NUR 222: Therapeutic Communication & Recognizing and Responding to Patient Stress, Anxiety, and Coping

Which is an example of the therapeutic communication technique of “seeking clarification”?

A. “Can we talk more about how you feel about your father?”

B. “How does your mood today compare with yesterday?”

C. “Tell me what you mean when you say you don’t feel well.”

D. “I notice that you seem angry today.”

C.

Which is an example of the nontherapeutic technique of “false reassurance”?

A. “Don’t worry, everything will work out.”

B. “Hang in there, every dog has his day.”

C. “That’s good. I’m glad that you…”

D. “I think you should…”

A.

Which of the following is an example of an open-ended question?

A. “Do you have a family history of diabetes?”

B. “Are you in pain?”

C. “Are you going to your doctor’s appointment tomorrow?”

D. “Tell me about your health concerns.”

D.

Which statement by the instructor best provides information about the different aspects of therapeutic communication specified?

A. "Electronics in healthcare may increase the nonverbal in person interactions we have with our patients"

B. "Use of therapeutic touch and personal space may vary throughout the patient interaction"

C. "Pacing of a therapeutic communication is driven by the environment the patient is in"

D. "It does not matter if a nurse appears unkempt, as long as they do their job".

B.

During the orientation phase of the nurse-client relationship, the nurse does which of the following?

A. Promote the patient's problem-solving skills.

B. Discuss ways that the patient can incorporate new skills in daily routine.

C. Clarify the role of the nurse and responsibilities of both the nurse and patient.

D. Talk with other care givers that have information about the patient.

C.

Which communication technique is nontherapeutic?

A. Focusing

B. Sympathizing

C. Sharing humor

D. Clarifying

B.

Which communication technique is the nurse using when commenting that the patient's words do not reflect their actions?

A. Sharing hope

B. Sharing feelings

C. Confrontation

D. Sharing empathy

C.

Which communication technique is the nurse using when stating, "This medication is to help lower your blood pressure" while giving the patient the medication?

 A. Making assumptions

 B. Providing information

 C. Using paraphrasing

 D. Sharing observations

B.

A patient is sitting with arms and legs crossed during an interview. What does this behavior indicate?

A. Mild pain in the abdomen

B. Interest in listening to the nurse

C. A defensive attitude

D. Confidence in facing the interview

C.

Which statement would block communication?

 A. "It sounds like this has been a hard time for you."

 B. "If you use your oxygen when you walk, you may be able to walk farther."

 C. "You need to stop always putting so much salt on your food?"

 D. "In summary, it seems as if you are having difficulty taking your medication because it costs too much when insurance doesn't cover it. ."

C.

A sexual assault victim comes into the emergency department with cuts on his hands from smashing a glass vase. Which ego-defense mechanism is at play in this scenario?

A. Dissociation

B. Displacement

C. Identification

D. Denial

B.

Which statement regarding the nature of coping is true?

A. Coping ensures successful resolution of the stressor.

B. Coping is an innate process that is similar for everyone.

C. The manner of coping may vary with time.

D. All coping styles are healthy responses to stress.

C.

The process by which the person interprets a stressor as either a threat or a challenge is:

A. Homeostasis

B. Stressor

C. Fight-or-flight response

D. Stress appraisal

C.

Narrowed focus is first noted when experiencing anxiety that is

A. Moderate

B. Mild

C. Severe

A. ??

therapeutic communication characteristics (5)

• develops in healthcare settings

• distinct boundaries

• focus on the patient

• topics oriented to goals and objectives in patient care

• confidential

social communication characteristics (4)

• develops in a multitude of settings

• boundaries much less clear

• focus on both parties (in healthy relationships)

• ongoing and intimate from both parties

__________ promotes personal growth and helps patients reach their health-related outcomes

therapeutic communication

__________ encourages patient to think and talk about their health situation and express how they are feeling regarding it

therapeutic communication

3 phases of therapeutic communication

orientation, working, termination

orientation (2)

• always begins with eye contact, warmth, and developing rapport

• nurse introduces self and the purpose of the working relationship

working (4)

setting SMART objectives, talking, patient self-expression, taking action to meet goals

termination (2)

• evaluation of reaching goals

• clear boundary the TC relationship is paused or has ended

developing rapport

ask patient about something they are interested in based on cues around them

_____ or ______ can interfere with accurately perceiving and interpreting messages from others

perceptual biases, stereotypes

self check-in characteristics (6)

• listening to other viewpoints

• examining how/where you were raised may have predisposed you to bias

• educating yourself with content from other groups

• Do NOT expect your patients to educate you

• self-reflection

• patient’s preferred name and pronouns

verbal communication characteristics (4)

vocabulary - actual words you use

pacing - how fast/slow you speak; allowing pauses for response

intonation - high, low

clarity - communicate in as few words as possible, ask one question at a time

nonverbal communication characteristics (7)

appearance, posture/movement, facial expressions, eye contact, gestures, sounds, personal space

personal space (2)

