Nursing Interventions *denotes collaborative interventions

Rationale

Introduce yourself to the client. Explain your role on the unit or within the treatment team.

An introduction and explanation will help the client know what to expect from you, other staff, and the hospitalization.

Assess the client’s behavior, attitudes, problems, and needs.

Baseline data are essential for developing a plan of nursing care.

Obtain the client’s perception of his or her problems and what the client expects to gain from the relationship or hospitalization.

The client’s actions are based on his or her perceptions, which may or may not be the same as other people’s perceptions or objective reality.

Make your expectations for the relationship clear to the client.

Defining your expectations helps the client identify his or her role and understand what is expected of him or her.

Be honest in all interactions with the client. Avoid glossing over any unpleasant topics or circumstances. Take a matter-of-fact approach to such problems as commitment, legal difficulties, and so forth.

Honesty is essential if a trusting relationship is to develop. You are not doing the client a favor by avoiding unpleasant areas; the client will need to deal with these problems. You show that you are trustworthy by discussing these issues without judging or rejecting the client.

Let the client know that you will work with him or her for a specified period of time and that the relationship will end when the client is no longer in treatment.

Explaining the time limitations helps to set the limits of the professional relationship. It also conveys your positive expectation that the client will improve and leave the hospital.

Show the client you accept him or her as a person by initiating interactions, remaining with the client in silence, using active listening, and so forth.

Conveying acceptance can help the client feel worthwhile. It is possible to accept the client yet not accept “negative” or undesirable behaviors.

Encourage the client to interact with other staff and clients. Avoid becoming the only one the client can talk to about his or her feelings and problems.

Becoming the sole confidant of the client may seem flattering, but it may be manipulative on the part of the client, and it inhibits the client’s ability to form relationships with others.

Let the client know that pertinent information will be communicated to other staff members. Do not promise to keep secrets (e.g., from other staff) as a way of obtaining information from the client.

A promise of keeping secrets is not one you can keep. The client has a right to know how information is communicated and used in his or her treatment.

Be consistent with the client at all times.

Your consistency demonstrates that you are trustworthy, and it reinforces limits.

Set and maintain limits on the client’s “negative” or unacceptable behavior; withdraw your attention from the client if necessary when it is safe to do so.

Lack of attention can help extinguish unacceptable behavior. The client’s safety and the safety of others are priorities.

Do not allow the client to bargain to obtain special favors, avoid responsibilities, gain privileges, or otherwise subvert limits.

Allowing bargaining permits the client to be manipulative and undermines limits and trust.

Give attention and positive feedback for acceptable or positive behavior.

Desirable behaviors increase when they are positively reinforced.

When limiting the client’s behaviors, offer acceptable alternatives (e.g., “Don’t try to hit someone when you’re angry—try punching your pillow instead.”). See “Key Considerations in Mental Health Nursing: Limit-Setting.”

By offering alternative ways to express feelings, you teach acceptable as well as unacceptable behavior. The client is more likely to abandon old behaviors if new ones are available.

Establish a regular schedule for interacting with the client (such as 1 hour each day or 10 minutes every hour), whatever fits your schedule and the client is able to tolerate.

Regular schedules provide consistency, which enhances trust. The client also can see that your interest in him or her continues.

At the beginning of your interaction with the client, inform him or her of how much time you have to spend. If you must interrupt the interaction, tell the client when you expect to return.

Discussing your schedule conveys your respect for the client and lets the client know what to expect from you.

Do whatever you say you will do, and, conversely, do not make promises you cannot keep. If extenuating circumstances prevent you from following through, apologize and honestly explain this to the client. Expect the client to be disappointed or angry; help him or her to express these feelings appropriately, and give support for doing so.

The client must know what to expect and will trust you more when you follow through. Extenuating circumstances that necessitate a change of plans happen in everyday life; the client has the opportunity to deal with the frustration or disappointment that may ensue in an acceptable manner.

Teach the client social skills. Describe and demonstrate specific skills, such as eye contact, attentive listening, nodding, and so forth. Discuss the types of topics that are appropriate for social conversation, such as the weather, news, local events, and so forth.

The client may never have learned basic social skills and how to use them appropriately.

Help the client identify and implement ways of expressing emotions and communicating with others.

The client’s ability to identify and express feelings and to communicate with others is impaired.

Assist the client in identifying personal behaviors or problem areas in his or her life situation that interfere with relationships or interactions with others.

The client must identify what behaviors or problems need modification before change can occur.

Teach the client a step-by-step approach to solving problems: identifying the problem, exploring alternatives, evaluating the possible consequences of the alternative solutions, making a decision, and implementing the solution.

The client may be unaware of a logical process for examining and resolving problems.

