154 UNIT III  Psychosocial Nursing Tools
TABLE 9-2    THERAPEUTIC COMMUNICATION TECHNIQUES
THERAPEUTIC TECHNIQUE DESCRIPTION
Silence Gives the person time to collect thoughts or think
through a point.
Accepting Indicates that the person has been understood. An
accepting statement does not necessarily indicate
agreement but is nonjudgmental.
Giving recognition Indicates awareness of change and personal efforts.
Does not imply good or bad, right or wrong.
Offering self Offers presence, interest, and a desire to understand.
Is not offered to get the person to talk or behave in
a specific way.
Offering general leads Allows the other person to take direction in the
discussion. Indicates that the nurse is interested
in what comes next.
Giving broad openings Clarifies that the lead is to be taken by the patient.
However, the nurse discourages pleasantries and
small talk.
Placing the events in time Puts events and actions in better perspective. Notes
or sequence cause-and-effect relationships and identifies patterns
of interpersonal difficulties.
Making observations Calls attention to the person’s behavior (e.g., trembling,
nail biting, restless mannerisms). Encourages patient
to notice the behavior and describe thoughts and
feelings for mutual understanding. Helpful with mute
and withdrawn people.
Encouraging description of Increases the nurse’s understanding of the patient’s
perception perceptions. Talking about feelings and difficulties
can lessen the need to act them out inappropriately.
Encouraging comparison Brings out recurring themes in experiences or
interpersonal relationships. Helps the person
clarify similarities and differences.
Restating Repeats the main idea expressed. Gives the patient
an idea of what has been communicated. If the
message has been misunderstood, the patient can
clarify it.
Reflecting Directs questions, feelings, and ideas back 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 person.
Focusing Concentrates attention on a single point. It is
especially useful when the patient jumps from
topic to topic. If a person is experiencing a
severe or panic level of anxiety, the nurse should
not persist until the anxiety lessens.
Exploring Examines certain ideas, experiences, or relationships
more fully. If the patient chooses not to elaborate by
answering no, the nurse does not probe or pry. In
such a case, the nurse respects the patient’s wishes.
EXAMPLE
Encouraging a person to talk by waiting
for the answers.
“Yes.”
“Uh-huh.”
“I follow what you say.”
“Good morning, Mr. James.”
“You’ve combed your hair today.”
“I see you’ve eaten your whole lunch.”
“I would like to spend time with you.”
“I’ll stay here and sit with you awhile.”
“Go on.”
“And then?”
“Tell me about it.”
“Where would you like to begin?”
“What are you thinking about?”
“What would you like to discuss?”
“What happened before?”
“When did this happen?”
“You appear tense.”
“I notice you’re biting your lips.”
“You appear nervous whenever John
enters the room.”
“What do these voices seem to be
saying?”
“What is happening now?”
“Tell me when you feel anxious.”
“Has this ever happened before?”
“Is this how you felt when . . .?”
“Was it something like . . .?”
Patient:”I can’t sleep. I stay awake all
night.”
Nurse:”You have difficulty sleeping?”
or
Patient:”I 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?”
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 of ‘ending it all.’”
“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 9  Communication and the Clinical Interview 155

