Dr. James Malce Alo

Primarily initiated for the purpose of

friendship, socialization, companionship, or

accomplishment of task.

Communication (may be superficial): usually

focuses on sharing ideas, feelings, and

experiences and meets the basic need for

people to interact.

Advise if often given.

Roles may shift.

Acceptable in nursing, but must be limited.

If relationship becomes more social than

therapeutic, serious work that moves the

client forward will not be done.

Involves two people who are emotionally

committed to each other.

Both parties are concerned about having

their individual needs met and helping each

other to meet needs as well.

May include sexual or emotional intimacy as

well as sharing of mutual goals.

NO PLACE in the nurse-client interaction.

Differs from the social or intimate

relationship in many ways because it focuses

on the needs, experiences, feelings, and

ideas of the clients only.

Nurse and client agree about the areas to

communicate to work on and evaluate the

outcomes.

Nurse uses communication skills, personal

strengths, and understanding of human

behavior to interact with the client.

Parameters are clear: the focus is the client’s

needs, not the nurse’s.

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 on his or her own.

The nurse who has self-confidence rooted in

self-awareness is ready to establish

appropriate therapeutic relationships with

clients.

Awareness of his or her strengths at any

particular moment is a good start.

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 own

words and actions and can be relied on to do

what he or she says.

Congruence occurs when words and actions

match.

Trust erodes when a client sees inconsistency

between what the nurse says and does.

Trust is difficult to establish in the following:

Paranoia

Low self-esteem

Anxiety

Caring

Openness

Objectivity

Respect

Interest

Understanding

Consistency

Treating the client

as a human being

Suggesting without

telling

Approachability

Listening

Keeping promises

Honesty

When the nurse is comfortable with himself

or herself, aware of his or her strengths and

limitations, and clearly focused, the client

perceives a genuine person showing genuine

interest.

The nurse should be open and honest and

display congruent behavior.

Sometimes, responding with truth and

honesty alone does not provide the best

professional response.

The nurse may choose to disclose to the

client a personal experience related to the

client’s current concerns.

Be selective about personal examples.

Maybe from the nurse’s past experience, not a

current problem that is still being resolved, or a

recent, still painful experience.

Day-to-day experiences, not value-laden.

The ability to perceive the meanings and

feelings of the client and to communicate

that understanding to the client.

One of the essential skills a nurse must

develop.

Both the client and the nurse give a “gift of

self” when empathy occurs.

Understand the difference between empathy

and sympathy (feelings of concern or

compassion one shows for another).

By expressing sympathy, the nurse may

project his or her personal concerns onto the

client, thus inhibiting the client’s expression

of feelings.

Avoiding judgments of the person, no matter

what the behavior is.

E.g., The nurse does not become upset or

respond negatively to a client’s outbursts, anger

or acting out.

Does not mean acceptance of inappropriate

behaviors 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.

The nurse who appreciates the client as a

unique worthwhile human being can respect

the client regardless of his or her behavior,

background or style.

Measures to convey respect and positive

regard:

Calling client by name

Spending time with client

Listening and responding openly

Considering client’s ideas and preferences when

planning care.

The nurse relies on presence, or attending,

which is using nonverbal and verbal

communication techniques to make the

client aware that he is receiving full

attention.

Nonverbal techniques: leaning toward the

client, eye contact, being relaxed, having

the arms rested at the side, and interested

but neutral attitude.

Verbally attending: nurse avoids value

judgment about the client’s behavior.

Begins when the nurse and client meet and

ends when the client begins to identify

problems to examine.

Activities:

Establish roles

Establish the purpose of the meeting and the

parameters of the subsequent meeting

Identify client’s problems

Clarify expectations

Before the meeting:

Read background materials available on the

client

Become familiar with the medications the client

is taking

Gather necessary paper work

Arrange for a quiet, private and comfortable

setting

Self-assessment

Examine preconceptions about the client and

ensure to put them aside and get to know the

real person.

The nurse begins to build trust with the

client.

Share appropriate information about oneself:

name, reason for being in the unit, and level

of schooling

Listen closely to the client’s history,

perceptions and misconceptions.

Be very empathetic and understanding.

It may take several sessions before a client

trust the nurse.

Nurse-client Contracts

Agree responsibilities in an informal or verbal

contract

A formal or written contract may be appropriate

at times.

State the following:

Time, place, and length of sessions

When session will terminate

Who will be involved in the treatment plan

Client responsibilities (arrive on time, end on time)

Nurse’s responsibilities (arrive on time, end on time,

evaluate progress with client, document sessions)

Confidentiality:

Respecting the client’s right to keep private

information about his or her mental and physical care

and related care.

Allowing only those dealing with client’s care to have

access to the information that the client divulges.

Only under precisely defined conditions can third

parties have access to this information.

