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Core communication
skills in mental health
nursing
Introduction
Communication in mental health nursing is an essential component of all therapeutic interventions. The knowledge and interpersonal skills that a nurse uses to communicate are essential aspects of helping the person who is experi- encing mental health problems or distress, as well as facilitating the develop- ment of a positive nurse–client relationship. This requires the mental health nurse to use a range of appropriate and effective communication and engage- ment skills with individuals, their carers and other significant people involved in their care. This chapter examines the verbal and non-verbal communica- tion skills that are most relevant to mental health nursing, and illustrates how each skill can be used in practice.
Learning outcomes
By the end of this chapter, you should be better able to:
1 describe the components of therapeutic communication skills 2 demonstrate an understanding of how the different communication skills can be used in clinical practice 3 use interpersonal skills in clinical practice.
Interpersonal skills
Effective interpersonal skills are central to a mental health nurse’s ability to form a sound therapeutic alliance and to the role of mental health nurses (Peplau, 1952). In mental health nursing, communication skills form the basis of every intervention. Good interpersonal skills are what each mental health nurse needs to make nursing happen. These skills are the building blocks or, as Stevenson (2008, p.109) describes them, ‘the nuts and bolts – the basic techniques and principles in which everyone engaging in clinical practice in mental health needs to be fluent’. In order to communicate effectively the mental health nurse needs to work towards being proficient in using the basic
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communication tools; this means knowing what skill s/he is using and why, and being able to move skilfully from one skill to another as and when the purpose of the interaction requires. In addition, given that different clients have different needs, it is inevitable that mental health nurses will use different skills with different clients in various mental health settings. As Stevenson (2008, p.109) points out, ‘one size does not fit all’. Interpersonal skills that are commonly used in mental health practice are described below. Each skill is explained and supported with specific examples and exercises. These descriptions are by no means intended to be exhaustive or prescriptive but instead we aim to provide the general principles for the use of each skill presented. Each skill is described as a stand-alone piece of communication; however, it is important to remember that when used in practice, these skills will be used interdependently. Furthermore, ‘when all the skills are being used together, the mental health nurse provides the proper, respectful conditions that facilitate a positive change to occur’ (Stickley and Stacey, 2009, p.47). The following communication skills will be explained:
listening
paraphrasing
summarizing
questioning
non-verbal communication.
Listening
Listening is the most important skill and often the most challenging. In our experience, mental health nurses often worry about what they are going to say, what questions they should ask, or whether they have asked the right question. While such concerns are common and understandable for the newcomer to mental health nursing, these thoughts can distract the mental health nurse from listening to the person who is talking. One of the common mistakes made by novice mental health nurses as well as experienced nurses is to talk too much. When we are talking, we are not listening! The best and the most therapeutic thing to do is to say less and listen more. Mental health nurses and indeed other helping practitioners, however, often find this difficult. One common reason for this is that many mental health nurses believe they are not doing anything when they are just listening (Bonham, 2004) and as a result they underestimate the value of simply listening and more importantly its therapeutic effect. Listening to a client does not mean that you are doing nothing; instead, you are allowing a space for the person to talk. Stevenson (2008, p.110) echoes this and states that ‘even if the mental health nurse does nothing but listen, there is likely to be a therapeutic effect’. Several studies have also reported that people who used mental health services value having the opportunity to tell their story and more importantly being heard (Jensen, 2000; Kai and Crosland, 2001; Moyle, 2003; Koivisto et al., 2004; Gilburt et al., 2008; Hopkins et al., 2009).
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showing it in your body movements, for example nodding of head, leaning
forward.
Listening to non-verbal communication
Much of the communication that takes place between people is non-verbal. Our faces and bodies are extremely communicative. Being able to read non- verbal messages or body language is an important factor in establishing and maintaining relationships (Carton et al., 1999). Body language includes many different aspects of non-verbal behaviour, including:
eye contact such as staring, avoiding eye contact
facial expressions such as frowning, smiling, clenching or ‘biting’ lips, rais-
ing eyebrows
voice, such as tone, volume, accent, inflection, pauses
body movement, such as posture, gestures, fidgeting
physiological responses, such as perspiring, breathing rapidly, blushing
appearance, such as dress.
