NURSE-PATIENT

RELATIONSHIP

COMMUNICATION
TECHNIQUES
 Trust may develop in the nurse-client
relationship when the nurse:
A. avoids limit setting
B. encourages the client to use “testing”
behaviors
C. tells the client how he should behave
D. uses consistency in approaching the
client
Answer: D
Rationale: One of the most important
elements of trust is consistency. The
client learns to trust that the nurse will
follow through and d what is promised.
Avoiding limit setting will not instill trust,
nor will encouraging testing behaviors
or telling the client how he should
behave.
COMPONENTS OF A THERAPEUTIC
RELATIONSHIP

P-OSITIVE REGARD-unconditional, non-judgmental

attitude, implies respect irregardless of the patient’s
behavior, background or lifestyle

Ex. Patient: “I was so mad, I yelled at my mother for

an hour.”
X Nurse:”Well, that didn’t help, did it?” or “I can’t
believe you did it.”
* Nurse: “you must have been really upset.”
A-CCEPTANCE-nurse does not become upset or
respond negatively to a client’s outbursts, anger or
acting out

Ex. A client puts his arm around the waist of the

nurse:
X Nurse: “John, stop that! What’s gotten into you? I
am leaving!”
* Nurse: “John, do not place your hand on me. We
are working on your relationship with your girlfriend
and that does not require you to touch me. Now. Let’s
continue.”
G-ENUINE INTEREST-nurse is clearly
focused and is comfortable with
himself/herself (client can detect artificial
behavior)
Ex. The nurse asking a question and then not waiting
for an answer, talking over the client or assuring the
client that everything will be all right.
E-MPATHY-ability of the nurse to perceive the
meanings and feelings of the patient and
communicates that understanding to the patient

Ex. Patient: “I’m so confused! My son just visited and

wants to know where the safety deposit box key is.”
Nurse: “You’re confused because your son asked for
the safety deposit key?”
T-RUST-patient is confident of the nurse
and the nurse’s presence conveys
integrity and reliability
Trusting behaviors: caring, consistency,
approachability, listening, keeping
promises, honesty
SELF-AWARENESS & THERAPEUTIC
USE OF SELF

Self-awareness- process of developing an

understanding of one’s own values, beliefs,
thoughts, feelings, attitudes, motivations,
prejudices, strengths and limitations and how
these qualities affect others
Therapeutic Use of Self-the nurse beginning
to use aspects of his or her personality,
experiences, values, feelings, intelligence,
needs, coping skills and perceptions to
establish relationship with clients
JOHARI’S WINDOW
OPEN-QUALITIES BLIND-
ONE KNOWS QUALITIES
ABOUT ONESELF KNOWN ONLY TO
AND OTHERS ALSO THERS
KNOW
HIDDEN- UNKNOWN-
QUALITIES UNDISCOVERED
KNOWN ONLY TO QUALITIES BY
SELF ONESELF AND
OTHERS
If quadrant 1 is the longest list- indicates that
the nurse is open to others
Smaller quadrant 1 means the nurse shares
little about himself/herself with others
If quadrants 1 and 3 are both small, the
person demonstrates little insight
GOAL- to work toward moving qualities from
quadrants 2,3 and 4 into quadrant 1
3 TYPES OF RELATIONSHIP
S –OCIAL –primarily initiated for the purpose
of friendship, socialization, companionship
and accomplishment of task
I-NTIMATE- involves two people who are
emotionally committed to each other. Both
parties are concerned about having their
individual needs met.
T-HERAPEUTIC- focus is on the patient’s
needs ONLY
 PHASES
PRE-INTERACTION-major task is self-
awareness
ORIENTATION- major task is contract setting
WORKING- major task is identification of
problems and exploring towards resolution.
TERMINATION- major task is resolve feelings
of loss and evaluate progress of solutions
 While pacing in the hall, a client with
paranoid schizophrenia runs to the nurse and
says, “Why are you poisoning me? I know
you work for central thought control! You can
keep my thoughts. Give me back my soul!”
How should the nurse respond during the
early stage of the therapeutic process?
A. “I’m a nurse. I’m not poisoning you. It’s
against the nursing code of ethics.”
