Unit 5-Therapeutic communication and interpersonal relationship

Mr. Vinodkumar Patil

Objectives •General objective

▫After completion of the unit student is able to establish effective nurse patient relationship

Specific objectives

Define communication Explain communication skills Describe the relevance of a therapeutic nurse-

client relationship. Discuss the dynamics of a therapeutic nurse-

client relationship. Discuss the importance of self-awareness in the

nurse-client relationship. Identify goals of the nurse-client relationship. Describe the phases of relationship development

and the tasks associated with each phase.

Introduction

•Communication refers to •Communication is very significant in

nursing

Definitions of Communication•It is a complex process of sending and

receiving verbal and nonverbal messages and allows for exchange of information’s, feelings, needs and preference.

•Communication is the process that people use to exchange information. Messages are simultaneously sent and received on two levels: verbally through the use of words and nonverbally by behaviors that accompany the words (Balzer Riley, 2000).

Conti…• Communication is ‘a process by which two or

more people exchange ideas, facts, feelings or impressions in ways that each gains ‘common understanding’ of meaning, intent and use of a message’. – Paul Leagens.

• Webster’s New Collegiate Dictionary defines “Communication as a process by which information is exchanged between individuals through a common system of symbols, signs or behavior. A person who sends the message is called sender or encoder and the other who receives the message is called receiver or decoder.

Communication skills or Abilities of the Nurse

•GENERAL ABILITIES ▫Ability to read ▫Ability to express oneself in writing ▫Ability to speak ▫Ability to listen and interpret

SPECIAL ABILITIES •Ability to observe and interpret observation •Ability to guide the nurse-patient interaction

in order to accomplish goals. •Ability to recognize when to speak and when

to be silent - developing a sense of timing. •Ability to wait - to proceed at the patient's

pace/speed. •Ability to evaluate participation of the patient

in the nurse-patient relationship.

Communication takes place on two levels•Verbal Communication •Nonverbal Communication

▫It has been estimated that about 7% of meaning is transmitted by words

▫38% is transmitted by paralinguistic cues such as voice

▫And 55% is transmitted by body cues.

Types of Nonverbal Behavior

•Vocal cues include all the nonverbal qualities of speech.

•Action cues are body movements•Object cues are the speaker's intentional

and non-intentional use of all objects

Conti…•Space

▫Intimate space: up-to 18 inches▫Personal space: 18 inches to 4 feet▫Social-consultative space: 9 to 12 feet▫Public space: 12 feet and more

•Touch

Elements of a professional communication•Courtesy

▫To practice courtesy, the nurse says hello, goodbye and knock the door before entering, and use self introduction.

▫The nurse states her purpose, address people by name, say please and thank you to team members are included in it.

Conti…•Use of names•Privacy and confidentiality•Trustworthiness

▫Being trustworthy means helping others without hesitation when help is needed.

▫To foster trust, the nurse communicates warmth and demonstrates consistency, reliability, honesty and competence.

Conti…•Autonomity and Responsibility

▫Autonomity is the ability to be self directed and independent in gain goals and advocating for others

•Assertiveness▫It comprises respect for others, respect for

yourself, self awareness, and effective, clear, and consistent communication.

▫Assertiveness conveys a sense of self assurance while also communicating respect for the other person.

In last class•Definition of communication•Levels of communication•Abilities of nurse•Elements of professional communication

Types of communication techniques

•Therapeutic communication technique ▫These are specific responses that

encourage the expression of feelings and ideas and convey the nurse’s acceptance and respect.

•Non-therapeutic communication technique ▫The technique, which hinder or damage

professional relationships are called non-therapeutic communication techniques.

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 unfolded•Facilitate the client’s expression of

emotions

Conti…•Teach the client and family necessary self-

care skills.•Recognize the client’s needs.•Implement interventions designed to

address the client’s needs.•Guide the client toward identifying a plan

of action to a satisfying and socially acceptable resolution.

Principles and Characteristics of Therapeutic communication

•The patient should be the primary focus of interaction

•A professional attitude sets the tone of the therapeutic relationship

•Use self-disclosure cautiously and only when it has a therapeutic purpose.

•Avoid social relationship with patients•Maintain patient confidentiality

Conti…•Assess the patient’s intellectual

competence to determine the level of understanding

•Implement interventions from a theoretic base

•Maintain a non-judgmental attitude. Avoid making judgments about patient’s behavior

•Avoid giving advice•Guide the patient to reinterpret his or her

experiences rationally.