TABLE 9-2    THERAPEUTIC COMMUNICATION TECHNIQUES—cont'd

THERAPEUTIC TECHNIQUE
Giving information
Seeking clarification
Presenting reality
Voicing doubt
Seeking consensual validation
Verbalizing the implied
Encouraging evaluation
Attempting to translate into
feelings
Suggesting collaboration
Summarizing
Encouraging formulation of a
plan of action
Adapted from Hays, J. S., & Larson, K. (1963). Interacting with patients. New York, NY: Macmillan. Copyright © 1963 by Macmillan Publishing Company.
DESCRIPTION EXAMPLE
Makes facts the person needs available. Supplies “My purpose for being here is . . .”
knowledge from which decisions can be made or “This medication is for . . .”
conclusions drawn. For example, the patient needs “The test will determine . . .”
to know the role of the nurse, the purpose of the
nurse-patient relationship, and the time, place, and
duration of the meetings.
Helps patients clarify their own thoughts and “I am not sure I follow you.“
maximize mutual understanding between nurse “What would you say is the main point
and patient. of what you just said?”
“Give an example of a time you thought
everyone hated you.”
Indicates what is real. The nurse does not argue or “That was Dr. Todd, not a man from the
try to convince the patient, just describes personal Mafia.”
perceptions or facts in the situation. “That was the sound of a car backfiring.”
“Your mother is not here; I am a nurse.”
Undermines the patient’s beliefs by not reinforcing “Isn’t that unusual?”
the exaggerated or false perceptions. “Really?”
“That’s hard to believe.”
Clarifies that both the nurse and patient share mutual “Tell me whether my understanding
understanding of communications. Helps the patient agrees with yours.”
become clearer about what he or she is thinking.
Puts into concrete terms what the patient implies, Patient:”I can’t talk to you or anyone
making the patient’s communication more explicit. else. It’s a waste of time.”
Nurse:”Do you feel that no one
understands?”
Aids the patient in considering other persons and “How do you feel about . . .?”
events from the perspective of the patient’s own “What did it mean to you when he said
set of values. he couldn’t stay?”
Responds to the feelings expressed, not just the Patient:”I am dead inside.”
content. Often termed decoding. Nurse:”Are you saying that you feel
lifeless? Does life seem meaningless
to you?”
Emphasizes working with the patient, not doing “Perhaps you and I can discover what
things for the patient. Encourages the view that produces your anxiety.“
change is possible through collaboration. “Perhaps by working together, we can
come up with some ideas that might
improve your communications with
your spouse.”
Brings together important points of discussion to “Have I got this straight?”
enhance understanding. Also allows the opportunity to “You said that . . .”
clarify communications so that both nurse and patient “During the past hour, you and I have
leave the interview with the same ideas in mind. discussed . . .”
Allows the patient to identify alternative actions for “What could you do to let anger out
interpersonal situations the patient finds disturbing harmlessly?”
(e.g., when anger or anxiety is provoked). “The next time this comes up, what
might you do to handle it?”
“What are some other ways you can
approach your boss?”