B. “I’m a nurse, and you’re a client in the
hospital. I’m not going to harm you.”
C. “I’m not poisoning you. And how could I
possibly steal your soul?”
D. “I sense anger. Are you feeling angry today?”
THERAPEUTIC COMMUNICATION
TECHNIQUES
ACCEPTING-indicating reception
“yes.”, “I follow what you said.”, Nodding
Rationale: Indicates that the nurse has
heard and followed the train of thought.
Does not indicate agreement but is
nonjudgmental. Facial expression
should also be congruent with the
verbal content.
BROAD OPENING
Allowing the client to take the initiative in
introducing the topic
“Is there something you’d like to talk about?”;
“Where would you like to begin?”
Rationale: This makes explicit that the client
has the lead in the interaction. It may
stimulate the client to take the initiative.
CONSENSUAL VALIDATION
Searching for mutual understanding, for
accord on the meaning of the words
“Tell me whether my understanding agrees
with yours.”; “Are you using these words to
convey that…?”
Rationale: It is essential that the words being
used have the same meaning for both
participants to avoid misunderstanding.
ENCOURAGING COMPARISON
Asking that similarities and differences be
noted
“Was it something like…?”, “Have you had
similar experiences?”
Rationale: Comparing ideas, experiences, or
relationships brings out many recurring
themes. It might also help the client recall
past coping strategies
ENCOURAGING DESCRIPTION OF
PERCEPTIONS
Asking the client to verbalize what she or he
perceives
“What is happening?”, “What does the voice
seem to be saying?”
Rationale: This may relieve the tension the
client is feeling and he or she might be less
likely to take action on ideas that are harmful
or frightening.
ENCOURAGING EXPRESSION
Asking the client to appraise the quality of his
or her experience
“What are your feelings on regard to…?”,
“does this contribute to your distress?”
Rationale: This may encourage the client to
make his or her own appraisal rather than
accepting the opinion of others
EXPLORING
Delving further into a subject or idea. (can
also be thru asking for an example)
“Tell me more about that.”, “Would you
describe it more fully?”, “give me an example
of you and your wife not getting along
Rationale: Any problem or concern can be
better understood if explored in depth.If client
is unwilling to explore, the nurse must
respect.
‘FOCUSING
Concentrating on a single point
“This point seems worth looking more
closely.”, “of all the concerns you’ve
mentioned, which is most troublesome?”
Rationale:A useful technique when client
jumps from one topic to another (flight of
ideas). To avoid overwhelming the client also.
FORMULATING A PLAN OF ACTION
Asking the client to consider kinds of behavior
likely to be appropriate in future situations
“What could you do to let your anger out
harmlessly?”, “Next time this comes up, what
might you do to handle it?”
Rationale: Making definite plans increases the
likelihood that the client will cope more
effectively in similar situations.
GENERAL LEADS
Giving encouragement to continue
“Go on.”, “And then?”, “tell me about it.”
Rationale: Indicates that the nurse is
listening and following what the client
had said without taking away the
initiative for the interaction.
GIVING INFORMATION
Making available the facts that the client
needs
“My name is..”, “Visiting hours are…”, My
purpose in being here is…”
Rationale: Informing the client of facts
increases his or her knowledge about a topic
or lets the client know what to expect. It builds
trust.
GIVING RECOGNITION
Acknowledging, indicating awareness
“Good morning Mr. S”, “I’ve noticed that
you’ve combed your hair today.”
Rationale: This shows that the nurse
recognizes the client as a person, as an
individual. It does not carry the notion of
value.
 Making Observations
Verbalizing what the nurse perceives
“You appear tense..”
“I notice that your biting your lips”
Rationale: Sometimes clients cannot
verbalize or make themselves
understood. Or the client may not be
ready to talk.
 OFFERING SELF
Making oneself available
“I’ll sit with you awhile”
“I’ll stay here with you”
“I’m interested in what you think”
Rationale: It is important that this offer is
unconditional, that is the client does not have
to respond verbally to get the nurse’s
attention
 PLACING EVENT IN TIME AND SEQUENCE
-Clarifying the relationship of events in time
-“What seemed to lead up to…?
“Was this before or after?”
