Chapter 6

Feedback is useful when it

-Is descriptive rather than evaluative and focused on the behavior rather than on the client -Is specific rather than general -Is directed toward behavior that the client has the capacity to modify -Imparts information rather than offers advice -Is well-timed

Working phase

-Maintain trust and rapport. -Promote client's insight and perception of reality. -Use problem-solving model to work toward achievement of established goals. -Overcome resistance behaviors. -Continuously evaluate progress toward goal attainment. -Transference: -Countertransference:

Giving recognition:

Acknowledging, indicating awareness

Giving broad openings:

Allows client to select the topic

Requesting an explanation:

Asking "why" implies that the client must defend his or her behavior or feelings

Introducing an unrelated topic:

Causes the nurse to take over the direction of the discussion

Placing the event in time or sequence:

Clarifies the relationship of events in time

Presenting reality:

Clarifying misconceptions that the client may be expressing

Probing:

Pushing for answers to issues that the client does not wish to discuss causes the client to feel used and valued only for what is shared with the nurse

Offering self:

Making oneself available

Verbalizing the implied:

Putting into words what client has only implied

Conditions Essential to Development of a Therapeutic Relationship

Rapport Trust Respect Genuineness Empathy REGRT

Rejecting:

Refusing to consider client's ideas or behavior

Interpreting:

Results in the therapist telling client the meaning of his or her experience

Defending:

To defend what client has criticized implies that the client has no right to express ideas, opinions, or feelings

Therapeutic nurse-client relationships can occur only when

each views the other as a unique human being. When this occurs, both participants have needs met by the relationship.

Self-disclosure

on the part of the nurse may be appropriate when it is judged that the information may therapeutically benefit the client. It should never be undertaken for the purpose of meeting the nurse's needs.

The way in which an individual positions his or her body communicates messages regarding

self-esteem, gender identity, status, and interpersonal warmth or coldness.

Density refers to

the number of people within a given environmental space. It has been shown to influence interpersonal interaction. Some studies indicate that a correlation exists between prolonged high-density situations and certain behaviors, such as aggression, stress, criminal activity, hostility toward others, and a deterioration of mental and physical health.

The orientation phase is

when the nurse and client become acquainted with each other. Tasks during this phase include creating creating an environment for the establishment of trust and rapport, establishing a contract for intervention that details the expectations and responsibilities of both parties, gathering assessment information, identifying the client's strengths and limitations, formulating nursing diagnoses, setting goals that are mutually agreeable, developing a plan of action that is realistic, and exploring feelings of both the client and nurse.

Focusing:

Taking notice of a single idea or even a single word

Process Recordings

-Process recordings are written reports of verbal interactions with clients. -They are written by the nurse or student as a tool for improving communication techniques. -Process recordings are written reports of verbal interactions with clients. They are verbatim accounts and used as a tool for improving interpersonal communication techniques. The process recording can take many forms, but usually includes the verbal and nonverbal communication of both nurse and client. An example of one type of process recording is presented in Table 6-5 in the text.

The environment in which the transaction takes place

-Territoriality, density, and distance are aspects of environment that communicate messages. -Territoriality: The innate tendency to own space -Density: The number of people within a given environmental space -Distance: The means by which various cultures use space to communicate

4. As the move-out date to leave the shelter gets closer, a battered wife states, "I'm afraid to leave here. I'm afraid for my safety and the safety of my children." Which nursing statement is most supportive? A "This is a difficult transition. Let's formulate a plan to keep you all safe in the community." B "It's the policy that clients can only live here for 30 days. Maybe we can ask for more time." C "You've had a month to come up with a plan for keeping you and your family safe." D"Hopefully, your husband has been in counseling. I'm sure this will work out fine."

A-The nurse is using the therapeutic techniques of "reflection" and "formulating a plan of action." The use of these communication facilitators indicates that the nurse is supportive of the client's feelings and appreciates the need for a safety plan.

3. The unit manager needs to meet with a client who is exhibiting escalating hostility. Which would be the most appropriate location for the nurse to meet with this client? A. The client's room with the door shut B. A quiet corner of the day room C. The nurse's station D. The unit's treatment room

B-A quiet corner of the day room provides for some privacy in a neutral space while not limiting access to help if safety issues arise.

