Chapter 8: Communication Skills: Medium for All Nursing Practice

Welcome back to The Deep Dive.

I wanna start today with a little thought experiment.

So picture this,

you're walking into a room to meet someone for the very first time, and you want them to like you, right?

You wanna get some information from them, and fundamentally, you wanna help them.

So naturally, you do what we all do.

You smile, you ask about their day, maybe you compliment their shoes, you try to find some common ground, like, oh, you're a Yankees fan, I love the Yankees.

That is just how human beings connect.

It's how we survive socially.

It is, it's the social grease that keeps everyday interactions moving smoothly.

Exactly.

Now imagine doing all of that, being charming, finding common ground, chatting about the game, and then being told by your instructor that you are actually failing at your job, and not just failing, but potentially harming the person you're trying to help.

Oh yeah, that is the absolute splash of cold water that hits practically every nursing student when they start their psychiatric rotation.

It's a total paradigm shift.

It really is, and that's our mission for you today.

We are tearing down everything you think you know about just talking to people, and we're gonna rebuild it from the ground up.

We are diving deep into chapter eight of Essentials of Psychiatric Mental Health Nursing.

That's the fourth edition by Varkarolis and Fosbray.

And the title of this specific chapter is so telling.

It's called Communication Skills, Medium for All Nursing Practice.

Medium.

That is such an interesting word choice.

I mean, it's not called communication skills, a nice thing to have.

No, not at all.

Think about a painter, right?

The medium is the oil paint or the watercolor.

Without the paint, there literally is no art.

In surgical nursing, the medium might be the scalpel.

In med surg, it might be the IV line.

But in psychiatric nursing, the medium, the actual physical tool you use to do the work is communication.

If you cannot communicate therapeutically, you aren't just awkward.

You are functionally unable to provide care.

You have no tools.

You're showing up to a surgery without a scalpel.

So to guide you through this transition today, we really need to take you from being a quote unquote social communicator, which is what you've been practicing your whole life, and turn you into a therapeutic communicator.

And let me tell you, the text makes it incredibly clear.

This is not natural.

It's not.

It is a scientifically grounded, highly professional skill set that you have to study, practice, and honestly really struggle with at first.

And we are really gonna get into the weeds here.

We aren't just gonna list off vocabulary terms.

We're gonna look at the theory behind it.

We're gonna break down Berlo's model of communication.

We're gonna look at why asking a simple why question actually triggers neurological defensiveness.

We're even gonna role play the specific techniques right here so you can hear the difference.

And we'll look at the traps, the things you say to be nice that actually end up backfiring horribly.

But first, I think we have to start with the foundational premise of the chapter.

And it starts with a concept that sort of broke my brain a little bit when I first read it.

The author states simply, we cannot not communicate.

I love that.

We cannot not communicate.

I actually tried to test this.

I sat in my chair before we started recording today and thought, okay, I'm not gonna communicate anything.

I'm just gonna sit here.

And what did you look like?

Well, I had my arms crossed because I was concentrating.

I was just staring blankly at the wall.

My brow was probably furrowed.

Right, so if I walked into the studio and saw you sitting like that, what message would I immediately receive?

Probably that I'm angry or really busy or maybe that I'm just totally ignoring you.

Exactly, you were screaming stay away or I am deep in thought without opening your mouth or making a single sound.

That is the first big lesson here.

Human interaction is constant.

Every posture, every glance,

every single silence is a data packet being sent to the other person.

And in a psychiatric setting where patients are often hypervigilant or maybe experiencing paranoia, they are reading those data packets with an incredible intensity.

They are.

So if a nurse walks into a room, checks the monitor, and walks out without making eye contact or saying a word,

they haven't avoided a conversation.

They have actively communicated that you are not worth my time or I'm only interested in this machine, not you as a human being.

That is so powerful to keep in mind and I think that brings us perfectly to the foundational split the authors make early in the chapter.

You have to deeply understand the difference between a social relationship and a therapeutic relationship.

Oh, this is crucial because I think students read this section and go, yeah, yeah, professional boundaries don't date the patients, got it.

But it is so much more subtle than that.

Right, it's not just about obvious boundaries.

Exactly.

A social relationship like the one you and I have or the one you have with your friends is defined by mutuality.