Therapeutic communication technique •Interview

▫face to face interaction ▫Helps▫Interview can be structured or

unstructured•History collection •Mental status examination •Health education •Counseling

Conti…•Active listening

▫Several nonverbal skills have been identified as facilitative skills for attentive listening. SOLER.

▫S – Sit facing the client▫O – Observe an open posture ▫L – Lean toward the client▫E – Establish and maintain intermittent eye

contact▫R – Relax

Therapeutic value•Listening is an active process of receiving

information.•Non-verbally communicates to the patient

the nurse’s interest and acceptance.

Empathy• Is the ability to understand and accept another

person’s reality to accurately perceive feelings, and to communicate this understanding to the client.

• Definition: • Ability to enter in to the life of other person, to

accurately perceive his current feelings and their meanings. It understands the patients’ world from his internal frame of reference rather than from the nurses own external frame of reference.

Development of Empathy•Nurse must be receptive to the patients feeling

and perceptions•Nurse must understand the patients

communication•Nurse should be able to put herself in the

patient’s place and assume his role and communicate this understanding to patient

•It’s not desirable to feel the same emotions as the patient

•Empathy should not be confused with sympathy

Conti…•Several therapeutic communication

techniques, such as reflection, restatement, and clarification, help the nurse to send empathetic messages to the client.

•For example, a client says, “I’m so confused! My son just visited and wants to know where the safety deposit box key is.”

Conti…•Using reflection, the nurse responds,

“You’re confused because your son asked for the safety deposit key?”

•The nurse using clarification responds, “Are you confused about the purpose of your son’s visit?”

A nursing study conducted by Mansfield identified specific verbal and nonverbal behaviors that conveyed high levels of empathy to patient:

• Having nurse introduce himself/herself to the patient• Head and body positions turned towards patient and

occasionally leaning forward• Verbal responses to the patients previous comments,

responses that focus on his strengths and resources• Consistent eye contact, facial expressions• Conveying interest, concern, and warmth by the

nurse’s own facial expression• A tone of voice consistent with facial expressions and

verbal responses• Mirror imaging of body positions and gestures

Techniques Conti…•Accepting: Conveys an attitude of

reception and regard. •Example: “Yes.” “I follow what you said.”

Nodding•Rationale: An accepting response

indicates the nurse has heard and followed the train of thought.

Broad Openings• Allows the client to take the initiative in

introducing the topic; emphasizes the importance of the client's role in the interaction.

• Example: “Is there something you’d like to talk about?” “Where would you like to begin?”

• Rationale: Broad openings make explicit that the client has the lead in the interaction.

• For the client who is hesitant about talking, broad openings may stimulate him or her to take the initiative.

Encouraging description of perceptions•Asking the client to verbalize what is

being perceived; often used with clients experiencing hallucinations.

•Example: “Tell me when you feel anxious.” “What is happening?” “What does the voice seem to be saying?”

•Rationale: To understand the client, the nurse must see things from his or her perspective.

Conti…•Restating•Reflecting•Focusing

Exploring•Delving further into a subject, idea,

experience, or relationship; especially helpful with clients who tend to remain on a superficial level of communication.

•Example: “Tell me more about that.” “Would you describe it more fully?” “What kind of work?”

•Rationale: When clients deal with topics superficially, exploring can help them examine the issue more fully.

Seeking clarification and validation• Clarifying the meaning of what has been said

facilitates and increases understanding for both client and nurse.

• Example: “Tell me whether my understanding of it agrees with yours.” “Are you using this word to convey that . . . ?”

• Rationale: For verbal communication to be meaningful, it is essential that the words being used have the same meaning for both (all) participants.

• Sometimes words, phrases, or slang terms have different meanings and can be easily misunderstood.

Presenting reality• When the client has a misperception of the

environment, the nurse defines reality.• Example: “I see no one else in the room.” “Your

mother is not here; I am a nurse.”• Rationale: When it is obvious that the client is

misinterpreting reality, the nurse can indicate what is real.

• The nurse does this by calmly and quietly expressing the nurse’s perceptions or the facts not by way of arguing with the client or belittling his or her experience

Touch

•Many messages, such as affection, emotional support, encouragement, tenderness, and personal attention are conveyed through touch.

Knapp (1980) identified five types of touch:

•Functional-professional touch •Social-polite touch •Friendship-warmth touch •Love-intimacy touch •Sexual-arousal touch

Using silence •Silence allows the client to think and gain

insight.