Using denial:

Blocks discussion with client and avoids helping client identify and explore areas of difficulty

Accepting:

Conveys positive regard

Exploring:

Delving further into a subject, idea, experience, or relationship

Reflecting:

Directs questions or feelings back to client so that they may be recognized and accepted

Professional boundary concerns commonly include issues such as

Self-disclosure Gift-giving Touch Friendship or romantic association

1. Which is the primary nursing goal when establishing a therapeutic relationship with a client? A. To promote client growth B. To develop the nurse's personal identity C. To establish a purposeful social interaction D. To develop communication skills

A The goal of a therapeutic nursing interaction is to promote client insight and behavioral change directed toward client growth.

Belittling feelings expressed:

Causes client to feel insignificant or unimportant

Culture or religion

Cultural mores, norms, ideas, and customs provide the basis for ways of thinking. Cultural mores, norms, ideas, and customs provide the basis for our way of thinking. Cultural values are learned and differ from society to society. Religion also can influence communication. Symbolic gestures, such as wearing a cross around the neck or hanging a crucifix on the wall can communicate an individual's religious beliefs.

Voicing doubt:

Expressing uncertainty as to the reality of client's perception

Approving or disapproving:

Implies that the nurse has the right to pass judgment on the "goodness" or "badness" of client's behavior -Several approaches are considered to be barriers to open communication between the nurse and client. Hays and Larson identified a number of these techniques, which are presented in Table 6-4 in the text. Nurses should recognize and eliminate the use of these patterns in their relationships with clients. Avoiding these communication barriers enhance the nurse-client relationship.

Agreeing or disagreeing:

Implies that the nurse has the right to pass judgment on whether the client's ideas or opinions are "right" or "wrong"

Giving advice:

Implies that the nurse knows what is best for client and that client is incapable of any self-direction

Formulating plan of action:

Striving to prevent anger or anxiety escalating to unmanageable level when stressor recurs

Phases of a Therapeutic Nurse-Client Relationship

The therapeutic interpersonal relationship is the means by which the nursing process is implemented. Through the relationship, problems are identified and resolution is sought. Tasks of the relationship have been categorized into four phases. Describe each of these phases.

Termination phase

Therapeutic conclusion of relationship occurs when -Progress has been made toward attainment of the goals. -A plan of action for more adaptive coping with future stressful situations has been established. -Feelings about termination of the relationship are recognized and explored.

Transference: Countertransference:

Transference: Occurs when the client unconsciously displaces (or "transfers") to the nurse feelings formed toward a person from the past Countertransference: Refers to the nurse's behavioral and emotional response to the client

Interpersonal communication is

a transaction between the sender and the receiver. Both persons participate simultaneously.

Empathy is the

ability to see beyond outward behavior and to understand the situation from the client's point of view. With empathy, the nurse can accurately perceive and understand the meaning and relevance of the client's thoughts and feelings.

In the transactional model,

both participants perceive each other, listen to each other, and simultaneously engage in the process of creating meaning in a relationship.

Both sender and receiver bring

certain preexisting conditions to the exchange that influence the intended message and the way in which the message is interpreted. Both the sender and receiver bring certain preexisting conditions to the exchange that influence both the intended message and the way in which it is interpreted.

The nurse-client relationship is the foundation on which

psychiatric nursing is established.

Interpersonal communication is a

transaction between the sender and the receiver. In the transactional model of communication, both participants simultaneously perceive each other, listen to each other, and mutually are involved in creating meaning in a relationship.

Orientation (introductory) phase

-Create an environment for trust and rapport. -Establish contract for intervention. -Gather assessment data. -Identify client's strengths and limitations. -Formulate nursing diagnoses. -Set mutually agreeable goals. -Develop a realistic plan of action. -Explore feelings of both client and nurse.

Interpersonal communication techniques are the

"tools" of psychosocial intervention. -Therapeutic use of self is the instrument for delivery of that care. Interpersonal communication techniques (both verbal and nonverbal) are the "tools" of psychosocial intervention.