In practice, both clients and mental health nurses send many messages and clues through their non-verbal behaviour. It is therefore important that mental health nurses are aware of their own non-verbal body language before they can explore clients’ non-verbal behaviour. In practice, however, we may not always be aware of the non-verbal messages that we communicate and, more importantly, how they might affect our interactions and relationship with clients, their families and work colleagues. For example, how often have you said ‘ It’s not what s/he said, but it’s the way it was said’ or alternatively someone has said to you ‘ it’s not what you said, but it’s how you said it ’? Effective helpers therefore need to learn ‘body language’ and how to use it effectively in their interactions with clients, while at the same time being careful not to over-interpret non-verbal communication (Egan, 2010, p.147). Also, when working with clients from different cultural backgrounds, it is important that the mental health nurse is mindful of and sensitive to different practices concerning the use of eye contact and gender, and modify his/her body language accordingly. For example in a number of cultures, including African and Asian, maintaining eye contact with someone who is in a position of authority is likely to be ‘interpreted as a demonstration of an equality that is disrespectful and inappropriate’ (Sully and Dallas, 2005, p.5). Non-verbal communication either on its own or together can influence verbal communication in the following ways:
confirm what is being said verbally, for example when talking about the
recent death of her father, the client looked sad and became tearful
confuse what is being said, for example when telling the client she wanted
to hear his story, the nurse kept looking at her watch and fidgeting with her pen
Core communication skills in mental health nursing 5
emphasize what is being said verbally, for example when talking about his
anger towards his family for ‘forcing him to come into hospital’, the client clenched his fist and banged the table
add intensity to the verbal message, for example when asking for extra
medication to stop the voices, the client stood up and put his hands over his ears and shouted ‘I want them to stop, I want them to stop.’
The SOLER position
Egan (2010, p.135) identifies certain non-verbal skills summarized in the acronym SOLER that can help the mental health nurse to create the thera- peutic space and tune in to what the client is saying. These are:
S: sitting facing the client squarely, at an angle O: adopting an open posture, arms and legs uncrossed L: leaning (at times) towards the person E: maintaining good eye contact, without staring R: relaxed posture.
As with all interpersonal skills there are a host of things that can hinder the ability to listen attentively. Some of these include:
distractions in the room, for example noise from TV or radio
seating, for example uncomfortable place to sit and listen
temperature of room, for example feeling too cold or too hot and stuffy
lack of time
listening to self rather than to client, for example worrying about what you
are going to say next, how the client might respond to what you say
hearing the client talk about things that you find difficult to believe, for
example that the voices are instructing them to say or do specific things
hearing the client talk about very painful experiences that you find very
emotionally difficult to hear, for example accounts of physical, psycholog- ical or sexual abuse.
We will now look at how using a simple framework can help the listener to structure and organize their conversations with service users, their carers and others who care for and support them.
Listening to verbal communication
Having a framework when listening to a person’s story helps to develop ‘clinical mindfulness’ and assists the listener to organize what the person has said (Bricker et al. 2007, p.25). The following provides a framework to help you focus both your listening and attending with a view to gaining a greater understanding of the person and their story.
Core communication skills in mental health nursing 7
Non-verbal messages: As previously discussed, there are non-verbal
cues, such as facial expressions, body movements and voice tone, which may confirm or deny what is being spoken. Non-verbal behaviours can mean a number of things and caution needs to be used when reading non-verbal behaviour. For example, on observing the client’s behaviour of pacing up and down the ward, the mental health nurse might con- clude, incorrectly, that the client is anxious or angry, whereas the client later explains that she feels very cold and is walking up and down to keep herself warm. Source: Adapted from Cully (1992)
The following box consists of a list of behaviours and characteristics that a good listener might demonstrate (Bonham, 2004, p. 21).
The helpful person
is quiet for most of the conversation, for example allowed you to do
most of the talking
is encouraging, for example demonstrates by their body language that
they understand what you are saying. They nod and maintain eye con- tact without staring and appear interested
sits or stands in a similar way to you and at a comfortable distance from
you, not too close or not too far away.
appears relaxed to what you are saying, asks to repeat or clarify some-
thing to make sure that they understand you
might sometimes repeat back to you what you have said or summarise
what you have said to ensure sure that they understand you
might convey a sense that they are ‘in tune’ with what you are saying
or experiencing
does not judge you
gives you ample time to talk
leaves you feeling respected
Practice exercise
Think of a time when you experienced or observed someone to be very helpful in
practice.
