Case study background
You are a student nurse doing capstone in an acute-care mental health unit. Your preceptor, Joan has been quite busy the first couple of hours of the shift.
Now the charge nurse tells Joan that the unit is getting a new admission and asks if she would please take it. Joan looks frustrated, but says, “Sure, I’ll be glad to.”
After the charge nurse leaves, Joan tells you, “I don’t know how we are going to do another admission. I just finished charting on the one we got at the first of the shift!” You reassure her that you will help as much as possible.
Joan lets you take report on the new patient. The nurse in the other hospital’s Emergency Department gives a quick report. “We are really busy, so this will be fast,” she says.
You ask what questions you can think of, but wish you knew more. Joan had to go get something for one of her other clients. The ED is about 2 hours away, so you are hoping it will give Joan time to get caught up. Here is the report the ED nurse gave you. You write it out in a more legible way so that you can tell Joan when she gets back from the client’s room.
Client name: Robert S.
Diagnosis: depression and anxiety
Issue: thoughts of suicide
Home medication: amitriptyline
Allergies: none
Medications given in the ED: none
After you show Joan the ED nurse’s report, she says, “We had better go check on our other patients before we get the new one.”
You look down at the report sheet you received at hand-off report. You and Joan have 3 patients. Here is what the report sheet says.
Room 3
Devin A., 54-year-old male, diagnosed with post-traumatic stress disorder and obsessive-compulsive disorder, most recent medication given was lorazepam prn.
Room 4A:
Matthew M., 49-year-old with bipolar disorder, currently has depression and some suicidality.
Room 4B
Samuel J., 37-year-old with depression, has been using a monoamine oxidase inhibitor antidepressant medication at home, which the psychiatrist wants to change to another medication.
Joan and you didn’t get very much time with Devin, the client who came right at shift change. The nurse had just asked questions quickly and the client didn’t seem to want to talk. She finished entering her assessment at the computer at the nurses’ station.
Joan says to you, “I don’t want to go back into Devin’s room. He won’t talk to us anyway. Just go see how he is and if he needs anything while I go see the other two patients and do my shift assessments on them. They are both in the same room so it shouldn’t take me long.”
You remember how Joan spoke with the new client while admitting him. She was looking down at an intake form without any eye contact while she asked questions. She did not smile at the client but had a serious look on her face. You were sitting off to the side observing since you had not seen an admission done before. Joan had asked closed-ended questions. Whenever the client gave an additional comment, Joan changed the subject to continue the intake assessment. She closed the interview by saying, “It’s going to be all right, so don’t worry about a thing.”
Before going back into the new client’s room, you consider ways to get him to talk with you. In your mental health class, you have been discussing therapeutic communication techniques. You decide to start with a question.
Student nurse: “Hello, Devin.” You sit down in the chair near the client’s bed. He is lying down.
Devin: says nothing, but looks at you.
Student: “How is everything going?”
Devin: “That’s a pretty big answer. Are you sure you have time to hear it?”
Student:: “I have the time, and I really want to know. It’s a big answer, huh?”
Devin: “Yeah.”
Devin sits up in bed and leans his back against the wall so he can face you. He explains how his day went and why he ended up in the ED and then in the mental health unit. You keep him talking by saying things like, “Go on,” and, “Please tell me more about how you felt about that.”
You maintain eye contact throughout the conversation. At one point Devin stops talking. You look at his face and get the feeling that he isn’t really finished, but that he’s just thinking through his words before saying more. You keep quiet while he does and resist the temptation to talk then let him continue when he wants to.
https://youtu.be/QwfvDB9sfLw
After visiting with Devin, you are surprised to notice that you’ve been in his room about 40 minutes. At the nurses’ station Joan is typing at the computer. “Almost done with my documentation on 4A and 4B,” she says. She seems more relaxed than before.
You ask her, “What else do you need me to do?”
Joan says, “Let’s give our medications before our new patient gets here.” She saves her work then rushes to the medication room and you follow.
She gets the medications ready and double checks them with you. Then you administer medications to your three clients. As you give the medications you explain each of them to the clients and ask if they have any questions. One of your clients, Samuel J., seems unsure about his medication.
Before administering it, you go back to the medication room to check his medication record to see if there is a discrepancy. Samuel’s medication, phenelzine, looks like it has been discontinued. You go back to the client.
Student nurse: “Did the doctor discontinue your phenelzine?”
Samuel: “Yes, he told me that he would have me stop taking it for two weeks and then start me on another antidepressant.”
Student nurse: “The provider said that you will not be taking phenelzine for two weeks, starting today, then you’ll begin another medication for your depression after that. Is that right?”
Samuel: “That is correct. Hey, I’m kind of hungry, do you think I could have some string cheese? I’ve been wanting some of that for awhile.”
