Communication with Patients in Mental Health Nursing

Introduction

One of the most useful ways in which we can help other people is to listen and communicate with them in ways that enable them to share their troubles and feel better.

During the following lines we will describe a number of listening, communication and helping skills. These skills are basic counseling skills that could be generally used in everyday life.

But today we will focus on how these skills could affect nurse-patient relationship, and how it could finally result in deep inner satisfaction for both; the nurse and the patient.

For shading more light on the importance of communicational skills in nursing career (www.yourcommunicationskills.com) tells us that the large part of a nursing career involves both verbal and non-verbal transmission of information to the patient and to the medical team and visa versa. When considering this idea of nursing and communicating there is also what is called therapeutic communication in nursing. This involves the human element of appropriate emotions in the nursing arena.

Therapeutic Communication in Nursing reinforces the nurse-patient relationship. It makes the nurse appear more humane to a patient. Therapeutic Communication in Nursing can help cut through barriers of culture and gender, establish a connection if there was a breakdown in communication and help deal in a situation where empathy is needed with the patient.

As mentioned in (Communication skills for nursing practice book, page 57-60) , Communication skills such as listening, questioning , touch, paraphrasing and body language are used specifically by nurses in developing a trusting relationship or what is often referred to as “Rapport” with patients.

These communication behaviors convey warmth and genuine to patients (Caairs-Verhallen et al.,1999).

Listening

Listening is one of the most important of the non-verbal communication skills but its value is often underestimated. Hearing what another person is saying to us is just a small part of listening, Active listening requires that you give the other person your complete attention.

“you must be silent if you wish to listen to another ,to listen with openness. This involves silencing not only your month but also your mind”,(Perry ,1996,Page9)

Touch

Touch is highly valued non-verbal communication in nursing (DeVos,1989;Nesbitt Blondis and Jackson,1982;Wondark,1998). Because of the potential intimacy of physical touch there are further barriers to its use in practice. Although the nurse may reassure or greet a patient with a pat on the hand, hand-hold , or touch to shoulder, this may cause discomfort for either the client or the nurse for a variety of personal reasons (Gleeson and Timmins,2004). Knowledge and awareness of these barriers are essential to the skilful use of touch. In addition, touching should not be provided to patients in a routine way. Patient preference and need should be identified. It should be confined in most situations to patting or holding the hand.

Questioning

It is another communication skill. It includes starting a conversation, gaining information, increasing our knowledge, encouraging participation and encouraging others to reflect, evaluate and be critical. Also determining the level of knowledge in others and control conversations.

To achieve these goals there are more than one type of questions. There are open, closed and circular questions. Questions are also classified according to the amount of information required in response to the question asked.

Patients may answer questions but the answer may seem vague. for example :

Nurse: Hi John, Has that injection lessened your pain, it should be working by now?

Patient: Eh, Yes I think it is.

Nurse: Are you sure, you don’t seem to be comfortable?

Patient: Well actually the injection hasn’t made any difference; I’m still in a lot of pain.

This shows that also the nurse was implying that the injection is working and so the patient found it difficult to tell her that he is still in pain.

Sometimes patients did not understand the question because of the terminology used. So simple language is essential. Questions must be not lengthy or convoluted.

Language

Nurses have the responsibility to give final vital information to patients to facilitate their recovery. Doctors often provide information that parents did not understand and required translation and simplification by nurses after the event.Patients are often assured when they are given information about their illness, plan of care, and length of time they will be in hospital and how they can cope at home. However, patients can become stressed or even more anxious if they are given too much information over a short period of time.

These all must be done in a way that support the patient-nurse relationship by using a non-verbal communication element which is: Paralinguistic “It is not what you say , it is how you say it”

These are non-verbal communication elements that refer to tone and pitch of the voice and accent of the speaker and the speed at which they speak.

Appearance also matter. Patients observe the physical appearance of the nurse , for example how she wears her uniform and the expression on her face ,and based on their own personal values and beliefs they decide if a nurse looks like a good person and therefore, trustworthy. The nurse needs to be aware of the message that her appearance is sending to patients. Awareness of the non-verbal messages we send to others is essential as it will often provide an explanation as to why people respond to us the way they do.

How ever barriers exist to the operation of these skills in practice. These can occur within the nurse, within the patient and within the environment. It is essential that nurses explore current methods of communication delivery, existent barriers and methods for overcoming these barriers.

