Structuring The Relationship

1. Structuring The Relationship

2. Therapeutic relationship • Primarily human connection and central to providing nursing care • Therapeutic relationship refers to holistic approach of nursing care including physical, emotional, psychological and social health education and care.

3. Characteristics of Therapeutic relationship • It is a healing relationship between health professional and client in need for care. • The goal is to promote health and wellbeing • It is an interdependent relationship

4. Types of Communication • Intrapersonal • Interpersonal

5. Intrapersonal Communication • Individuals give themselves all kinds of positive and negative messages • An example of positive self-talk is “I know I can do this!” • An example of dysfunctional self-talk is “I’ll never get better.”

6. Interpersonal Communication • Occurs between 2 or more people and contains both verbal and nonverbal messages • Consists of: • Social communication • Therapeutic communication

7. Social Communication • Occurs in everyday situations usually away from the work setting • Interaction is superficial and light; usually not goal directed • It’s purposes are to maintain relationships and for enjoyment • Consists of sharing information equally between 2 or more individuals

8. Therapeutic Communication • Occurs between the nurse and the client but is client focused • It is a learned skill involving both verbal and nonverbal communication • The purpose is to promote client growth • The medium through which health promotion interventions occur • Involves the disclosure of personal information by the client

9. Principles of the Nurse-Client Relationship • The relationship is therapeutic rather than social • The focus remains on the client’s issues rather than on the nurse’s or other issues • The relationship is purposeful and goal directed • It is objective versus subjective in quality • It is time limited versus open ended

10. Therapeutic vs Social • A therapeutic relationship is formed to • help clients solve problems • make decisions • achieve growth • learn coping strategies • let go of unwanted behaviors • reinforce self-worth • examine relationships

11. Therapeutic vs Social • The meetings between nurse and client are not for mutual satisfaction. • The nurse can be friendly with the client, but is not there to be the client’s friend. • The majority of the interaction is focused and therapeutic.

12. Client Focus • During an interaction, a client may redirect the focus away from self by changing the subject, talking about the weather, etc. • The nurse needs to recognize this as a divergent tactic, confront this behavior, and refocus the client.

13. Goal Direction • The primary purpose of a therapeutic relationship is helping clients to meet adaptive goals. • Nurse and client work together to identify problematic areas in client’s life • Once goals are established, the nurse and client agree to work toward those goals.

14. Objective vs Subjective • Nurses can be therapeutic only if they remain objective. • Objectivity refers to remaining free from bias, prejudice, and personal identification in interaction with the client and being able to process information based on facts. • Subjectivity refers to emphasis on one’s own feelings, attitudes, and opinions when interacting with the client.

15. Time-Limited Interactions • Time of meetings • Number of meetings that will take place • Provides structure • Lets client know that relationship will end

16. Role of Nurse • Self-awareness • Professional boundaries • Level of involvement • Therapeutic use of self • Self-disclosure

17. Code of ethics for nurses by ANA (2001) • transparency 3 ( page 34)

18. Patient’s Bill of Rights • Civil Rights • Client Consent • Communication • Freedom from Harm • Dignity and Respect • Confidentiality • Participation in Treatment Plan

19. Stages of the Nurse-Client Relationship • Pre-orientation phase • Orientation phase • Working phase • Termination phase

20. Preorientation Phase • Takes place prior to meeting with the client • 1st gather data about the client, his or her condition, and the present situation • Nurse then examines his or her thoughts, feelings, perceptions, and attitudes about this particular client

21. Orientation Phase • The nurse-client become acquainted; build trust and rapport • A contract is established • Includes time and place for the meeting, as well as the purpose of the meetings • Dependability is imperative for both the nurse and the client • Client strengths, limitations, and problem areas are identified • Outcome criteria and a plan of care are established

22. Working Phase • Orientation phase ends and working phase begins when the client takes responsibility for his or her own behavior change • Client shows commitment to working on issues that have caused a life disruption • Clients’ needs are prioritized- safety and health come first • RN assists the client to change problematic behaviors in a safe environment

23. Termination Phase • Relationship comes to a close • This phase begins in the orientation phase when meeting times are established- lets the client know that the relationship will come to an end • Avoids confusing the client who may be unable to recognized boundaries in a relationship • Termination occurs when the client has improved or has been discharged

24. AssessmentThe Nurse-Client Interview • The success of the interview depends on the development of trust, rapport, and respect between the nurse and client

25. Principles of Communication

26. Components of Communication • Sender • The individual who initiates transmission • Message • The information being sent and received • Medium • The method by which the message is sent • Receiver • Receives and interprets the message • Feedback • The measure by which the effectiveness of the message is gauged

27. Communication Verbal - written & spoken messages exchanged in the form of words as the element of language Nonverbal - messages that do not involve spoken/written word and are conveyed by behavior or through any of the five senses

28. Content - the actual content of the message, what is literally said, words Metacommunication- how the message is to be understood, or the intent of the meaning. Example: “You look lovely” saidw/ a frown

29. Assessment of Communication • Includes analysis of how verbal and nonverbal modes are used to structure communication • What are the messages conveyed by each? • Are the messages congruent?

