therapeutic communication. components of the nurse-client relationship trust genuine interest...

THERAPEUTIC COMMUNICATIO

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Components of the Nurse-Client Relationship

• Trust• Genuine interest• Empathy• Acceptance• Positive Regard• Therapeutic Use of Self

Types of relationships

Social

•Friendship •Companion•Use small talk•superficial

Intimate

•Emotional commitment•May be sexual/•emotional•Intimacy

Therapeutic

•Focus on client needs•Experiences,•Feelings, ideas•Goal oriented

Types of interpersonal relationships

• Kinship relationships (including family relationships)

involve relating to someone else: – genetically (consanguinity, as for example in

fatherhood, motherhood) – through marriage (affinity, as for example as a

father-in-law, mother-in-law, uncle by marriage, aunt by marriage)

• Formalized intimate relationships long-term relationships

recognized by law and formalized through public ceremony (for example, the relationships of marriage and of civil union)

• Non-formalized intimate relationships long-term relationships such as loving relationships or

romantic relationships with or without living together; with the "other person" often called lover, boyfriend or girlfriend (as distinct from just a male or female friend), or "significant other“.

• If the partners live together, the relationship may resemble marriage, with the parties possibly called "husband" and "wife".

• Soulmates, individuals intimately drawn to one another

through a favorable "meeting of minds" and who find mutual acceptance and/or understanding with one another. Soulmates may feel themselves bonded together for a lifetime; and hence may become sexual partners — but not necessarily.

• Casual relationships sexual relationships extending beyond "one-

night stands" that exclusively consist of sexual behavior; one can label the participants as "friends with benefits" when limited to considering sexual intercourse, or regard them as sexual partners in a wider sense.

• Platonic love an affectionate relationship into which the

sexual element does not enter, especially in cases where one might easily assume otherwise.

• Friendship which consists of mutual love, trust,

respect, and (often unconditional) acceptance; and usually implies the discovery or establishment of common ground between the individuals involved; see also internet friendship.

• Partners or co-workers in a profession, business, or a common workplace. Compare team.

• Participation in a community, for example, a community of interest or practice.

Phases of the Nurse-Client Relationship:

• Pre-Orientation- Self assessmentexamine own feelings, fears, anxieties.

• Orientation – Introductory Phaseestablish trust, share information with

client; discrete self-disclosure.convey support, facilitate healingeducate

• The Working Phase – Problems identifiedExploration- guide client to examine

feelings/responses, develop new coping skills.

Termination Phase – Resolution phaseExamine goals achieved;Explore feelings regarding terminationEstablish plan for continuing assistance

Obstacles to the Therapeutic Relationship:

• Inappropriate Boundaries

• Encouraging dependence

• Non acceptance/Avoidance

• Resistance

Roles of the Nurse:

• Teacher

• Caregiver

• Advocate

• Parent- Surrogate

Characteristics of

communication

Responsive dimensions

• Genuineness- the nurse is open, honest, and sincere.

• Respect- unconditional positive regard. The nurse’s attitude is nonjudgmental.

• Empathy- sensitivity to the pt’s current feelings and the verbal ability to communicate this understanding.

• concreteness

Action dimensions• Confrontation• Immediacy• Therapist self-disclosure• Catharsis• Role playing

Therapeutic Communication

• Boundaries:

Intimate

Personal

Social

Public

Non Verbal Communication

• Eye Contact• Body Language• Boundaries• Facial Expressions• Silence• Vocal cues

Non Verbal Communication

• Space (comfort zone)• Touch ( action/personal space – used

cautiously)• Appearance – communicates a particular

image/one’s mental status ( use of clothing, make-up etc.)

• Be aware of own non-verbal cues!!

Traits of Therapeutic Communication

• Genuineness• Positive Regard• Empathy• Trustworthiness• Clarity• Responsibility• Assertiveness

Conditions Affecting Communication

• Values• Attitudes• Beliefs• Perceptions• Culture or Religion• Social Status• Gender• Age or developmental level• Environment

Enhancing Communication

• Silence• Support/reassurance• Sharing Observations• Acknowledge feelings• Broad – open ended statements• Information giving• Interpretation

Active listening

– Expression of interest.– Leaning forward.– Nodding head.– Verbalizations such as “Uh-huh” and “Go on…”– Frequent validation.– Attempt to fully understand.

