume it’s my fault or it’s something wrong with me.”

Question 3

Accepting

Answer 3

Acceptance conveys an attitude of reception and regard.

“Yes, I understand what you said.”

Eye contact; nodding.

Question 4

Giving recognition

Answer 4

Acknowledging and indicating awareness is better than complimenting, which reflects the nurse’s judgment.

“Hello, Mr. J. I notice that you made a ceramic ashtray in OT.”

“I see you made your bed.”

Question 5

offering self

Answer 5

Willingness to spend time with the patient and show interest on an unconditional basis helps to increase the patient’s feelings of self-worth.

“I’ll stay with you a while.”

“We can eat our lunch together.”

“I’m interested in hearing your thoughts about the group you just attended.”

Question 6

Giving broad openings

Answer 6

Broad openings allow the patient to direct the focus of the interaction and emphasizes the importance of the patient’s role in the communication process.

“What would you like to talk about today?”

“Is there anything you want to discuss?”

Question 7

offering general leads

Answer 7

General leads offer the patient encouragement to continue with minimal input from the nurse.

“Yes, I see.”

“Go on.”

“And after that?”

Question 8

Placing the event in time or sequence

Answer 8

Encouraging the patient to identify the sequence of events and when they occurred in time facilitates organizing one’s thoughts about their experiences.

“What happened first?”

“What happened next?”

“Was this before or after …?”

“When did this happen?”

Question 9

Making observations

Answer 9

Verbalizing observations about a patient’s behavior or appearance encourages the patient to develop awareness of how they are perceived by others and promotes exploration of issues that may be problematic.

“You appear sad today.”

“I notice you are pacing a lot.”

“I notice that when I ask you about whether you have thoughts of suicide you change the subject.”

Question 10

Encouraging description of perceptions

Answer 10

Asking the patient to verbalize his or her perceptions facilitates the patient’s ability to develop awareness and understanding. For the patient experiencing hallucinations, it can facilitate both nurse’s and patient’s clarification about what the patient’s perceptual experiences are communicating.

“Tell me more about the voices you said you are hearing.”

“What was it that increased your agitation during the group activity?”

“Are these voices you hear directing you to take some action?”

Question 11

Encouraging Comparison

Answer 11

Asking the patient to compare similarities and differences in ideas, experiences, or interpersonal relationships helps the patient recognize life experiences that tend to recur and those aspects of life that are changeable.

“Was this episode similar to …?”

“How does this compare with the time when …?”

“What was your response the last time this situation occurred?”

Question 12

Restating

Answer 12

Repeating the main idea of what the patient has said lets the patient know whether an expressed statement has been understood and gives him or her the chance to continue or to clarify if necessary.

Patient: “I can’t study. My mind keeps wandering.”

Nurse: “You have trouble concentrating.”

Patient: “I can’t take that new job. What if I can’t do it?”

Nurse: “You’re afraid you will fail in this new position.”

Question 13

Reflecting

Answer 13

Questions and feelings are referred back to the patient so that the patient is empowered to actively engage in problem-solving rather than simply asking the nurse for advice.

Patient: “Don’t you think I should tell my boss I’m not putting up with that?”

Nurse: “What do you think you should do?”

Patient: “She makes me so upset!”

Nurse: “So you’re feeling angry at your boss?”

Question 14

Focusing

Answer 14

Taking notice of a single idea or even a single word works especially well with a patient who is moving rapidly from one thought to another. However, focusing is very difficult for a patient with severe anxiety so in this case the nurse should not pursue focusing until the anxiety level decreases.

“Tell me more about this specific point.”

Question 15

Exploring

Answer 15

When the nurse hears the patient mention an issue or theme that seems relevant, the nurse asks the patient to explore this further. Exploring facilitates the patient’s development of awareness and understanding about events, thoughts, and feelings. However, if the patient chooses not to disclose further information, the nurse should refrain from pushing or probing in an area that obviously creates discomfort.

“Please explain that situation in more detail.”

“Tell me more about that particular situation.”

“You mentioned feeling like no one cares about you. Tell me more about those feelings.”

Question 16

Seeking clarification and validation

Answer 16

Striving to explain vague or incomprehensible statements and searching for mutual understanding of what has been said facilitates and increases understanding for both patient and nurse.

“I’m not sure that I understand. Would you please explain?”

“Tell me if my understanding agrees with yours.”

“Do I understand correctly that you said …?”