Identify which of the above behaviours were used.
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Touch
Touch, as a form of non-verbal communication, is an important component of therapeutic communication. In mental health nursing, touch can be used as a means of reassuring and/or breaking down barriers between nurse and client (Gleeson and Higgins, 2009). Touch can be instrumental or procedural, whereby the use of touch is necessary or deliberate, for example administering an injection, taking a client’s pulse or blood pressure, bathing or dressing a client. In contrast, ‘expressive’ touch is non-procedural, more spontaneous and a demonstration of affection, for example holding a client’s hand, placing a hand on a client’s shoulder (Watson, 1975). As with all communication skills, touch needs to be used with care and respect. Before using touch, mental health nurses need to consider the following points.
Offer touch respectfully based on the needs of the person as opposed to your
own needs. For example the nurse asks the distressed client ‘Would you like me to hold your hand?’, rather than the nurse initiating holding the client’s hand to allay his/her own feelings of discomfort and/or assuming that the client wants or needs to be touched.
Respect the client’s culture, age, ethnicity and gender; for example do not
assume that it is OK to touch older clients or children without their per- mission. Also, in some cultures, it is unacceptable to be touched by people who are not intimate unless it is in the administration of specific physical care.
Be mindful that clients who experience mental health problems or distress
may require special consideration when using touch, as their responses may not always be predictable, for example if a client believes that ‘all females want to harm him’ it is important that the client’s personal space is respected, particularly by female nurses.
Be aware of your own level of (dis)comfort and be genuine when using
touch, for example if you are uncomfortable about using touch then it is better for the client and yourself that you do not force or impose the use of touch without seeking permission.
Similar to other therapeutic interventions, touch should always be used
genuinely and for the client’s best interest.
Silence
Being able to be silent and still with the client, particularly when s/he is dis- tressed, demonstrates the ability to be present and with the person (Benner, 2001, p.50). However, this can often evoke some discomfort for both the men- tal health nurse and the person in distress. As a result, silences can often feel longer than they actually are, especially if the person finds them uncomfort- able. Learning to ‘ sit with ’ silence requires practice. One way of learning this skill is for the mental health nurse to practise pausing for five seconds before making an intervention (Stickley and Stacey, 2009). This can help the mental
10 Communication Skills for Mental Health Nurses
Zoe: Mm, yes, yes, I think that is right. I do not feel very able to think very clearly now, and I have been a bit forgetful over the last couple of weeks. I forgot my keys the other day, which is very unusual for me.
Example 2
Dylan: [with an angry tone] I suppose I felt uncomfortable when my brother asked me to lend him the money. It is not because I do not have the money, I can afford it. I don’t know why I was angry, but I, don’t want to seem miserly. Nurse: You felt annoyed when he asked you and didn’t want him to think you were mean. Dylan: Yes, that’s right I did feel annoyed... but I also felt guilty... He is my youngest brother and he has no one else.
Summarizing
This skill involves offering the client a pr´ecis or summary of the information that s/he has given. A summary is essentially a longer paraphrase, however it should not be presented as a list of facts. Summarizing can be a very useful intervention, particularly if the person in distress has given you a lot of infor- mation. For the client, hearing a summary of what s/he has said can help to clarify and reassure them that the nurse has heard correctly. It also gives the client the opportunity to correct any misunderstandings, elaborate further as well as hear the main points of their story. When using a summary you may begin by saying something like ‘So, to sum up, you have mentioned several issues concerning... ’
Probing skills
Probing skills involve questioning. The most useful forms of questions are open ended and begin with ‘when’, ‘what’, ‘how’, ‘who’ or ‘where’. Asking an open-ended question invites a full descriptive response. For example, if you were exploring a person’s experience of hearing voices, you might use some of the following open questions.
Examples of open questions
When did you first hear the voices?
How many voices do you hear?
What do the voices say to you?
When are the voices loudest?
Who knows that you hear voices?
How do you feel, when the voices say...?
What were you doing when the voices became louder?
What helps you to cope with the voices?