Assist the client in identifying more effective methods of dealing with stress. Teach the client basic stress management techniques, such as conscious breathing and relaxation, moderate physical activity, and so forth.

The client may be dealing with stress in the most effective way he or she can and may need to learn new skills and behaviors.

Anticipate the client’s anxiety or insecurity about being discharged from the hospital and terminating the therapeutic relationship, including the possibility that the client may revert to manipulative behavior or his or her presenting problem behavior as termination approaches. Remember: The termination phase of the therapeutic relationship should begin in the introductory or orientation phase and should be reinforced as a goal and as a positive outcome throughout the entire therapeutic relationship.

Once the client is comfortable in the relationship, you may expect that he or she will perceive the end of the relationship as threatening and the beginning of other relationships as entailing risk. In addition, the termination of the relationship is a loss for the client (and for the staff).

Point out to the client that his or her success in relationships in the hospital can serve as learning experiences to be used in establishing and maintaining other types of relationships after discharge.

The client may not be aware of the steps in building relationships; you can help the client learn about relationships and build social skills by using the client’s current relationships and interactions as examples. Recognizing the client’s successes can help build confidence.

^*Assist the client in identifying sources of support outside the hospital, including agencies or individuals in the community and on the Internet, if appropriate, as well as significant others in his or her personal life.

Community support may help the client deal with future stress and avoid hospitalization.

^*Assist the client in making plans for discharge (returning home, employment, and so on). See Care Plan 2: Discharge Planning.

Making specific discharge plans enhances the client’s chances for success in the community.

Nursing Interventions *denotes collaborative interventions

Rationale

On admission, ask the client about his or her expectations for hospitalization and plans for discharge. Attempt to keep discharge plans as a focus for discussion throughout the client’s hospitalization.

Discussing discharge plans will reinforce the idea that the client’s hospitalization is temporary and that discharge is the eventual goal.

Encourage the client to identify his or her goals and expectations after discharge.

Focusing on the client’s life outside the hospital may help to diminish fears of discharge.

Help the client assess personal needs for specificity and structure. If it is indicated, assist the client in making a time schedule or other structure for activities (work, study, recreation, solitude, social activities, and significant relationships).

The client may be overwhelmed by the lack of structure in the home environment after a stay in an institution, which often is very structured and in which the client’s choices and need for decision making are limited.

Use role-playing and setting up hypothetical situations with the client when discussing discharge plans.

Anticipatory guidance can be effective in preparing the client for future situations. Role-playing and hypothetical situations allow the client to practice new behaviors in a nonthreatening environment and to receive feedback on new skills.

Teach the client about his or her illness, medications (action, toxic symptoms, and side effects), nutrition, exercise, and medical conditions requiring physical care, if needed.

The client needs health information to participate effectively in his or her own care and to achieve independence and optimal health outside the hospital.

Talk with the client regarding medication or other treatment schedules and reasons for continuing therapy. Attempt to involve the client in treatment decisions, especially regarding therapies after discharge.

The client’s participation in decisions may increase his or her motivation to continue therapies.

Talk with the client about ways to meet personal needs after discharge (e.g., obtaining food, money, shelter, clothing, transportation, and a job).

The client may need direction or assistance in making these plans.

^*Assess the client’s skills related to meeting the above needs (e.g., using a telephone and directory, managing a checkbook and bank accounts, contacting other community resources, arranging job interviews). Work with the client and obtain help from other disciplines if indicated, such as vocational rehabilitation, therapeutic education, and so forth.

The client may lack daily living skills and may need to develop and practice them before discharge.

^*Before discharge, encourage the client to make arrangements as independently as possible (e.g., find housing, open bank accounts, obtain a job). Give support for these activities. Work with other members of the treatment team to identify resources if additional assistance is needed.

The client will be leaving the support of the hospital and staff and needs to be as independent as possible.

Encourage the client to continue working toward goals that have been identified but not yet realized (e.g., obtaining a high school diploma or graduate equivalent, vocational plans, divorce). Give positive support for goal identification and work that has begun.

The client is leaving a supportive environment and may need encouragement to continue working toward goals outside the hospital.

If the client is transferring to another facility, give the client factual feedback regarding his or her progress, and discuss the need for further treatment. Point out the reasons for the transfer, if possible, such as the need for longer-term or another type of care, different treatment structure, or another location. Involve the client in the decision-making process and offer the client choices as much as possible.

It is important that the client understand the reasons for continued treatment, transfer decisions, and so forth, as much as possible. Giving the client choices or input will help diminish feelings of helplessness and frustration.

Stress that transfer to another care setting is not a punishment.

The client may see the need for continued care as a failure on his or her part.

^*Attempt to give the client information about this new environment; arrange a visit before the transfer, if possible, or provide the name of a contact person at the new facility.

Information about the new environment will help diminish the client’s anxiety.