Mutuality, meaning both people get something out of it.

Right, the needs of both parties are met.

Think about going out for coffee with a friend.

I tell you about my stress at work and you listen.

That feels really good for me.

Then because we are friends, you naturally expect a turn.

You tell me about your relationship drama and I listen.

We swap advice, we validate each other.

It's a two -way street.

If I just talked about myself for three hours and never once asked how you were doing, you'd stop having coffee with me.

I would, I'd say you were a terrible friend.

But, and this is the hard pivot for nursing students,

a therapeutic relationship is not mutual in that sense at all.

It is strictly one -way traffic.

One -way traffic, meaning the focus is 100 % on the patient.

100 % on the patient's needs, the nurse's needs, the need to be liked, the need to vent about a hard shift, the need to feel smart or healthy.

All of that has to be completely set aside.

That sounds incredibly draining and also kind of artificial.

Like if a patient asks me, hey, do you have kids?

My human instinct is to just say, yeah, I have two girls.

Why is that considered bad in this context?

Well, it's not necessarily evil, but you have to constantly ask yourself why you are answering.

In a social setting, you answer to build a bond.

In a therapeutic setting, you have to calculate in a split second, does sharing this personal information actually help the patient's treatment goals?

Give me an example of when sharing that might actually hurt the process.

Okay, let's say a patient was admitted because they are deeply grieving the sudden loss of a child.

They look at you and ask if you have kids.

If you smile and say, yes, I have two girls, they're wonderful, you might inadvertently trigger a massive wave of pain.

Or worse, the patient might suddenly feel like they have to protect your feelings or take care of your happiness.

You've accidentally shifted the spotlight onto your life.

Exactly.

The therapeutic response might be briefly acknowledging it, but immediately pivoting the focus back.

You might say, I do, but I know you are hurting so much right now because of the loss of your son.

Tell me more about what you're feeling today.

I see.

So the difference is the ultimate purpose of the interaction.

It's goal -directed.

Correct.

It is scientifically based and goal -directed.

We aren't hanging out.

We are working.

And this is vital because of the unique nature of psychiatric illness.

The text makes a great point here that you have to internalize.

In medsurg nursing, the symptoms are physical.

Right.

A broken femur, a heart murmur, a drop in oxygen saturation.

But in psychiatric nursing, the symptoms are communication and relationship deficits.

Wow.

The symptoms are the communication deficits.

The text lists things like extreme withdrawal, feelings of hopelessness, manipulation, or sensory distortions.

Think about it.

If a patient is actively experiencing auditory hallucinations, hearing voices, or if they're in an acute manic phase and talking a mile a minute, jumping from topic to topic, their communication equipment is broken.

That is the pathology itself.

So if you, the nurse, are just operating on your standard social defaults, you will completely crash and burn.

You need a much higher level of intentional skill to navigate their distortion.

You do.

And there's another distinction here in the text that I think trips students up constantly.

And that is the difference between assessment and therapeutic communication.

Oh, this is a big one.

I see this error all the time in clinicals.

A student comes out of a patient's room beaming and says, I had a great therapeutic conversation.

And I'll ask, okay, what did you talk about?

And they say, well, I asked how long they've been feeling depressed.

I asked what medications they're currently taking.

I asked if they have a history of trauma.

That sounds like an interrogation.

Right, it's an interview.

That is assessment.

Assessment is information gathering to meet the nurse's need for data.

You need to fill out your admission database.

You are essentially extracting resources from the patient.

Extracting, that's a harsh word, but it's accurate.

It's necessary.

We have to have that data to build a care plan, but do not call it therapeutic communication.

Therapeutic communication is an active intervention.

It is designed solely to meet the patient's need in that moment.

It's asking a question not to fill a checkbox on a form, but to help the patient explore a confusing feeling or realize a destructive pattern or simply reduce their immediate anxiety.

Okay, so if I ask, how long have you been depressed?

That is clearly assessment.

What would the therapeutic version of that interaction look like?

A therapeutic approach would sound more like you mentioned earlier that you've been feeling down for a long time.

What is it like for you when the depression gets really heavy?

Oh wow, I can physically feel the difference in those two approaches.

One is asking for a statistic, the other is an invitation to share a burden.

Exactly, one closes the file, the other opens the heart.

