Psychiatric Mental Health Nursing by Videbeck

114 Unit 2 BUILDING THENURSE–CLIENTRELATIONSHIP

internal mental activities and concentrating exclu-
sively on what the client says. Active observation
means watching the speaker’s nonverbal actions as
he or she communicates.
Peplau (1952) used observation as the first step
in the therapeutic interaction. The nurse observes
the client’s behavior and guides him or her in giving

detailed descriptions of that behavior. The nurse also

documents these details. To help the client develop

insight into his or her interpersonal skills, the nurse

analyzes the information obtained, determines the

underlying needs that relate to the behavior, and

connects pieces of information (makes links between

various sections of the conversation).

A common misconception by students learning

the art of therapeutic communication is that they

always must be ready with questions the instant the

client has finished speaking. Hence, they are con-

stantly thinking ahead regarding the next question

rather than actively listening to what the client is say-

ing. The result can be that the nurse does not under-

stand the client’s concerns, and the conversation is

vague, superficial, and frustrating to both partici-

pants. When a superficial conversation occurs, the

nurse may complain that the client is not cooperat-

ing, is repeating things, or is not taking responsibil-

ity for getting better. Superficiality, however, can

be the result of the nurse’s failure to listen to cues in

the client’s responses and repeatedly asking the same

question. The nurse does not get details and works

from his or her assumptions rather than from the

client’s true situation.

While listening to a client’s story, it is almost

impossible for the nurse not to make assumptions.

A person’s life experiences, knowledge base, values,

and prejudices often color the interpretation of a mes-

sage. In therapeutic communication, the nurse must

ask specific questions to get the entire story from the

client’s perspective, to clarify assumptions, and to de-

velop empathy with the client. Empathy is the abil-

ity to place oneself into the experience of another for

Four types of touch. A—Functional–professional touch;

B—Social–polite touch; C—Friendship–warmth touch;

D—Love–intimacy touch.

Saying he wanted to discuss his wife’s condition, a man

accompanied the nurse down the narrow hallway of his

house but did not move away when they reached the

parlor. He was 12 inches from the nurse. The nurse was

uncomfortable with his closeness, but she did not per-

ceive any physical threat from him. Because this was the

first visit to this home, the nurse indicated two easy

chairs and said, “Let’s sit over here, Mr. Barrett” (offer-

ing collaboration). If sitting down were not an option and

Mr. Barrett moved in to compensate for the nurse’s back-

ing up, the nurse could neutrally say, “I feel uncomfort-

able when anyone invades my personal space, Mr. Bar-

rett. Please back up at least 12 inches” (setting limits). In

this message, the nurse has taken the blame instead of

shaming the other person and has gently given an order

for a specific distance between herself and Mr. Barrett. If

Mr. Barrett were to move closer to the nurse again, the

CLINICALVIGNETTE: PERSONALBOUNDARIESBETWEENNURSE ANDCLIENT

nurse would note the behavior and ask the client about

it—for example, “You have moved in again very close to

me, Mr. Barrett. What is that about?” (encouraging eval-

uation). The use of an open-ended question provides an

opportunity for the client to address his behavior. He

may have difficulty hearing the nurse, want to keep this

discussion confidential so his wife will not hear it, may

come from a culture in which 12 inches is an appropriate

distance for a conversation, or be using his closeness as

a manipulative behavior (ensure attention, threat, or sex-

ual invitation). After discussing Mr. Barrett’s response and

understanding that he can hear adequately, the nurse

can add, “We can speak just fine from 2 or 3 feet apart,

Mr. Barrett. Otherwise, I will leave or we can continue

this discussion in your wife’s room,” (setting limits). If

Mr. Barrett again moves closer, the nurse will leave or

move to the wife’s room to continue the interview.