Rationale: It helps both the nurse and client to
see them in perspective.Client may gain
insight in cause-and-effect behavior and
consequences
PRESENTING REALITY
Offering for consideration that which is real
“I see no one else in the room.”
“Your mother is not here; I am a nurse.”
Rationale: The nurse indicates what is real
through not arguing with the client. The intent
is to indicate an alternative line of thought for
the client to consider and not to ‘convince” the
client that he/she is wrong.
REFLECTING
Directing client actions, thoughts, and
feelings back to client
Client: “Do you think I should tell the
doctor…? Nurse: “Do you think you should?”
Rationale: Encourages the client to recognize
and accept his or her own feelings. The nurse
indicates that the client’s point of view has
value and has the right to air opinions, ideas
 RESTATING
Repeating the main idea expressed
Client: I can’t sleep. I stay awake all night.”
Nurse:You have difficulty sleeping.”
Client:”I’m really mad, and upset”
Nurse: You’re really mad and upset.”
Rationale: Nurse repeats what the client has said in
approximately or nearly the same words the client
had used to let the client know that he/she
communicated the idea effectively
 SEEKING INFORMATION
Seeking to make clear that which is not
meaningful or that which is vague
“I’m not sure that I follow.”
“Have I heard you correctly?”
Rationale: This helps the nurse to avoid making
assumptions that understanding has occurred
when it has not.Also for the client to articulate
feelings.
Silence
Absence of verbal communication, which
provides time for for the client to put thoughts
or feelings into words, regain composure, or
continue talking
Nurses says nothing but continues to
maintain eye contact and conveys interest.
Rationale: Gives time for the client to
organize thoughts, direct the topic of
interaction or focus on issues that are most
important.
Suggesting Collaboration
Offering to share , to strive, to work with
the client for his or her benefit
“ Perhaps you and I can discuss and
discover the triggers for your anxiety”
Rationale: The nurse offers to do things
with, rather than for the client.
Summarizing
Organizing and summing up that which has
gone before
“Have I got this straight?”, “You’ve said
that…”,”During the past hour, you and I have
discussed..”
Rationale: This seeks to bring out the
important points of the discussion and to
increase the awareness and understanding of
both participants.
 Translating into Feelings
seeking to verbalize client’s feelings that he
or she expresses only indirectly
Client: “I’m dead”
Nurse: “Are you suggesting that you feel
lifeless?”
Rationale:To understand, the nurse must
concentrate on what the client might be
feeling to express himself/herself this way.
Verbalizing the Implied
Voicing what the client has hinted at or
suggested
Client: I cant’ talk to you or anyone. It’s a
waste of time.” Nurse: “Do you feel that no
one understands”
Rationale: The client may have difficulty
communicating directly. The nurse should
take care to express only what is fairly
obvious.
Voicing Doubt
Expressing uncertainty about the reality of the
client’s perceptions
“Isn’t that unusual?”,“Really?”,“That’s hard to
believe.”
Rationale: Such permits the client to become
aware that others do not necessarily perceive
events in the same way or draw the same
conclusions
Reminder:
Allow client to express feelings more
often than possible without being
judgmental in order to understand what
is going on with the client. This would
facilitate better action in dealing with
client’s concerns thus helping him arrive
at solutions at his own pace.
Nontherapeutic Communication
Techniques
D-iscourages expression of feelings
O-verwhelming the patient/client
R-eassuring the client
S-ympathizing with the client
A-rguing with the client
L-limiting the ideas, opinions, of the client
T-hreatening the client
J-udgmental
Advising-telling the client what to do
“I think you should..”
Rationale: Implies that only the nurse
knows what is best for the client
Agreeing
Indicating accord with the client
“that’s right.” “I agree”
Rationale: approval indicates the client is
“right” rather than “wrong’ which gives him/her
the impression that he or she is right because
of agreement with the nurse. There is no
opportunity for the client to change his or her
mind.
Belittling Feelings expressed
Misjudging the degree of the client’s comfort
Client: “I have nothing to live for..I wish I was
dead”
Nurse: “Everybody gets down in the dumps.”
Rationale: When the client tries to equate the
intense and overwhelming feelings the client has
expressed to “everybody’, the nurse implies that
the discomfort is temporary, mild, self-limiting or
not very important.
