The Therapeutic Nurse-Client Relationship Use of Therapeutic Communication

Self Awareness & Nurse - Client Relationship Quad I Open to self/public – What you know about self And what others also know about you Quad 2 Blind – the unaware self Qualities others know about you –but you are unaware of. Quad 3 The hidden /private self Qualities only you know Quad 4 Unknown self EMPTY quad – the undiscovered self- Qualities not known by self/ others

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

Phases of the Nurse-Client Relationship: Pre-Orientation- Self assessment examine own feelings, fears, anxieties. Orientation – Introductory Phase establish trust, share information with client; discrete self-disclosure. convey support, facilitate healing educate

Phases of Therapeutic Nurse-Client Relationship—cont’d. The Working Phase – Problems identified Exploration- guide client to examine feelings/responses, develop new coping skills Termination Phase – Resolution phase Examine goals achieved; Explore feelings regarding termination Establish 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

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

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

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

Enhancing Communication Restating Reflecting Clarification Confrontation Offering Alternatives Voicing doubt Role-playing Use of Humor – use cautiously/discretely

Non-therapeutic responses Advising Agreeing Belittling feelings Challenging Defending Disagreeing Disapproving Probing

Caring for clients from different socio-cultural backgrounds Important !! – Analyze self! – know your own beliefs/values/customs/behaviors Avoid being judgmental Rules for communication vary since they arise from cultural norms! Understand differences in communication among various cultures Ask families for assistance re: their culture Reflect on your emotions/journal write feelings

Therapeutic communication ?’s 1. The nurse is meeting a new client on the unit.Which action, by the nurse, is most effective in initiating the nurse-client relationship? Introduce self and explain the purpose and the plan for the relationship. Describe the nurse’s family and ask the client to describe his/her family. Wait until the client indicates a readiness to establish a relationship. Ask the client why he/she was brought to the hospital.

2. Mrs. F. has remained close to the nurse all day 2. Mrs. F. has remained close to the nurse all day. When the nurse talked with other clients during dinner, Mrs. F. tried to regain the nurse’s attention and began to shout, “You’re just like my mother. You pay attention to everyone but me!” The best interpretation of this behavior is that Mrs. F. is exhibiting resistance. Mrs. F. has been spoiled by her family. The nurse has failed to meet Mrs. F’s needs. Mrs. F. is demonstrating transference.

3. The nurse is caring for a Native American client who says, “I don’t want you to touch me.I’ll take care of myself.” Which nursing response is most therapeutic? “Okay, if that’s what you want.I’ll just leave this cup for you to collect your urine.” “If you don’t want our care, why did you come here?” “Why are you being so difficult? I only want to help you.” “It sounds as though you want to take care of yourself. Let’s work together so you can do things for yourself.”

4. The client says to the nurse “I am going to die, I wish my family would stop hoping for a cure! I get so angry when they carry on like this! After all, I’m the one who’s dying.” The most therapeutic response is: “You’re feeling angry that your family continues to hope for you to be cured.” “I think we should talk more about your anger with your family.” “Well, it sounds like you’re being pessimistic. After all, years ago people died of pneumonia.” “Have you shared your feelings with your family?”

5. The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, “How is Carol doing? She is my best friend and is seen at your clinic every week.” The most appropriate nursing response is which of the following? “I’m not supposed to discuss this, but because you are my neighbor, I can tell you that she is doing great!” I’m not supposed to discuss this, but because you are my neighbor, I can tell you that she really has some problems!” “If you want to know about Carol, you need to ask her yourself.” “I cannot discuss any client situation with you.”

6. The nurse is preparing the client for the termination phase of the nurse-client relationship. The nurse prepares to implement which nursing task is most appropriate for this phase? Identifying expected outcomes Planning short term goals Making appropriate referrals Developing realistic solutions

7. During the termination phase of the nurse-client relationship, the clinic nurse observes that the client continuously demonstrates bursts of anger. The most appropriate interpretation of the behavior is that the client Requires further treatment and is not ready to be discharged. Is displaying typical behaviors that can occur during termination. Needs to be admitted to the hospital. Needs to be referred to the psychiatrist as soon as possible.

8. A client looks at a mirror and cries out, “I look like a bird 8. A client looks at a mirror and cries out, “I look like a bird. This is not my face.” The nurse responds therapeutically by saying: “What kind of a bird do you think you are?” “That must be very distressing to you, your face does not look different to me.” “Maybe the light is playing tricks on you.” “Why do you think that you look like a bird?”

9. A 32 year old mother of 2 young children diagnosed with cervical cancer with metastacies, tells her nurse “I’m going to die, aren’t I ?” The nurse’s most appropriate response would be: “No, you are not . After all you are receiving the latest treatment available, and your doctor is one of the best in this area.” “We are all going to die sometime.” “What did your doctor tell you?” “I don’t know. You have a serious illness. Do you have feelings that you would like to talk about?”

A client relates angrily to the nurse that his wife says he is selfish A client relates angrily to the nurse that his wife says he is selfish. Which response by the nurse would be most helpful? “That’s just her opinion.” “I don’t think that you are selfish.” “Everyone is a little bit selfish.” “You sound angry – tell me more about what went on.”

11. The most therapeutic response a nurse could make to a student who begins to cry upon learning that a failing grade was received on a final exam is: “You’ll make it next time.” “Failing an exam is an upsetting thing to happen.” “How close were you to passing?” “It won’t seem so important 5 years from now.”