Nonverbal Communication

-Components of nonverbal communication -Physical appearance and dress -Body movement and posture -Touch -Facial expressions -Eye behavior -Vocal cues or paralanguage

Using silence:

Allows client to take control of the discussion, if he or she so desires

Encouraging comparison:

Asking client to compare similarities and differences in ideas, experiences, or interpersonal relationships

Encouraging description of perceptions:

Asking client to verbalize what is being perceived

5. The nurse is performing an initial assessment on a newly admitted client who is oriented times four. Which of the following communication techniques would best facilitate obtaining accurate and complete client data? A. Closed-ended questions B. Requesting an explanation C. Open-ended questions D. Interpreting

C- Open-ended questions are phrased in a way that gathers as much information as possible. By the use of phrases such as "Tell me about..." or "Describe to me..." a varied and rich body of information can be assessed.

2. A client threatens to kill himself, his wife, and their children if the wife follows through with divorce proceedings. During the preinteraction phase of the nurse-client relationship, which interaction should the nurse employ? A. Acknowledging the client's actions and encouraging alternative behaviors B. Establishing rapport and developing treatment goals C. Providing community resources on aggression management D. Exploring personal thoughts and feelings that may adversely impact the provision of care

D- In the pre-interaction phase, the nurse must clarify personal attitudes, values, and beliefs to become aware of how these might affect the nurse's ability to care for various clients. This occurs before the nurse meets the client.

Therapeutic use of self

Definition: Ability to use one's personality consciously and in full awareness in an attempt to establish relatedness and to structure nursing interventions -Nurses must possess self-awareness, self-understanding, and a philosophical belief about life, death, and the overall human condition. -Travelbee described the instrument for delivery of the process of interpersonal nursing as the therapeutic use of self, which she defined as "the ability to use one's personality consciously and in full awareness in an attempt to establish relatedness and to structure nursing interventions."

Offering general leads:

Encourages client to continue

Values, attitudes, and beliefs

Example: Attitudes of prejudice are expressed through negative stereotyping. -Values, attitudes, and beliefs are learned ways of thinking. Children generally adopt the value systems and internalize the attitudes and beliefs of their parents. Children may retain this way of thinking into adulthood or develop a different set of attitudes and values as they mature. Values, attitudes, and beliefs can influence communication in numerous ways. For example, prejudice is expressed verbally through negative stereotyping.

Age or developmental level

Example: The influence of developmental level on communication is especially evident during adolescence, with words such as dude, cool, awesome, and others. -Age influences communication, especially during adolescence. Words such as "dude," "groovy," "clueless," "awesome," "cool," and "wasted" have had special meaning for different generations of adolescents. The technological age has produced a whole new language for today's adolescents. Developmental influences on communication may relate to physiological alterations. One example is American Sign Language, the system of unique gestures used by many people who are deaf or hearing impaired. Individuals who are blind at birth never learn the subtle nonverbal gesticulations that accompany language and can totally change the meaning of the spoken word.

Social status

High-status persons often convey their high-power position with gestures of hands on hips, power dressing, greater height, and more distance when communicating with individuals considered to be of lower social status. Studies of nonverbal indicators of social status or power have suggested that high-status persons are associated with gestures that communicate their higher-power position. For example, they use less eye contact, have a more relaxed posture, use louder voice pitch, place hands on hips more frequently, are "power dressers," have greater height, and maintain more distance when communicating with individuals considered to be of lower social status.

Restating:

Lets client know whether an expressed statement has been understood

Gender

Masculine and feminine gestures influence messages conveyed in communication with others. Gender influences the manner in which individuals communicate. Most cultures have gender signals that are recognized as either masculine or feminine and provide a basis for distinguishing between members of each gender. Roles have historically been identified as either male or female. For example, in the United States masculinity typically was communicated through such roles as husband, father, breadwinner, doctor, lawyer, or engineer. Traditional female roles included wife, mother, homemaker, nurse, teacher, or secretary. Gender signals are beginning to change in the United States as gender roles become less distinct.

Giving reassurance:

May discourage client from further expression of feelings if client believes the feelings will only be downplayed or ridiculed

SOLER

S: Sit squarely facing the client O: Observe an open posture L: Lean forward toward the client E: Establish eye contact R: Relax S: Sit squarely facing the client. This gives the message that the nurse is there to listen and is interested in what the client has to say. O: Observe an open posture. Posture is considered "open" when arms and legs remain uncrossed. This suggests that the nurse is "open" to what the client has to say. With a "closed" posture, the nurse can convey a somewhat defensive stance, possibly invoking a similar response in the client. L: Lean forward toward the client. This conveys to the client that you are involved in the interaction, interested in what is being said, and making a sincere effort to be attentive. E: Establish eye contact. Direct eye contact is another behavior that conveys the nurse's involvement and willingness to listen to what the client has to say. The absence of eye contact, or the constant shifting of eye contact, gives the message that the nurse is not really interested in what is being said.