Nontherapeutic Communication Techniques Excessive Questioning

Although people may use “nontherapeutic” or ineffective commu- Excessive questioning—asking multiple questions (particularly
nication techniques in their daily lives, they can cause problems closed-ended) consecutively or rapidly—casts the nurse in the
for nurses because they tend to impede or shut down nurse-patient role of interrogator who demands information without respect
interaction. Table 9-3 describes nontherapeutic communication for the patient’s willingness or readiness to respond. This ap-
techniques and suggests more helpful responses. proach conveys a lack of respect for and sensitivity to the patient’s
156 UNIT III  Psychosocial Nursing Tools
TABLE 9-3    NONTHERAPEUTIC COMMUNICATION TECHNIQUES
NONTHERAPEUTIC
TECHNIQUE
Giving premature advice
Minimizing feelings
Falsely reassuring
Making value judgments
Asking “why” questions
Asking excessive questions
Giving approval, agreeing
Disapproving, disagreeing
Changing the subject
Adapted from Hays, J. S., & Larson, K. (1963). Interacting with patients. New York, NY: Macmillan. Copyright © 1963 by Macmillan Publishing Company.
DESCRIPTION
Assumes the nurse knows best
and the patient can’t think for
self. Inhibits problem solving
and fosters dependency.
Indicates that the nurse is unable to
understand or empathize with the
patient. Here the patient’s feelings
or experiences are being belittled,
which can cause the patient to feel
small or insignificant.
Underrates a person’s feelings and
belittles a person’s concerns.
May cause the patient to stop sharing
feelings if the patient thinks he or
she will be ridiculed or not taken
seriously.
Prevents problem solving. Can make
the patient feel guilty, angry, misun-
derstood, not supported, or anxious
to leave.
Implies criticism; often has the effect
of making the patient feel defensive.
Results in the patient’s not knowing
which question to answer and pos-
sibly being confused about what is
being asked.
Implies the patient is doing the right
thing—and that not doing it is wrong.
May lead the patient to focus on
pleasing the nurse or clinician;
denies the patient the 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 alienated
and isolated and increase feelings of
hopelessness.
EXAMPLE
“Get out of this situation
immediately.”
Patient:”I wish I were
dead.”
Nurse:”Everyone gets
down in the dumps.”
“I know what you mean.”
“You should feel happy
you’re getting better.”
“Things get worse before
they get better.”
“I wouldn’t worry about
that.”
“Everything will be all
right.”
“You will do just fine,
you’ll see.”
“How come you still
smoke when your wife
has lung cancer?”
“Why did you stop taking
your medication?”
Nurse: “How’s your ap-
petite? Are you losing
weight? Are you eating
enough?”
Patient: “No.”
“I’m proud of you for
applying for that job.”
“I agree with your
decision.”
“You really should have
shown up for the
medication group.”
“I disagree with that.”
Patient:”I’d like to die.”
Nurse: ”Did you go to
Alcoholics Anonymous
like we discussed?”
MORE HELPFUL RESPONSE
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?”
Empathizing and exploring:
“You must be feeling very upset.
Are you thinking of hurting
yourself?”
Clarifying the patient’s message:
“What specifically are you worried
about?”
“What do you think could go
wrong?”
“What are you concerned might
happen?”
Making observations:
“I notice you are still smoking
even though your wife has lung
cancer. Is this a problem?”
Asking open-ended questions;
giving a broad opening:
“Tell me some of the reasons that
led up to your not taking your
medications.”
Clarifying:
“Tell me about your eating habits
since you’ve been depressed.”
Making observations:
“I noticed that you applied for that
job.” “What factors will lead up
to your changing your mind?”
Asking open-ended questions;
giving a broad opening:
“What led to that decision?”
Exploring:
“What was going through your
mind when you decided not to
come to your medication group?”
“That’s one point of view. How did
you arrive at that conclusion?”
Validating and exploring:
Patient: ”I’d like to die.”
Nurse: ”This sounds serious. Have
you thought of harming yourself?”
 TABLE 6.1 Therapeutic Communication Techniques

Therapeutic
Communication Examples Rationale
Technique

An accepting response indicates the nurse has heard and

“Yes.”
Accepting— followed the train of thought. It does not indicate agreement
“I follow what
indicating but is nonjudgmental. Facial expression, tone of voice, and
you said.”
reception so forth also must convey acceptance or the words lose
Nodding
their meaning.
“Is there
Broad openings— something
allowing the client you’d like Broad openings make it explicit that the client has the lead in
to take the to talk the interaction. For the client who is hesitant about talking,
initiative in about?” broad openings may stimulate him or her to take the
introducing the “Where would initiative.
topic you like to
begin?”
“Tell me
Consensual
whether my
validation—
understanding For verbal communication to be meaningful, it is essential
searching for
of it agrees that the words being used have the same meaning for both
mutual
with yours.” or all participants. Sometimes, words, phrases, or slang
understanding, for
“Are you using terms have different meanings to different people and can
accord in the
this word to be easily misunderstood.
meaning of the
convey
words
that…?”
Encouraging “Was it
Comparing ideas, experiences, or relationships brings out
comparison— something
many recurring themes. The client benefits from making
asking that like…?”
these comparisons because he or she might recall past
similarities and “Have you had
coping strategies that were effective or remember that he or
differences be similar
she has survived a similar situation.
noted experiences?”
“Tell me when
Encouraging you feel
To understand the client, the nurse must see things from his or
description of anxious.”
her perspective. Encouraging the client to fully describe
perceptions— “What is
ideas may relieve the tension the client is feeling, and he or
asking the client to happening?”
she might be less likely to take action on ideas that are
verbalize what he “What does the
harmful or frightening.
or she perceives voice seem to
be saying?”
“What are your
Encouraging
feelings in
expression— The nurse asks the client to consider people and events in
regard to…?”
asking the client to light of his or her own values. Doing so encourages the
“Does this
appraise the client to make his or her own appraisal rather than to accept
contribute to
quality of his or the opinion of others.
your
her experiences
distress?”