Active Listening!!

• S – Sit facing the client• O – Open Posture• L – Lean forward towards client• E – Establish eye contact• R- Relax!!

Open-ended questions

• “Tell me what happened?”• “How are you today?”

Restating

– Pt.: “I couldn’t sleep all night.”– Nurse:”You couldn’t sleep all night.” or “You couldn’t sleep all night?”– Pt.: “My husband is very worried about me.” – Nurse:”Your husband is very worried about you.” “Your husband is very worried about you?”

Clarifying, validating

• “I’m having some difficulty. Could you help me understand?”

Reflecting or validating

signifies understanding, empathy, interest, and respect for the patient. It consists of repeating in fewer and different words the essential ideas of the patient. (similar to paraphrasing). Reflection can refer to content or feelings.

Informing

• “I think you need to know more about how your medication works.”

Focusing

• “Can we continue talking about your mother right now?”

Theme Identification

• “I’ve noticed that in all of the relationships that you have described, you’ve been hurt or rejected by the man. Do you think this is an underlying issue?”

Silence

– If you don’t know what to say, say nothing.– Gives patient time to think.– Gives nurse time to think.– May allow patient to expand upon what he was

saying or think of a new topic to discuss.– As anxiety grows, patient is more likely to say

something.

Exploring

– Trying to get the patient to expand upon a topic or bring up another topic.

– “Would you tell me more about that?”– “What else makes you feel that way?”

Summarizing

”So far we have talked about.”

NON-THERAPEUTIC COMMUNICATION

False Reassurance

– “Everything’s going to be all right.”– “You’re doing just fine.”– Pt.: “I’m afraid I won’t wake up from the surgery.”– Nurse:”Sure you will.”

• Giving approval or disapproval; being judgmental; agreeing or disagreeing– “I wouldn’t say that.”– “Of course; I agree.”

• Giving advice– “If I were you…”– “I think you should…”– “It seems to me the best course of action is…”

• Defending– Pt.: “The nurses were very slow answering my light last

night.”– Nurse:”I don’t know how you can say that. This floor has

the best nurses in the hospital.”

• Minimizing feelings– Pt.: “I’m quite scared about this surgery.”– Nurse:”Oh, everyone feels that way before an

operation.”– Pt.: ”I really hate shots.”– Nurse.”Don’t be silly. It’s just a little stick.”

• Changing the subject– Pt.: “I hope someone comes to visit me today.”– Nurse:”It’s such a beautiful day today.”

• Social response- nurse uses superficial social conversation that is not

client-centered.- “How does the coffee taste today?”

ETHICS & RESPONSIBILITIES

“An ethic is a standard of behaviour or a belief valued by an individual or group”.

It describes what ought to be, rather than what is a goal to which one aspires.

Responsible ethical choice involves:-

• Accountability• Risk • Commitment• Justice

SIGMAN- elements of responsible ethical behavior for the nurse.

• Involves a moral obligation or duty to do or to refrain from doing something is within the power of the person.

• Involves source of responsibility – reward, praise or punishment.

• Cause of behavior is internal.• Behavior itself is not expressed through

ignorance, is respectful of the laws, maintains one’s integrity and freedom of choice and attempts to do justice.

ELEMENTS OF THE CONTRACT

1. Name of the individuals.2. Role of the nurse and the client.3. Responsibilities of nurse and the client.4. Expectations of the nurse and the client.5. Purpose of the relationship.6. Meeting location.7. Time of meetings.8. Conditions for termination.9. Confidentiality.

PROCESS OF FORMULATING CONTRACT

• STEP 1 – the contract begins with introduction.

• STEP 2 – explanation• STEP 3 - expectation• STEP 4 – description of do’s & don’ts• STEP 5- discussion on relationship• STEP 6 – meeting timings• STEP 7- meeting length• STEP 8 – review termination conditions• STEP 9- issue of confidentiality

METHODS OF CONTRACTING

• LEVEL I or care contacts.• LEVEL II or social contracts.• LEVEL III or relationship contracts.• LEVEL IV or structural change

contracts.

GOALS

1. To cope with present problems.2. To understand problem.3. To understand his active participation in an

experience.4. To identify emerging problems realistically.5. To find out a new alternative for his or her

problems.6. To try out new patterns of behavior.7. To communicate.8. To socialize.9. To find a meaning in his illness.