You assign another staff member get the snack for the client while you go report to Joan about the discontinued medication.
Answer the following questions regarding the case study.
Discuss the Nurse-Client relationship that the nurse and student nurse were developing with their clients. (Chapter 5)
What therapeutic communication and listening techniques were used? Please give an example of each you see from the case study. Also give the rationale of why each technique is therapeutic. (Chapter 6)
Which non-therapeutic communication techniques were used and what are the rationales of why they should not be used? Give examples for each from the case study. (Chapter 6)
What body language did you notice in the interactions described?
For each of the 3 medications mentioned in the case study, tell what is the medication class, therapeutic use, special considerations and teaching to include.
Did you notice any safety issues in this case study?
What should have been done differently, or what suggestions for improvement do you have for either the nurse or the student nurse?
The relationships between the nurse, the student nurse, and their clients reflect varying levels of professionalism, empathy, and adherence to therapeutic principles. Effective nurse-client relationships are based on trust, respect, empathy, and therapeutic communication. In this case study, Joan’s interactions are somewhat mechanical and task-oriented, which may hinder the development of trust and rapport. For instance, Joan’s approach to Devin during his intake assessment involved closed-ended questions and a lack of eye contact, which may have made him feel undervalued and discouraged open communication.
Conversely, the student nurse displayed a more patient-centered and empathetic approach. By sitting near Devin, maintaining eye contact, and actively listening, the student nurse demonstrated respect and genuine interest in his experiences. This interaction encouraged Devin to open up and share his thoughts, illustrating the importance of creating a safe and supportive environment. According to Peplau's Theory of Interpersonal Relations, such therapeutic engagement fosters the client’s trust and facilitates their movement through the phases of orientation, working, and resolution.
Several therapeutic communication techniques were evident in the case study, primarily in the student nurse’s interaction with Devin.
Active Listening:
The student nurse maintained eye contact, nodded, and used verbal cues like “Go on” and “Please tell me more.” This demonstrated attentiveness and encouraged Devin to continue sharing. Active listening is therapeutic because it conveys genuine interest and validates the client’s feelings, which is essential in building rapport.
Reflection:
When Devin said, “That’s a pretty big answer. Are you sure you have time to hear it?” the student nurse responded, “I have the time, and I really want to know. It’s a big answer, huh?” This mirrored Devin’s words and emotions, showing empathy and encouraging him to elaborate further.
Silence:
The student nurse resisted the urge to interrupt when Devin paused to gather his thoughts. Silence is therapeutic as it provides space for clients to process and articulate their thoughts, fostering a deeper exploration of their feelings.
Therapeutic communication techniques like these create a nonjudgmental and supportive atmosphere, allowing clients to feel heard and understood. This fosters trust and opens pathways for effective intervention, particularly in mental health settings.
Some non-therapeutic communication techniques were used in the case study, primarily by Joan, and these could have undermined the nurse-client relationship.
Using Closed-Ended Questions:
Joan’s reliance on closed-ended questions during Devin’s intake limited the depth of his responses and conveyed a lack of interest in his broader experiences. For example, she focused solely on completing the intake form without exploring his emotional state. This approach can make clients feel dehumanized and hesitant to engage further.
False Reassurance:
Joan concluded the intake by saying, “It’s going to be all right, so don’t worry about a thing.” While intended to comfort, this statement dismisses the client’s feelings and fails to address the underlying issues, potentially leading to mistrust.
Non-therapeutic communication techniques can create barriers to effective interaction by invalidating the client’s emotions or discouraging open dialogue. For mental health clients, such approaches may exacerbate feelings of isolation or helplessness.
Body language played a significant role in shaping the interactions described in the case study. Joan’s lack of eye contact and serious demeanor during Devin’s intake likely communicated disinterest or detachment, which may have negatively impacted his willingness to share.
In contrast, the student nurse’s use of open body language—sitting near the client, maintaining eye contact, and leaning slightly forward—conveyed attentiveness and empathy. These nonverbal cues complemented the student nurse’s verbal communication, reinforcing a supportive and caring presence.
The case study mentions three medications: amitriptyline, lorazepam, and phenelzine. Each has distinct therapeutic uses and considerations:
Several safety issues emerged in the case study:
This case study highlights the complexities of nursing practice in acute-care mental health settings, emphasizing the critical role of communication, safety, and empathy. While the student nurse demonstrated commendable therapeutic skills, Joan’s interactions revealed areas for growth. By addressing these gaps and implementing systemic improvements, the quality of care can be enhanced, leading to better outcomes for clients like Devin, Matthew, and Samuel. Statistical evidence supports that improved nurse-client communication reduces hospital readmissions and enhances patient satisfaction, underscoring the importance of these practices in mental health care.
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