Challenging
Demanding proof from the client
“But how can you be President of the
Philippines?”
Rationale: This causes the client to
defend the delusions or misperceptions
more strongly than before
Defending
Attempting to protect someone or
something from verbal attack
“This hospital has a fine reputation.”
Rationale: this implies that the client
has no right to express impressions,
opinions or feelings.
Disagreeing
Opposing the client’s ideas
“That’s wrong”, “I definitely disagree
with..”
Rationale: Implies that the client is
‘wrong” which may make the client
defensive
Disapproving
Denouncing the client’s behavior or
ideas
“That’s bad”, “I’d rather you wouldn’t”
Rationale: This implies that the nurse
has the right to pass judgment on the
client’s thoughts or actions
Giving approval
Sanctioning the client’s behavior or
ideas
“ That’s good.” “I’m glad that..”
Rationale: this tends to limit the client’s
freedom to think, speak or act in a
certain way.
 Giving Literal Responses
Responding to a figurative comment as
though it were a statement of fact
Client: “They’re looking in my head with
television camera.”
Nurse: “Try not to watch television
Rationale: Often the client is at loss to describe
his/her feelings, so such comments are the
best he or she can do.The nurse should focus
on the feelings of the nurse.
Indicating the existence of an external
source
“What makes you say that?”, “What
made you do that?”, “Who told you that
you are a prophet?”
Rationale: This implies that the client
was compelled to think in a certain way.
Interpreting
Asking to make conscious that which is
unconscious
“What you really mean is..”, “Unconsciously
you’re saying that..”
Rationale: The client’s thoughts and feelings
are his or her own, not to be interpreted by
the nurse or for hidden meaning.
 Introducing an unrelated topic
Changing the subject
Client: “I’d like to die.”
Nurse: “did you have visitors last night?”
Rationale: This would make the nurse take
away the initiative away from the client. This
may mean that the nurse does not know how
to respond or is uncomfortable with the topic.
Making stereotyped comments
Offering meaningless cliches or trite
comments
“Keep your chin up.”,“Just have a
positive outlook.”
Rationale:such comments has no value
to the NPR
Probing
Persistent questioning of the client
“Now tell me about this problem. I need
to know.”
Rationale: This tends to make the client
feel used or invaded.
Reassuring
Indicating there is no reason for anxiety
“Everything will be alright.”
Rationale: attempts to dispel the client’s
anxiety by implying that there is not
sufficient reason for concern completely
devalue the client’s feelings
Rejecting
Refusing to consider or showing
contempt for the client’s behavior, ideas
“Let’s not discuss..”
Rationale: This close the topic off from
exploration which may in turn make the
client feel rejected.
Requesting an explanation
Asking the client to provide reasons for
thoughts, feelings, behaviors, events
‘Why do you think that?”, “Why do you
feel that way?”
Rationale: “Why” question is
intimidating
Testing
Appraising the client’s degree of insight
“Do you know what kind of hospital this
is?”
Rationale: This can force the client to
try to recognize his/her problems which
may in turn meet the nurse’s needs but
not helpful to the client
 Using Denial
Refusing to admit that a problem exists
Client: “I am nothing.”
Nurse: “Of course, you’re something.”
Rationale: This dismisses the client’s
comments without attempting to
discover the feelings or meaning behind
them.
 RECOGNIZING THERAPEUTIC
FROM NON-THERAPEUTIC
COMMUNICATION TECHNIQUES
 1.Situation: Carlo, a depressed client is
admitted in the psychiatric ward. He will
undergo Electroconvulsive therapy.
He states “I’m afraid because my roommate told
me I”ll forget everything and my memory will
never return”. What is the best response?
A. “There’s a money-back guarantee if you lose
your memory.
B. “There will be no memory loss, you will just
forget who you are”
C . “There is memory loss but it’s only
temporary.”
D. “ What you don’t know wont hurt you.”
 2. One afternoon, after visiting hours,
Vince becomes agitated and talkative.
