Relationship Development and Therapeutic Communication

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

Nontherapeutic Communication Techniques

-Giving reassurance -Rejecting -Approving or disapproving -Agreeing or disagreeing -Giving advice -Probing -Defending -Requesting and explanation -Indicating the existence of an external source of power -Belittling feelings expressed -Making stereotyped comments, cliches, and trite expressions -Using denial -Interpreting -Introducing an unrelated topic

Components of nonverbal communication

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

Therapeutic communication techniques

-Using silence -Accepting -Giving recognition -Offering self -Giving broad openings -Offering general leads -Placing the event in time or sequence -Making observations -Encouraging description of perceptions -Encouraging comparison -Restating -Reflecting -Focusing -Exploring -Seeking clarification and validation -Presenting reality -Voicing doubt -Verbalizing the implied -Attempting to translate words into feelings -Formulating plan of action

c. "Thank you. I will share these with the rest of the staff."

1. Nurse Mary has been providing care for Tom during his hospital stay. On Tom's day of discharge, his wife brings a bouquet of flowers and box of chocolates to his room. He presents these gifts to Nurse Mary saying, "Thank you for taking care of me." What is a correct response by the nurse? a. "I don't accept gifts from patients." b. "Thank you so much! It is so nice to be appreciated." c. "Thank you. I will share these with the rest of the staff." d. "Hospital policy forbids me to accept gifts from patients."

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

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

A quiet corner of the day room 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

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? The client's room with the door shut A quiet corner of the day room The nurse's station The unit's treatment room

"This is a difficult transition. Let's formulate a plan to keep you all safe in the community." Th nurse is using the therapeutic technique 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

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? "This is a difficult transition. Let's formulate a plan to keep you all safe in the community." "It's the policy that clients can only live here for 30 days. Maybe we can ask for more time." "You've had a month to come up with a plan for keeping you and your family safe." "Hopefully, your husband has been in counseling. I'm sure this will work out fine."

Open-ended questions 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

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? Closed-ended questions Requesting an explanation Open-ended questions Interpreting

Exploring personal thoughts and feelings that may adversely impact the provision of care 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

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? Acknowledging the client's actions and encouraging alternative behaviors Establishing rapport and developing treatment goals Providing community resources on aggression management Exploring personal thoughts and feelings that may adversely impact the provision of care

Giving recognition

Acknowledging, indicating, awareness

S: Sit silently facing the client O: Observe an open posture L: Lean forward toward the client E: Establish eye contact R: Relax

Active listening (SOLER)

Giving broad opening

Allows client to select the topic

Using silence

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

Interpersonal communication techniques (both verbal and nonverbal)

Are the "tools" of psychosocial intervention

Process Recordings

Are written reports of verbal interactions with clients. They are verbatim accounts and used as a tool for improving interpersonal communication techniques It can take many form, but usually includes the verbal and nonverbal communication of both nurse and client (example is Table 6-5) They are written by the nurse or student as a tool for improving communication techniques

Requesting an explanation

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

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

Using denial

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

Transactional model

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

pre-existing conditions

Both the sender and receiver bring certain _________ ________ to the exchange that influence the intended message and the way in which the message is interpreted:

Belittling feelings expressed

Causes client to feel insignificant or unimportant

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

-Rapport -Trust -Respect -Genuineness -Empathy

Conditions Essential to Development of a Therapeutic Relationship

Exploring

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

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 constant shifting of eye contact, gives the message that the nurse is not really interested in what is being said

Reflecting

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

Offering general leads

Encourages client to continue

Indicating the existence of an external source of power

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

Termination phase

End of the nurse-client relationship. Termination of the relationship may occur for a variety of reasons, such as: -Progress has been made toward attainment of the goals -The mutually agreed-on goals may have been reached -A plan of action for more adaptive coping with future stressful situations has been established -The client may be discharged from the hospital Feelings about termination of the relationship are recognized and explored

Voicing doubt

Expressing uncertainty as to the reality of client's perception

Values, attitudes, and beliefs -Example: Attitudes of prejudice are expressed through negative stereotyping. -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. Culture or religion -Cultural mores, norms, ideas, and customs provide the basis for ways 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. Social Status -High-status persons often convey their high-power position with gestures of hands on hips, power-dressing, greater height, use less eye contact, and more distance when communicating with individuals considered to be of lower status 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. Age or developmental level -The influence of developmental level on communication is especially evident during adolescence, with words such as dude, cool, and awesome. 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. The environmental in which a transaction takes place -Territoriality, density, and distance are aspects of environment that communicate messages

Examples of pre-existing conditions

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

Feedback is useful when it....

