MODULE 2 Outcomes

intimate zone

(0-18 in between people): This amount of space is comfortable for parents with young children, people who mutually desire personal contact, or people whispering. Invasion of this intimate zone by anyone else is threatening and produces anxiety.

public zone

(12-25 ft): This is an acceptable distance between a speaker and an audience, small groups, and other informal functions

personal zone

(18-36 in): This distance is comfortable between family and friends who are talking.

social zone

(4-12 ft): This distance is acceptable for communication in social, work, and business settings.

intimate relationship

A healthy intimate relationship involves two people who are emotionally committed to each other. Both parties are concerned about having their individual needs met and helping each other meet the needs as well. The relationship may include sexual or emotional intimacy as well as sharing of mutual goals. Evaluation of the interaction may be ongoing or not. The intimate relationship has no place in the nurse-client interaction.

social relationship

A social relationship is primarily initiated for the purpose of friendship, socialization, companionship, or accomplishment of a task. Communication, which may be superficial, usually focuses on sharing ideas, feelings, and experiences and meets the basic need for people to interact. Advice is often given. Roles may shift during social interactions. Outcomes of this kind of relationship are rarely assessed. When a nurse greets a client and chats about the weather or a sports event or engages in small talk or socializing, this is a social interaction. This is acceptable in nursing, but for the nurse-client relationship to accomplish the goals that have been decided on, social interaction must be limited. If the relationship becomes more social than therapeutic, serious work that moves the client forward will not be done.

closed body position

such as crossed legs or arms folded across the chest, indicate that the interaction might threaten the listener who is defensive or not accepting. A better, more accepting body position is to sit facing the client with both feet on the floor, knees parallel, hands at the side of the body, and legs uncrossed or crossed only at the ankle.

termination phase - client

Abandons old needs •Aspires to new goals •Becomes independent of helping person •Applies new problem-solving skills •Maintains changes in style of communication and interaction •Shows positive changes in view of self •Integrates illness •Exhibits ability to stand alone

functional, professional, social polite, friendship, love intimacy, sexual arousal

As intimacy increases, the need for distance decreases. Knapp (1980) identified five types of touch:

I see you are sad, I'm so sorry for you

sympathy

Attitudes

Attitudes are general feelings or a frame of reference around which a person organizes knowledge about the world. Attitudes, such as hopeful, optimistic, pessimistic, positive, and negative, color how we look at the world and people. A positive mental attitude occurs when a person chooses to put a positive spin on an experience, a comment, or a judgment. For example, in a crowded grocery line, the person at the front pays with change, slowly counting it out. The person waiting in line who has a positive attitude would be thankful for the extra minutes and would begin to use them to do deep breathing exercises and to relax. A negative attitude also colors how one views the world and other people. For example, a person who has had an unpleasant experience with a rude waiter may develop a negative attitude toward all waiters. Such a negative attitude might cause the person to behave impolitely and unpleasantly with every waiter he or she encounters. The nurse should reevaluate and readjust beliefs and attitudes periodically as he or she gains experience and wisdom. Ongoing self-awareness allows the nurse to accept values, attitudes, and beliefs of others that may differ from his or her own. Box 5.2 lists questions designed to increase the nurse's cultural awareness. A person who does not assess personal attitudes and beliefs may hold a prejudice or bias toward a group of people because of preconceived ideas or stereotypical images of that group. It is not uncommon for a person to be ethnocentric about his or her own culture (believing one's own culture other to be superior to others), particularly when the person has no experience with any culture than his or her own.

self awareness

Before he or she can begin to understand clients, the nurse must first know him or herself. Self-awareness is the process of developing an understanding of one's own values, beliefs, thoughts, feelings, attitudes, motivations, prejudices, strengths, and limitations and how these qualities affect others. It allows the nurse to observe, pay attention to, and understand the subtle responses and reactions of clients when interacting with them.

beliefs

Beliefs are ideas that one holds to be true, for example, "All old people are hard of hearing," "If the sun is shining, it will be a good day," or "Peas should be planted on St. Patrick's Day." Some beliefs have objective evidence to substantiate them. For example, people who believe in evolution have accepted the evidence that supports this explanation for the origins of life. Other beliefs are irrational and may persist, despite these beliefs having no supportive evidence or the existence of contradictory empirical evidence. For example, many people harbor irrational beliefs about cultures different from their own that they developed simply from others' comments or fear of the unknown, not from any evidence to support such beliefs.

Therapeutic Use of Self

By developing self-awareness and beginning to understand his or her attitudes, the nurse can begin to use aspects of his or her personality, experiences, values, feelings, intelligence, needs, coping skills, and perceptions to establish relationships with clients. This is called therapeutic use of self. Nurses use themselves as a therapeutic tool to establish therapeutic relationships with clients and help clients grow, change, and heal. Peplau (1952), who described this therapeutic use of self in the nurse-client relationship, believed that nurses must clearly understand themselves to promote their clients' growth and to avoid limiting clients' choices to those that nurses value. The nurse's personal actions arise from conscious and unconscious responses that are formed by life experiences and educational, spiritual, and cultural values. Nurses (and all people) tend to use many automatic responses or behaviors just because they are familiar. They need to examine such accepted ways of responding or behaving and evaluate how they help or hinder the therapeutic relationship.