Adult clients can decide which family members, if

any, may be involved in treatment and may have

access to clinical information.

The nurse must avoid any promises to keep secret.

Tarasoff vs. University of California (1976): releases professionals from previleged communication with their clients should the client make a homicidal threat (duty to warn).

Document client problems with planned interventions.

The client needs to know the limits of confidentiality in the nurse-client interactions and how the nurse will use and share this information with professionals involved in the care.

Self-disclosure:

Revealing personal information such as

biographical information and personal ideas,

thoughts, and feelings about oneself to others.

Some purposeful, well-planned, self-disclosure

can improve rapport between the nurse and the

client.

May be use to convey support, educate clients,

and demonstrate that anxiety is normal and that

many people deal with stress and problems in

their lives.

Self- disclosure may help the client feel more

comfortable and more willing to share

thoughts and feelings, or help the client gain

insight into the situation.

Consider cultural factors.

Disclosing personal information to the

patient can be harmful and inappropriate, so

it must be planned and considered

thoughtfully in advance.

Spontaneously self-disclosing personal

information can have negative results.

Two sub-phases:

Problem identification: client identifies the

issues or concerns causing the problems.

Exploitation: the nurse guide the client to

examine feelings and responses and to develop

better coping skills and a more positive self-

image.

Encourages behavior change and develops

independence.

The client must believe that the nurse will

not turn away or be upset when the client

reveals experiences, issues and behaviors,

and problems.

The client will sometimes use outrageous

stories or acting-out behaviors to test the

nurse.

The nurse must remember that it is the

client who examines and explores problem

situations and relationships.

Specific tasks: Maintaining the relationship

Gathering the data

Exploring perceptions of reality

Developing positive coping mechanisms

Promoting a positive self-concept

Encourage 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

Transference: the client unconsciously

transfer to the nurse feelings he or she has

for significant others.

Countertransference: the nurse responds to

the client based on personal unconscious

needs and conflicts.

SELF-AWARENESS is important so that the

nurse can identify when transference and

countertransference might occur.

Final stage of the in the nurse-client

relationship.

Begins when the problems are resolved, and

it ends when the relationship is ended.

Nurse and client usually have feelings about

ending the relationship.

Clients may feel the termination as an

impending loss.

Clients may avoid termination by acting angry or as if the problem is not resolved.

Acknowledge the client’s angry feelings and assure 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.

Secrets; reluctance to talk to others about

the work being done with the client.

Sudden increase in phone calls between the

nurse and client calls outside the clinical

hours.

Nurse making exceptions for client than

normal.

Inappropriate gift-giving between client and

the 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 the client.

Change in the 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’s policies.

Realize that all staff members, whether male

or female, junior or senior, or from any

discipline are at risk for over-involvement or

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.

Privacy is desirable but not always possible in

therapeutic communication.

Possible venues:

Interview/ conference room

End of the hall

Quiet corner of the day room or lobby

Evaluate whether interacting in the client’s

room is therapeutic.

Proxemics: study of distance zones between people during communication. Intimate zone (0-18 inches between people):

parents with children, people who mutually desire personal contact, or people whispering. Invasion is threatening and produces anxiety.

Personal zone (18-36 inches): family and friends who are talking.

Social zone (4-12 feet): communication in social, work, and business settings.

Public zone (12-25 feet): between speaker and an audience, small groups, and other informal functions.

Consider the culture of the client.

Hispanic, Mediterranean, East Indian, Asian, and

Middle Eastern: comfortable with less that 4-12

feet distance.

When invading the personal zone, the nurse

should ask permission.

Therapeutic communication interaction is

most comfortable when the client and the

nurse are 3-6 feet apart.

If client invades the nurse’s personal space,

the nurse should set limits gradually.

Five types:

Functional-professional: touch is used in examination or procedures.

Social-polite: touch is used in greeting, such as hand-shake and the “air kisses” some women use to greet acquaintances, or when a gentle hand guides someone for the correct direction.

Friendship-warmth: touch involves a hug in greeting, an arm thrown around the shoulder of a good friend, or the backslapping some men used to greet friends or relatives.

Love-intimacy: touch involves tight hugs and kisses between lovers and close relatives.

Sexual arousal: touch used by lovers.

Touching a client can be comforting and

supportive when it is welcomed and

permitted.

Observe for cues that show whether touch is

desired or indicated.

Although touch can be comforting and

therapeutic, it is an invasion of intimate

personal space.

When performing a procedure, prepare the client

verbally before starting the procedure.

Active listening: refraining from other

internal mental activities and

concentrating exclusively on what the

client says.

Active observation: watching the

speaker’s nonverbal actions as he or she

communicates.

Active listening and observation help the

nurse to:

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.

Understanding the client’s perceptions of the

issue instead of jumping to conclusions.

Interpret and respond to the message

objectively.

Thank you!

Dr. JMA