The nurse using collaboration
technique of communication will ask
him;
A. “What would you like to discuss?”
B. “Perhaps you and I can discover what
causes your anxiety”
C. “What are you thinking about?
D. “Has this ever happened before?”
 3. In a nurse-patient interaction, John
says “I don’t want to talk today. “ The
nurse responds therapeutically by
saying:
A. “What made you say that?”
B. “I’ll sit with you for a while.”
C. “Are you not feeling well today?”
D. “Why are you reluctant to talk?”
 4.In a therapeutic communication, one of
the techniques being used is validation.
Which of the following statements is an
example?
A. “Are you sure of what you said?”
B. “Is that really what you believe?”
C. “Something seems to be bothering you.
Would you like to talk about it?”
D. “What proof do you have that someone
is out to harm you?”
 5. As the nurse stands near the window in
the client’s room, the client shouts, “Come
away from the window! They’ll see you!”
Which of the following responses by the
nurse would be best?
A. Who are they?
B. No one will see me.
C. You have no reason to be afraid.
D. What will happen if they do see me?
 6. During the initial interview, a client with
schizophrenia suddenly turns to the next chair and
whispers, “Now just leave, I told you to stay home.
There‘s not enough work here for both of us.” What is
the nurse’s best initial response?
A. “When people are under stress, they may see or hear
things that others do not. Is that what just happened?”
B. “I’m having a difficult time hearing you. Please look at
me when you talk.”
C. “There is no one else in this room. What are you
doing?”
D.“Who are you talking to? Are you hallucinating?”
 7. A client with major depression tells the
nurse, “Life’s just not worth living. I can’t stand
the pain any longer.” What is the nurse’s best
response?
B. “Sometimes when people feel depressed and
helpless, they feel like hurting themselves. Do
you feel like hurting yourself?”
C. “Perhaps you should discuss this in group
therapy today.”
D. “I think you may want to use your p.r.n.
lorazepam now.”
E. “You don’t feel like living?”
 A client has just begun to discuss important
feelings when the time of the interview is up.
The next day, when the nurse meets with the
client at the agreed-upon time, the initial
intervention would be to say:
A. “Good morning! How are you today?”
B. “Yesterday you were talking about some very
important feelings. Let’s continue.”
C. “What would you like to talk about today?”
D. Nothing and wait for the client to open a topic.
 A nurse observes a client sitting alone in her
room crying. As the nurse approaches her, the
client states, “I’m feeling sad. I don’t want to talk
now.” The nurse’s best response would be:
A. “I’ll help you feel better if you talk about it.”
B. “I’ll come back when you feel like talking.”
C. “I’ll stay with you a few minutes.”
D. “Sometimes it helps to talk.”
 14. A client says to the nurse, “Dr. Lim has
surely botched my case. I can’t believe
they’d let her continue to practice.” Which
of the following is an appropriate
response?
A. “Dr. Lim is a fine doctor and one worthy of
respect.”
B. “Dr. Lim has been sued before and her
practice is questionable.”
C. “You seem to have some concerns with Dr.
Lim.”
D. “Dr. Lim usually provides good care.”
 17. Mrs. Kravitz, a woman diagnosed
with schizophrenia, says to an
approaching nurse, “I don’t want to
talk.” What is the best nursing
response?
A. “That’s you’re choice!”
B. “Why don’t you want to talk to me?”
C. “There’s no need to talk with me.”
D. “I’ll sit with you for a while.”
 Mrs. Valle yells for the nurse. As the
nurse arrives and enters the room, the
client says, “Do you see? There! God
is appearing!” Which of the following
is the best nursing response?
A. “No, I don’t see him but I understand
that he is real to you.”
B. “He is not there. You must be imagining
things.”
C. “Show me where God appears to you.”
D. “God is appearing?”
 Pong a 25 year old man admitted in an acute
psychotic state caused by ingestion of
lysergic acid di-ethylamide (LSD), sees red
spiders crawling on his bed. Which of the
following is the appropriate nursing
response?
A. “Come on Pong, you’re putting me on.”
B. Swat the red spiders as if to kill them in the
client’s presence.
C. “I understand you believe you see spiders,
Pong, I am not seeing any.”
