This work attempts to examine a number of issues generated by the discussion on the communication skills of the mental health nurse. Nursing actions are planned to promote, maintain, and restore the client’s well-being and health. Clients and nurses alike come to the communication with unique cognitive, affective, and psychomotor abilities that they use in their joint endeavor of enhancing the clients’ well-being. Mental health nurses are responsible for encouraging this interchange of ideas, values, and skills. In an effective helping communication there is a definite and guaranteed interchange between clients and nurses in all three dimensions. The communicative role of the nurse is, thus, an important one.
Communication Skills of the Mental Health Nurse
Communication is a life-long learning process for the nurse. Nurses make the intimate journey with the client and family from the miracle of birth to the mystery of death. Nurses build assertive communication for this journey. Nurses provide education that helps clients change life-long habits. Nurses communicate with people under stress: clients, family, and colleagues. Nurses deal with anger and depression, with dementia and psychosis, with joy and despair. Nurses serve as client advocates and as members of interdisciplinary teams who may have different ideas about priorities for care. Despite the complexity of technology and the multiple demands on a nurse’s time, it is the intimate moments of connection that can make all the difference in the quality of care and meaning for the client and the nurse. As nurses refine their communications skills and build their confidence, they can move from novice to expert. Nurses honor the differences in clients with humility and learn and grow in their ability to trust their intuition — the sacred moment of connection when we ac-
knowledge the divine presence in each of us, the essence of each person. Communication involves the reciprocal process of sending and receiving messages between two
or more people. This work will focus on the communication skills of the mental health nurse.
Communication can either facilitate the development of a therapeutic relationship or create barriers (Burleson 2003). In general, there are two parts to face-to-face communication: the verbal expression of the sender’s thoughts and feelings, and the nonverbal expression. Verbally, cognitive and affective messages are sent through words, voice inflection, and rate of speech; nonverbally, messages are conveyed by eye movements, facial expressions, and body language. Senders determine what message they want to transmit to the receiver and encode their thoughts and feelings into words and gestures. Senders’ messages are transmitted to the receiver through sound, sight, touch, and occasionally, through smell and taste. Receivers of the messages have to decode the verbal and nonverbal transmission to make sense of the thoughts and feelings communicated by senders. After decoding the senders’ words, speech patterns, and facial and body movements, the receivers encode return messages, either verbally, through words, or nonverbally, through gestures. Figure 1 illustrates this reciprocal nature of the communication process. At any point in an interpersonal communication we send and receive verbal and nonverbal messages about thoughts and feelings. The assertive nurse appears confident and comfortable. Assertive behavior is contrasted with nonassertive or passive behavior, in which individuals disregard their own needs and rights, and aggressive behavior, in which individuals disregard the needs and rights of others (Figure 2).
The communication between mental health nurse and clients typology is divided into two broad categories: client–nurse communications and person-in-situation, or environmental, interventions. There are six intervention methods within the client–worker communications category:
1. Sustainment. Communications designed to convey interest, understanding, confidence, and reassurance constitute the bulk of sustainment. Frequently, these are nonverbal cues, such as attentive posture, minimal prompts (repeating a word the client has used ina questioning manner), nods, and smiles. Sparingly used supportive statements such as “You seem to be coping well with an enormous amount of pressure” or “It is to be expected that this would be difficult to deal with” reflect a level of understanding of the client’s situation and sustain the communication.
2. Direct influence. This communication type is really a continuum of interventions that range from tentative suggestion through directive advice giving. Giving direct advice is seldom appropriate to the mental health nurse. Even so, suggestions such as “I wonder whether it might make sense to consider X strategy for handling this problem” or “Have you thought about trying to do X in that situation?” fall within the range of mental health nurse work interventions in health care settings.
3. Exploration, description, and ventilation. These communications are designed to promote client disclosures through questions and other techniques. Although using minimal prompts and nodding are also involved in sustainment, the goal differs when they are used in this context. The exploration of clients’ problems, motivations, and strengths, their descriptions of interactions and situations, and their opportunity to allow open expression of emotions are all goals of this type of intervention.
4. Person–situation reflection. Reflection of client communications is often a main goal of intervention. Burleson (2003) divides the types of reflection into six further categories: reflections of others (clients’ own health or other aspects of the exterior world); client behavior (including its effects on others or on self); the nature of clients’ behavior, thoughts, and feelings; the causes and provocations of behavior; self-image, values, and principles from an evaluative stance; and feelings about the nurse or the client–nurse relationship.
