NURSE CLIENT RELATIONSHIP NURSE CLIENT INTERACTION MODULE 4

NURSE CLIENT INTERACTION (COMMUNICATION)

COMMUNICATION : is the process that people use to exchange information. Is an interaction between two or more people that involves the exchange of information between a sender and a receiver Messages are simultaneously sent and received on two levels:
Verbally through the use of words Non- verbally by behaviors that accompany the words.

THERAPEUTIC COMMUNICATION
Is an interpersonal interaction between the nurse and client during which the nurse focuses on the clients specific needs to promote an effective exchange of information. therapeutic communication techniques helps the nurse understand and empathize with the clients experience. All nurses need skills in therapeutic communication to effectively apply the nursing process and to meet standards of care for their client.

Therapeutic Communication can help Nurses to accomplish Goals:

1. Establish a therapeutic nurse- client relationship 2. Identify the most important client concern at that moment (client centered goal). 3. Assess the clients perception of the problem as it unfolds. (the clients thoughts and feelings about the situation, others and self).

 4. Facilitate the clients expression of emotions. 5. Teach the client and family necessary selfcare skills. 6. Recognize the clients needs. 7. Implement intervention designed to address the clients needs. 8. Guide the client toward identifying a plan of action to a satisfying and socially acceptable resolution.

To have Effective Therapeutic Communication the nurse must consider:

Privacy and Respect of Boundaries Use of Touch Active listening and observation

1. PRIVACY AND RESPECT BOUNDARIES

Privacy is desirable but not always possible in Therapeutic Communication. ( delicate information the nurse should know or the patient would revealed) An interview or conference room is optimal, if the nurse believes this setting is not isolative for interaction. The nurse needs to evaluate whether interacting in the clients room is therapeutic. Ex. If the client has difficulty maintaining boundaries or has been making sexual comments, then the clients room is not the best setting.

 BOUNDARIES PROXEMICS: is the study of distance zones

between people during communication. People feel more comfortable with smaller distance when communicating with someone they know rather than strangers.

4 Distance Zones: 1. Intimate 2. Personal 3. Social 4. Intimate

4 Distance Zones:
1. Intimate zone ( 0 to 18 inches between people) : this amount of space is comfortable for parents with young children, people who mutually desire personal contact, or people whispering. invasion of this intimate zone by anyone else is threatening and produces anxiety. 2. Personal zone (18 to 36 inches) : this distance is comfortable between family and friends who are talking.

 3. Social zone (4 to 12 feet): this distance is acceptable for communication in social, work, and business settings. 4. Public zone (12 to 25 feet): this is acceptable distance between a speaker and an audience, small groups, and other informal functions. Both the client and the nurse can feel threatened, if one invades the others personal or intimate zone, which can result tension, irritability, fidgeting (uneasy, nervous) , or even flight. When the nurse must invade the intimate or personal zone, the nurse should ask the clients permission.

2. touch
AS INTIMACY INCREASES, THE NEED FOR DISTANCE DECREASES. 5 TYPES OF TOUCH: 1. Functional- Professional touch: is used in examination or procedure. 2. Social- Polite touch: is used in greetings, such as hand shake 3. Friendship- Warmth touch: hug in greeting, back slapping 4. Love- intimacy touch: tight hugs and kisses between lovers or close relatives. 5. Sexual- Arousal touch: used by lovers, specially the married couple.

3. ACTIVE LISTENING AND OBSERVATION

To receive the senders simultaneous messages, the nurse must use active listening and active observation. Active listening : means refraining from other internal mental activities and concentrating exclusively on what the client says. Active observation : means watching the speakers nonverbal action as he/ she communicates.

 COMMON MISCONCEPTION OF STUDENTS learning the art of THERAPEUTIC COMMUNICATION = is that they always must be ready with questions the instant the client has finished speaking. They are constantly thinking ahead regarding the next question rather than actively listening to what the client is saying. The result can be that the nurse does not understand the clients concerns, and the conversation is vague, superficial, and frustrating to both participants.

Active Listening and Observation

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 /her perceptions fully. Understand the clients perceptions of the issue instead of jumping to conclusions. Interpret and respond to the message objectively.