244
 “Tell me more
about that.” When clients deal with topics superficially, exploring can
Exploring—delving “Would you help them examine the issue more fully. Any problem or
further into a describe it concern can be better understood if explored in depth. If the
subject or an idea more fully?” client expresses an unwillingness to explore a subject,
“What kind of however, the nurse must respect his or her wishes.
work?”
“This point
seems worth
looking at
The nurse encourages the client to concentrate his or her
more closely.”
Focusing— energies on a single point, which may prevent a multitude
“Of all the
concentrating on a of factors or problems from overwhelming the client. It is
concerns
single point also a useful technique when a client jumps from one topic
you’ve
to another.
mentioned,
which is most
troublesome?”
“What could
Formulating a plan you do to let
of action—asking your anger out
It may be helpful for the client to plan in advance what he or
the client to harmlessly?”
she might do in future similar situations. Making definite
consider kinds of “Next time this
plans increases the likelihood that the client will cope more
behavior likely to comes up,
effectively in a similar situation.
be appropriate in what might
future situations you do to
handle it?”
General leads indicate that the nurse is listening and following
General leads— “Go on.”
what the client is saying without taking away the initiative
giving “And then?”
for the interaction. They also encourage the client to
encouragement to “Tell me about
continue if he or she is hesitant or uncomfortable about the
continue it.”
topic.
“My name is
Giving information …”
Informing the client of facts increases his or her knowledge
—making “Visiting hours
about a topic or lets the client know what to expect. The
available the facts are …”
nurse is functioning as a resource person. Giving
that the client “My purpose in
information also builds trust with the client.
needs being here
is …”
“Good morning,
Mr. S …”
“You’ve
Greeting the client by name, indicating awareness of change,
Giving recognition finished your
or noting efforts the client has made all show that the nurse
—acknowledging, list of things
recognizes the client as a person, as an individual. Such
indicating to do.”
recognition does not carry the notion of value, that is, of
awareness “I notice that
being “good” or “bad.”
you’ve
combed your
hair.”
“You appear

245
 tense.”
Making “Are you
observations— uncomfortable Sometimes clients cannot verbalize or make themselves
verbalizing what when…?” understood. Or the client may not be ready to talk.
the nurse perceives “I notice that
you’re biting
your lip.”
“I’ll sit with you
awhile.”
The nurse can offer his or her presence, interest, and desire to
Offering self— “I’ll stay here
understand. It is important that this offer is unconditional;
making oneself with you.”
that is, the client does not have to respond verbally to get
available “I’m interested
the nurse’s attention.
in what you
think.”
“What seemed
to lead up Putting events in proper sequence helps both the nurse and the
Placing event in
client to see them in perspective. The client may gain
time or sequence to…?”
insight into cause-and-effect behavior and consequences or
—clarifying the “Was this before
the client may be able to see that perhaps some things are
relationship of or after…?”
not related. The nurse may gain information about recurrent
events in time “When did this
patterns or themes in the client’s behavior or relationships.
happen?”
“I see no one
else in the When it is obvious that the client is misinterpreting reality,
room.” the nurse can indicate what is real. The nurse does this by
Presenting reality—
“That sound was calmly and quietly expressing his or her perceptions or the
offering for
a car facts, not by way of arguing with the client or belittling his
consideration that
backfiring.” or her experience. The intent is to indicate an alternative
which is real
“Your mother is line of thought for the client to consider, not to “convince”
not here; I am the client that he or she is wrong.
a nurse.”
Client: “Do you
think I should
tell the
doctor…?”
Nurse: “Do you
think you
Reflecting— should?”
Reflection encourages the client to recognize and accept his
directing client Client: “My
or her own feelings. The nurse indicates that the client’s
actions, thoughts, brother
point of view has value and that the client has the right to
and feelings back spends all my
have opinions, make decisions, and think independently.
to client money and
then has nerve
to ask for
more.”
Nurse: “This
causes you to
feel angry?”
Client: “I can’t
sleep. I stay

