CHAPTER

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t \.I
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10

lnterview

Communication and the Clinical

181

can become a definite barrier to communication. To

avoid overuse of restating, the nurse can combine
restatements with direct questions that encourage
descriptions: "What does yo:ur life lack?" 'vVhat kiid
of meaning is missing?" "Descdbe a day in your life

want to further explore this area. Possible openers

thatappearsemptytoyou."

indude:

Exploring.

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

"Tell me msre abaut your relationship

Reflecting. Reflection is a means of assisting peo,ple

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

)t
1} \i $.g
J \,'
S
\ , .\ X
\\
il the patient when sensitive issues are being discussed.
\P .$ S The nurse might then describe briefly to the patient the
> .n \ g apparent meaning of the emotional tone of the patient's
\D S \\rverbal and nonverbal behavior. For examplg to reflect
patient's feelings about his or her [t[e, a good begin*i F.t} gning
might be, "You sound as if you have had many
\\
- -od {dirJrrolr,t*"n t ."
\ 6 ! \l sf'ri"i"g observations with a patimt shows accep-

tf.il h $ pta.,ce ,rrJ tl,ut the patient

has^

your full attention.

*,,j...N)ffiJ"#."ffi;*xH#*r#r:mffm:l
$ X S::"fftT:"T:f:ff H",Tffil-:'"iH,*f;,li

with your

wife."
"Describe your relationship with your wiJe."
" Giae me an example of how you and your wife

don't

get along."

A"ki"g for an example can greatly claily

vague or

generic statement made by a patient.

Patient "No one likes me."

Nurss "Give me an example of one person who

doesn't like you."
of
Patienh "Everything I do is wrong."
Nurge: "Give me an example of one thing you do
that you think is wrong."
Table 10-2 lisb more examples of therapeutic communication techniques.

.[usfinxg"#trmt"#:ffiT# "ff f":H:l l:

Asking Ouestions and Eliciting Patient

Responses
Open-Ended Ouestions. Many of the examples

(Amold & Boggs, 2007). For example:

S t'\P ($ $\ technique
Patient
"Nurse, do you think I really need to be
hospitalized?"

above and in Table 70-2 arc open-mded. fli.:er-i*end*d

qalclrf,i+m* and commerrts encourage l*gthy rcsponses
and information about ercperiences, perrcqptions, or

Nurse: "What do you think, Jane?"

responses to a situation- For example:

o "What do you perceive as your biggest problem

$r{
Nt

Patient "I don't know; thafs why I'm asking you."

Nurse: "I'll be willing to share my impression with
you at the end of this first session. Howevel,
you've probably thought about hospitalization
and have some feelings about it. I wonder what

.
.

they are."

right now?"
"Give me an example of some of the stresses you
are under right now"
"Tell me more about your relationship with your
wrte?"
Text continued on page 184

Using

silence

Accepting

$
Giving

recognition

Gives the person time to collect thoughts

think through a point.

or

Encouraging a person to talk by waiting for the

answers.

been
statement

"Yes."
lndicates that the person has
"Uh-huh."
understood. An accepting
does not necessarily indicate agreement " l follow what you sayl'
but is noniudgmental. (Nurse should not
imply understanding when (slhe does not
understand.)

lndicates awareness of change and personal "Good morning, Mr. JamesJ'

"You've combed your hair todayl'
efforts. Does not imply good or bad, right
"l see you've eaten your whole lunch."

wrong.

or

Offers presence, interest, and a desire to

understand. ls not offered to get the person
to talk or behave in a specific way.

"l would

like to spend time with youl'

"l'll stay here and sit with you awhilel'

Continued

182

Unit 3

Offering general

Psychosocial Nursing Tools

leads

Allows the other person to take direction "Go on."

in the discussion. lndicates that the nurse is 'And then7"
interested in what comes next.
"Tell me about itl'
"Where would you like to begin?"
Clarifies that the lead is to be taken by the
patient. However, the nurse discourages
"What are you thinking aboutT"
pleasantries and small talk.
"What would you like to discuss?"
Puts events and actions in befter perspective.
Notes cause-and-effect relationships
and identifies patterns of interpersonal

"What happened before?"