Now I wanna address the giant elephant in the room for anyone studying this, or maybe the elephant at the nursing station,

fear.

Yes, they need to be scariest.

Every single nursing student I've ever talked to is completely terrified of saying the wrong thing.

They think these patients are so fragile.

If I use the wrong word, I'm gonna break them.

I'm gonna somehow make their suicide risk worse or trigger a psychotic break.

It's a paralyzing fear.

And the textbook authors, Varkarolis and Fosbray, they really don't sugarcoat this at all.

They explicitly ask the rhetorical question in the text, will I say the wrong thing?

And the answer they give.

Yes,

you probably will.

Which is really not the comfort I think students are looking for.

But it's the honest reality.

You are learning a completely new language.

You are going to stumble.

You are going to ask a why question when you absolutely shouldn't.

You are gonna interrupt a silence too early.

But, and this is the massive neon sign, but in this chapter, the text emphasizes that saying the wrong thing is rarely harmful.

If your underlying intent is honest, respectful and compassionate.

So the patient isn't sitting there grading your grammar or your textbook technique.

They are fundamentally reading your intent.

Human beings are incredibly intuitive lie detectors.

If you are stumbling over your words, but your eyes are kind and you are leaning in and you clearly genuinely wanna understand and help them, the patient will almost always forgive the clumsy phrasing.

They feel the underlying process, which we'll get to much more than the literal content of your words.

That is such a relief.

It's not a magic spell.

You don't have to pronounce the words perfectly or the potion explodes.

You just have to truly care and be present.

But you do have to actively try to get better.

You can't just care and stay unskilled forever.

You have to learn the framework.

Right, so let's look at the mechanics of how this communication actually works.

The text brings up a classic theoretical framework,

Berlo's model from 1960.

David Berlo.

It's a really elegant communication theory.

SMCR, Source Message Channel Receiver.

Let's break this down for you, but I wanna apply it to a real psych ward scenario because abstract models in textbooks can be a little dry.

Deal, let's ground it.

Okay, let's say we have a patient.

Let's call him Mr.

Jones.

He's highly anxious.

He's pacing up and down the hallway.

He's the sender in this model, right?

In this specific moment, yes.

There was a stimulus, which is his internal anxiety.

That stimulus triggers a need to communicate something to the outside world.

So he initiates the process.

He is the sender.

And he encodes a message.

Right, now the message might be clear.

He might say, I am feeling very anxious.

Or because of his illness, it might be coded.

He might say, is the doctor coming?

Is the doctor coming?

Over and over again.

The text notes that the formulation of the message is heavily affected by personal factors.

His current mood, his background, his cognitive ability in that moment.

If he's in a manic episode, the message might literally be a disorganized word salad.

Then we have the media or the channel.

And we're not talking about television here.

No, it's the physical sense used to transmit the message.

Auditory, visual, tactile, olfactory.

Now think about the typical psych ward environment.

This is where Berlo's model gets really practical.

What creates noise in that channel?

While alarms are beeping down the hall, other patients might be yelling or crying.

The TV is blaring in the common day room.

The fluorescent lights are buzzing.

Exactly.

So Mr.

Jones is sending an auditory message, but the channel is completely jammed with environmental interference.

And then we finally have the receiver, which is you, the nursing student.

And I have my own internal noise happening.

You absolutely do.

You're stressed about your clinical grade.

You're hungry because you missed breakfast.

Maybe you have an unconscious bias that pacing patients are dangerous.

That is your personal factor filter.

So the message has to survive his disorganized encoding, travel through a noisy, chaotic channel, and make it past my biased, stressed out decoding process.

It's honestly a miracle we understand each other at all.

It really is a miracle.

And that's exactly why the final step of Berlo's model feedback is totally non -negotiable in nursing.

The text refers to this specifically as validation.

You cannot ever just assume you understood the message correctly.

You have to actively loop it back to the sender.

You have to say, Mr.

Jones, you keep asking about the doctor, but I notice you seem very restless pacing the hall.

Are you feeling anxious right now?

You have to check if the message you receive actually matches the message he intended to send.

If you skip this validation step, you are just guessing you are not nursing.

The text also heavily emphasizes relationship factors in this communication model, specifically the difference between symmetrical and complementary relationships.