Congruence

Congruence occurs when words and actions match. For example, the nurse says to the client, "I have to leave now to go to a clinical conference, but I will be back at 2 PM," and indeed returns at 2 PM to see the client. The nurse needs to exhibit congruent behaviors to build trust with the client. Trust erodes when a client sees inconsistency between what the nurse says and does. Inconsistent or incongruent behaviors include making verbal commitments and not following through on them. example of incongruent behavior is when the nurse's voice or body language is inconsistent with the words he or she speaks.

exploitation phase - nurse

Continues assessment •Meets needs as they emerge •Understands reason for shifts in behavior •Initiates rehabilitative plans •Reduces anxiety •Identifies positive factors •Helps plan for total needs •Facilitates forward movement of personality •Deals with therapeutic impasse

To understand what a client means, the nurse watches and listens carefully for cues.

Cues (overt and covert) are verbal or nonverbal messages that signal key words or issues for the client. Finding cues is a function of active listening. Cues can be buried in what a client says or can be acted out in the process of communication. Often, cue words introduced by the client can help the nurse know what to ask next or how to respond to the client. The nurse builds his or her responses on these cue words or

identification phase - nurse

Maintains separate identity •Exhibits ability to edit speech or control focal attention •Shows unconditional acceptance •Helps express needs and feelings •Assesses and adjusts to needs •Provides information •Provides experiences that diminish feelings of helplessness •Does not allow anxiety to overwhelm client •Helps client focus on cues •Helps client develop responses to cues •Uses word stimuli

Orientation of the Nurse-Client Relationship

During the orientation phase of the nurse-client relationship, the nurse establishes roles, the purpose of the relationship, and the parameters of subsequent meetings; identifies the client's problems; and clarifies expectations. The nurse's fulfillment of these activities includes active listening. The client is responsible for attending agreed-upon sessions, participating during the sessions, and sharing feelings and needs The nurse needs to listen closely to the client's history, perceptions, and misconceptions. He or she needs to convey empathy and understanding. If the relationship gets off to a positive start, it is more likely to succeed and to meet established goals. At the first meeting, the client may be distrustful if previous relationships with nurses have been unsatisfactory. The client may use rambling speech, act out, or exaggerate episodes as ploys to avoid discussing the real problems. It may take several sessions until the client believes that he or she can trust the nurse.

social, intimate, and therapeutic.

Each relationship is unique because of the various combinations of traits and characteristics of and circumstances related to the people involved. Although every relationship is different, all relationships may be categorized into three major types:

Empathy

Empathy is the ability of the nurse to perceive the meanings and feelings of the client and to communicate that understanding to the client. It is considered one of the essential skills a nurse must develop to provide high-quality, compassionate care. Being able to put him or herself in the client's shoes does not mean that the nurse has had the exact experiences as that of the client. Nevertheless, by listening and sensing the importance of the situation to the client, the nurse can imagine the client's feelings about the experience. Both the client and the nurse give a "gift of self" when empathy occurs—the client by feeling safe enough to share feelings and the nurse by listening closely enough to understand. Empathy has been shown to positively influence client outcomes. Clients tend to feel better about themselves and more understood when the nurse is empathetic. Several therapeutic communication techniques, such as reflection, restatement, and clarification, help the nurse send empathetic messages to the client

Therapeutic Engagement

Establishing a therapeutic relationship is a central component of effective care. Service users value positive attitudes, being listened to, and trusting those providing care. Nurses value the ability to relate to clients through talking, listening, and expressing empathy. Yet, a disproportionate amount of nurses' time is spent in other activities, sometimes allowing little time for the activities of the therapeutic relationship. The next step would be developing a way to measure the effectiveness of therapeutic relationships and then dedicating ample time for clients and nurses to engage in this therapeutic process.

being an advocate

In the advocate role, the nurse informs the client and then supports him or her in whatever decision he or she makes. In psychiatric-mental health nursing, advocacy is a bit different from medical-surgical settings because of the nature of the client's illness. For example, the nurse cannot support a client's decision to hurt him or herself or another person. Advocacy is the process of acting on the client's behalf when he or she cannot do so. This includes ensuring privacy and dignity, promoting informed consent, preventing unnecessary examinations and procedures, accessing needed services and benefits, and ensuring safety from abuse and exploitation by a health professional or authority figure. For example, if a physician begins to examine a client without closing the curtains and the nurse steps in and properly drapes the client and closes the curtains, the nurse has just acted as the client's advocate. Being an advocate has risks.

trust erodes when

Inconsistent or incongruent behaviors include making verbal commitments and not following through on them. example of incongruent behavior is when the nurse's voice or body language is inconsistent with the words he or she speaks.