During my readings an example for a student nurse interests me. She was asked to give a patient an injection. She had seen it done before but not really done one. The staff nurse supervised her and told her exactly what she had to do. She felt confident while she was carrying out the exact steps she was told. The staff nurse was doing all the talking but she was actually just focusing on how to do the injection and she did not pay attention to the patient.

After done and everything went good, she looked back at these minutes and feel that she could have talked to the patient and explain things and involve her a little.

I think this example shows how a nurse deep inside has the desire to communicate with the patient and make him/her feel better not only by medical treatment but also by just caring in one of the ways mentioned afterwards.

If I were the patient, I would be little afraid that a student nurse is giving me an injection. I will sure worry if they are talking above my head about things I don’t understand and wonder what they are doing to me.

As a nurse, I will make sure to involve the patient so he/she could feel at ease with what is going on and safe in the same time. This could also make him trust his nurse and mostly may lead to obeying her without resist concerning his medical treatment.

As mentioned in (Communication skills for nurses practice) there are more than one model which can increase the communication skills for nurses with their patients

Using model of Dairy or journal

This journal or diary would represent a narrative giving a description account of one’s experiences of the practice of nursing. It may be useful for articulating and clarifying thoughts and facilitate the development of questions about practice that may be investigated through one’s course of study or by subsequently asking questions of a mentor/preceptor or staff nurse.

The dairy may show a simple description of day’s activities and can easily reveal an item that needed to be addresses.

This type of work is personal and superficial.

In order to deepen the level of analysis the use of reflection model may be used.

Using reflection model

Using this model provides a little more structure than a dairy or journal. It provides specific guidelines and direction for the thought processes. This can be used on a specific topic or incident being discussed within a dairy or it can be performed as an isolated reflection exercise. It is useful to use the steps of the cycle of reflection as subheadings to describe and analyse the situation.

Criticisms of model use include the tendency for students to focus on negative aspects of their practice. There is also a tendency for this type of reflection to be self-limiting.

One method of advancing reflection and experiential learning is critical analysis.

Using Critical analysis model

This method requires an on going enquiry and analysis rather than simply relying upon prior knowledge and policies. This way involves examining notes from the classroom, textbooks, ward policies and observation of practice and recording these in the journal. It also encourages the recognition of multiple perspectives. It also involves different levels of analysis

Using any of these models leads to a better relationship and communication skills between the nurse and patients. These also become a good reference for the nurse to review once again and use better techniques in communicating with the patients.

One-to-One Nurse-Patient Relationship

According to (Components of psychiatric-Mental Health Nursing, pages 108-110,Peplau (1952)) discusses the phases of one-to-one nurse-patient relationships established in psychiatric-mental health nursing. Such relationship can be divided into three phases: initiating or orienting, working, and terminating.

The phases are effective in both inpatient and outpatient settings. The following is a summary of each of the phases, including therapeutic tasks or goals to be accomplished.

Initiating or Orienting Phase

This is the first step of the therapeutic relationship. During this phase , the nurse sets the stage for a one-to-one relationship by becoming acquainted with the patient. The patient must feel accepted as she or he develops a feeling of trust towards the nurse. Allow the patient to set the pace of relationship. The patient is a unique person who is ill and may be experiencing feelings of loneliness, fear, anger, disgust, despair, rejection. As a patient , the person seeks comfort and help in handling various stressors , in doing so, the patient accepts another’s assistance in problem solving or goal setting. The following tasks are to be accomplished during the initiating phase:

  1. Building trust and rapport by demonstrating acceptance.
  2. Establishing a therapeutic environment.
  3. Establishing a mode of communication acceptable to both the patient and nurse.
  4. Initiating a therapeutic contract by establishing a time ,place, and duration for each meeting, as well as the length of time the relationship will be in effect.
  5. Assessing the patient’s strengths and weakness.

Working phase

This is the second phase of the therapeutic relationship. The patient begins to relax, trusts the nurse, and is able to discuss mutually agreed-upon goals with the nurse as the assessment process continues and a plan of care develops. During this phase, the patient is able to focus on unpleasant, painful aspects of life with the nurse’s supportive help. Therapeutic tasks accomplished during the working phase include:

  1. Exploring perception of reality.
  2. Developing positive coping behaviors.
  3. Identifying available support systems.
  4. Promoting a positive self-concept.
  5. Encouraging verbalization of feelings.
  6. Developing a plan of action with realistic goals.
  7. Implementing the plan of action.
  8. Evaluating the results of the plan of action.
  9. Promoting independence.