D. Discuss details of the hallucinations with him.
 COMMON CLIENT
BEHAVIORS & NURSE
RESPONSES
 WHAT TO DO IF THE
CLIENT CRIES
Possible reactions by the nurse: Nurse may feel
uncomfortable and experience increased anxiety or
feel somehow responsible for making the person cry
Useful responses by the Nurse: Nurse should stay
with the client and reinforce that its all right to cry
often. It is at this time that feelings are closest to the
surface and can be best identified
“You seem ready to cry.”, “You still are upset about
your brother’s death?”, “What are you thinking right
now?”
Nurse offers tissues when appropriate
What to do if the client asks
the nurse to keep a secret
Possible reactions by the nurse: Nurse may feel
conflict because the nurse wants the client to share
important information but is unsure about making
such a promise
Useful responses by the nurse: Nurse cannot make
such a promise. The information maybe important to
the health or safety of the client and others.
“I can not make that promise. It might be important
for me to share it with other staff.”
The client then decides whether to share the
information or not.
What to do if the client leaves
before the session is over
Possible reactions by the nurse: Nurse may feel
rejected, thinking it was something that he or she did.
The nurse may experience increased anxiety or feel
abandoned by the client.
Useful responses: Some clients are not able to relate
for long periods of time without experiencing an
increased in anxiety, On the other hand, the client
maybe testing the nurse.
“I will wait for you here for 15 minutes until our time is
up.”,
During this time, the nurse does not engage in
conversation with any other client or other staff.
When the time is up, the nurse approaches the client,
What to do if another client
interrupts during time with
your selected client
Possible reactions by nurse: nurse may feel a
conflict. The nurse does not want to appear rude.
Sometimes the nurse tries to engage both clients in
conversation
Useful responses: The time the nurse had contracted
with a selected client is that client’s time.
By keeping their part of the contract, nurses
demonstrate that they mean what they say and that
they view the sessions are important.
“I am with Mr. Rob for the next 20 minutes. At 10AM,
after our time is up, I can talk to you for 5 minutes.”
What to do if the client says
he wants to kill himself
Possible reactions by the nurse: Nurse may feel
overwhelmed or responsible to “talk the client out of
it”. The nurse may pick up some of the client’s
feelings of hopelessness
Useful responses: Nurse tells the client that this is
serious, that the nurse does not want harm to come
to the client and that this information needs to be
reported to other staff.
“this is very serious Mrs. Lamb. I do not want any
harm to come to you. I will have to report this to the
other staff.”
The nurse can then discuss with the client the
feelings and circumstances that led up to this.
What to do if the client says
she does not want to talk
Possible reactions: the nurse new to this situation may feel
rejected or ineffectual
Useful responses: At first, the nurse might say something
to this effect: “ Its all right. I would like to spend time with
you. We don’t have to talk.”
The nurse might spend short, frequent periods of time (e.g.
5 minutes) with the client throughout the day.
“Our 5 minutes is up. I”ll be back at 10AM and stay with
you for 5 more minutes.”
This gives the client the opportunity to understand that the
nurse means what he/she says and is back on time
consistently. This also gives the client time between visits
to assess the nurse and perhaps feel less threatened.
What to do if the client seeks
to prolong the interview
Possible reactions: sometimes clients will open up
dynamic or ‘juicy” topics right before the interview
time is up. This is often done to test or manipulate the
nurse. The nurse might feel tempted to extend the
scheduled time or might not want to hurt the client’s
feelings.
Useful responses: The nurse sets limits and restates
and reinforces the original contract.
The nurse states that they will use the issues for the
next session.
“Our time is up now, Mr. Jones. This would be a good
place to start at our next sessions which is
Wednesday at 10AM”
 What to do if the client gives
the nurse a present
Possible reactions: The nurse may feel
uncomfortable when offered a gift-the
meaning needs to be examined. Is the gift:
• A way of getting better care
• A way to maintain self-esteem
• A way of making the nurse feel guilty
• A sincere expression of thanks
Possible guidelines:
-if the gift is expensive, the best policy is perhaps to
graciously refuse
-if the gift is inexpensive and is given at the end of
hospitalization in which a relationship has developed,
graciously accept.
-if the gift is inexpensive and is given at the beginning of
hospitalization, graciously refuse
“Thank you, but it is our job to care for our clients. Are
you concerned that some aspect of your care will be
overlooked?”