This is all about power dynamics.

A symmetrical relationship is between equals, friends, colleagues, siblings.

We generally have the same status and authority.

A complementary relationship involves an inherent inequality in status or power.

One person has more control, knowledge, or authority.

And the nurse -patient relationship is always complementary.

It has to be.

And I know modern nursing philosophy is all about partnership and patient empowerment.

We really wanna feel like equals with our patients.

But we have to be intellectually honest here.

You have the keys to the unit.

You control the medications.

You get to go home at 7 p .m.

and they cannot leave.

You have the legal authority to place them in restraints if it becomes absolutely necessary.

So if we pretend that massive power difference doesn't exist, we're actually just confusing the patient.

Exactly.

If you act like a buddy, trying to force a symmetrical dynamic, but then 30 minutes later, you have to enforce a unit rule, like no phones during group therapy, enforcing a complementary dynamic,

the patient feels incredibly betrayed.

They think, I thought we were friends.

Acknowledging the professional hierarchy while still being deeply respectful and compassionate actually creates psychological safety.

It sets clear, predictable boundaries.

That makes so much sense.

Now I wanna move to the part of the chapter that I found honestly the most jarring, the ratio of verbal to nonverbal communication.

The statistics here are very humbling for anyone who likes to talk a lot.

The text says, verbal communication, the actual literal words we obsess over choosing accounts for only five to 10 % of the message.

Five to 10%, let that sink in.

That means if you write down a perfect transcript of what you said to a patient, you have captured less than a 10th of the actual interaction.

Which leaves up to 95 % for nonverbal communication.

Tone of voice,

pitch, pacing of your speech,

use of silence, your posture, eye contact, facial expressions, even your gait as you walk into the room.

The text categorizes the verbal part as the content and the nonverbal part as the process.

A good way to think of it is that content is the lyrics of a song.

Process is the music.

Oh, I really like that analogy.

You can sing the words I love you to the tune of a soft, sweet, acoustic guitar.

And it clearly means love.

But you can take those exact same lyrics, I love you, and scream them to the tune of aggressive death metal.

And it means something entirely different.

The lyrics, the content, didn't change at all.

But the music, the process, changed the entire reality of the message.

Yeah, when the lyrics fit the music perfectly, that's what the book calls a congruent message.

Right, if a student says, I'm really worried about passing this exam, and they're visibly frowning, looking pale, and their voice is literally shaking, the content and process align perfectly.

It's a healthy, easy -to -read communication.

But the danger zone in psychiatry is when they don't match.

Incongruent or double messages?

Mixed messages.

The lyrics say one thing, but the music says the exact opposite.

The text provides this vignette about a mother and daughter that is just, it's physically painful to read.

It's a perfect example of the double bind.

Can we walk through this for everyone?

Please, it's a classic, almost archetypal psychiatric dynamic.

So a teenage daughter wants to go out with her friends for the evening.

She goes and asks her mom.

The mom is chronically ill, but she's not helpless.

The mom says, and these are the exact words, oh, that's okay, go ahead, have fun.

I'll just sit here by myself.

Okay, let's stop right there.

The literal content, the verbal message, is you have my permission to go out.

But the text explicitly describes her nonverbal behavior while she says this.

She speaks very slowly.

Her tone is deeply martyred.

She slumps down heavily in her chair.

She lets her cane drop to the floor with a loud clatter.

And she looks profoundly sad.

Right, so the process, the music, is screaming, if you leave me here alone, you are a terrible selfish daughter and I will suffer immensely because of you.

It's a total trap.

It is a profound cognitive trap.

It's called the double bind because the receiver, the daughter, is bound and trapped no matter what choice she makes.

If the daughter goes out, she is consumed by guilt because she knows her mom is sad.

If the daughter decides to stay home, the mom could just say, why did you stay?

I literally told you to go have fun.

The mom wins the power struggle either way and the daughter loses either way.

It puts the receiver in a completely no -win situation.

This happens in families all the time, but it obviously happens with patients on the unit too.

A patient might look at you and say, I'm fine, everything is just great.

While they are clenching their fists so hard, their knuckles are turning white.

Exactly,

so knowing this 90 % rule, what does the skilled nurse do?

Do you listen to the words or do you listen to the fists?