exploitation phase - client

Makes full use of services •Identifies new goals •Attempts to attain new goals •Rapid shifts in behavior: dependent and independent •Exploitative behavior •Self-directing •Develops skill in interpersonal relationships and problem-solving •Displays changes in manner of communication (more open, flexible)

working phase

Maintaining the relationship •Gathering more data •Exploring perceptions of reality •Developing positive coping mechanisms •Promoting a positive self-concept •Encouraging verbalization of feelings •Facilitating behavior change •Working through resistance •Evaluating progress and redefining goals as appropriate •Providing opportunities for the client to practice new behaviors •Promoting independence

Therapeutic Communication

Nurses who observe that a psychiatric client is pacing with pursed lips and a furrowed brow should avoid presuming that the client's behavior is motivated by anxiety. The nurse must validate whether this is the case and encourage the client to delve into why he or she is behaving that way. Doing so fosters a sense of well-being and allows the nurse to proceed appropriately.

inappropriate boundaries

One of the biggest risks for boundary violations is when the nurse believes "there is no way I would ever do anything nontherapeutic." Boundary violations often begin unintentionally, or may even be well-intentioned, such as the nurse sharing personal relationship problems, thinking it might help the client. Once personal information has been shared, it cannot be retracted. The harm to the therapeutic relationship cannot be undone. If a client is attracted to a nurse or vice versa, it is up to the nurse to maintain professional boundaries. Accepting gifts or giving a client one's home address or phone number would be considered a breach of ethical conduct. Nurses must continually assess themselves and ensure they keep their feelings in check and focus on the clients' interests and needs.

Johari window (Luft, 1970), which creates a "word portrait"

One tool that is useful in learning more about oneself is the Johari window (Luft, 1970), which creates a "word portrait" of a person in four areas and indicates how well that person knows him or herself and communicates with others. The four areas evaluated are as follows: •Quadrant 1: Open/public—self-qualities one knows about oneself and others also know •Quadrant 2: Blind/unaware—self-qualities known only to others •Quadrant 3: Hidden/private—self-qualities known only to oneself •Quadrant 4: Unknown—an empty quadrant to symbolize qualities as yet undiscovered by oneself or others In creating a Johari window, the first step is for the nurse to appraise his or her own qualities by creating a list of them: values, attitudes, feelings, strengths, behaviors, accomplishments, needs, desires, and thoughts. The second step is to find out others' perceptions by interviewing them and asking them to identify qualities, both positive

identification phase - client

Participates in identifying problems •Begins to be aware of time •Responds to help •Identifies with nurse •Recognizes nurse as a person •Explores feelings •Fluctuates dependence, independence, and interdependence in relationship with nurse •Increases focal attention •Changes appearance (for better or worse) •Understands continuity between sessions (process and content) •Testing maneuvers decrease

being care giver

The primary caregiving role in mental health settings is the implementation of the therapeutic relationship to build trust, explore feelings, assist the client in problem-solving, and help the client meet psychosocial needs. If the client also requires physical nursing care, the nurse may need to explain to the client the need for touch while performing physical care. Some clients may confuse physical care with intimacy and sexual interest, which can erode the therapeutic relationship. The nurse must consider the relationship boundaries and parameters that have been established and must repeat the goals that were established together at the beginning of the relationship.

orientation phase - nurse

Responds to client •Gives parameters of meetings •Explains roles •Gathers data •Helps client identify problem •Helps client plan use of community resources and services •Reduces anxiety and tension •Practices active listening •Focuses client's energies •Clarifies preconceptions and expectations of nurse

These responses cut off communication and make it more difficult for the interaction to continue.

Responses such as "everything will work out" or "maybe tomorrow will be a better day" may be intended to comfort the client, but instead may impede the communication process. Asking "why" questions (in an effort to gain information) may be perceived as criticism by the client, conveying a negative judgment from the nurse. Many of these responses are common in social interaction. Therefore, it takes practice for the nurse to avoid making these types of comments.

negative behaviors that hinder nurse/pt relationship

Secrets; reluctance to talk to others about the work being done with clients •Sudden increase in phone calls between nurse and client or calls outside clinical hours •Nurse making more exceptions for client than normal •Inappropriate gift-giving between client and nurse •Loaning, trading, or selling goods or possessions •Nurse disclosure of personal issues or information •Inappropriate touching, comforting, or physical contact •Overdoing, overprotecting, or overidentifying with client •Change in nurse's body language, dress, or appearance (with no other satisfactory explanation) •Extended one-on-one sessions or home visits •Spending off-duty time with the client •Thinking about the client frequently when away from work •Becoming defensive if another person questions the nurse's care of the client •Ignoring agency policies

Establishing a therapeutic relationship

is one of the most important responsibilities of the nurse when working with clients. Communication is the means by which a therapeutic relationship is initiated, maintained, and terminated. The therapeutic relationship, includes confidentiality, self-disclosure, and therapeutic use of self. To have effective therapeutic communication, the nurse must also consider privacy and respect of boundaries, use of touch, and active listening and observation.

orientation phase - client

Seeks assistance •Conveys needs •Asks questions •Shares preconceptions and expectations of nurse based on past experience

The positioning of the nurse and client in relation to each other is also important.