VERBAL COMMUNICATION SKILLS

1. USING CONCRETE MESSAGES 2. USING THERAPEUTIC COMMUNICATION TECHNIQUES

1. USING CONCRETE MESSAGE

nurse should use words that are clear as possible when speaking to the client so that the client can understand the message. In concrete message , the words are explicit and need no interpretation. Concrete questions, are clear, direct, and easy to understand. Ex. "what health symptoms caused you to come to the hospital today? or when was the last time you took your antidepressant medications?

2. USING THERAPEUTIC COMMUNICATION TECHNIQUES:

The choice of technique depends on the intent of the interaction and the clients ability to communicate verbally. Overall , the nurse selects techniques that facilitate the interaction and enhance communication between client and nurse. Techniques such as exploring, focusing, restating, and reflecting encourage the client to discuss his/her feelings or concerns in more depth.

THERAPEUTIC COMMUNICATION TECHNIQUES:

1. Accepting : indicating reception Ex. yes I follow what you said. Nodding 2. Broad opening: allowing the client to take the initiative in introducing the topic. Ex. Is there something youd like to talk about? Where would you like to begin? 3. Consensual validation: searching to mutual understanding, for accord in the meaning of the words. Ex. Tell me whether my understanding of it agrees with yours.

 4. Encouraging comparison: asking that similarities and differences be noted. Ex. Was it something like...? Have you had similar experiences? 5. Encouraging description of perceptions: asking the client to verbalize what he/ she perceives. Ex. Tell me when you feel anxious What is happening? What does the voice seem to be saying?

 6. Encouraging expression: asking the client to appraise the quality of his/her experiences. Ex. What are your feelings in regard to....? Does this contribute to your distress? 7. Exploring: delving further into a subject or idea. Ex. Tell me more about that. Would you describe it more fully? 8. Focusing: concentrating on a single point. Ex. This point seems worth looking at more closely.

 9. Formulating a plan of action: asking the client to consider kinds of behavior likely to be appropriate in future situations. Ex. What could you do to let your anger out harmlessly? 10. General leads: giving encouragement to continue. Ex. Go on and then? Tell me about it. 11. Giving information: making available the facts that the client needs. Ex. My name is.... Visiting hours are... My purpose in being here is.....

 12. Giving recognition: acknowledging, indicating awareness: Good morning, Mr. S....... I notice that youve combed your hair. 13. Making observations: verbalizing what the nurse perceives. Ex. You appear tense. I notice youre biting your lip. 14. Offering self: making oneself available. Ex. Ill sit with you awhile.

 15. Presenting reality: offering for consideration that which is real. Ex. Ill see no one else in the room. 16. Reflecting: directing client actions. Thoughts, and feelings back to client. Ex. Client: do you think I should tell the doctor....? Nurse: do you think you should?

 17. Restating: repeating the main idea expressed. Ex. Client: I cant sleep. I stay awake all the night. Nurse: you have difficulty sleeping. 18. Seeking information: seeking to make clear that which is not meaningful or that which is vague. Ex. Im not sure that I follow. Have I heard you correctly?

AVOIDING NONTHERAPEUTIC COMMUNICATION

In contrast, there are many therapeutic techniques that nurses should avoid. These responses cut off communication and make it more difficult for the interaction to continue. Responses such as Everything will work out or May be tomorrow will be a better day may be intended to comfort the client, but instead may impede the communication process.

NONTHERAPEUTIC COMMUNICATION TECHNIQUES:

1. Advising: telling the client what to do. Ex. I think you should... 2. Agreeing: indicating accord with the client. Ex. Thats right. 3. Belittling feelings expressed: misjudging the degree of the clients discomfort. Ex. Client: I have nothing to live for... I wish I was dead. Nurse: Everybody gets down in the dumps. or Ive felt that way myself.

 4. Challenging: demanding proof from client. Ex. But how can you be president of the United State? If youre dead, why is you heart beating? 5. Defending: attempting to protect someone or something from verbal attack. Ex. This hospital has a fine reputation. Im sure your doctor has your best interests in mind.

 6. Disagreeing: opposing the clients ideas. Ex. thats wrong. 7. Disapproving: denouncing the clients behavior or ideas. Ex. Thats bad Id rather you wouldnt 8. Giving approval: sanctioning the clients behavior or ideas. Ex. Thats good. Im glad that...