Non-therapeutic communication techniques

•Asking personal questions •Giving personal opinions •Changing the subject •False reassurance •Sympathy•Approval or disapproval •Passive or aggressive responses •Arguing•Rejecting

Barriers in effective communication•Personal barriers

▫Language▫Mental state▫Personality complexes▫Bias and prejudice▫Impatience▫Inhibition attitude▫Hospitalization▫Cultural factors▫Age and sex

Conti…•Physical impediments•Psychological factors•Mechanical factors•Educational difference•Organizational barriers•Rumours•Pathological barriers

Dynamics of therapeutic nurse patient relationship

• 1. Therapeutic use of self:– Is defined as the ability to use one’s personality

consciously and in full awareness in an attempt to establish relatedness and to structure nursing interventions.

• 2. Self awareness:– The process of understanding one’s own beliefs,

thoughts, motivations, biases and limitations and recognizing how they affect others.

3. Johari window 1. 2

Behaviors, feelings and thoughts known to the individual and others

Things that other know but the individual does not know

3 4

Private/hidden self things about self known only to self.

Unknown self aspects of the self that are unknown to the individual and to others.

Therapeutic Nurse Patient relationship

INTRODUCTION

• The nurse-client relationship is the foundation upon which psychiatric nursing is established.

• It is a relationship in which both participants must recognize each other as unique and important human beings.

• It is also a relationship in which mutual learning occurs.

Definition of relationship

• It is defined as a state of being related or state affinity between two individuals. Example- friendship and colleagues

• TYPES OF RELATIONSHIP– SOCIAL RELATIONSHIP– INTIMATE RELATIONSHIP– THERAPEUTIC RELATIONSHIP

SOCIAL RELATIONSHIP

• It is most common type of relationship between two individuals in every day life.

• Individuals are equally involved in this relationship and meet their needs through relationship

• There is no predetermined goal or focus in relationship.

• Continuation of the relationship is not determined at the onset

• It may last for months or years.• Ex: friends, work colleagues and neighbors.

INTIMATE RELATIONSHIP

• It is the relationship between two individuals committed to one another, caring for and respecting each other.

• The intimate relationship forms the basis for marriage and other partner type relationship

THERAPEUTIC RELATIONSHIP

• Definition therapeutic relationship: – it is a relationship where the nurse and

client work together towards the goal of assisting the client to regain the inner resources to meet life challenges and facilitate growth.

Conti…

• It is the professional relationship • The client and nurse work together • It is goal oriented, interaction is purposefully

established

GOALS OF THE THERAPEUTIC NURSE CLIENT RELATIONSHIP

• The nurse helps the client to cope with the present problems

• The nurse helps the client to understand his problem• The nurse helps the client to find out a new

alternative for his or her problem • The nurse helps the client to communicate. • The nurse helps the client to socialize • The nurse helps the client to find a meaning in his

illness

Characteristics

• Rapport• Trust• Respect• Genuineness• Empathy

Rapport

• Rapport implies special feelings on the part of both the client and the nurse based on acceptance, warmth, friendliness, common interest, a sense of trust and non judgmental attitude.

Trust

• To trust another, one must feel confidence in that person’s presence, reliability, integrity, veracity and sincere desire to provide assistance when requested.

• Trustworthiness is demonstrated through nursing interventions that convey a sense of warmth and caring to the client.

Respect

• To show respect is to believe in the dignity and worth of an individual regardless of his or her unacceptable behavior. – Calling the client by name ( and title, if the client

prefers)– Spending time with the client– Allowing for sufficient time to answer the client’s

questions and concern.

Genuineness

• The concept of genuineness refers to the nurse’s ability to be open, honest, and “real” in interactions with the client.

Empathy

• Empathy is the ability to see beyond outward behavior and to understand the situation from client’s point of view.

• With empathy, while understanding the client’s thoughts and feelings, the nurse is able to maintain sufficient objectivity to allow the client to achieve problem resolution with minimal assistance

PHASES OF NURSE CLIENT RELATIONSHIP

1. Pre-orientation phase2. Orientation phase3. Working phase 4. Termination phase

PRE-INTERACTION PHASE

• Definition:– This is a phase in which a nurse goes through

before the actual interaction with the client.

– This phase begins when the nurse is assigned a client to develop therapeutic relationship with him, till she goes to him for interaction.

Reaction of the nurse in pre-interaction phase

• The nurse feels and thinks about the client before interaction according to her knowledge, fears and mis-concepts

• Express feelings of inadequacy and fear of hurting or exploiting the client

• Fear of psychiatric clients related to the stereotyped psychiatric clients abusive and violent behaviour

Conti…• Nurse tries to collect information from secondary

sources• The nurse plans how she is going to interact with

the clients.• The nurse may express anxiety regarding the client

related to whether my client talks to me? He may not like me or not accept me?