246
 awake all
night.”
Nurse: “You The nurse repeats what the client has said in approximately or
have nearly the same words the client has used. This restatement
Restating— difficulty lets the client know that he or she communicated the idea
repeating the main sleeping.”
effectively. This encourages the client to continue. Or if the
idea expressed Client: “I’m client has been misunderstood, he or she can clarify his or
really mad, her thoughts.
I’m really
upset.”
Nurse: “You’re
really mad
and upset.”
Seeking
information— “I’m not sure The nurse should seek clarification throughout interactions
seeking to make that I follow.” with clients. Doing so can help the nurse to avoid making
clear that which is “Have I heard assumptions that understanding has occurred when it has
not meaningful or you not. It helps the client articulate thoughts, feelings, and
that which is correctly?” ideas more clearly.
vague
Silence—absence of
verbal
Nurse says
communication, Silence often encourages the client to verbalize, provided that
nothing but
which provides it is interested and expectant. Silence gives the client time
continues to
time for the client to organize thoughts, direct the topic of interaction, or focus
maintain eye
to put thoughts or on issues that are most important. Much nonverbal behavior
contact and
feelings into takes place during silence, and the nurse needs to be aware
conveys
words, to regain of the client and his or her own nonverbal behavior.
interest.
composure, or to
continue talking
“Perhaps you
and I can
discuss and
Suggesting
discover the
collaboration— The nurse seeks to offer a relationship in which the client can
triggers for
offering to share, identify problems in living with others, grow emotionally,
your anxiety.”
to strive, and to and improve the ability to form satisfactory relationships.
“Let’s go to
work with the The nurse offers to do things with, rather than for, the
your room,
client for his or her client.
and I’ll help
benefit
you find what
you’re
looking for.”
“Have I got this
Summarization seeks to bring out the important points of the
straight?”
Summarizing— discussion and seeks to increase the awareness and
“You’ve said
organizing and understanding of both participants. It omits the irrelevant
that….”
summing up that and organizes the pertinent aspects of the interaction. It
“During the past allows both client and nurse to depart with the same ideas
which has gone
hour, you and and provides a sense of closure at the completion of each
before
I have
discussion.
discussed….”

247
 Client: “I’m
dead.”
Nurse: “Are you
Translating into suggesting
feelings—seeking that you feel
Often what the client says, when taken literally, seems
to verbalize lifeless?”
meaningless or far removed from reality. To understand,
client’s feelings Client: “I’m
the nurse must concentrate on what the client might be
that he or she way out in the feeling to express him or herself this way.
expresses only ocean.”
indirectly Nurse: “You
seem to feel
lonely or
deserted.”
Client: “I can’t
Putting into words what the client has implied or said
talk to you or
indirectly tends to make the discussion less obscure. The
Verbalizing the anyone. It’s a
nurse should be as direct as possible without being
implied—voicing waste of
unfeelingly blunt or obtuse. The client may have difficulty
what the client has time.”
communicating directly. The nurse should take care to
hinted at or Nurse: “Do you
express only what is fairly obvious; otherwise, the nurse
suggested feel that no
may be jumping to conclusions or interpreting the client’s
one
communication.
understands?”
Another means of responding to distortions of reality is to
express doubt. Such expression permits the client to
Voicing doubt—
“Isn’t that become aware that others do not necessarily perceive events
expressing
unusual?” in the same way or draw the same conclusions. This does
uncertainty about
“Really?” not mean the client will alter his or her point of view, but at
the reality of the
“That’s hard to least the nurse will encourage the client to reconsider or
client’s
believe.” reevaluate what has happened. The nurse neither agreed nor
perceptions
disagreed; however, he or she has not let the misperceptions
and distortions pass without comment.

Adapted from Hays, J. S., & Larson, K. (1963). Interactions with patients. New York, NY:
Macmillan Press.

Concept Mastery Alert

Therapeutic Communication
Nurses who observe that a psychiatric client is pacing with pursed lips and a furrowed
brow should avoid presuming that the client’s behavior is motivated by anxiety. The
nurse must validate whether this is the case and encourage the client to delve into why
he or she is behaving that way. Doing so fosters a sense of well-being and allows the
nurse to proceed appropriately.