 9. Interpreting: asking to make conscious that which is unconscious; telling the client the meaning of his or her experience. Ex. What you really mean is.... Unconsciously youre saying.... 10. Probing: persistent questioning of the client. Ex. Now tell me about this problem. You know I have to find out.

INTERPRETING SIGNALS OR CUES

To understand what the client means, the nurse watches and listens carefully for cues. CUES: are verbal or nonverbal messages that signal key words or issues for the client. Cue words introduced by the client can help the nurse to know what to ask next or how to respond to the client.

INTERPRETING SIGNALS OR CUES (1/2)

Ex. Client: I had a boyfriend when I was younger. Nurse: You had a boyfriend? (reflecting, direct the clients actions, thoughts, and feelings back to client) Tell me about you and your boyfriend. (encouraging description) How old were you when you had this boyfriend? (placing events in time or sequences)

NONVERBAL COMMUNICATION SKILLS

Is behavior that a person exhibits while delivering verbal content. It includes: facial expression, eye contact, space , time, boundaries, and body movements.

Nonverbal communication
involves the unconscious mind acting out emotions related to the verbal content, the situation, the environment, and the relationship between the speaker and the listener.

1. FACIAL EXPRESSION
The human face produces the most visible, complex, and sometimes confusing nonverbal messages. Facial movements connect with words to illustrate meaning; this connection demonstrates the speakers internal dialogue.

Facial expression can be categorized into:

Expressive Impassive Confusing

Expressive:
face portrays the persons momentby- moment thoughts, feelings and needs. These expression may be evident even when the person does not want to reveal his/her emotions.

Impassive:
is frozen into an emotionless deadpan expression similar to mask.
EX. FLAT AFFECT

Confusing:
facial expression is one that is the opposite of what the person wants to convey. A person who is verbally expressing sad or angry feelings while smiling is exhibiting a confusing expression.

Facial expression
often affect the listeners response. The nurse should identify the facial expression and ask the client to validate nurses interpretation of it. Ex. youre smiling, but I sense you are very angry.

2. BODY LANGUAGE
Gesture , postures, movements, and body positions. Is a nonverbal form of communication. Closed Body Position Accepting Body Position

CLOSED BODY POSITION

such as crossed legs or arms folded across the chest, indicate that interaction might threaten the listener who is defensive or not accepting

ACCEPTING BODY POSITION

is to sit facing the client with both feet on the floor, knees parallel, hands at the sides of the body, and legs uncrossed or crossed only at the ankle. This open posture demonstrate unconditional positive regard, trust, care and acceptance. The nurse indicates interest in and acceptance of the client by facing and slightly leaning toward him or her while maintaining nonthreatening eye contact

VOCAL CUES
Are nonverbal sound signals transmitted along with the content: voice volume, tone, pitch, intensity, emphasis, speed, and pauses augment the senders message. Volume : the loudness of the voice, can indicate anger, fear, happiness, or deafness. Tone: can indicate whether someone is relaxed, agitated or bored. Pitch: varies from shrill and high to low and threatening.

 Intensity: is the power, severity, and strength behind the words, indicating the importance of the message. Emphasis: refers to accents on words or phrases that highlight the subject or give insight on the topic. Speed: is number of words spoken per minute.

EYE CONTACT
The eyes have been called the mirror of the soul because they often reflect our emotions. Looking into the other persons eyes during communication, is used to assess the other person and the environment and to indicate whose turn it is to speak it increases during listening but decreases while speaking. Although maintaining good eye contact is usually desirable, it is important that the nurse doesnt STARE at the client.

SILENCE
Or long pauses in communication may indicate many different things. The client may be depressed and struggling to find the energy to talk. Sometimes pauses indicate the client is thoughtfully considering the question before responding. At times, the client may seem to be LOST IN HIS/HER OWN THOUGHTS and not paying attention to the nurse. It is important to allow the client sufficient time to respond, even if it seems like a long time.

Therapeutic relationship
The nurses relationship with the patient consists of a series of goal-directed interactions through which the nurse assesses patients problems, elicits patient input, selects interventions, and evaluates the effectiveness of care.