Sitting beside or across from the client can put the client at ease, while sitting behind a desk (creating a physical barrier) can increase the formality of the setting and may decrease the client's willingness to open up and communicate freely. The nurse may wish to create a more formal setting with some clients, however, such as those who have difficulty maintaining boundaries.

comfort zone according to culture

Some people from different cultures (e.g., Hispanic, Mediterranean, East Indian, Asian, and Middle Eastern) are more comfortable with less than 4 to 12 ft of space between them while talking. The nurse of European American or African American heritage may feel uncomfortable if clients from these cultures stand close when talking. Conversely, clients from these backgrounds may perceive the nurse as remote and indifferent

termination phase - nurse

Sustains relationship as long as client feels necessary •Promotes family interaction to assist with goal planning •Teaches preventive measures •Uses community agencies •Teaches self-care •Terminates nurse-client relationship

ROLES OF THE NURSE IN A THERAPEUTIC RELATIONSHIP

TEACHER, CARE GIVER, ADVOCATE, Parent/surrogate As when working with clients in any other nursing setting, the psychiatric nurse uses various roles to provide needed care to the client. The nurse understands the importance of assuming the appropriate role for the work that he or she is doing with the client

duty to warn

The Tarasoff vs. Regents of the University of California decision in 1976 releases professionals from privileged communication with their clients should a client make a homicidal threat. The decision requires the nurse to notify intended victims and police of such a threat. In this circumstance, the nurse must report the homicidal threat to the nursing supervisor and attending physician so that both the police and the intended victim can be notified. This is called a duty to warn and is discussed more fully in Chapter 9. The nurse documents the client's problems with planned interventions. The client must understand that the nurse will collect data about him or her that helps in

Nurse client contract

The contract should state the following: •Time, place, and length of sessions •When sessions will terminate •Who will be involved in the treatment plan (family members or health team members) •Client responsibilities (arrive on time and end on time) •Nurse's responsibilities (arrive on time, end on time, maintain confidentiality at all times, evaluate progress with client, and document sessions)

Johari window

The goal is to work toward moving qualities from quadrants 2, 3, and 4 into quadrant 1 (qualities known to self and others). Doing so indicates that the nurse is gaining self-knowledge and awareness.

A confusing facial expression

is one that is the opposite of what the person wants to convey. A person who is verbally expressing sad or angry feelings while smiling is exhibiting a confusing facial expression.

appropriate boundaries.

The nurse must evaluate the use of touch based on the client's preferences, history, and needs. The nurse may find touch supportive, but the client may not. Likewise, a client may use touch too much, and again the nurse must set

feelings of sympathy encourage dependence

The nurse must not let feelings of empathy turn into sympathy for the client. Unlike the therapeutic use of empathy, the nurse who feels sorry for the client often tries to compensate by trying to please him or her. When the nurse's behavior is rooted in sympathy, the client finds it easier to manipulate the nurse's feelings. This discourages the client from exploring his or her problems, thoughts, and feelings; discourages client growth; and often leads to client dependency. The client may make increased requests of the nurse for help and assistance or may regress and act as if he or she cannot carry out tasks previously done. These can be signals that the nurse has been "overdoing" for the client and may be contributing to the client's dependency. Clients often test the nurse to see how much the nurse is willing to do. If the client cooperates only when the nurse is in attendance and does not carry out agreed-on behavior in the nurse's absence, the client has become too dependent. In any of these instances, the nurse needs to reassess his or her professional behavior and refocus on the client's needs and therapeutic goals.

positive regard

The nurse who appreciates the client as a unique worthwhile human being can respect the client regardless of his or her behavior, background, or lifestyle. This unconditional nonjudgmental attitude is known as positive regard and implies respect. Calling the client by name, spending time with the client, and listening and responding openly are measures by which the nurse conveys respect and positive regard to the client. The nurse also conveys positive regard by considering the client's ideas and preferences when planning care. Doing so shows that the nurse believes the client has the ability to make positive and meaningful contributions to his or her own plan of care. The nurse relies on presence, or attending, which is using nonverbal and verbal communication techniques to make the client aware that he or she is receiving full attention. Nonverbal techniques that create an atmosphere of presence include leaning toward the client, maintaining eye contact, being relaxed, having arms resting at the sides, and having an interested but neutral attitude. Verbally attending means that the nurse avoids communicating value judgments about the client's behavior. For example, the client may say, "I was so mad, I yelled and screamed at my mother for an hour." If the nurse responds with, "Well, that didn't help, did it?" or "I can't believe you did that," the nurse is communicating a value judgment that the client was "wrong" or "bad." A better response would be "What happened then?" or "You must have been really upset." The nurse maintains attention on the client and avoids communicating negative opinions or value judgments about the client's behavior.