You absolutely have to listen to the fists.

You have to therapeutically address the incongruence.

This is a core clinical skill.

Now, you don't aggressively call them a liar.

You don't say you're not fine.

You reflect and validate.

You say, Mr.

Smith,

you're saying you're fine, but I notice your fists are clenched tight and your jaw is tense.

That usually means someone is upset or angry.

Can you help me understand what's happening right now?

You validate the reality of their non -verbal behavior.

You bring the music into the open discussion.

Exactly, you make the implicit completely explicit.

That is the heart of therapeutic communication.

Okay, I wanna pivot to the toolbox.

This is part four of our deep dive.

These are the specific evidence -based tools Varkarolis and Fosbury give us to actually do this work.

And I wanna role -play these a bit because reading definitions from a textbook is pretty dry.

Let's do it.

Role -playing is the only way to really learn it.

The very first tool they list is silence.

And I have to say, as a host who talks into a microphone for a living, silence is my absolute enemy.

Dead air is a mistake.

In everyday social life, silence is incredibly awkward.

If we just stop talking right now for 10 straight seconds, the listeners would assume their podcast app crashed and check their phones.

Exactly, we rush to fill the void.

But in a clinical psychiatric setting,

silence is an absolute powerhouse of a tool.

The text is very clear that silence is not an absence of communication.

It is a specific active channel for transmitting messages.

Why does it work so well though?

Why isn't it just seen as the nurse being lazy or ignoring the patient?

Two big reasons.

First is simply processing time.

Many psychiatric medications cause cognitive slowing as a side effect.

Major depression literally causes psychomotor retardation.

It physically takes longer for their neurons to fire, formulate a thought, and turn it into a spoken sentence.

If you ask a question and don't get an answer in two seconds and you anxiously jump in with another question to fill the void, you've just cut their wire while they were actively trying to send the signal.

So you have to just wait.

You have to learn to sit comfortably in the awkwardness.

You have to embrace the awkwardness.

By staying silent but attentive, you are non -vobally saying I have time.

You are worth waiting for.

I am not rushing you.

It serves as a huge support for patients who lack confidence in their own thoughts.

The text does give a warning though about what it calls icy silence.

Yeah, you don't wanna just stare them down without blinking.

That's perceived as aggression or anger.

The silence has to be expectant and warm.

You maintain soft eyes, maybe a slight nod, and an open, relaxed posture.

Next tool in the box is active listening.

Now this sounds like a corporate buzzword.

Oh, I'm actively listening.

What does that actually mean in a nursing context?

It means you are engaging your entire brain in the interaction.

You aren't just acting as a physical recording device for their words.

You're actively observing their non -verbal behaviors.

You're listening for false notes or inconsistencies in their story.

And this is by far the hardest part.

You are engaging in constant self -regulation.

The textbook calls this quieting oneself.

Yes,

you have to actively tell your own internal monologue to shut up.

You cannot be thinking about your lunch break or the fact that your feet hurt or planning what brilliant thing you're gonna say next.

You have to be completely psychologically and emotionally present because if you are faking it, psychiatric patients will know instantly their radar for inauthenticity is incredibly high.

Okay, let's get into the verbal techniques, the clarifying techniques, the text lists, paraphrasing, restating, reflecting of feelings and exploring.

I'm gonna play the role of a newly admitted patient.

You play the nurse.

Show me the difference between these tools.

Okay, I'm ready.

Lay it on me.

Scenario is I just got admitted to the unit.

I'm sitting on my bed and I say, I just don't know why I'm here.

My whole life is a mess.

Absolutely nothing is going right for me.

Okay,

first tool is paraphrasing.

This is summarizing your basic content in fewer words.

I might look at you and say, so in other words, you're feeling like everything in your life is chaotic right now and you're really unsure about this hospital admission.

Okay, as a patient that feels like a solid check -in.

It tells me you heard the facts of what I said.

Right, it validates the content.

Now let's try restating.

This involves mirroring your exact key words back to you to prompt you to elaborate.

You said my life is a mess.

I might simply say your life is a mess.

Oh, that immediately forces me to explain how it's a mess.

I can't just leave it at that.

Exactly, it's very gentle nudge to keep going.

But a big warning here from the text, do not overuse restating.