"When did this happen?"

difficulties.
Making

observations

(e.9.,

"You appear tensel'

Calls attention to the person's behavior
trembling, nail biting, restless mannerisms). "l notice you're biting your lipsl'
"You appear nervous whenever John enters
Encourages patient to notice the
ior and describe thoughts and feelings
the room."
mutual understanding. Helpful with mute
and withdrawn people.

behavfor

Encouraging description

perception

of

the

"What do these voices seem to be saying?"

lncreases the nurse's understanding of
patient's perceptions. Talking about feelings "What is happening now?"
"Tell me when you feel anxious."
and difficulties can lesssn the need to
them out inappropriately.

act

"Has this ever happened before?"

Brings out recurring themes in experiences
or interpersonal relationships. Helps the per- " ls this how you felt when... ?"
"Was it something like... 7"
son clarify similarities and differences.

Restating

the main idea expressed. Gives

the patient an idea of what has been
communicated. lf the message has been
misunderstood, the patient can clarify it.

Flepeats

Patient: "1 can't sleep. I stay awake all nightl'

Nurse; "You have difficulty sleeping?"

or
Patient: " l don't know. . . he always has some
excuse for not coming over or keeping our

appointments."
Nurse: "You think he no longer wants to see

you?"

Reflecting

Directs questions. feelings. and ideas bac{<

to the patient. Encourages the patient to
accept his or her own ideas and feelings.
Acknowledges the patient's right to
have opinions and make decisions and
encourages the patient to think of self as a
capable

Focusing

person.

Concentrates attention on a single point.

It is especially useful when the patient
jumps from topic to topic" lf a person is
experiencing a severe or panic level of
anxiety, the nurse should not persist until
the anxiety lessens.

or
patient
no,
sudr

Examines certain ideas, experiences,

relationships more fully. ll the
chooses not to elaborate by answering
the nurse does not probe or pry. ln
a case, the nurse respects the patient's

wishes.

Patient: "What should I do about my husband's affair.?"

Nurse; "What do you think you should do?"

or
Patient: "My brother spends all of my money
and then has the nerve to ask for more."
Nurse: "You feel angry when this happens?"

"This point you are making about leaving school seems worth looking at more
closely."

"You've mentioned many things. Let's go back

to your thinking o{ ending it alll'
"Tell me more about that."
"Would you describe it more fully?"

"Could you talk about how it was that you

learned your mom was dying of cancer?"

CHAPTER

1O

Communication and the Clinical lnterview

Makes facts the person needs available.

Supplies knowledge from which decisions
can be made or conclusions drawn. For
example, the patient needs to know the
role of the nurse; the purpose o{ the
nurse-patient relationship; and the time,
place, and duration of the meetings.
Seeking

clarification

and

Helps patients clarify their own thoughts

maximize mutual understanding

nurse and

patient.

between

183

"My purpose for being here is... "

"This medication is for... "
"The test wlll determine.. . "

"l am not sure I follow youl'

"What would you say is the main point of
what you just said?"
"Give an example of a time you thought
everyone hated youl'

Presenting

Voicing

reality

doubt

lndicates what is real. The nurse does not

argue or try to convince the patient, just
describes personal perceptions or facts in
the situation.

"That was Dr. Todd, not a man from the

Undermines the patient's beliefs by not

reinforcing the exaggerated or false

"lsn't that unusual?"

perceptions.

consensual
validation

Seeking

Mafia."

"That was the sound of a car backfiringl'

"Your mother is not here; I am a nurse."
"Really7"

"Thats hard to believe."

share "Tell me whether my understanding agrees

mutual understanding of communications- with yours."

Clarifies that both the nurse and patient

Helps the patient become clearer about

what he or she is thinking.

the
patient's
communication more explicit.
evaluation Aids the patient in considering people and

Verbalizing the

Encouraging

implied

Puts into concrete terms what

patient implies, making the

events from the perspecrive of the

own set of
Attempting to translate

feelings
Suggesting

into

waste of time."