• The nurse should also explore feelings of inferiority, insecurity, approval seeking behavior etc.

TASKS

• Explores own feelings, fantasies and fears • Analyze own professional strengths and

limitations• Gather data about client wherever possible• Plan for first meeting with client .• Set the objectives for interaction phase• Takes help of the clinical supervisor or co-

worker to overcome fears.

PROBLEMS ENCOUNTERED

• Difficulty in self analysis and self acceptance• Anxiety• Nurse may also experience boredom, anger,

indifference and depression

WAYS TO OVERCOME

• The nurse needs help from her supervisor and peers in self analysis and feeling reality in order to help clients to do likewise.

• This provides opportunity to explore feelings and fears and develops useful insight into one’s professional role

INTRODUCTORY / ORIENTATION PHASE

• Definition:– This is a phase which begins when the nurse goes

to the client, introduces self and gets introduction about him.

– The nurse and client who are strangers meet for the first time and become acquaintances.

– This ends when the client and nurse accept each other as a unique human being.

TASKS

• Establishment of contact, rapport, trust and acceptance

• Establish communication, assist in the verbal expression of thoughts and feelings

• Gather data, including the client’s feelings, strengths and weaknesses

• Define client’s problems, set priorities for nursing intervention

• Mutually set goals

WORKING PHASE

• During this phase the nurse and client actively work on meeting the goals which they had established during the orientation phase.

• The characteristic features of this phase are that the nurse is able to overcome anxiety and the client’s fear of unknown is also decreased.

TASKS

• The nurse collects the data in detail from primary and secondary sources and identifies the needs of the client

• The nurse assists the client to identify his or her problems

• Help the client to communicate• Encourages the client to socialize• The nurse helps the client to find an alternative

solution to his or her problem or development of insight and use of constructive coping mechanism

Conti…

• Encourages the client to use new patterns of behavior

• The nurse helps the client to understand that he has a significant role in his treatment

• She prepares the client for termination of relationship by reminding him during the interviews

• Provide him with opportunities for independent functioning

• Evaluate problems and goals, refine as necessary

Working phases helps the nurse to

• Develop knowledge and skills in psychiatric nursing

• Identifies his/her strengths and weaknesses as a nurse while interacting with the client

• She/he learns to take guidance from experts and the supervisor during difficulty

• Group discussion about the client helps her to share her knowledge with other team members.

BARRIERS

• Testing of nurses• Progress of the client• Difficulty in collecting and interpreting the

data• Fear of closeness• Life stresses of the nurse• Resistance behaviour• Transference• Counter transference

TERMINATION PHASE

• It is also called as resolution phase or end phase.

• Goal: – To bring a therapeutic end to the relationship.

CRITERIA FOR DETERMINING CLIENT’S READINESS FOR TERMINATION

• Client experiences relief from presenting problems

• Client social function has improved and isolation has decreased

• Clients ego functions are strengthened and he has attained a sense of identity

• Client employs more effective and productive defense mechanisms

• Client has achieved planned treatment goals

CAUSES OF TERMINATION

• The client may be discharged• The client may go on parole and does not come

back to the hospital• The nurse may terminate relationship due to

various reasons i.e., the student nurse completes her psychiatric posting or experience or client has improved and no longer needs to have one to one relationship

• When the client is in hospital and the nurse terminates relationship

TASKS OF TERMINATION PHASE

• Establish reality of separation• Mutually, explore feelings of rejection, loss,

sadness, anger and related behaviour• Review progress of therapy and attainment of

goals• Formulate plans for meetings future therapy

needs.

Dynamics of therapeutic Nurse-Patient Relationship

1. Therapeutic use of self2. Gaining self-awareness3. The Johari window

Therapeutic use of self

• The ability to use one’s personality consciously and in full awareness in an attempt to establishing relatedness and to structure nursing interventions.

Gaining self-awareness

• Self awareness is the process of understanding one’s own beliefs, thoughts, motivations, biases and limitations and recognising how they affect others.

The Johari window

• One tool that is useful in learning more aboutoneself is the Johari window

• which creates a “word portrait” of a person in four areas and indicates how well that person knows himself or herself and communicates with others.

• The four areas evaluated are as follows:

Conti…

• Quadrant 1: Open/public self: qualities one knows about oneself and others also know

• Quadrant 2: Blind/unaware self: qualities known only to others

• Quadrant 3: Hidden/private self: qualities known only to oneself

• Quadrant 4: Unknown: an empty quadrant to symbolize qualities as yet undiscovered by oneself or others

Therapeutic impasses