SOCIAL RELATIONSHIP
is primarily initiated for the purpose of friendship, socialization, companionship, or accomplishment of task. Communication, w/c may be superficial, Usually sharing of ideas, feelings and experiences and meets basic need for people to interact. Advise is often given.

INTIMATE RELATIONSHIP healthy 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. The relationship may include sexual or emotional intimacy as well as sharing of mutual goals.

THERAPEUTIC RELATIONSHIP
Differs from the social and intimate relationship in many ways because it focuses on the needs, experiences, feelings, and ideas of the client only. The nurse and client agree about the areas to work on and evaluate the outcomes.

THERAPEUTIC RELATIONSHIP
The nurse uses communication skills, personal strengths, and understanding of human behavior to interact with the client. The nurse should not be concerned about whether or not the client likes him/her or grateful. The nurse must constantly focus on the clients needs not his/her own.

COMPONENTS OF A THERAPEUTIC RELATIONSHIP

Trust Genuine interest Empathy Acceptance Positive regard Self-awareness Therapeutic use of self

Trust
Trust develops when the client believes that the nurse will be consistent in his/her words and actions and can be relied on to do what he or she says.

Genuine Interest
The client perceives a genuine person showing genuine interest.
A client with mental illness can detect when someone is exhibiting dishonest or artificial behavior such as asking a question and then not waiting for the answer, talking over him or her, or assuring him/her everything will be all right.

Empathy
Is the ability of the nurse to perceive the meaning and feelings of the client and to communicate that understanding to the client. It is considered one of the essential skills a nurse must develop. Being able to put himself/herself in the clients shoes does not mean that the nurse has had the same exact experiences as the client. Ex. Empathy : I see you are sad.... How can I help you? Ex. Sympathy : I feel so sorry for you.

Acceptance
The nurse who does not become upset or respond negatively to a clients outbursts, anger, or acting out conveys acceptance to the client. Avoiding judgment s of the person, no matter what the behavior, is acceptance. This does not mean acceptance of inappropriate behavior but acceptance of the person as worthy.

 The nurse must set boundaries in the nurseclient relationship. Ex. A client puts his arm around the nurses waist. An appropriate response would be for the nurse to
remove his hand and say, john, do not place your hand on me. We are working in your relation with your girlfriend and that does not require you to touch me. Now, lets continue.

Positive Regard
The nurse who appreciates the client as a simple worth while human being can respect the client regardless of his or her behavior, background, or lifestyle. Calling the client by name, spending time with the client, and listening and responding openly are measures by which the nurse conveys respect and positive regard to the client.

Self- Awareness
Before the nurse can begin to understand clients, the nurse must know himself /herself. Self awareness: is the process of developing an understanding of one owns values, beliefs, thoughts, feelings, attitude, motivations, prejudices, strengths, and limitations and how these qualities affect others.

Values:
are abstract standards that give a person a sense of right and wrong and establish a code of conduct for living. Sample values: hard work, honesty, sincerity, cleanliness,, and orderliness.

Beliefs
are ideas that one holds to be true, Ex. if the sun is shining, it will be a good day. Some Beliefs have objective evidence to substantiate them. Ex. People who believe in evolution have accepted the evidence that supports this explanation for the origin of life.

Attitudes:
are general feelings or a frame of reference around which a person organizes knowledge about world. Attitudes such as: hopeful, optimistic, pessimistic, positive, and negative, color how we look at the world and people.

Therapeutic use of Self

By developing self- awareness and beginning to understand his/ her attitudes, the nurse can begin to use aspects of his/her personality, experiences, values, feelings, intelligence, needs, coping skills, and perceptions to establish relationships with client.

Nurses use themselves as therapeutic tool to establish therapeutic relationships with clients and help clients grow, change, and heal.

JOHARI WINDOW
One tool that useful in learning more about oneself. Which creates a word portrait of a person in four areas and indicates how well that person knows himself/ herself and communicates with others. The Four Areas evaluated are as follows: Quadrant 1: Open /Public self = qualities one knows about oneself and others also know.

 Quadrant 2: Blind/ Unaware self = qualities know 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.