248
Avoiding Nontherapeutic Communication
In contrast, there are many nontherapeutic techniques that nurses should avoid
(Table 6.2). These responses cut off communication and make it more
difficult for the interaction to continue. Responses such as “everything will
work out” or “maybe tomorrow will be a better day” may be intended to
comfort the client, but instead may impede the communication process.
Asking “why” questions (in an effort to gain information) may be perceived
as criticism by the client, conveying a negative judgment from the nurse.
Many of these responses are common in social interaction. Therefore, it takes
practice for the nurse to avoid making these types of comments.

TABLE 6.2 Nontherapeutic Communication Techniques

Techniques Examples Rationale

“I think you
Advising—telling the should …” Giving advice implies that only the nurse knows what is
client what to do “Why don’t you best for the client.
…”
Approval indicates the client is “right” rather than
“wrong.” This gives the client the impression that he or
she is “right” because of agreement with the nurse.
Agreeing—indicating “That’s right.”
Opinions and conclusions should be exclusively the
accord with the client “I agree.”
client’s. When the nurse agrees with the client, there is
no opportunity for the client to change his or her mind
without being “wrong.”
Client: “I have
nothing to live
When the nurse tries to equate the intense and
for … I wish I
Belittling feelings overwhelming feelings the client has expressed to
was dead.”
expressed— “everybody” or to the nurse’s own feelings, the nurse
Nurse:
misjudging the degree implies that the discomfort is temporary, mild, self-
“Everybody
of the client’s limiting, or not that important. The client is focused on
gets down in
discomfort his or her own worries and feelings; hearing the
the dumps,” or
problems or feelings of others is not helpful.
“I’ve felt that
way myself.”
“But how can you
Often, the nurse believes that if he or she can challenge
be president of
the client to prove unrealistic ideas, the client will
Challenging— the United
realize there is no “proof” and then will recognize
demanding proof from States?”
reality. Actually, challenging causes the client to
the client “If you’re dead,
defend the delusions or misperceptions more strongly
why is your
than before.
heart beating?”
“This hospital has Defending what the client has criticized implies that he
a fine

249
Defending—attempting reputation.” or she has no right to express impressions, opinions, or
to protect someone or “I’m sure your feelings. Telling the client that his or her criticism is
something from doctor has your unjust or unfounded does not change the client’s
verbal attack best interests in feelings but only serves to block further
mind.” communication.
“That’s wrong.”
“I definitely
Disagreeing implies the client is “wrong.” Consequently,
Disagreeing—opposing disagree with
the client feels defensive about his or her point of view
the client’s ideas …”
or ideas.
“I don’t believe
that.”
Disapproving—
“That’s bad.” Disapproval implies that the nurse has the right to pass
denouncing the
“I’d rather you judgment on the client’s thoughts or actions. It further
client’s behavior or
wouldn’t …” implies that the client is expected to please the nurse.
ideas
Saying what the client thinks or feels is “good” implies
Giving approval—
that the opposite is “bad.” Approval, then, tends to
sanctioning the “That’s good.”
limit the client’s freedom to think, speak, or act in a
client’s behavior or “I’m glad that …”
certain way. This can lead to the client’s acting in a
ideas
particular way just to please the nurse.
Client: “They’re
looking in my
Giving literal head with a
responses— television Often, the client is at a loss to describe his or her
responding to a camera.” feelings, so such comments are the best he or she can
figurative comment as Nurse: “Try not do. Usually, it is helpful for the nurse to focus on the
though it were a to watch client’s feelings in response to such statements.
statement of fact television” or
“What
channel?”
Indicating the
“What makes you The nurse can ask, “What happened?” or “What events
existence of an
say that?” led you to draw such a conclusion?” However, to
external source—
“What made you question, “What made you think that?” implies that the
attributing the source
do that?” client was made or compelled to think in a certain way.
of thoughts, feelings,
“Who told you Usually, the nurse does not intend to suggest that the
and behaviors to
that you were a source is external, but that is often what the client
others or to outside
prophet?” thinks.
influences
Interpreting—asking to
“What you really
make conscious that The client’s thoughts and feelings are his or her own, not
mean is …”
which is unconscious; to be interpreted by the nurse for hidden meaning.
“Unconsciously
telling the client the Only the client can identify or confirm the presence of
you’re saying
meaning of his or her feelings.
…”
experience
The nurse takes the initiative for the interaction away
from the client. This usually happens because the nurse
Client: “I’d like is uncomfortable, doesn’t know how to respond, or has
Introducing an to die.” a topic he or she would rather discuss.
unrelated topic— Nurse: “Did you The client’s thoughts and feelings are his or her own, not