"How do you feel about...7"

patient's "What did it mean to you when he said

he

couldn't stay?"

just
decoding.

Responds to the feelings expressed, not

Patient: "1 am dead inside."

Nurse: ?re you saying that you feel lifeless?
Does life seem meaningless to you7"

not "Perhaps you ahd I can discover what

Encourages produces your anxietyl'
through " Perhaps by working together, we can come

Emphasizes working with the patient,

doing things for the patient.
the view that change is possible

collaboration.

Summarizing

Nurse: "Do you feel that no one understands?"

values.

the content. Often termed

collaboration

Patient: "1 can't talk to you or anyone else. lt's

up with some ideas that might improve your

communications with your spouse."

Brings together important points of discussion "Have I got this straight?"

"You said that. . . "
to enhance understanding. Also allows
opportunity to clarify communications so that "During the past hour, you and I have
discussed... "
both nurse and patient leave the

the

interview

with the same ideas in mind.

Encouraging iormulation
a plan of

action

of

Allows the patient to identify alternative "What could you do to let anger out
harmlessly? "
actions for interpersonal situations the
patient finds disturbing (e.9., when anger or "The next time this comes up, what might you
do to handle it?"
anxiety is provoked).
"What are some other ways you can approach
your boss?"

Adapted from Hays, J. S-, & Larson, K. {1963}.

Interacfing with patients.

New York: Macmillan.

Unit 3

184

Psychosocial Nursing Tools

Since open-ended quesdons are not intmsive and

do not put the patient on the defensive, they help the
clinician illicit information, especially in the begir,ning of an interyiew or when a patient is guarded or
resistant to answering questions. They are particulady
useful when establishing rapport with a person.

Closed-Ended Ouestions. Nurses are usually urged

to ask open-ended questions to elicit more ttlan a "yes"

ot "rto" response. Howeveq, closed-ended questions,

when used sparingly, can give you specific and needed
information. {- i *'reri *crl.*l l:'i :; ;.r l.r :,,til.id rx 5 atre most useful during an initial assessment or intake interyiew or
to ascertain results, as ilt "Are the medications helping
you?" "When did you start hearing yoices?" "Did you

Giving

seek therapy after your first suicide attempt?" Care

needs to be exercised with thi$ technique. Frequent
use of closed-ended questions during time spent with
patierrts can close an interview down rapidly; this is
especially true with guarded or resistant patients.

Nontherapeutic Gommunication
Techniques
Although people may use "nontherapeutic" or ineffective communication techniques in their daily lives,
they can cause problems for nurses because they tend
to impede or shut down nurse-patient interaction.
rlrr,
Table 10-3 dgscribes ra.l.: rlr h,l n ++ p; i
l i?ri{'t ;i.r. ;r^-ri.i
iri.i:rlii:;rt',tl. and suggests more helpfuI responses.
r-!1

best "Get out of this situation

for immediately:'
self. lnhibits problem solving
and fosters dependency.

premature Assumes the nurse knows

advice

and the patient can't think

Minimizing feelings lndicates that the nurse is

unable to understand or

Patient: " l wish I were

Encouraging problem solving:

"What are the pros and cons of your
situation?"
"What were some of the actions you
thought you might take?"
"What are some of the ways you have
thought of to meet your goals?"

dead." Empathizing and exploring:

Nurse; f'Everyone gets down "You must be feeling very upset. Are
empathize with the patient.
in the dumps."
you thinking of hurting yourself?"
Here the patient's feelings or " l know what you mean."
experiences are being beli'ttled, "You should feel happy you're
getting better."
which can cause the patient to
feel small or insignificant. "Things get worse before
they get better."

Undenates a person's feelings and "l wouldn't worry about that."