Seeking clarification and validation:

Striving to explain what is vague and searching for mutual understanding

Making stereotyped comments, clichés, and trite expressions:

These are meaningless in a nurse-client relationship.

Making observations:

Verbalizing what is observed or perceived

A therapeutic relationship is

an interaction between two people (usually a caregiver and a care receiver) in which input from both participants contributes to a climate of healing, growth promotion, and/or illness prevention.

The termination phase is the

end of the nurse-client relationship. Termination of the relationship may occur for a variety of reasons: the mutually agreed-on goals may have been reached; the client may be discharged from the hospital; or, in the case of a student nurse, it may be the end of a clinical rotation.

Professional boundaries limit and outline

expectations for appropriate professional relationships with clients. -Boundaries are borders or limits in a relationship. They determine the extent of acceptable limits. Many different types of boundaries exist such as material boundaries, social boundaries, personal boundaries, and professional boundaries. It is important for both the nurse and the client to understand these boundaries.

Paralanguage is the

gestural component of the spoken word. It consists of pitch, tone, and loudness of spoken messages, the rate of speaking, expressively placed pauses, and emphasis assigned to certain words. These vocal cues greatly influence the way individuals interpret verbal messages.

Therapeutic relationships are

goal-oriented and directed at learning and growth promotion.

Rapport

implies special feelings on the part of both the client and the nurse based on acceptance, warmth, friendliness, common interest, a sense of trust, and a nonjudgmental attitude.

It is through eye contact that

individuals view and are viewed by others in a revealing way. An interpersonal connectedness occurs through eye contact. In American culture, eye contact conveys a personal interest in the other person. Eye contact indicates that the communication channel is open, and it is often the initiating factor in verbal interaction between two people.

Territoriality is the

innate tendency to own space. Individuals lay claim to areas around them as their own. This influences communication when an interaction takes place in the territory "owned" by one or the other.

To show respect

is to believe in the dignity and worth of an individual regardless of his or her unacceptable behavior. The attitude is nonjudgmental, and the respect is unconditional in that it does not depend on the behavior of the client to meet certain standards.

Gift giving

may be part of the therapeutic process for people who receive care. Cultural belief and values may also enter into the decision of whether to accept a gift from a client. Accepting financial gifts is never appropriate, but in some instances nurses may be permitted to suggest instead a donation to a charity of the client's choice. If acceptance of a small gift of gratitude is deemed appropriate, the nurse may choose to share it with other staff members who have been involved in the client's care.

When a nurse is acquainted with a client, the relationship must

move from one of a personal nature to professional. If the nurse is unable to accomplish this separation, he or she should withdraw from the nurse-client relationship. Romantic, sexual, or similar personal relationships are never appropriate between nurse and client.

Facial expressions

primarily reveal an individual's emotional states, such as happiness, sadness, anger, surprise, and fear. The face is a complex multimessage system. Facial expressions serve to complement and qualify other communication behaviors and at times even take the place of verbal messages.

Transference occurs when

the client unconsciously displaces to the nurse feelings formed toward a person from his or her past. Transference can interfere with the therapeutic interaction when the feelings being expressed include anger and hostility. Anger toward the nurse can be manifested by uncooperativeness and resistance to the therapy. Transference can also take the form of overwhelming affection for the nurse or excessive dependency on the nurse

Therapeutic use of self is

the instrument for delivery of care to clients in need of psychosocial intervention.

Distance is

the means by which various cultures use space to communicate.

The concept of genuineness refers to

the nurse's ability to be open, honest, and, "real" in interactions with the client. To be "real" is to be aware of what one is experiencing internally and to allow the quality of this inner experiencing to be apparent in the therapeutic relationship.

Countertransference refers to

the nurse's behavioral and emotional response to the client. These responses may be related to unresolved feelings toward significant others from the nurse's past, or they may be generated in response to transference feelings on the part of the client.