Question 17

Presenting reality

Answer 17

When the patient has a misperception of the environment, the nurse defines reality by expressing his or her perception of the situation without challenging the patient’s perceptions.

“I understand that the voices seem real to you, but I do not hear any voices.”

“I don’t see anyone else in the room but you and me.”

Question 18

Voicing doubt

Answer 18

Expressing uncertainty as to the reality of the patient’s perceptions is a technique often used with patients experiencing delusional thinking.

“It’s difficult to believe that the President of the United States would be listening to all of your phone calls.”

“I find that hard to believe [or accept].”

“That seems rather doubtful to me.”

Question 19

Verbalizing the implied

Answer 19

Putting into words what the patient has only implied or said indirectly is a technique that can be helpful with patients experiencing impaired verbal communication.

Patient: “I can’t talk about this … you haven’t been where I’ve been.”

Nurse: “Does it seem like no one could understand your thoughts and feelings unless they’ve had the same experiences you’ve had?”

Patient: “I … I don’t know where to begin.”

Nurse: “So it feels overwhelming to think about sharing the details of this experience.”

Question 20

Attempting to translate words into feelings

Answer 20

When the patient has difficulty identifying feelings or feelings are expressed indirectly, the nurse tries to “desymbolize” what has been said and to find clues to the underlying true feelings.

Patient: “I’m just an empty pit.”

Nurse: “It sounds like you are feeling hopeless, is that right?”

Question 21

Formulating a plan of action

Answer 21

Encouraging the patient to identify a plan for behavior change promotes developing better coping skills.

“What could you do differently if you are faced with this situation in the future?”

“What are some steps you could take to manage your anger without punching someone?”

“What is one thing you might be willing to try to decrease your anxiety instead of using alcohol?”

Question 22

Giving false reassurance

Answer 22

False reassurance conveys that the nurse already knows the outcome of a situation and minimizes the patient’s expressed concerns. It may discourage the patient from further expression of feelings if he or she believes the feelings will be downplayed or ridiculed.

Patient: “My husband doesn’t love me anymore. I think he wants a divorce.”

Nurse: “I’m sure he must still love you. Everything will be fine.”

Better alternative: “Tell me more about what’s been happening in your relationship with your husband.”

Question 23

Rejecting

Answer 23

Refusing to consider or showing contempt for the patient’s ideas or behavior may cause the patient to discontinue interaction with the nurse for fear of further rejection.

Patient: “Since I started taking this medication I can’t be intimate with my girlfriend.”

Nurse: “Let’s not talk about that right now.”

Better alternative: “Tell me more about what you mean by not being able ‘to be intimate’ with your girlfriend.”

Question 24

Approving or disapproving

Answer 24

Sanctioning or denouncing the patient’s ideas or behavior implies that the nurse has the right to pass judgment on whether the patient’s ideas or behaviors are “good” or “bad” and that the patient is expected to please the nurse. The nurse’s acceptance of the patient is then seen as conditional depending on the patient’s behavior.

“It’s good that you confronted your wife about her behavior.”

“You shouldn’t yell at your wife.”

Better alternative: “What happened after you confronted your wife in a loud voice?”

Question 25

Agreeing or disagreeing

Answer 25

Indicating accord with or opposition to the patient’s ideas or opinions implies that the nurse has the right to pass judgment on whether the patient’s ideas or opinions are “right” or “wrong.” Agreement prevents the patient from later modifying his or her point of view without admitting error. Disagreement implies inaccuracy, provoking the need for defensiveness on the part of the patient. Patient: “I think my doctor doesn’t care about me.” Nurse: “I disagree. You shouldn’t think that way.” Or “I can’t believe that’s true.” Better alternative: “Tell me more about why you think your doctor doesn’t care.”

Question 26

Giving advice

Answer 26

Telling the patient what to do or how to behave implies that the nurse knows what is best and nurtures the patient in the dependent role by discouraging independent thinking. “You need to do deep breathing exercises when you become anxious.” “You should stop drinking alcohol and start going to Alcoholics Anonymous meetings.” Better alternative: “What do you think you should do?” or “Let’s explore some options for solving this problem.”

Question 27

Probing

Answer 27

Persistent questioning of the patient and pushing for answers to issues the patient does not wish to discuss causes the patient to feel used and valued only for what information the nurse is seeking and may place the patient on the defensive. “Why was your family angry with you?” “How many times did you receive poor evaluations before you got fired?” “How many girlfriends were you lying to?” Better alternative: The nurse should actively listen to the patient’s response and discontinue the interaction at the first sign of discomfort.