5. Pattern–dynamic reflection. Communication for the purpose of reflecting back general patterns in the clients’ behavior and the motivations behind the behavior are given a separate category. Much interpretive and analytic work is done with this type of communication.
6. Developmental reflection. Like pattern–dynamic reflection, this type of communication identifies patterns in client motivation and behavior; however, the focus is on historical developmental patterns. Framing reflections in terms of prior client development is a hallmark of this type of interaction.
Acceptance, and its associated value of being non-judgmental, is extensively examined in communication skills. It involves ‘respect and concern’ and ‘an uncompromising belief in the innate worth of the individual human being’ (Atkinson 2002). It is essential not simply that the worker should have these beliefs, but that the client actually experiences himself being respected by the worker. We do not display unconditional positive regard: there is an expectation by the worker that change will occur. Acceptance, however, requires humility. Indeed, it may go beyond simple refusal to judge, but actively to seek to understand can be a prerequisite to acceptance. A final element is the commitment implied by acceptance: that although the client may behave in ways disapproved of, the relationship will continue as far as the nurse is concerned. Atkinson (2002) stresses consciously attempting to suspend personal value judgments, opinions, attitudes and feelings about the issues raised, and concentrate on accepting the client’s values, feelings and opinions (p. 174).
The nurse should accept the patient as he or she is, and in addition to accepting him/her as he is, the nurse should treat the patient as an emotionally able stranger and relate to him/her as such until evidence shows otherwise. Nurses must remain true to their values while accepting the patient’s right to follow his/her conscience, they must display tolerance of themselves and others and must be non-judgmental so the patient feels free to express his/her real feelings. To be accepting is, at base, to be friendly.
Empathy, listening and individualizing are a closely related cluster of qualities. Empathy is perhaps the most widely discussed element in nursing communication skills. Atkinson (2002) suggests it is imaginatively understanding others: ‘the power to feel imaginatively the experience of the other person…to “get on the same wavelength” as them’. The nurses attempt to ‘put themselves in another’s shoes’. However, this should not overwhelm them. Burleson (2003) calls it controlled emotional involvement. Burleson identifies a continual movement between merging with the client and regaining an objective stance. We recognize that we are a separate person, and this is necessary to maintain a sense of proportion. There is a clear intuitive dimension. Jordan (1979, p. 20) considers ‘it requires the exercise of all her [the worker’s] intuitive and imaginative capacities’ to go beyond the detail of the message. It also has a more cognitive element. It involves ‘building up our knowledge’ (Atkinson 2002) and methods of reasoning…to make an objective analysis… [and] the theoretical knowledge [to obtain]…a mental representation of the other (Burleson & Planalp 2000).
Listening is a closely associated practice element. Indeed, it would appear a prerequisite to any degree of accurate empathy. Although non-verbal cues may be used, the ability to listen significantly facilitates understanding of the client and the meaning for him of his circumstances. Listening, however, is not a passive activity. Atkinson (2002) emphasizes nurse involvement, and the active seeking for ‘information’: ‘a listener who is able to respond actively and appropriately to the messages he receives’. Riley (2000) considers likewise it is not a passive ‘hearing’. It is an active search for the meaning in and an active understanding of, the client’s communication. (p. 168)
It is this active striving for meaning which links it to empathy, the attempt to understand. It is ‘listen and know what I mean’ (Worden 2003). Listening, though, has a further positive element: actually encouraging the client to express himself. It involves listening hard, not only to the words which the client is using, but also the overtones of what he is saying together with encouraging the client to formulate and express his worries.
Individualization is also closely associated with empathy: for to empathize is to do so with an individual who has unique qualities. Individualization is the recognition and understanding of each client’s unique qualities based on the right to be treated not just as a human being, but as this human being with his personal differences. Individualization possesses two central characteristics: like others it involves recognition of uniqueness, but also one of value – a valuation of an individual’s potential accomplishments. Barrett (2003) identifies three ways in which it occurs in practice: in the present through the current nurse-client relationship; in description of the past through which the client presents their biography; and discussing future actions contributing to his/her personal identity. Overall treatment should be geared to individual needs. Above all, individualization means being free from projecting stereotypes on to people.