Core communication skills in mental health nursing 11
The following illustrates examples of other categories of questions, which can be used when working with clients and their families/carers. These include the following:
cognitive questions; these focus on the person’s thoughts or beliefs
affective questions; these focus on the person’s feelings, mood or affect
behavioural questions; these focus on the person’s behaviour or
actions
time-orientated questions focus on issues relating to time, such as past,
present and future.
Other useful open questions
Cognitive questions: What do you think about when you have a panic attack? What did you think would happen when you took the overdose? What do you think causes the voices to say those things? Affective questions: When you were told about your son’s diagnosis, how did you feel? How do you feel when the voices call you names? How do you feel after you have injured (cut) yourself? Behavioural questions: What did you do when you had the panic attack? What does your son do when he gets angry? What can you do to reduce the stress caused by the voices? Time-orientated questions: What did you do in the past that helped you to manage the voices? What can you do now to reduce the urge to cut yourself? What could you do in the next two hours to keep yourself safe?
Unhelpful questions
Unhelpful questions include the following.
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‘Why were you late?’; ‘Why did you say that?’ Such questions may cause the person to feel defensive and/or irritated. Therefore, it may not be surprising that the following why question might evoke such a limited response: Nurse: ‘Why didn’t you take your medication?’ Client: ‘Because I forgot.’
Poorly timed questions
As with all interpersonal skills, timing is critical to asking effective questions. For example, if a client who is very distressed relates having an argument with his father and the nurses asks, ‘What did you say that might have con- tributed to the argument?’ it is unlikely that the client will be willing to explore his own behaviour at this particular time and may feel unheard by the nurse. Learning to ask questions without using ‘why’ can be challenging and re- quire patience and plenty of practice. The following illustrates some practice examples of ‘why’ questions and how these questions might be asked more effectively.
‘Why’ questions Alternative phrasings
Why didn’t you take your medication?
What stopped you from taking your medication? Why did you take an overdose? What made you take an overdose? Why did you discharge yourself from hospital?
What happened that led you to discharge yourself? Why do you get anxious? What do you think causes you to feel anxious? Why did you say that? What made you say that?
Using skills in practice
As with most acquired skills, learning how to use the different interpersonal skills and use them effectively takes time, practice, motivation, and the courage to make mistakes and be imperfect. There are no verbal formulas or magical sentences that will solve clients’ problems. Equally, there are no set ‘right or wrong’ or ‘good or bad’ communication skills. Instead, there are useful and non-useful skills and interventions. Learning how to communicate effectively in practice will present mental health nurses with different learning oppor- tunities and challenges; but in order for lifelong learning to take place we strongly encourage you to take some time to think about each interaction, your communication skills and their therapeutic effectiveness. The following
14 Communication Skills for Mental Health Nurses
questions provide a simple framework to help you evaluate your interactions in clinical practice.
Practice exercise
Take some time to think about a recent interaction that took place during your clinical practice. Reflect on the following questions and jot down your thoughts, ideas and feelings in your journal. Try to be as specific as possible in your answers, as illustrated below. You may also wish to spend some time reflecting on your answers with a colleague or your mentor.
Reflective questions
1 What did I like best about my use of interpersonal skills? For example: I liked best that I listened even though at times I was tempted to ask a question.
2 What did I like least about my use of interpersonal skills? For example: I liked least that I asked a closed and leading question a few times.
3 If I were to do this interaction again, what would I do differently and why? For example: I would summarize what the client said to me. This would have helped me to stop worrying that I was going to forget what the client said, and as a result I didn’t listen to the client.
4 What have I learnt from this interaction? For example: I learnt that I need to practise the use of summarizing.
Conclusion
This chapter has outlined the different verbal and non-verbal skills that are used in mental health practice. These interpersonal skills can be learnt and used in various clinical encounters. It is not enough, however, simply to learn communication skills and techniques; they must be integrated into your own style of working as a mental health nurse. As with all new learning, this will require time, practise and a willingness to be open to feedback from clients and colleagues about your use of different skills and their therapeutic impact in practice. While we hope that this chapter is useful to you in developing your repertoire of communication skills, it is not intended to be the only source of learning. Nevertheless, we hope it provides a useful framework to iden- tify and clarify what skills you are using and, more importantly, to consider its usefulness in developing your communication skills as a mental health nurse.