Question 28

Defending

Answer 28

Defending someone or something the patient has criticized minimizes or completely ignores the patient’s concerns. Defending may cause the patient to think the nurse is taking sides against him or her. “None of the nurses here would lie to you.” “You have a very capable physician.” “Your children want only what’s best for you.” Better alternative: “Tell me more about these concerns you’ve expressed.”

Question 29

Requesting an explanation

Answer 29

This technique involves asking the patient why he or she has certain thoughts, feelings, and behaviors. Asking “why” a patient did something or feels a certain way can be very intimidating and implies that the patient must defend his or her behavior or feelings. “Why do you think people are out to get you?” “Why do you feel depressed?” “Why were you taking drugs?” Better alternative: “Describe what you were feeling just before that happened.”

Question 30

indicating the existence of an external source of power

Answer 30

Attributing the source of thoughts, feelings, and behavior to others or to outside influences encourages the patient to project blame for his or her thoughts or behaviors on others rather than accepting the responsibility personally. “What made you go on a drinking binge?” “What made you say that you are a worthless person?” Better alternative: “What was happening just before you started binge drinking?” “What do you mean when you say you are ‘a worthless person’?”

Question 31

Belittling or minimizing feelings

Answer 31

When the nurse minimizes the degree of the patient’s discomfort, a lack of empathy and understanding may be conveyed. When the nurse tells the patient to “cheer up” or “everybody feels that way,” the patient may feel that his or her concerns are insignificant or unimportant. Patient: “I don’t even have the energy to go to work.” Nurse: “We’ve all felt like that at times. You’ve just got to ‘perk up’ and get moving.” Better alternative: “Tell me more about what you are feeling right now.”

Question 32

Making stereotyped comments

Answer 32

Trite expressions are meaningless in a nurse-patient relationship. When the nurse uses meaningless expressions, it encourages a similar response from the patient. “How are you?” “Hang in there.” “It’ll all work out.” Better alternative: Choose words, sentences, and nonverbal language that convey a sincere interest in encouraging the patient to share more about the patient’s thoughts, feelings, and behaviors.

Question 33

Using denial

Answer 33

Denying that a problem exists blocks discussion with the patient and avoids helping the patient identify and explore areas of difficulty. Patient: “I have a problem interacting with people.” Nurse: “You’re doing fine.” Better alternative: “Tell me more about that.”

Question 34

Interpreting

Answer 34

nterpreting attempts to tell the patient the meaning of his or her experience. Erroneous interpretations may leave the patient feeling that the nurse doesn’t understand him or her, or that the nurse is being smug. “What you really mean is….” “Your continued drinking is your way of avoiding discussing your anger over the divorce….” Better alternative: “Tell me more about what you’re thinking (or feeling).”

Question 35

Introducing an unrelated topic

Answer 35

When the nurse prematurely changes the subject, it conveys to the patient that the nurse does not want to discuss the original topic any further. This may occur in order to get to something that the nurse wants to discuss with the patient or to get away from a topic that he or she would prefer not to discuss. “Patient: “I don’t have anything to live for.” Nurse: “How well did you sleep last night?” Better alternative: “Tell me more.” Sometimes silence may be appropriate to convey that the nurse is willing to hear all of what the patient wants to say before moving on to a different topic.

Question 36

SOLER

Answer 36

S: Sit squarely facing the patient. This nonverbal cue gives the message that the nurse is there to listen and is interested in what the patient has to say. O: Observe an open posture. Posture is considered “open” when arms and legs remain uncrossed. This nonverbal cue suggests that the nurse is open to what the patient has to say. With a closed position, the nurse can convey a somewhat defensive stance, possibly invoking a similar response in the patient. L: Lean forward toward the patient. Leaning forward conveys to the patient that the nurse is involved in the interaction, interested in what is being said, and making a sincere effort to be attentive. E: Establish eye contact. Eye contact, intermittently directed, is another behavior that conveys the nurse’s involvement and willingness to listen to what the patient has to say. The absence of eye contact or the constant shifting of eye contact elsewhere in the environment gives the message that the nurse is not actually interested in what is being said. R: Relax. Whether sitting or standing during the interaction, the nurse should communicate a sense of being relaxed and comfortable with the patient. Restlessness and fidgetiness communicate a lack of interest and may convey a feeling of discomfort that is likely to be transferred to the patient.