Acceptance

The nurse who does not become upset or responds negatively to a client's outbursts, anger, or acting out conveys acceptance to the client. Avoiding judgments of the person, no matter what the behavior, is acceptance. This does not mean acceptance of inappropriate behavior but acceptance of the person as worthy. The nurse must set boundaries for behavior in the nurse-client relationship. By being clear and firm without anger or judgment, the nurse allows the client to feel intact while still conveying that certain behavior is unacceptable. For example, a client puts his arm around the nurse's waist. An appropriate response would be for the nurse to remove his hand and say ," Do not place your hand on me, we are working on your relationship wt your girlfriend and that does not require you to touch me."

establishing therapeutic relationship

The nurse who has self-confidence rooted in self-awareness is ready to establish appropriate therapeutic relationships with clients. Because personal growth is ongoing over one's lifetime, the nurse cannot expect to have complete self-knowledge. Awareness of his or her strengths and limitations at any particular moment, however, is a good start.

Nonacceptance and Avoidance

The nurse-client relationship can be jeopardized if the nurse finds the client's behavior unacceptable or distasteful and allows those feelings to show by avoiding the client or making verbal responses or facial expressions of annoyance or turning away from the client. The nurse should be aware of the client's behavior and background before beginning the relationship; if the nurse believes there may be conflict, he or she must explore this possibility with a colleague. If the nurse is aware of a prejudice that would place the client in an unfavorable light, he or she must explore this issue as well. Sometimes, by talking about and confronting these feelings, the nurse can accept the client and not let a prejudice hinder the relationship. If the nurse cannot resolve such negative feelings, however, he or she should consider requesting another assignment. It is the nurse's responsibility to treat each client with acceptance and positive regard, regardless of the client's history.

Trust

The nurse-client relationship requires trust. Trust builds when the client is confident in the nurse and when the nurse's presence conveys integrity and reliability. Trust develops when the client believes that the nurse will be consistent in his or her words and actions and can be relied on to do what he or she says. Some behaviors the nurse can exhibit to help build the client's trust include caring, interest, understanding, consistency, honesty, keeping promises, and listening to the client (Box 5.1). A caring therapeutic nurse-client relationship enables trust to develop, so the client can accept the assistance being offered. Trust erodes when a client sees inconsistency between what the nurse says and does

orientation phase

The orientation phase begins when the nurse and client meet and ends when the client begins to identify problems to examine. During the orientation phase, the nurse establishes roles, the purpose of meeting, and the parameters of subsequent meetings; identifies the client's problems; and clarifies expectations. Before meeting the client, the nurse has important work to do. The nurse reads background materials available on the client, becomes familiar with any medications the client is taking, gathers necessary paperwork, and arranges for a quiet, private, and comfortable setting. This is the time for self-assessment. The nurse should consider his or her personal strengths and limitations in working with this client. Are there any areas that might signal difficulty because of past experiences? For example, if this client is a spouse batterer and the nurse's father was also one, the nurse needs to consider the situation. How does it make him or her feel? What memories does it prompt, and can he or she work with the client without these memories interfering? The nurse must examine preconceptions about the client and ensure that he or she can put them aside and get to know the person. The nurse must come to each client without preconceptions or prejudices. It may be useful for the nurse to discuss all potential problem areas with a mentor. During the orientation phase, the nurse begins to build trust with the client. It is the nurse's responsibility to establish a therapeutic environment that fosters trust and understanding (Table 5.3). The nurse should share appropriate information about him or herself at this time, including name, reason for being on the unit, and level of schooling. For example, "Hello, James. My name is Ms. Ames, and I will be your nurse for the next six Tuesdays. I am a senior nursing student at the University of Mississippi."

being a teacher

The teacher role is inherent in most aspects of client care. During the working phase of the nurse-client relationship, the nurse may teach the client new methods of coping and solving problems. He or she may instruct the client about the medication regimen and available community resources. To be a good teacher, the nurse must feel confident about the knowledge he or she has and must know the limitations of that knowledge base. The nurse should be familiar with the resources in the health care setting and community and on the internet, which can provide needed information for clients. The nurse must be honest about what information he or she can provide and when and where to refer clients for further information. This behavior and honesty build trust in clients.

termination phase

The termination or resolution phase is the final stage in the nurse-client relationship. It begins when the problems are resolved and ends when the relationship is ended. Both the nurse and the client usually have feelings about ending the relationship; the client especially may feel the termination as an impending loss. Often, clients try to avoid termination by acting angry or as if the problem has not been resolved. The nurse can acknowledge the client's angry feelings and assure the client that this response is normal to ending a relationship. If the client tries to reopen and discuss old resolved issues, the nurse must avoid feeling as if the sessions were unsuccessful; instead, he or she should identify the client's stalling maneuvers and refocus the client on newly learned behaviors and skills to handle the problem. It is appropriate to tell the client that the nurse enjoyed the time spent with the client and will remember him or her, but it is inappropriate for the nurse to agree to see the client outside the therapeutic relationship.