If you do it too much, you just sound like a mechanical parrot.

I'm sad, you're sad, I'm hungry, you're hungry.

It gets incredibly annoying and condescending very fast.

I can definitely see that.

Okay, what about reflecting of feelings?

This one digs much deeper.

I'm gonna slightly ignore the literal facts you gave and focus entirely on the emotional tone.

I might say you sound as if you have had so many disappointments recently and you're feeling completely overwhelmed.

Wow, that hits way harder.

That makes me feel seen on an emotional level, not just a factual one.

Exactly, it helps the patient actually identify and own their feelings, which they often can't do on their own.

And finally, we have exploring.

This is what I use when I need more specific details.

I might say you mentioned that nothing is going right.

Give me an example of one thing that happened this past week.

Give me an example.

That seems like the magic phrase.

It absolutely is.

It cuts right through vague global complaints.

Saying everything is bad is impossible for us to treat.

Saying my boss fired me on Tuesday is a specific stressor that we can actually work with in therapy.

Exploring examines ideas much more fully.

I really wanna touch on the advanced question section because these seem really fascinating.

They list the projective question and the presupposition question, which they call the miracle question.

These are fantastic advanced tools for breaking through a patient's stuckness.

The projective question usually starts with a what if.

Like if you had three wishes, what would they be?

Why do we use something that sounds like a fairy tale?

Because patients, especially those with chronic depression or trauma,

constantly censor their own desires.

They truly believe they can't ever have what they want, so they won't even say it out loud.

By framing it as a complete fantasy, if you had a magic wand, you bypass that harsh internal censor.

You find out what their core values and true goals are.

And the miracle question.

This one goes, suppose you woke up tomorrow morning and a miracle happened while you were sleeping and this entire problem was gone.

What would be different in your life?

This technique actually comes from solution -focused brief therapy.

It is designed to abruptly shift the patient's brain from problem mode directly into solution mode.

How does that actually work neurologically?

When you are severely depressed,

your brain is caught in an endless loop focusing on the pain and the obstacles.

The miracle question forces your brain to vividly visualize a specific future where the pain is absent.

The patient might answer, well, I would actually get out of bed.

I would make myself pancakes.

I would finally call my sister back.

And suddenly, as the nurse, you have a concrete roadmap.

You can say, okay, let's work on calling your sister today.

It identifies motivation.

I love that so much.

It's not just a clever parlor trick to make them talk.

It's forcing a neurological shift toward hope.

Exactly, it's incredibly evidence -based.

Now we have to pivot to the dark side of the chapter, part five, the non -therapeutic techniques, the traps.

The long list of things we do every day socially that are actually toxic clinically.

And just for context here, the text points out that medical errors stemming from miscommunication are a leading cause of death, third leading cause behind heart disease and cancer.

So bad communication isn't just rude, it's dangerous.

The biggest trap on this list, and honestly, the one I struggle with the most is the why question.

Ah, the dreaded why.

But wait a second.

In journalism, in science, in police work, why is literally the most important question you can ask?

Why did this happen?

Why is the sky blue?

Why on earth is it forbidden in nursing?

Because context is absolutely everything.

In a scientific investigation, why him seeks an objective cause?

In an interpersonal relationship, especially a vulnerable one, why inherently implies criticism and judgment?

Demonstrate this for me.

Ask me a why question right now.

Okay, you were a few minutes late to the recording studio today.

Why were you late?

Well, I mean, traffic was really bad on the interstate and I had to stop to get coffee for us.

I didn't mean to hold things up.

Do you see what just happened?

You instantly got defensive.

You felt - I really did.

I felt exactly like a kid sitting outside the principal's office.

That is exactly what the word why does to a psychiatric patient.

Why are you so anxious?

Why did you stop taking your meds?

Why did you smash that chair in the day room?

It demands a logical justification that they probably don't even have.

It forces them into a corner and makes them defensive.

So how do I get that crucial information without using the word why?

You swap it out for what?

Instead of asking why were you late, I should say what happened that delayed you this morning.

Oh, traffic was just crazy on I -95.

See?

I get the exact same information, but without triggering your defensiveness.

Instead of why did you smash the chair, you ask what was happening right before you smashed the chair.

It invites a narrative story, not a defensive excuse.

That is a very subtle but incredibly powerful shift.