30. Are the messages consistent w/the client’s culturally defined and taken- for-granted rules? • To what extent are stereotypes about the self/others conveyed by the structure of the client’s communication? • How does the structure of the client’s communication contribute to the problem (s) for which help is sought?

31. Nonverbal Communication • Believed to be the most important part of any message • Includes elements such as: • Tone of voice • Hand and body movements • Facial expressions • 90% of communication is thought to be nonverbal • Nonverbal cues should have congruence with the verbal message

32. Four Categories of Nonverbal Cues: • Body cues (kinetics) • Includes facial expressions, reflexes, body posture, hand gestures , eye movements, mannerisms • Space (proxemics) • Touch • Appearance

33. Therapeutic Techniques

34. Therapeutic Techniques • Introducing self • Enables client to meet nurse • Offering self • The nurse offers his or her presence, interest, and desire to understand without making any demands on the patient. • “We can sit here quietly; there’s no need to talk unless you want to.”

35. Therapeutic Techniques • Active Listening • Utilizing both verbal and nonverbal skills that show the client that the nurse is attentive to what is being said • Facing client; maintaining eye contact; “Go on, I hear what you are saying.”

36. Therapeutic Techniques • Open questions • Assist the client to discuss and clarify what is on their minds, what concerns them, and their attitudes and feelings • Allow clients the freedom of expression and doesn’t impose excessive limits • “Where would you like to begin?” • “What brought you into the hospital?”

37. Therapeutic Techniques • Closed questions • Provide structure • Replies are usually “yes” or “no” • Little freedom in latitude of response • “Where is your pain?’ • “Are you feeling suicidal?”

38. Therapeutic Techniques • Waiting in Silence • Used so that the client has time to verbalize feelings • Empathizing • Demonstrates warmth and acknowledges client’s feelings • “That must have been very difficult for you.”

39. Therapeutic Techniques • Providing Information • Nurse gives patient facts or specific information that is needed • Questions are answered simply and directed • “You are on the locked unit now.” • “Here is a copy of the unit rules; let’s go over a few important items.”

40. Therapeutic Techniques • Restating • Using different words to repeat the main idea the patient has expressed • Lets the client know that the nurse has heard and understands them • You say that you are saddened by your friend’s death.”

41. Therapeutic Techniques • Clarifying • The nurse makes an effort to have the patient clarify comments that are vague • “You spoke so softly I did not hear what you said.” • “I’m not able to follow that thought; could you tell me a little more about it?”

42. Therapeutic Techniques • Offering Reality • The nurse notices that the patient is misinterpreting reality • An effort is made to indicate what is real from unreal • “That’s a stain on the blanket, it is not a bug.” • “The scream came from the program on TV.”

43. Therapeutic Techniques • Stating Observations • Nurse offers a view of what is seen or heard to increase verbalization • “I see you are quite anxious.” • “You keep rubbing you forehead; are you in discomfort?”

44. Therapeutic Techniques • Summarizing • A concise review of the main ideas that have been discussed • Allows clients to sense whether the nurse understood their message • “From what you describe, your family seems….”

45. Therapeutic Techniques • Focusing • Focuses on a subject until the important points come into clear view for both the client and the nurse • “You touched on his drinking. Tell me more about that.” • Encouraging plan formation • Helps the client develop steps to make changes and solve problems • “Can you think of another way you might be able to handle a situation like this?” • “In what way can you make these visits less upsetting?”

46. Therapeutic Techniques • Role Playing • The nurse plays the part of a person the client needs to say something to • “Let’s go over what you want to say to her.” • Confronting • The nurse supports the client but directly challenges inaction on the part of the client • “You keep telling me that you want to quit drinking, but what actions have you taken thus far to aid with your sobriety?”

47. Reflecting - directing back to the client’s questions, feelings, ideas; encouraging client to bring forth his/her own ideas, which the nurse thereby acknowledges Client: “Do you think I should tell the doctor?” Nurse: “You are wondering if it is important?” • Encouraging evaluation – “What are your feelings in regard to…? Does this contribute to your discomfort?”

48. Verbalizing the implied Client: “My wife pushes me around just like my mother & sister do.” Nurse: “Is it your impression that women are domineering?” • Attempting to translate in to feelings Client: “I’ve been in the hospital for 6 weeks. I might as well be dead.” Nurse: “You think that you’re not getting better?”

49. Non-Therapeutic Responses

50. Probing • Serves to control the nature of the client’s responses • Questioning resembles interrogation rather than an interaction—client may feel overwhelmed and withdraw • Tends to put patient on the defensive • “Why do you do this?” • “Why do you feel this way?”