therapeutic relationship

The therapeutic relationship differs from the social or intimate relationship in many ways because it focuses on the needs, experiences, feelings, and ideas of the client only. The nurse and client agree about the areas to work on and evaluate the outcomes. The nurse uses communication skills, personal strengths, and understanding of human behavior to interact with the client. In the therapeutic relationship, the parameters are clear; the focus is the client's needs, not the nurse's. The nurse should not be concerned about whether or not the client likes him or her or is grateful. Such concern is a signal that the nurse is focusing on a personal need to be liked or needed. The nurse must guard against allowing the therapeutic relationship to slip into a more social relationship and must constantly focus on the client's needs, not his or her own. The nurse's level of self-awareness can either benefit or hamper the therapeutic relationship. For example, if the nurse is nervous around the client, the relationship is more apt to stay social because superficiality is safer. If the nurse is aware of his or her fears, he or she can discuss them with the instructor, paving the way for a more therapeutic relationship to develop.

Working

The working phase of the nurse-client relationship is usually divided into two subphases. During problem identification, the client identifies the issues or concerns causing problems. During exploitation, the nurse guides the client to examine feelings and responses and develop better coping skills and a more positive self-image; this encourages behavior change and develops independence.

Active listening, Active observation

To receive the sender's simultaneous messages, the nurse must use active listening and active observation. Active listening means refraining from other internal mental activities and concentrating exclusively on what the client says. Active observation means watching the speaker's nonverbal actions as he or she communicates. Peplau (1952) used observation as the first step in the therapeutic interaction

Trusting behavior

Trust is built in the nurse-client relationship when the nurse exhibits the following behaviors: •Caring •Openness •Objectivity •Respect •Interest •Understanding •Consistency •Treating the client as a human being •Suggesting without telling •Approachability •Listening •Keeping promises •Honesty

your values

Your values are your ideas about what is most important to you in your life—what you want to live by and live for. They are the silent forces behind many of your actions and decisions. The goal of "values clarification" is for their influence to become fully conscious, for you to explore and honestly acknowledge what you truly value at this time. You can be more self-directed and effective when you know which values you really choose to keep and live by as an adult and which ones will get priority over others

Values

Values are abstract standards that give a person a sense of right and wrong and establish a code of conduct for living. Sample values include hard work, honesty, sincerity, cleanliness, and orderliness. To gain insight into oneself and personal values, the values clarification process is helpful. The values clarification process has three steps: choosing, prizing, and acting. Choosing is when the person considers a range of possibilities and freely chooses the value that feels right. Prizing is when the person considers the value, cherishes it, and publicly attaches it to him or herself. Acting is when the person puts the value into action. For example, a clean and orderly student has been assigned to live with another student who leaves clothes and food all over the room. At first, the orderly student is unsure why she hesitates to return to the room and feels tense around her roommate. As she examines the situation, she realizes that they view the use of personal space differently (choosing). Next, she discusses her conflict and choices with her adviser and friends (prizing). Finally, she decides to negotiate with her roommate for a compromise (acting)

being a surrogate

When a client exhibits childlike behavior or when a nurse is required to provide personal care such as feeding or bathing, the nurse may be tempted to assume the parental role as evidenced in choice of words and nonverbal communication. The nurse may begin to sound authoritative with an attitude of "I know what's best for you." Often, the client responds by acting more childlike and stubborn. Neither party realizes they have fallen from adult-adult communication to parent-child communication. It is easy for the client to view the nurse in such circumstances as a parent surrogate. In such situations, the nurse must be clear and firm and set limits or reiterate the previously set limits. By retaining an open, easygoing, nonjudgmental attitude, the nurse can continue to nurture the client while establishing boundaries

genuine interest

When the nurse is comfortable with him or herself, aware of his or her strengths and limitations, and clearly focused, the client perceives a genuine person showing genuine interest. A client with mental illness can detect when someone is exhibiting dishonest or artificial behavior, such as asking a question and then not waiting for the answer, talking over him or her, or assuring him or her everything will be alright. The nurse should be open and honest and display congruent behavior. Sometimes, however, responding with truth and honesty alone does not provide the best professional response. In such cases, the nurse may choose to disclose to the client a personal experience related to the client's current concerns. It is essential, however, that the nurse is selective about personal examples. These examples should be from the nurse's past experience, not a current problem the nurse is still trying to resolve, or a recent, still painful experience. Self-disclosure examples are most helpful to the client when they represent common day-to-day experiences and do not involve value-laden topics. For example, the nurse might share an experience of being frustrated with a coworker's tardiness or being worried when a child failed an exam at school. It is rarely helpful to share personal experiences such as going through a divorce or the infidelity of a spouse or partner. Self-disclosure can be helpful on occasion, but the nurse must not shift emphasis to his or her own problems rather than the client's.

Overt cues

are clear, direct statements of intent, such as "I want to die." The message is clear that the client is thinking of suicide or self-harm

Vocal cues

are nonverbal sound signals transmitted along with the content: voice volume, tone, pitch, intensity, emphasis, speed, and pauses augment the sender's message.