Okay, let's look at the next trap.

Giving approval or disapproval?

Saying things like I'm so proud of you or you did a really good job.

Again, I have to push back here.

Positive reinforcement is a good thing.

If a severely depressed patient hasn't showered in a week and they finally take a shower, shouldn't I be encouraging?

Shouldn't I say good job?

I'm so proud of you.

That feels so right to say that, doesn't it?

But here is the massive danger.

When you do that, you shift the patient's locus of control.

Break that down for us.

What does that mean?

If I tell you I am proud of you, you're now doing the healthy behavior to please me.

You're seeking my external approval.

But what happens when my shift ends?

What happens next week when you get discharged and I'm out there to praise you?

If the external validation disappears, the behavior usually stops entirely.

Ah, I see.

It inadvertently fosters dependency on the nurse.

Yes.

We desperately want the patient to be proud of themselves.

We want to build internal motivation.

So instead of saying, I'm proud of you, you focus on their experience.

You say, I noticed you took a shower today.

How did that feel for you?

And they might say, it actually felt really good to be clean for once.

Boom, now they have identified their own internal reward.

They own the victory themselves, not you.

That is so much harder to do in the moment though, because saying I'm proud of you just slips out so automatically.

It really does.

You have to actively practice biting your tongue to catch it.

There's another trap here.

Advising, telling a patient you should leave your abusive husband or you really should stop drinking.

The tyranny of the shoulds.

Here is the fundamental problem with giving advice.

If your advice works out perfectly, you get all the credit, which doesn't help their self -esteem.

But if it fails, you get all the blame.

Right, they come back and say, nurse, I left my husband exactly like you said and now I'm completely homeless and broke.

This is entirely your fault.

Exactly.

You took on liability for their life choices.

And more importantly, simply telling someone what to do implies that they're completely incapable of solving their own problems.

It is deeply disempowering.

The therapeutic approach is to help them analyze it.

You ask, what do you see as some of the possible pros and cons of staying with your husband?

You help them solve the puzzle themselves.

The text also briefly mentions a few other traps, like minimizing feelings, saying, oh, everyone gets down sometimes,

or falsely reassuring, telling them everything will be just fine when you don't know that, or changing the subject because you as the nurse are uncomfortable.

All of those are just ways for the nurse to escape an uncomfortable emotional moment.

They shut down the patient's expression completely.

Let's move on to part six of the chapter.

Communicating across cultures.

The authors spend a lot of time on what they call cultural filters.

We all have them.

A cultural filter is just the lens through which we view and interpret the world.

It dictates what we notice and what we ignore.

The extreme danger in nursing is when we unconsciously assume our specific filter is the universal truth, and anyone acting differently is exhibiting pathology.

The text highlights four major problematic areas here.

Communication styles, eye contact, touch, and the filters themselves.

I wanna really dig into communication styles and eye contact because it seems like these directly lead to dangerous misdiagnoses.

They absolutely do.

Let's look at communication styles first.

Now the text makes some broad cultural generalizations here to prove a point, and obviously every single individual is unique, but it notes that in some Hispanic cultures, a highly emotional, intensely dramatic style of communication is considered perfectly normal.

It's simply how you show you care about an issue.

So a nursing student from a very low emotion culture, say a stereotypical British or German background,

might see that dramatic expression in the ER and think, what?

They might write on the chart, patient is highly labile, potentially manic,

completely out of control.

They literally see psychiatric pathology where there is only a normal cultural expression.

And it works the exact opposite way too.

Yes, in many Asian cultures, emotional restraint and stoicism are highly valued.

Openly expressing intense negative emotion might be considered bad taste or a burden to others.

So a Western nurse might look at a stoic patient who just experienced a trauma, and chart patient has a flat effect, is withdrawn, not engaging in treatment.

When in reality they are suffering deeply, but just expressing it respectfully according to their culture.

Correct, the unexamined cultural filter leads to massive false positives and false negatives in psychiatric diagnosis.

And what about eye contact?

This one is huge.

This is a classic trap.

In mainstream Western US culture, we teach children from birth, look me in the eye when I'm speaking to you.

We associate direct eye contact with honesty, attention and self -confidence.

But in many other cultures, the text mentions Hispanic, Asian and Native American cultures.

