Psychiatric Mental Health Nursing by Videbeck

(Nancy Kaufman) #1

kept former friends away. In fact, it was in just this
way that she could accept the caring of some friends
and release the importance of those who would not or
could not be there for her. In this situation, exploring
perceptions and the meaning of the loss helped the
bereaved to make cognitive shifts that valuably in-
fluenced her emotional experience.
When loss occurs, especially if it is sudden and
without warning, the cognitive defense mechanism of
denial acts as a cushion to soften the effects. Typical
verbal responses are, “I can’t believe this has hap-
pened. It can’t be true. There’s been a mistake.”
Adaptive denial,in which the client gradually
adjusts to the reality of the loss, can help the client
let go of previous (before the loss) perceptions while
creating new ways of thinking about himself or her-
self, others, and the world. For example, Margaret had
to face the reality that, although she believed that a
priest (because he was a priest) would care about her
being alone in the surgery waiting room, he actually
was concerned only about getting a paper. Gradually
she was able to relinquish this assumption.
Effective communication skills can be useful in
helping the client in adaptive denial move toward ac-
ceptance. In the following example, the nurse has
heard in report that Ms. Morrison received the news
of her upcoming mastectomy. She enters Ms. Morri-
son’s room and sees her crying with a full tray of food
untouched.
Nurse: “You must be quite upset about the news
you received from your doctor about your surgery.”
(using reflection, assuming the client was cry-
ing as an expected response of grief. Focusing
on the surgery is an indirect approach regard-
ing the subject of cancer.)
Client: “I’m not having surgery. You have me
mistaken for someone else.”(using denial)
Nurse: “I saw you crying and wonder what is up-
setting you. I’m interested in how you are feeling.”
(focusing on behavior and sharing observation
while indicating concern and accepting the
client’s denial)
Client: “I’m just not hungry. I don’t have an ap-
petite and I’m not clear what the doctor said.”(focus-
ing on physiologic response; nonresponsive to
nurse’s encouragement to talk about feelings;
acknowledging doctor’s visit but unsure of what
he said—beginning to adjust cognitively to real-
ity of condition)
Nurse: “I wonder if not wanting to eat may be re-
lated to what you are feeling. Are there times when
you don’t have an appetite and you feel upset about
something?”(suggesting a connection between
physiologic response and feelings; promoting
adaptive denial)
Client: “Well, as a matter of fact, yes. But I can’t
think what I would be upset about.”(acknowledg-


ing a connection between behavior and feeling;
continuing to deny reality)
Nurse: “You said you were unclear about what the
doctor said. I wonder if things didn’t seem clear be-
cause it may have upset you to hear what he had to say.
Then tonight you don’t have an appetite.” (using
client’s experience to make connection between
doctor’s news and client’s physiologic response
and behavior)
Client: “What did he say, do you know?”(Re-
questing information; demonstrating a readi-
ness to hear it again while continuing to adjust
to reality)
In this example, the nurse gently but persis-
tently guides the client toward acknowledging the re-
ality of her impending loss.

INTERVENTIONS REGARDING SUPPORT

The nurse can help the client to reach out and accept
what others want to give in support of his or her griev-
ing process.
Nurse: “Who in your life would really want to
know what you’ve just heard from the doctor?”(seek-
ing information about situational support for
the client)
Client: “Oh, I’m really alone. I’m not married.”
Nurse: “There’s no one who would care about this
news?”(voicing doubt)
Client: “Oh, maybe a friend I talk with on the
phone now and then.”
Nurse: “Why don’t I get the phone book for you
and you can call her right now?”(continuing to
offer presence; suggesting an immediate source
of support; developing a plan of action provid-
ing further support)
Many Internet resources are available to nurses
who want to help a client find information, support
groups, and activities related to the grieving process.
Bereavement and Hospice Support Netline is one
source with numerous Internet links to various orga-
nizations that provide support and education through-
out the United States. If a client does not have Inter-
net access, most public libraries can help to locate
groups and activities that would serve his or her
needs. Depending on the state where a person lives,
specific groups exist for those who have lost a child,
spouse, or other loved one to suicide, murder, motor
vehicle accident, or cancer.

INTERVENTIONS REGARDING

COPING BEHAVIORS

When attempting to focus Ms. Morrison on the real-
ity of her surgery, the nurse was helping her shift
from an unconscious mechanism of denial to conscious

254 Unit 3 CURRENTSOCIAL ANDEMOTIONALCONCERNS
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