Building Nurse- Client RelationshipPresented by: ERIC F. PAZZIUAGAN, RN, MAN

Types of Relationships:

Social Relationship 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.

Intimate Relationship 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.

Therapeutic Relationship

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.

Establishing the Therapeutic Relationship

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.

Components of a Therapeutic Relationship

Trust 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

Trusting Behaviors (Nurse)

Caring Openness Objectivity Respect Interest Understanding Consistency

Treating the client as a human being

Suggesting without telling

Approachability Listening Keeping promises Honesty

Genuine Interest 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.

Empathy 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.

Acceptance 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.

Positive Regard 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.

Phases of the Nurse-Client Relationship

Orientation Phase 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.

Working Phase 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.

Termination 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.

Possible Warnings or Signals of Abuse of the Nurse-Client

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.

Methods to Avoid Inappropriate Relationships Between Nurses and Clients

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.

THERAPEUTIC COMMUNICATION

Therapeutic Communication

An interpersonal interaction between the nurse and the client during which the nurse focuses on the client’s specific needs to promote an effective exchange of information.

Skilled use helps the nurse understand and emphatize with the client’s experience.

Goals of Therapeutic Communication

Establish a therapeutic nurse-client relationship.

Identify the most important client concern at that moment (the client-centered goal).

Assess the client’s perception of the problem as it unfolds. This includes detailed actions (behaviors and messages) of the people involved and the client’s thoughts and feelings about the situation, others, and self.

Facilitate the client’s expression of emotions.

Teach the client and family necessary self-care skills.

Recognize the client’s needs. Guide the client toward identifying a

plan of action to a satisfying and socially acceptable situation.

Privacy and Respecting Boundaries

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.

Touch 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 and Observation

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.