If the gift is money, it maybe best to graciously refuse
TESTING BEHAVIORS
USED BY CLIENTS
 The nurse who uses self-disclosure
should:
A. refocus on the client’s experience as
quickly as possible
B. allow the client to ask questions about
the nurse’s experience
C. discuss the nurse’s experience in detail
D. have the client explain his or her
perception of what the nurse has
revealed
Answer: A
Rationale: The nurse’s self-disclosure
should be brief and to the point so that
the interaction can be refocused on the
client’s experience. Because the client
is the focus of the nurse-client
relationship, the discussion shouldn’t
dwell on the nurse’s own experience.
 I. Client Behavior: shifts focus of interview to the
nurse; off the client
Client example: “Do you have any children?” or “Are
you married?”
Nurse’s response: “This time is for you.”
If appropriate, the nurse could add:
• “Do you have any children?” or “What about your
children?”
• “Are you married?”
Rationale: Nurse sticks to the contract and refocuses
back to the client and the client’s concerns.
 Client Behavior: Tries to get the nurse to take
care of him.
Client example: “Could you tell my doctor…”
Nurse’s response: “I’ll leave a message with
the ward that you want to see him.” or “You
know best what you want to say to him. I’ll be
interested in what he has to say.”
Rationale: Nurse validates that the client is able
to do many things for him/herself. This aids in
increasing self-esteem.
Client Behavior: Makes sexual advances
toward the nurse (e.g. touching the nurse’s
arm, wanting to hold hands or kiss the nurse.)
Client example: “Would you go out with me…
Why not?” or “Can I kiss you?…Why not?”
Nurse’s response: “I am not comfortable
having you touch me.”, the nurse briefly
reiterates the nurse’s role, “This time is for
you to focus on your problems and concerns.”
(rationale: frequently restating the nurse’s role
throughout the relationship can help maintain
boundaries)
 Cont’d
If the client stops: “I wonder what this is about?”
1. Is the client afraid the nurse won’t like
him/her?
2. Is the client trying to take the focus off of
his/her problems?(Rationale: whenever possible, the
meaning of the client’s behavior should be explored)
Nurse’s response: If the client continues:
“If you can’t cease this behavior, I”ll have to leave. I”ll
be back at (time) to spend time with you then.
Rationale: leaving gives the client time to gain control .
The nurse returns at the stated time.
 Culture
Culture is the composite of human
behavior
Cultural competence-the skills that
allow individuals to understand and
appreciate cultural differences
Cultural diversity of America is
expanding-last decade, 12 million new
immigrants came to the United States
Ethnic and racial minorities are admitted
to psychiatric hospitals at higher rates,
greater drop outs and enter mental
health treatment at a later stage of
illness
Culturally-competent Care: awareness
of own culture
 Aspects of psychiatric mental health nursing:
F-focusing on establishing rapport
A-assessing whether behavior is usual within the culture
I-incorporating cultural health practices and healers into
plan of care
R-recognizing and supporting the importance of
religious beliefs
B-being familiar with health practices and healers of
particular culture
U-understanding how the client interprets his or her
illness
D-determining the client’s expectations and
misconceptions regarding treatment
S-supporting the spiritual beliefs about the illness and
treatment
CULTURAL BARRIERS
TO TREATMENT
I- inaccessibility of treatment
M-misunderstanding of procedures
I-insensitivity of staff to cultural beliefs
L-language differences
 Spirituality
Spirituality- life principle that pervades a client’s
entire being, integrating and transcending one’s
biological and psychosocial nature
Defining characteristics of spiritual distress:
V- verbalizes inner conflicts about beliefs
I-is unable to participate in his/her usual religious
practices
S-shows anger towards a higher power
E- expresses concern with the meaning of life
Q-questions the meaning of his/her existence
C- concerned about moral/ethical implications of
therapeutic regimen
 Therapeutic nursing
mgt.
Promote a spiritual well-being by informing a clergy
member with the client’s permission and arranging a
visit
Provide spiritual art work, music or reading material
Promote positive sense of meaning by facilitating
experiences that are known to create a sense of
purpose
Be therapeutically present with active listening
Facilitate religious beliefs and practices