• most patient interactions in hospital/exam room should be at 18-40 inches

• may adjust throughout exam/history taking

eye contact

lack of this denotes lack of trust, may be offensive in some cultures

verbal TC techniques (9)

sharing empathy, sharing humor, confrontation, sharing feelings, silence, providing information, clarifying, focusing, paraphrasing

sharing empathy

accurately perceiving another’s feelings and communicating this understanding to another

ex. “ it seems you are very frustrated that this diagnosis was not found sooner”

sharing humor

because people can experience joy even in difficult times, should only be used with patients you know quite well

ex. After spending 30 minutes resituating a colostomy bag, it pops off when you turn

to chart. “Welp. THAT didn’t work! Oh well. Now I get to spend some more time

with you!”

confrontation

presenting facts on dissonant statements/actions in the patient’s history, use only with familiar patients with soundly established trust

ex. “You say you are ready to change your smoking habits, but you are continuing to smoke the same about daily.”

sharing feelings

encouraging patient self-expression and help them acknowledge their feelings

ex. “Being in the hospital for so long seems to be causing you some anger. It is OK to be angry. Tell me more about what is making you angry”

silence

ex. After a patient states, “I really have been struggling lately”. Look at them,

unhurried, on their level, and nod. They will fill the space.

providing information

giving relevant information when a patient asks or nonverbally appears to need information.

ex. A nurse finds a new heart murmur on a post-op heart surgery patient after listening to the patient’s chest for a full 60 seconds (longer than typical). States to patient, “I listened for a long time because I believe I am hearing a new heart murmur. Since you have had heart surgery, I need to let your surgeon know about that. She will be here momentarily. I will stay with you until she comes.”

clarifying

ensuring the nurse is interpreting the patient’s verbal/nonverbal communication correctly

ex. You said her fever started two days ago, but you said she has been coughing for a week. Typically the fever starts at the same time as the cough. Can you clarify what you mean?

focusing

entering a conversation on key elements. Redirecting.

ex. Patient lists 20 ailments they want addressed. “Tell me which 3 of those things you listed are most important to you, and we will start there.”

ex. This often needs to be used with chatty patients. “Thank you for that information of your history of eczema. But I am needing some more information on your son’s current viral rash. When did it appear?”

paraphrasing

restating another’s message more briefly in your own words.

ex. Patient has 3 minute monologue on why he is frustrated with his physician’s office. “It seems you are frustrated my office’s responsiveness to your needs. What is one way I can help with that today?”

non-therapeutic verbal techniques (5)

sharing opinions, generalization, false reassurance, sympathy, use of medical jargon

sharing opinions

nurse judges the patient’s situation based on the nurses’ set of beliefs.

ex. “You should talk to your mom about the difficulty you are having with depression”

generalization

using stereotyped remarks applying to ‘all people’.

ex. “Everyone feels like they have difficulty with remembering their medications. You are no different.”

reassurance

providing reassurance when the outcome is unknown.

ex. “God will take care of everything.” “You will get through this”

sympathy

The nurse overindulging in empathy, allowing themselves to be the center of the worry instead of the patient.

ex. “I just can’t imagine how you feel with this breast cancer diagnosis. My family would be so scared”

use of medical jargon

Use 5th grade level communication of medical terms, no matter what the patient’s educational level.

factors that influences communication (7)

• Bodily needs (pain, potty, tired)

• Emotional status

• Developmental age (3 year olds are not the same as 40 year olds)

• History of trauma

• Attitudes/beliefs

• Neurocognitive disorders (Autism, ADHD, stroke, mental health)

  • Hearing aids, glasses, communication assistive devices

• Environment (lighting, temperature, timing, privacy, noise, phone, family present)

______ can interrupt therapeutic communication

electronic health records

nurse eyes on computer more can equal…

less eyes on patient and may miss important cues and nonverbal interactions

_______ can promote communication

electronic health records

electronic health records characteristics (4)

• Electronic messaging for timely responses

• Patients and nurses/provider can view health information together in in-person visit

• Telehealth and screen sharing

• Reviewing lab result trends, checking upcoming appointments, need for prescription refills, etc. without leaving the patient beside/exam room

______ focuses on brief, respectful, accurate, and safe exchange of patient information

healthcare team communication

______ focuses on expression of feelings

therapeutic communication

what is ISBAR used for

communicate with the healthcare team

ISBAR

I: Introduction

• Introduce yourself, location, and title. Introduce patient name, age, room, diagnosis.

• “Hello Dr. Jackson. This is Morgan, RN on 4 north.

• S: Situation

• I am calling about jessie taylor, the 5 yo patient with seizures on 4N in room 407. I think she may be having breakthrough seizures”

• B: Background

• The patient’s dose of seizure medication one was decreased so we could start seizure medication 2 without over sedating her.