Johari window

3 PHASES/ STAGES OF NURSE- CLIENT RELATIONSHIP

1. ORIENTATION STAGE 2. WORKING STAGE 3. TERMINAL STAGE

ORIENTATION PHASE
Begins when the nurse and client meet and ends when the client begins to identify problems to examine.

Before meeting the client: The nurse reads background materials available on the client. Becomes familiar with any medications the client is taking The nurse should consider his/her personal strengths and limitations in working with this client (self assessment). Acceptance is the foundation of all therapeutic relationship.

(orientation phase)
During the Orientation Phase: The nurse establishes roles The purpose of meeting and parameters of subsequent meetings Identifies the clients problems, and clarifies expectations. Built trust: it is the nurse responsibility to establish a therapeutic environment that foster trust and understanding.

 The nurse should share appropriate information about himself/herself at this time, including name, reason for being on the unit, and level of schooling. (self- disclosure) The nurse needs to listen closely to the clients history, perceptions and misconceptions. The nurse needs to convey empathy and understanding.

 Reality testing : is accepting the patients

perception, feelings and thoughts as neither right or wrong, but at the same time offering other options or points of view to the client in a non-argumentative manner for the purpose of helping the client arrive at more realistic conclusion.
To provide structure: is to intervene when client loses control of his feelings and behaviors by medications, offering self, restrain, seclusion and by assessing client to observe a consistent daily schedule.

ORIENTATION PHASE: NURSE- CLIENT CONTRACTS

Although many clients have had prior experiences in the mental health system, the nurse must once again outline the responsibilities of the nurse and client. Both nurse and client agree on these responsibilities in an informal or verbal contract.

ORIENTATION PHASE: CONFIDENTIALITY, DUTY TO WARN

MEANS RESPECTING THE CLIENTS RIGHT TO KEEP PRIVATE ANY INFORMATION ABOUT HIS/HER MENTAL AND PHYSICAL HEALTH AND RELATED CASE. DUTY TO WARN: The decision requires the nurse to notify intended victims and police of such threat. Ex. Suicidal threats, threat from the client to harm other person.

WORKING PHASE The phase where issues are addressed, Problems identified Solutions explored Nurse and client work to accomplish goals

Working exploration /identification phase

At this point the clients problem are identified and solutions are explore, applied and evaluated. The focus of the assessment and of the relationship is the clients behavior and the focus of the interaction is the clients feelings. The nurse should realize that the clients feelings of security are developed by being consistent at all times.

Working phase
Perception of reality, coping mechanisms and support system are identified. The nurse assists the patient to develop coping skills, positive self concept and independence in order to change the behavior of the client to one that is adaptive and appropriate. The nurse uses the techniques of communication and assumes different roles to help the client.

THE SPECIFIC TASKS OF WORKING PHASE INCLUDE THE FF:

Maintain the relationship Gathering more data Exploring perceptions of reality Developing positive coping mechanisms Promoting a positive self- concept Encouraging 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 to transfer to the nurse feelings he or she has for significant others. Countertransferrence: a similar process can occur when the nurse responds to the client based on personal unconscious needs and conflicts. Ex. If the nurse is the youngest in her family and often felt as if no one listened to her when she was a child, she may respond with anger to a client who does not listen or resist her help.

TERMINATION PHASE
OR RESOLUTION PHASE: is the final stage in the Nurse- client Relationship. It begins when the problems are resolved, and it ends when the relationship is ended. Both nurse and client usually have feelings about ending the relationship; the client especially may feel the termination as an impending loss. Often the clients try to avoid termination by acting angry or as if the problem has not been resolved.

 The nurse can acknowledge the clients angry feelings and assure the client that this response is normal to ending a relationship. It is appropriate to tell the client that the nurse enjoyed the time spent with the client and will remember him/he, but it is inappropriate for the nurse to agree to see the client outside the therapeutic relationship.

 Ex. Nurse Jones comes to see Mrs. Cruz for the last time.
Mrs. Cruz: is weeping quietly, oh, Ms. Jones, you have been so helpful to me. I just know I will go back to my old self without you here to help me.

Nurse Jones: Mrs. Cruz, I think weve had a very productive time together. You have learned so many new ways to have better relationships with your children, and I know you will go home and be able to use those skills. When you come back for your follow-up visit, I will want to hear about how things have changed at home.