Covert cues

are vague or indirect messages that need interpretation and exploration—for example, if a client says, "Nothing can help me." The nurse is unsure, but it sounds as if the client might be saying he or she feels so hopeless and helpless that he or she plans to commit suicide. The nurse can explore this covert cue to clarify the client's intent and to protect the client. Most suicidal people are ambivalent about whether to live or die and often admit their plan when directly asked about it. When the nurse suspects self-harm or suicide, he or she uses a yes-or-no question to elicit a clear response. Theme of hopelessness and suicidal ideation:

Therapeutic communication

is an interpersonal interaction between the nurse and the client during which the nurse focuses on the client's specific needs to promote an effective exchange of information. Skilled use of therapeutic communication techniques helps the nurse understand and empathize with the client's experience. All nurses need skills in therapeutic communication to effectively apply the nursing process and to meet standards of care for their clients.

Touching a client

can be comforting and supportive when it is welcome and permitted. The nurse should observe the client for cues that show whether touch is desired or indicated. For example, holding the hand of a sobbing mother whose child is ill is appropriate and therapeutic. If the mother pulls her hand away, however, she signals to the nurse that she feels uncomfortable being touched. The nurse can also ask the client about touching (e.g., "Would it help you to squeeze my hand?")

verbal communication

consists of the words a person uses to speak to one or more listeners. Words represent the objects and concepts being discussed. Placement of words into phrases and sentences that are understandable to both speaker and listeners gives an order and a meaning to these symbols.

in verbal communication

content is the literal words that a person speaks. Context is the environment in which communication occurs and can include time and the physical, social, emotional, and cultural environments.

congruent message

is conveyed when content and process agree. For example, a client says, "I know I haven't been myself. I need help." She has a sad facial expression and a genuine and sincere voice tone.

impassive face

is frozen into an emotionless deadpan expression similar to a mask.

process

denotes all nonverbal messages that the speaker uses to give meaning and context to the message. The process component of communication requires the listeners to observe the behaviors and sounds that accent the words and to interpret the speaker's nonverbal behaviors to assess whether they agree or disagree with the verbal content.

Peplau (1952)

described this therapeutic use of self in the nurse-client relationship, believed that nurses must clearly understand themselves to promote their clients' growth and to avoid limiting clients' choices to those that nurses value.

I see you are sad, how can i help you

empathy

body language

gestures, postures, movements, and body positions are a nonverbal form of communication.

Peplau's model (1952)

has three phases: orientation, working, and resolution or termination (Table 5.2). In real life, these phases are not that clear-cut; they overlap and interlock.

working

identification and exploitation are part which phase

Nurse theorist Hildegard Peplau (1952)

identified preconceptions, or ways one person expects another to behave or speak, as a roadblock to the formation of an authentic relationship. Preconceptions often prevent people from getting to know one another. Preconceptions and different or conflicting personal beliefs and values may prevent the nurse from developing a therapeutic relationship with a client. Here is an example of preconceptions that interfere with a therapeutic relationship: Mr. Lopez, a client, has the preconceived stereotypical idea that all male nurses are homosexual and refuses to have Samuel, a male nurse, take care of him. Samuel has a preconceived stereotypical notion that all Hispanic men are violent, so he is relieved that Mr. Lopez has refused to work with him. Both men are missing the opportunity to do some important work together because of incorrect preconceptions.

Both the client and the nurse can feel threatened

if one invades the other's personal or intimate zone, which can result in tension, irritability, fidgeting, or even flight. When the nurse must invade the intimate or personal zone, he or she should always ask the client's permission. For example, if a nurse performing an assessment in a community setting needs to take the client's blood pressure, he or she should say, "Mr. Smith, to take your blood pressure I will wrap this cuff around your arm and listen with my stethoscope. Is this acceptable to you?" He or she should ask permission in a yes-or-no format so the client's response is clear. This is one of the times when yes-or-no questions are appropriate.

context

includes the situation or circumstances that clarify the meaning of the content of the message.

•Friendship-warmth touch

involves a hug in greeting, an arm thrown around the shoulder of a good friend, or the backslapping some people use to greet friends and relatives.

love-intimacy touch

involves tight hugs and kisses between lovers or close relatives. •Sexual-arousal touch is used by lovers.

nonverbal communication

is the behavior that accompanies verbal content such as body language, eye contact, facial expression, tone of voice, speed and hesitations in speech, grunts and groans, and distance from the listeners. Nonverbal communication can indicate the speaker's thoughts, feelings, needs, and values that he or she acts out mostly unconsciously. Process denotes all nonverbal messages that the speaker uses to give meaning and context to the message. Nonverbal process represents a more accurate message than does verbal content

•Functional-professional touch

is used in examinations or procedures such as when the nurse touches a client to assess skin turgor or a massage therapist performs a massage.