Staring directly into the eyes of an authority figure like a doctor or a nurse is considered incredibly disrespectful and aggressive.

You look down to show proper deference and respect.

So the novice nurse thinks, wow, he won't look at me, he's shifty, he's definitely hiding something or he's paranoid.

But the patient is sitting there thinking, I am honoring this nurse's authority.

Total catastrophic communication breakdown.

You simply have to know who you're talking to and adapt your filter.

They also cover touch.

The difference between high touch cultures like Italian or French where touch equals warmth and low touch cultures where touch is highly intrusive.

But they give a really stark warning about the no touch policy in psych facilities.

Yes,

as a baseline rule, always check your specific facilities policy.

Especially with children, adolescents or patients with a severe trauma or abuse history, a well -meaning hand on the shoulder can trigger a massive PTSD flashback or be interpreted as an aggressive threat.

Touch is very high risk in psych.

The chapter also explicitly mentions LGBT considerations.

Yes, they highlight affirmative psychotherapy.

This is a crucial trend because individuals in the LGBT community often face immense rejection, harsh societal judgment and healthcare discrimination.

The nurse's role isn't just to be neutral, but to actively validate and advocate for these individuals ensuring the clinical environment is explicitly safe and affirming.

Let's quickly touch on technology, part seven of the outline, using telehealth and mobile apps.

It's absolutely the new frontier of psychiatric nursing.

Telehealth using video and internet is amazing for eliminating physical barriers.

If you live in a rural area or lack transportation, you can still get care.

The text notes the Department of Defense uses it heavily for treating soldiers with PTSD and depression who might never voluntarily walk into a crowded VA clinic.

But there's a dark side to the apps, right?

There is.

Mobile smartphone adoption is huge.

And there are some great apps out there.

The Substance Abuse and Mental Health Services Administration, SAMHSA, has a great suicide prevention app called Suicide Safe.

But the downside is the wild west nature of the app store.

There are thousands of mental health apps available that have absolute zero clinical data or research proving they actually work, plus massive privacy and confidentiality issues with patient data being sold.

Just because an app claims to treat anxiety doesn't mean it's therapeutically sound.

Okay, as we wrap up this deep dive, we get to part eight.

Evaluation of skills.

How do you actually know if you're getting better at this?

The text offers a tool called the Facilitative Skills Checklist.

I love a good checklist.

This takes all these abstract floating ideas like be therapeutic or show empathy and breaks them down into concrete, measurable behaviors.

How does a student actually use this?

It's for self -reflection.

After a patient interaction, you sit down and rate yourself from strongly agree to strongly disagree on specific statements.

Things like I maintain good eye contact.

I encourage others to talk about their feelings.

I avoid asking why questions.

I can accurately summarize basic ideas.

So it turns the mysterious art of communication into a measurable practice.

Exactly.

The ultimate goal is to move from awkwardly applying mechanical techniques to developing a highly natural internalized therapeutic style.

You rate yourself, you catch your bad habits and you adjust for the next patient.

So to summarize our journey today, we've covered the fundamental shift from being a social talker to a therapeutic professional.

We explored the massive 90 % power of nonverbal communication and the danger of double messages.

We opened up the toolbox to find silence, active listening and validation.

And we learned to dodge the traps of judgment, false reassurance and advice.

It is a massive amount of information.

But if you take only one single thing away from this entire chapter, let it be the concept of your intent.

If your intent is truly compassionate, you will find your way.

We like to end with a final provocative thought for you to mull over.

The text leaves us with a profound realization about that cultural filter we discussed.

It says that we literally cannot listen in a completely unbiased way.

It is biologically and socially impossible.

We are human.

We all have bias baked into us.

So the challenge for you, and I really want you to try this in your very next clinical conversation, is to ask yourself, what am I ignoring right now simply because of my own filter?

Am I ignoring the clenched fist because I'm so relieved they are smiling at me?

Am I ignoring their deep pain just because their cultural face is stoic?

That is the exact question that forces you to grow.

It makes you a better psychiatric nurse and honestly just a much better human being.

Absolutely.

Thank you so much for diving deep with us today into the medium of nursing practice.

Thank you.

It was a pleasure.

On behalf of the last minute lecture team, thanks for listening.

See you next time.