1. Communications that contribute to trust and mistrust of providers

2. Trust…
Trust is defined as an individual’s expectation that the communication behaviors of other s are reliable
Trust is to rely on the veracity and integrity of another individual
Evidence of trust occurs in patient’s perception that providers are sincere, honest, benevolent (caring), and credible in what they do

3. Trust is not something that is just absent or present
It is a complex phenomena that is manifested differently in interpersonal relationships, in particular situations

4. Establishing trust is important…
trust allows many things to happen:
1. Important to successful patient assessment where pt.’s disclosure is more complete
2. Identification with the nurse and the helping relationship enable pt to experiment and become skilled at aspects of self-care because trust is an influential factor and important behind the patient’s acceptance of provider opinion
3. Pt. learn to: cope with their limitations, Master skills and resolve problems and frustrations related to their health conditions

5. Trust potentiates change and patients are more likely to attempt new health related behavior
Establishing trust is felt to be an influential factor and important behind the patient’s acceptance of provider opinion

6. Trust occur when 2 conditions are met…
When patient perceive that nurses have their best interest in mind
When patient s perceive that the same nurse is capable and competent to help

7. Trust, respect and genuineness…
Acknowledging the value of patients and accepting their individuality (listening to pt. acknowledging their preferences, giving choices where possible

8. The process of establishing trust…
While it is true that trust is “earned”, it also true that some individuals have difficulty trusting under any circumstances
Patients’ personal health and social histories will reveal clues about their level of trust and the likelihood that trust will come easily

9. Trust like other aspects of interpersonal relationships is best viewed on a continuum
High level of trust or low level of trust, and somewhere in the middle a healthy appropriate level of trust

10. Trust and Mistrust…
Early origins of trust emanate from infancy from learning that a person will receive or have done what is needed
In time self-confidence results from perceiving that one is self-reliant
The process that patients go through in becoming confident in their abilities to render self-care parallel this primary experience

11. Clients who have healthy level of trust are more open and responsive
They are likely to communicate hope and faith and willing to take risk under provider guidance

12. Clients who mistrust behaves differently, they might communicate with defensiveness
They might be guarded with speech, exhibiting suspiciousness and caution

13. The nurse-client relationship
an interactive process between nurse and client that is goal-directed to help the client overcome temporary stress, to get along with other people, to adjust to the unalterable, and to overcome psychological blocks which stand in the way of self-realization

14. To allow the client to express thoughts, feelings, behaviors and life experiences, and life experiences in a meaningful way in order to promote healthy growth
To understand the significance of the client’s problems and the role of the client and the significant people in his or her life
To assist in the identification and resolution processes of the client’s problem areas

15. The process of establishing trust
Phases of therapeutic relationship

16. Nurse-client relationship is goal-directed and go through 3 or 4 phases. These phases are interrelated and each describes the responsibilities and task of the nurse and the client….

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

18. Preorientation Phase
Obtaining available information about the client from his or her chart, significant others, or other health team members. From this information, the initial assessment is begun.
Examining one’s feelings, fears, and anxieties about working with a particular client.
All individuals bring attitudes and feelings from prior experiences to the clinical setting. The nurse needs to be aware of how these preconceptions may affect his or her ability to care for individual clients.

19. Orientation, initiation, introductory...
The very first contact between provider and patient, whether through telephone or actual face to face encounter
This contact sets the tone and climate for the relationship, a statement of nurse’s name should be accompanied by an explanation of the role particularly in relation to the client

20. The Orientation (Introductory) Phase
Tasks include:
Creating an environment for the establishment of trust and rapport
Establishing a contract for intervention that details the expectations and
responsibilities of both the nurse and client
Gathering assessment information to build a strong client database
Identifying the client’s strengths and limitations
Formulating nursing diagnoses
Setting goals that are mutually agreeable to the nurse and client
Developing a plan of action that is realistic for meeting the established goals
Exploring feelings of both the client and nurse

21. Planned versus Spontaneous Exploration…
Direct
Nurse-led
Prescribed format
Information solicited
Topic areas determined by the nurse
More questioning techniques (probes) used
Responsive
Patient-led
No prescribed format
Meaning sought
Topic areas introduced by the patient
More exploratory statements (prompts) used

22. Therapeutic responding techniques related to assessment and orientation phase:
Introducing self
Offering self
Active listening
Questioning
Waiting in silence
listening
Empathizing
Reality orientation/ providing information
Summarizing
Reflection
Restating
Clarifying
Stating observations
Fostering description of perception
Voicing doubt
Identifying themes
Encouraging comparison
focusing

23. Working, implementing phase…
The therapeutic work of the relationship is accomplished during this phase. Tasks include:
Maintaining the trust and rapport that was established during the orientation phase
Promoting the client’s insight and perception of reality
Problem-solving.
Overcoming resistance behaviors on the part of the client as the
level of anxiety rises in response to discussion of painful issues
Continuously evaluating progress toward goal attainment

24. Termination…
Termination of the relationship may occur for a variety of reasons:
the mutually agreed-on goals may have been reached;
the client may be discharged from the hospital;
or, in the case of a student nurse, it may be the end of a clinical rotation.
Termination can be a difficult phase for both the client and nurse.
The main task involves:
Progress has been made toward attainment of mutually set goals.
A plan for continuing care or for assistance during stressful life experiences is mutually established by the nurse and client.
Feelings about termination of the relationship are recognized and explored. Both the nurse and client may experience feelings of sadness and loss.

25. Special communication techniques…
Self-disclosure
Touch
humor

26. Obstacles to therapeutic communication…
Resistance
Transference
Counter transference
Boundary violation

27. Resistance
occurs in clients who consciously or unconsciously maintain a lack of awareness of problems they are having to avoid anxiety.
Eg. A nurse can assure a client who resist discharge because of fear of failure or loneliness that such fears are not uncommon at the time of termination. The nurse can then remind the patient with his progress.

28. Transference
Is the unconscious response whereby clients associate the nurse with someone significant in their lives. Feelings and attitudes about the other person are transferred to the nurse.

29. Countertransfernce
Is initiated by the nurses’ emotional response to a specific client. Is is simply the nurse own transference.
To deal with, the nurse should conduct honest self-appraisal.

30. Boundary violations
Occurs when the nurse goes beyond the established therapeutic relationship and enters into social or personal relationship with the client.
Eg. A client may ask the nurse “ are you married”
Eg. The nurse accepts compensation or gifts for treatment.