•Social-polite touch

is used in greeting, such as a handshake and the "air kisses" some people use to greet acquaintances, or when a gentle hand guides someone in the correct direction.

Although touch can be comforting and therapeutic,

it is an invasion of intimate and personal space. Some clients with mental illness have difficulty understanding the concept of personal boundaries or knowing when touch is or is not appropriate. Clients with a history of abuse have had others touch them in harmful, hurtful ways, usually without their consent. They may be hesitant or even unable to tell others when touch is uncomfortable. most psychiatric inpatient, outpatient, and ambulatory care units have policies against clients touching one another or staff. Unless they need to get close to a client to perform some nursing care, staff members should serve as role models and refrain from invading clients' personal and intimate space. When a staff member is going to touch a client while performing nursing care, he or she must verbally prepare the client before starting the procedure. A client with paranoia may interpret being touched as a threat and may attempt to protect him or herself by striking the staff person.

orientation, working, termination

phases of patient client relationship

expressive face

portrays the person's moment-by-moment thoughts, feelings, and needs. These expressions may be evident even when the person does not want to reveal his or her emotions.

Peplau

studied and wrote about the interpersonal processes and the phases of the nurse-client relationship for 35 years. Her work provides the nursing profession with a model that can be used to understand and document progress with interpersonal interactions. Peplau's model (1952) has three phases: orientation, working, and resolution or termination (Table 5.2). In real life, these phases are not that clear-cut; they overlap and interlock.

volume

the loudness of the voice, can indicate anger, fear, happiness, or deafness.

The therapeutic communication interaction is most comfortable when

the nurse and client are 3 to 6 ft apart. If a client invades the nurse's intimate space (0-18 in), the nurse should set limits gradually, depending on how often the client has invaded the nurse's space and the safety of the situation.

communication

the process that people use to exchange information. Messages are simultaneously sent and received on two levels: verbally through the use of words and nonverbally by behaviors that accompany the words

Proxemics

the study of distance zones between people during communication. People feel more comfortable with smaller distances when communicating with someone they know rather than with strangers People from the United States, Canada, and many Eastern European nations generally observe four distance zones:

open posture demonstrates

unconditional positive regard, trust, care, and acceptance. The nurse indicates interest in and acceptance of the client by facing and slightly leaning toward him or her while maintaining nonthreatening eye contact.

choosing, prizing, acting (CPA)

values clarification process

incongruent message

when the content and process disagree—when what the speaker says and what he or she does do not agree—the speaker is giving an incongruent message. For example, if the client says, "I'm here to get help," but has a rigid posture, clenched fists, and an agitated and frowning facial expression and snarls the words through clenched teeth, the message is incongruent. The process or observed behavior invalidates what the speaker says (content).

Points to Consider When Building Therapeutic Relationships

•Attend workshops about values clarification, beliefs, and attitudes to help you assess and learn about yourself. •Keep a journal of thoughts, feelings, and lessons learned to provide self-insight. •Listen to feedback from colleagues about your relationships with clients. •Participate in group discussions on self-growth at the local library or health center to aid self-understanding. •Develop a continually changing care plan for self-growth. •Read books on topics that support the strengths you have identified and help you develop your areas of weakness.

Therapeutic communication can help nurses accomplish many goals:

•Establish a therapeutic nurse-client relationship. •Identify the most important client concern at that moment (the client-centered goal). •Assess the client's perception of the problem as it unfolds. This includes detailed actions (behaviors and messages) of the people involved and the client's thoughts and feelings about the situation, others, and self. •Facilitate the client's expression of emotions. •Teach the client and family the necessary self-care skills. •Recognize the client's needs. •Implement interventions designed to address the client's needs. •Guide the client toward identifying a plan of action to a satisfying and socially acceptable resolution.

Methods to Avoid Inappropriate Relationships between Nurses and Clients

•Realize that all staff members, whether male or female, junior or senior, or from any discipline, are at risk for over involvement and loss of boundaries. •Assume that boundary violations will occur. Supervisors should recognize potential "problem" clients and regularly raise the issue of sexual feelings or boundary loss with staff members. •Provide opportunities for staff members to discuss their dilemmas and effective ways of dealing with them. •Develop orientation programs to include how to set limits, how to recognize clues that the relationship is losing boundaries, what the institution expects of the professional, clearly defined consequences, case studies, how to develop skills to maintain boundaries, and recommended reading. •Provide resources for confidential and nonjudgmental assistance. •Hold regular meetings to discuss inappropriate relationships and feelings toward clients. •Provide senior staff to lead groups and model effective therapeutic interventions with difficult clients. •Use clinical vignettes for training. •Use situations that reflect not only sexual dilemmas but also other boundary violations, including problems with abuse of authority and power.

Active listening and observation help the nurse:

•Recognize the issue that is most important to the client at this time •Know what further questions to ask the client •Use additional therapeutic communication techniques to guide the client to describe his or her perceptions fully •Understand the client's perceptions of the issue instead of jumping to conclusions •Interpret and respond to the message objectively