Warning signs that indicate that professional boundaries of the nurse-client relationship may be in jeopardy

-Favoring one client's care over another's -Keeping secrets with a client -Changing dress style when working with a particular client -Swapping client assignments to care for a particular client -Giving special attention or treatment to one client over others -Spending free time with a client -Frequently thinking about the client when away from work -Sharing personal information or work concerns with the client -Receiving of gifts or continued contact and communication with the client after discharge

Goals are often achieved through use of the problem-solving model.

-Identify the client's problem. -Promote discussion of desired changes. -Discuss aspects that cannot realistically be changed and ways to cope with them more adaptively. -Discuss alternative strategies for creating changes that the client desires to make. The nurse should work to: Identify what is troubling the client. Encourage the client to discuss changes he or she would like to make. Discuss which changes are possible and which are not. Help the client explore feelings about things that cannot be changed. Discuss alternative strategies for creating changes.

There are four kinds of distance in interpersonal interactions.

-Intimate distance: The closest distance that individuals allow between themselves and others -Personal distance: The distance for interactions that are personal in nature, such as close conversation with friends -Social distance: The distance for conversation with strangers or acquaintances -Public distance: The distance for speaking in public or yelling to someone some distance away

Preinteraction phase

-Obtain information about the client from chart, significant others, or other health team members. -Examine one's own feelings, fears, and anxieties about working with a particular client.

Active Listening

-To listen actively is to be attentive to what client is saying, both verbally and nonverbally. -Several nonverbal behaviors have been designed to facilitate attentive listening. -To listen actively is to be attentive and really desire to hear and understand what the client is saying, both verbally and nonverbally. With active listening the nurse communicates acceptance and respect for the client, and trust is enhanced. A climate is established within the relationship that promotes openness and honest expression.

Goals and the problem-solving model (cont'd)

-Weigh benefits and consequences of each alternative. -Help client select an alternative. -Encourage client to implement the change. -Provide positive feedback for client's attempts to create change. -Help client evaluate outcomes of the change and make modifications as required.

Indicating the existence of an external source of power:

Encourages client to project blame for his or her thoughts or behaviors on others

Attempting to translate words into feelings:

Putting into words the feelings the client has expressed only indirectly

Touching

is required to perform the many therapeutic procedures involved in the physical care of clients. Caring touch is the touching of clients when there is no physical need. Touching or hugging can be beneficial when it is implemented with therapeutic intent and has the consent of the client. There are times when touch should be avoided or considered with extreme caution.

The therapeutic interpersonal relationship is the process by which

nurses provide care for clients in need of psychosocial intervention. -The nurse-client relationship is the foundation on which psychiatric nursing is established. It is a relationship in which both the nurse and the client must recognize each other as unique and important. It is also a relationship in which mutual learning occurs. The therapeutic interpersonal relationship is the process by which nurses provide care for clients in need of psychosocial intervention

To trust another,

one must feel confidence in that person's presence, reliability, integrity, veracity, and sincere desire to provide assistance when requested. Trust is the basis of a therapeutic relationship. The nurse working in psychiatry must perfect the skills that foster the development of trust.

Physical appearance and dress are

part of the total nonverbal stimuli that influence interpersonal responses and, under some conditions, they are the primary determinants of such responses. This includes clothing, hair, tattoos, cosmetics, and jewelry.

Touch is a

powerful communication tool. It can elicit both negative and positive reactions, depending on the people involved and the circumstances of the interaction. It is a very basic and primitive form of communication, and the appropriateness of its use is culturally determined.

The preinteraction phase involves

preparation for the first meeting with the client. Tasks include obtaining available information about the client from his or her chart, significant others, or other health team members, and examining one's feelings, fears, and anxieties about working with a particular client.

The working phase is when

the therapeutic work of the relationship takes place. Tasks during this phase include maintaining the trust and rapport that was established during the orientation phase, promoting the client's insight and perception of reality, problem-solving, overcoming resistance behaviors on the part of the client, and continuously evaluating progress.

The nurse-client relationship is a

therapeutic one in which both parties perceive the other as a human being. The nurse-client relationship is goal oriented, and ideally, the nurse and the client both decide what the goal will be. Most often, the goal is directed at learning and growth in order to bring about some type of positive change in the client's life.