"Everfihing will be all rightl'
belittles a persons concems.
patient
"You will do just fine, you'll
May cause the
to stop
sharing feelings if the patient
see."
thinks he or she will be
ridiculed or not taken seriously.

value
judgments

Making

Can " How come you still smoke

guilty, when your wife has lung
not
cancer?"
leave.

Prevents problem solving,

make the patient feel
angry misunderstood,
supported, or anxious to

lmplies criticism; often has the

effect of making the patient
feel defensive.

"Why did you stop taking

Cladfying the patient's message:

"What specifically are you worried
about?"
"What do you think could go wrongT"
"What are you concerned might
happen?"

Making observations:

"l notice

you are still smoking even

though your wife has lung cancer.
ls this a problem?"

Asking open-ended guestions;

giving a broad opening:
"Tell me some of the reasons that

your medication?"

led up to your not taking your

medications."
Asking

excessive

questions

Hesuhs in the patient's not

knowing Nurse: "How's your appetite? Cladfying:

and
about
what is being asked.
which question to ans\ /er
possibly being confused

Are you losing weight?

you eating

Are

enoughT"

Patient: "No!'

"Tell me about your eating habits

since you've been depressedJ'

CHAPTER

Giving

approval.

agreeing

Disapproving;
disagreeing

the
subject

Changing

1O

Communication and the Clinical lnterview

185

lmplies the patient is doing the "l'm proud of you for

Making obsermtions:
" l noticed that you applied for that
nght thing*and that not doing applying for that lob."
"l agree with your decision." job. What factors will lead up to
it is wrong.
May lead the patient to focus
your changing your mind7"
on pleasing the nurse or
Asking open-ended questions;
giving a broad opening:
clinician; denies the patient the
"What led to that decisionT"
opportunity to change his or
her mind or decision.
Can make a person defensive.

May invalidate the patient's

feelings and needs.
Can leave the patient feeling

isolated

alienated and
and increase feelings of
hopelessness.

Adapted from Hays, J. S., & Larson. K.i.1963l,.

lnteracting with patienls.

"You realty should have

shown up for the
medication group."

Exploring:
"What was going through your mind
when you decided not to come to

"l

your medication group?"

"That's one point of view How did
you arrive at that conclusion?"

disagree with thatl'

diel'
to

Patient: "1'd like to

Nurse: "Did you go
Alcoholics Anonymous

we

discussed?"

Validating and exploringr

Patient: "ld like to diel'

llke

Nurse: "This sounds serious. Have

you thought of harming yourself?"

New Yo*: Macmillan

Excessive Ouestioning
Excessive questioning-asking multiple questions
(particularly closed-ended) consecutively or very
rapidly--casts the nurse in the role of interrogatol,
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 liack of security in letting
the patient tell his or her own story. [t is better to ask
more open-ended questions and follow the patient's

often give our frierrds and family approval when they

do something well. Howeve4 in a nurse-patient relationship, giving praise and approval becomes much more
complex.

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,

value comrnent might be misinterpreted.

For example:

Giving approval: "You did a great job in group

telling John just what you thought about how

Giving Approval or Disapproval

rudely he treated you."

This message implies that the nurse was pleased
by the manner in which the patimt talked to |ohn.
The patient then sees such a rcsponse as a way to
please the nurse by doing the right thing. To continue
to please the nurse (and get approval), the patient may
continue the behavior. The behavior might be usefirl
for the patienf but when a behavior is being done to
please another person/ it is not coming from *re indi.
vidual's own volition or conviction. Also, when the

'You look great in that dress." "I'm proud of the way you
controlled your ternper at lundu" "Thafs a great quilt
you made." What could be bad about giving s,omeone a
pat on the back once in a while? Nothing, if it is done
without conveying a positive or negative judgment. We

other person the patient needs to please is not around,

the motivation for the new behavior might not be there
either. Thus the new response really is not a change
in behavior as much as a ploy to win approval and
acceptance from another.

lead. For example:

Excessive questioning: "I{hy did you leave your
wife? Did you feel angry at her? What did she do
to you? Are you going back to her?"
More therapeutic apprcach: "Tell me about the situation between you and your wife."