Communication skills of mental health nursing also discuss empathy. It is the ability to perceive accurately the feelings of another person and to communicate this understanding to him. It is the capacity for participating in a vicarious experience of another’s feelings, volitions or ideas. Atkinson (2002) considers it to be an absolutely essential element of interpersonal communication. Nurse authors recognize it goes beyond simply what another person says: it is the ability to perceive accurately the internal frame of reference of the other and involves the latent meaning of what has been said. It is necessary, though, to retain some separateness: it is the quality of objectivity which distinguishes empathy from sympathy. Overall seeing things through the other person’s eyes involves, first, responding to the words and reflecting them, and second, picking out the unspoken feelings behind what is said.
A further cluster of related concepts are authenticity, genuineness and openness. Authenticity requires the nurse be real and human in the communication. It implies spontaneity, the willingness to share one’s own feelings and reactions. Genuineness on the other hand means that there is a striving towards congruence between the nurses’ feelings and their behavior. Authenticity, then, means retaining one’s essential ‘humanness’, while genuineness is significant in the generation of authenticity: the worker openly providing information requested, and when appropriate initiates information sharing. This involves being honest about the reality of the nurse’s position: that the nurse’s powers and limitations are stated clearly when appropriate. Authenticity and openness, therefore, involve being authentic as a professional and not just a private person. Congruence means that nurses bring honest matches the underlying value system and essential self as a professional person. At a personal level it motivates a warm and nurturing heart, on objective, open and disciplined mind (heart and head). It is the synthesis of personal and professional which is significant: without this there is a loss of spontaneity with the worker appearing as a guarded professional. How does the nurse demonstrate genuineness? The nurse should give time, be sincere and be consistent in the attitudes and behavior shown during the communication. However sincerity does not involve cushioning the patient inappropriately from reality.
This work has examined issues relating to communication (or its likely effect) and client involvement in the process of intervention. The role of the mental health nurse in health communication bears both similarities and dissimilarities to that of the physician. The nurse is in a pivotal position on the patient care team. Often nurses claim that patients should be treated as people rather than cases, they do not communicate as they profess they should nor as they think they do. In summary, this work highlights the importance of practice and preparation in the development of mental health nurses’ communication skills. Changing and improving the way health care providers interact with patients is complicated for several reasons. First, many nurses have developed a style of communicating that they perceive to be effective and easy to use, especially if they have been practicing for a number of years. To diversify their communicative repertoire, nurses must believe in the need for change, learn new responses (e.g., open-ended questions, attentive listening), and identify and refrain from problematic behaviors. Because of these factors, it is unlikely that a single, brief intervention will lead to significant improvement in a health care provider’s communicative skills. Research to date indicates that the most successful communication skill interventions will be those that are intensive and employ diverse pedagogical techniques including expert and patient feedback, role playing, modeling, practice, group discussion, and watching one’s performance on videotape.
Atkinson, Mary. (2002). Mental Health Handbook for Schools. Routledge/Falmer: London.
Barrett, Sheila. (2003). Communication, Relationships and Care: A Reader. Routledge: New York.
Burleson, B. R., & Planalp, S. (2000). “Producing emotion(al) messages.” Communication Theory, 10.
Burleson, Brant R. (2003). Handbook of Communication and Social Interaction Skills. Lawrence Erlbaum Associates: Mahwah, NJ.
Riley, Julia Balzer. (2000). Communication in Nursing. Mosby: St. Louis, MO.
Worden, J. William. (2003). Grief Counselling and Grief Therapy: A Handbook for the Mental Health Practitioner. Brunner-Routledge: Hove, England.
Figure 1 The Human Communication Process
Figure 2 Assertive and Nonassertive Style of Communication
Attitude toward self
I’m not OK
You’re not OK
I’m not OK
You’re not OK
Makes own decision
Lets others choose for
him or her
Chooses for others
Behavior in problem
Flees, gives in
Clear, direct statement
of wants; objective
words; honest statement of feelings
Apologetic words; hedging; rambling; failing
to say what is meant
Loaded words; accusations; superior,
haughty words; labeling of other person
Actions instead of
words (not saying
what is felt); incongruence between
words and behaviors
Air of superiority; flip-
pant, sarcastic style
Firm, warm, confident
Weak, distant, soft,
Tense, shrill, loud, cold,
demanding, authoritarian, coldly silent
Warm, in contact, frank
Stooped; excessive lean-
ing for support
Hands on hips; feet
Gestures at appropriate
Fists pounding or
Pattern of relating
Puts himself or herself
up without putting
Puts himself or herself
Puts himself or herself
up by putting others
Response of others
Disrespect, guilt, anger,
Consequences of style
I win, you win; strives
for “win-win” or “no
I lose, you lose; only
succeeds by luck or
charity of others
I win, you lose; beats
out others at any cost
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