Rapport

Implies special feelings on the part of both the client and the nurse based on: -Acceptance -Warmth -Friendliness -Common interest -Sense of trust -Nonjudgemental attitude

Approving or disapproving

Implies that the nurse has the right to pass judgement on the "goodness" or "badness" of client's behavior

Agreeing or disagreeing

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

Giving advice

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

Therapeutic use of self

Instrument for the delivery of the process of interpersonal nursing. It can be 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." Nurses must possess -Self awareness -Self-understanding -Philosophical belief about life, death, and the overall human condition

Pre-interaction phase

Involves preparation for the first meeting with the client Tasks include: 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

Therapeutic nurse-client relationship

Is a therapeutic relationship that can occur when both parties view the other as a unique human being. (Note: you are not here to have your needs met, and it might be a problem if your relationship is too "friend-like" with the patient) It 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.

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

Distance

Is the means by which various cultures use space to communicate

eye contact

It is through _____ ______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.

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

Giving reassurance

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

Transference

Occurs when the client unconsciously displaces (or "transfers") to the nurse feelings formed toward a person from the past 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. It can also take the form of overwhelming affection for the nurse or excessive dependency on the nurse

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

Vocal cues or paralanguage

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.

-Pre-interaction phase -Orientation (introductory) phase -Working phase -Termination phase

Phases of a Therapeutic Nurse-Client Relationship

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

Boundaries in the Nurse-Client Relationship

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.

Self-disclosure Gift giving Touch Friendship or romantic association

Professional boundary concerns commonly include issues such as:

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

Attempting to translate words into feelings

Putting into words the feelings the client has expressed only indirectly

Verbalizing the implied

Putting into words what client has only implied

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 -Deterioration of mental and physical health

Seeking clarification and validation

Striving to explain what is vague and searching for mutual understanding

Formulating plan of action

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

Focusing

Taking notice of a single idea or even a single word

therapeutic interpersonal relationship

The _____ _____ _____ is the process by which nurses provide care for clients in need of psychosocial intervention.

Nurse-client

The ______-_____ 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

Intimate distance

The closest distance that individuals allow between themselves and others

Genuineness

The concept of ________ 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

Social distance

The distance for conversation with strangers or acquaintances

Personal distance

The distance for interactions that are personal in nature, such as close conversation with friends

Public distance

The distance for speaking in public or yelling to someone some distance away

-Identify the client's problem (identify what is troubling the client) -Promote discussion of desired changes (encourage the client to discuss changes he or she would like to make) -Discuss aspects that cannot realistically be changed and ways to cope with them more adaptively -Help the client explore feelings about things that cannot be changed -Discuss alternative strategies for creating changes that the client desires to make -Weigh the benefits and consequences of each alternative -Help the 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 change and make modifications as required

The goals of a therapeutic relationship should be based on a problem-solving model, meaning that a problem should be clearly identified and both the client and the nurse should work toward solving that problem The nurse should work to:

Territoriality

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

Body movement and posture

The way in which an individual positions his or her body communicates messages regarding self-esteem, gender identity, status, and interpersonal warmth or coldness.

-Intimate distance -Personal distance -Social distance -Public distance

There are four kinds of distance that people maintain from each other in interpersonal interactions

Making stereotyped comments, cliches, and trite expressions

These are meaningless in a nurse-client relationship

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

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

Trust

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

Defending

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

Active listening

To listen actively is to be attentive and really desire to hear 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. Several nonverbal behaviors have been designed to facilitate attentive listening

Respect

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

Friendship or romantic association

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.

Orientation (introductory) phase

When the nurse and the client become acquainted with each other Tasks during this phase include: Create an environment for trust and rapport Establish contract for intervention that details the expectations and responsibilities of both parties ("I'm going to be your primary nurse. We will talk about changes together.") Gather assessment data Identify the client's strengths and limitations Formulate nursing diagnoses Set mutually agreeable goals Develop a realistic plan of action Explore feelings of both the client and nurse

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 Most times touch should be AVOIDED or considered with extreme caution

Therapeutic relationships

are goal-oriented and directed at learning and growth promotion is an interaction between two people (usually a care giver and care receiver) in which input from both participants contributes to a climate of healing, growth promotion, and/or illness prevention.

Accepting

conveys positive regard

Feedback

is a method of communication that helps the client consider a modification of behavior. Gives information to clients about how they are being perceived by others. It should be presented in a manner that discourages defensiveness on the part of the client

Therapeutic use of self

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

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

Touch

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.

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.

Making observations

verbalizing what is observed or perceived

Working phase

Is when the therapeutic work of the relationship takes place Tasks during this time include: Maintain trust and rapport that was established during the orientation (introductory phase) Promote the client's insight and perception of reality Use problem-solving model to work toward achievement of established goals Overcome resistance behaviors on the part of the client Continuously evaluate progress toward goal attainment Transference Countertransference

Restating

Lets client know whether an expressed statement has been understood

Offering self

Making oneself available

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 the transference feelings on the part of the client

Rejecting

Refusing to consider client's ideas of behavior

Interpreting

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

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