• A: Assessment

• She has had 3 episode of repetitive eye twitching lasting 5 seconds each. Vital signs are stable on room air before during and after episodes.

• R: Recommendation

• Can you please come to the bedside to assess her or write new orders to treat? And what time can I expect that to be completed? Thank you. You can reach me on EPIC chat as needed.”

healthcare team communication tips (5)

• know who main team caring for patient is

• know all of the needed information before texting/calling

• avoid unnecessary information

• if you are not getting the response you need, be more assertive

• when all else fails, call a rapid response

stress (2)

• actual or alleged hazard to the balance of homeostasis

• brought about by external circumstances (finances, job deadline, exam)

anxiety (2)

• persistent, excessive worries that don't go away even in the absence of a stressor

• Triggers are more internal (I am not good enough, I am going to fail)

general adaptation syndrome stages

• body’s stepwise response to stress situation

1) Alarm reaction

2) Resistance

3) Exhaustion

alarm emotional symptoms (9)

lack of concentration, memory lapses, difficulty in making decisions, confusion, disorientation, panic attacks, irritability, tearfulness, rage

alarm physical symptoms (9)

• Increased heart rate, palpitations

• Increased respirations

• Vasodilatation of arteries to body’s periphery (arms and legs)

• Increased serum glucose levels

• Increased blood coagulation (clotting)

• Increased muscular strength

• Decreased gastric movement

• Antidiuresis (decreased urine production)

• Increased perspiration to cool body core temperature

chronic symptoms of stress (13)

Sleep pattern changes, fatigue, digestion changes, loss of sexual drive, headaches, aches and pains, infections, indigestion, rashes/hives, autoimmune diseases, hypertension, depression, anxiety/hypochondria

maladaptive responses to stress (7)

nail biting, restlessness, fidgeting, lcohol/drug abuse, deterioration of physical hygiene, withdraw from social connections, developing anxiety disorders (eating disorders, obsessive compulsive disorder, hypochondria)

adaptive responses to anxiety/coping skills (10)

crying, talking, therapy, sleep, exercise, deep breathing, relaxation, problem solving, music, prayer, social connections

anxiety

persistent worry after a stressor has passed

mild anxiety + response

• irritability, restlessness, insomnia

• response: encourage coping skills and make minimal adjustments to plan of care so patient’s most immediate concerns are addressed first

moderate anxiety + response

• An increase in physiological functions and psychomotor involvement

  • May experience headaches, stomach aches, palpitations, other symptoms at a mild rate

• Narrowed, but present focus

• response: Address patient’s anxiety first. Further question for causes of anxiety. Continue with plan of care.

severe anxiety + response

• Hyperactive, with all energy aimed at relief of physical and emotional symptoms

• Panic

• Paralysis of functioning can occur. The client may freeze and even lose consciousness

• Complete lack of focus

• Severely interrupts personal function (work, school, home)

• response: Provide patient and self with safe environment. Acknowledge presence of anxious thoughts. “I can see that you are upset. I am here to listen.” Focus on decreasing physical symptoms. Medication as needed. Reschedule plan of care/teaching for when patient’s anxiety is mild to moderate.

ego defense mechanisms to stress/anxiety - add to this

compensation, conversion, denial, displacement, dissociation, regression, repression - add to this

compensation

Making up for a deficiency in one aspect of self-image by strongly emphasizing a feature considered an asset

(e.g., a person who is a poor communicator relies on organizational skills)

conversion

Unconsciously repressing an anxiety-producing emotional conflict and transforming it into nonorganic symptoms

(e.g., difficulty in sleeping, loss of appetite)

denial

Avoiding emotional conflicts by refusing to consciously acknowledge anything that causes intolerable emotional pain

(e.g., a person refuses to discuss or acknowledge a personal loss)

displacement

Transferring emotions, ideas, or wishes from a stressful situation to a less anxiety-producing substitute

(e.g., a person transfers anger over an interpersonal conflict to a malfunctioning computer)

dissociation

Experiencing a subjective sense of numbing and a reduced awareness of one’s surroundings

regression

Coping with a stressor through actions and behaviors associated with an earlier developmental period

repression

thoughts are pushed into the subconscious as if the stress has never occurred. This is short term, and negative effects will result over time

therapeutic communication skills (7)

• communicate a sense of caring

• separate patient’s anxious behavior from the patient themselves

• encourage known coping skills

• modifying the environment

• spiritual support (chaplain)

• encouraging social support

• therapy + medications

secondary traumatic stress

trauma a person experiences from witnessing other people’s suffering

secondary traumatic stress symptoms (5)

• intrusive thoughts

• avoid interactions

• difficulty sleeping

• trouble relating to friends or family

• may engage in negative coping skills

  • lateral violence against coworkers

  • emotional abuse/neglect of family or friends

  • addiction (alcohol, drugs, gambling)

secondary traumatic stress treatment (3)

• recognitions (talking to to others)

• skilled clinician

• self care