Terminating phase

It is the final step of the therapeutic relationship. The nurse terminates the relationship when the mutually agreed-upon goals are reached , the patient is transferred or discharged or the nurse has finished the clinical rotation. As separation occurs it is not uncommon for the patient to exhibit regressive behavior, demonstrate hostility , or experience sadness. The patient may attempt to prolong the relationship as clinical symptoms separation anxiety are experienced.

Termination needs to occur if a therapeutic relationship is to be a complete process. Preparation for termination begins during the initiating phase.

I was very interested in an example written in (Using Therapeutic Communication to Connect With Patients, by Melanie Sears, MBA, RN ).A nurse was describing her feeling before and after using therapeutic communication with her patients :

I was taught in Nursing School that when someone expressed a feeling to reflect it back. I tried this technique in the room of a patient who had just received a diagnosis of cancer. He was obviously angry, so I said, “You sound angry.” He replied, “Hell yes, I’m mad and you nurses and doctors don’t give a damn.”

I felt scared to have this anger directed at me and confused about what to say, so I mumbled an excuse and slipped out of the room leaving his angry words hanging heavily in the air.

For the next few years, I avoided angry patients as much as possible. I would perform my duties as a nurse cheerfully and efficiently and thought I was doing a great job. I was puzzled as to why I wasn’t receiving more appreciation. After all, I constantly sacrificed my own needs to meet the needs of patients and administration, and I was efficient, tireless, strong, and had excellent skills. I worked much of the time in intensive care units where I was free to apply my skills and knowledge to keep patients alive, and where I didn’t have to communicate much because the patients were intubated. I often was distressed because I wanted respect and acknowledgment, but no matter how hard I tried, these needs remained unfulfilled.

It was not until I began taking workshops in Nonviolent Communication TM (NVC) that I began enjoying working with the “whole” patient. I found out that before I could deal effectively with angry patients, I had to first receive accurate understanding (empathy) for what caused the fear reaction in me that led me to avoid their anger. Next, I learned communication techniques for listening to what occurs inside a person and for expressing what was going on inside me. I had never learned how to deal with feelings. Giving and receiving empathy became my passion. A whole new world opened up to me, and my view of the world changed.

My relationships changed drastically and I began enjoying my work as a nurse.

After this I began empathizing with my patients and I noticed how much they appreciated me and how much calmer they felt after having someone listen to them express their feelings. I realized how in the past I had blocked communication by offering advice or trying to fix the problem when I heard someone express a feeling. It was a relief to me to know that I didn’t need to do anything when someone expressed feelings, and I became aware of how therapeutic it was for the patient when I was just present to share whatever was going on inside them.

So through these past lines we shad light on Therapeutic Communication in Nursing which reinforces the nurse-patient relationship. Nurses must be acquainted with some Communication skills such as listening, questioning, touch, paraphrasing and body languag.

There are more than one model which can increase the communication skills for nurses with their patients: Dairy or journal model, reflection model, and Critical analysis mode. We also mentioned that a One-to-One Nurse-Patient Relationship involves three phases: initiating, working, and terminating.

I could not find a better explanation for the importance of communication skills like that I read in ( Counseling skills in every day life, page 17). It states that, using counseling skills to help others can be very satisfying in deed. Through enabling other people to talk about and deal with their emotional experiences and find solutions to their problems, it is possible to achieve considerable personal satisfaction.

While in page 16, the book states that, if any one decided to use counseling skills, then you need to be aware that he will be deliberately inviting people to talk about painful emotions and difficult problems.

Conclusion

Before choosing to become a nurse, one must first examine themselves and look deep inside to see if they have the right qualities for this demanding job. Site (www.fratfiles.com) tells us that “the most important qualities to be a nurse is: caring, compassion, strong desire , willingness to help those in need, patience, honesty and above all, good health”. I totally agree with this, but for me it is simpler, to be a nurse, one must has the great desire for helping others with honesty. One can find his happiness once he sees gratitude and love in the eyes of others.