250
 last evening?” to be interpreted by the nurse for hidden meaning.
Only the client can identify or confirm the presence of
feelings.
“It’s for your own
good.”
“Keep your chin Social conversation contains many clichés and much
Making stereotyped
up.” meaningless chit-chat. Such comments are of no value
comments—offering
in the nurse–client relationship. Any automatic
meaningless clichés or “Just have a
positive responses lack the nurse’s consideration or
trite comments
attitude and thoughtfulness.
you’ll be better
in no time.”
“Now tell me
about this
problem. You Probing tends to make the client feel used or invaded.
Probing—persistent
know I have to Clients have the right not to talk about issues or
questioning of the
find out.” concerns if they choose. Pushing and probing by the
client
“Tell me your nurse will not encourage the client to talk.
psychiatric
history.”
“I wouldn’t worry
about that.” Attempts to dispel the client’s anxiety by implying that
Reassuring—indicating
“Everything will there is not sufficient reason for concern completely
there is no reason for
be alright.” devalue the client’s feelings. Vague reassurances
anxiety or other
without accompanying facts are meaningless to the
feelings of discomfort “You’re coming
along just client.
fine.”
Rejecting—refusing to
“Let’s not discuss
consider or showing When the nurse rejects any topic, he or she closes it off
…”
contempt for the from exploration. In turn, the client may feel
“I don’t want to
client’s ideas or personally rejected along with his or her ideas.
hear about …”
behaviors
Requesting an There is a difference between asking the client to
explanation—asking “Why do you describe what is occurring or has taken place and
the client to provide think that?” asking him or her to explain why. Usually, a “why”
reasons for thoughts, “Why do you feel question is intimidating. In addition, the client is
feelings, behaviors, that way?” unlikely to know “why” and may become defensive
and events trying to explain him or herself.
“Do you know
what kind of These types of questions force the client to try to
Testing—appraising the hospital this recognize his or her problems. The client’s
client’s degree of is?” acknowledgment that he or she doesn’t know these
insight “Do you still have things may meet the nurse’s needs but is not helpful
the idea for the client.
that…?”
Client: “I’m
nothing.”
Nurse: “Of
course you’re

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 course you’re The nurse denies the client’s feelings or the seriousness
Using denial—refusing something— of the situation by dismissing his or her comments
to admit that a
everybody’s without attempting to discover the feelings or meaning
problem exists
something.” behind them.
Client: “I’m
dead.”
Nurse: “Don’t be
silly.”

Adapted from Hays, J. S., & Larson, K. (1963). Interactions with patients. New York, NY:
Macmillan Press.

Interpreting Signals or Cues

To understand what a client means, the nurse watches and listens carefully for
cues. Cues (overt and covert) are verbal or nonverbal messages that signal key
words or issues for the client. Finding cues is a function of active listening.
Cues can be buried in what a client says or can be acted out in the process of
communication. Often, cue words introduced by the client can help the nurse
know what to ask next or how to respond to the client. The nurse builds his or
her responses on these cue words or concepts. Understanding this can relieve
pressure on students who are worried and anxious about what question to ask
next. The following example illustrates questions the nurse might ask when
responding to a client’s cue:

Client: “I had a boyfriend when I was younger.”

Nurse: “You had a boyfriend?” (reflecting)
“Tell me about you and your boyfriend.” (encouraging description)
“How old were you when you had this boyfriend?” (placing events in time
or sequence)

If a client has difficulty attending to a conversation and drifts into a

rambling discussion or a flight of ideas, the nurse listens carefully for a theme
or a topic around which the client composes his or her words. Using the
theme, the nurse can assess the nonverbal behaviors that accompany the
client’s words and build responses based on these cues. In the following
examples, certain cues help the nurse formulate further communication based
on themes.
Theme of sadness:

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