NCM 105 (Psychiatric Nursing ) LECTURE IV THREE PHASES OF NURSE-CLIENT RELATIONSHIP Nurse-Client Relationship the nurse and the

the client work together to assist client to grow and solve his problems. This relationship exists for the benefit of the client so that it is important that at every interaction, the nurse uses self therapeutically. This is achieved by maintaining the nurses self-awareness to prevent her unrecognized needs from influencing her perception of and behavior towards the client.

Three Phases of Nurse-Client Relationship: 1. Orientation Stage Establishing therapeutic environment. The roles, goals, rules and limitations of the relationship are defined, nurse gains trust of the client, and the mode of communication are acceptable for both nurse and patient is set. o Acceptance is the foundation of all therapeutic relationship o Acceptance of others requires acceptance of self first. Rapport is built by demonstrating acceptance and non-judgmental attitude. Acceptance of patient means encouraging the patient verbally and non-verbally to express both positive and negative feelings even if these are divergent from accepted norms and general viewpoint. o The nurse can encourage the client to share his/her feelings by making the client understand that no feeling is wrong. Trust of patient is gained by being consistent. Assessment of the client is made by obtaining data from primary and secondary sources. The patient set the pace of the relationship. During this phase, the problems are not yet been resolved but the clients feelings especially anxiety is reduced, by using palliative measures, to enable the client to relax enough to talk about his distressing feelings and thoughts. This stage progresses well when the nurses show empathy provide support to client and temporary structure until the client can control his own feelings and behavior. o Reality testing is accepting the patients perceptions, feelings and thoughts as neither right nor 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 conclusions. o To provide structure is to intervene when the client loses control of his own feelings and behaviors by medications, offering self, restrain, seclusion and by assisting client to observe a consistent daily schedule. 2. Working/ Exploration/ Identification Stage at this point, the clients problems are identified and solutions are explored, 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. Prepared by Dra Anna Katharina G Pena 1

Perception of reality, coping mechanisms and support systems 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. o The nurse uses the techniques of communication and assumes different roles to help the client.

3. Termination/ Resolution stage

the nurse terminates the relationship when the mutually agreed goals are met, the patient is discharged or transferred or the rotation is finished. The focus of this stage is the growth that has occurred in the client and the nurse helps the patient to become independent and responsible in making his own decisions. The relationship and the growth or change that has occurred in both the nurse and the patient is summarized. Client may become anxious and react with increased dependence, hostility and withdrawal, these are normal reactions and are signs of separation anxiety, these feelings and behavior should be discussed with the client. The nurse should be firm in maintaining professionalism until the end of the relationship. She should not promise the client that the relationship will be continued. The time parameters should be made early in the relationship and meetings are set further and further apart near the end to foster independence of the patient and prepare the latter gradually for the separation. The nurse should not give her address or telephone numbers to the patient. Referral for continuing health care and support after discharge provides additional resources for the client and the family. The goal of the therapeutic relationship have been met when the patient has developed emotional stability, cope positively, recognized sources or causes of anxiety, demonstrates ability to handle anxiety and independence, and is able to perform self-care. o Preparation of the termination phase begins at the orientation phase, when the duration and length of the nurse-client relationship was established. o It is normal for the client to experience separation anxiety such as sleeplessness, anorexia, physical symptoms, withdrawal and hostility.

Prepared by Dra Anna Katharina G Pena 2

Therapeutic Communication Interaction between the nurse and client during which the nurse focuses on
Therapeutic communication can help nurses to accomplish many goals:

the clients specific needs to promote an effective exchange of information.

Establish a therapeutic nurseclient relationship. Identify the most important client concern at that moment (the clientcentered goal). Assess the clients perception of the problem as it unfolded. This includes detailed actions(behaviors and messages) of the people involved and the clients thoughts and feelings about the situation, others, and self. Facilitate the clients expression of emotions. Teach the client and family necessary self-care skills. Recognize the clients needs. Implement interventions designed to address the clients needs. Guide the client toward identifying a plan of action to a satisfying and socially acceptable resolution.

Relationship Development and Therapeutic Communication Introduction The nurse-client relationship is the foundation on which psychiatric nursing is established. The therapeutic interpersonal relationship is the process by which nurses provide care for clients in need of psychosocial intervention. Therapeutic use of self is the instrument for delivery of care to clients in need of psychosocial intervention. Interpersonal communication techniques are the tools of psychosocial intervention. The Therapeutic Nurse-Client Relationship Therapeutic relationships are goal- oriented and directed at learning and growth promotion. How do Social Relationships differ from Therapeutic Relationships? Definition - ability to use ones personality consciously and in full awareness in an attempt to establish relatedness and to structure nursing interventions Nurses must possess self-awareness, self-understanding, and a philosophical belief about life, death, and the overall human condition Conditions Essential to Development of a Therapeutic Relationship Rapport Trust Respect Genuineness Empathy

Prepared by Dra Anna Katharina G Pena 3

Therapeutic Communication Techniques

Acceptingindicating reception Yes. I follow what you said. Nodding An accepting response indicates the nurse has heard and followed the train of thought. It does not indicate agreement but is nonjudgmental. Facial expression, tone of voice, and so forth also must convey acceptance or the words will lose their meaning. Silence often encourages the client to verbalize, provided that it is interested and expectant. Silence gives the client time to organize thoughts, direct the topic of interaction, or focus on issues that are most important. Much nonverbal behavior takes place during silence, and the nurse needs to be aware of the client and his or her own nonverbal behavior. The nurse can offer his or her presence, interest, and desire to understand. It is important that this offer is unconditional, that is, the client does not have to respond verbally to get the nurses attention. The nurse encourages the client to concentrate his or her energies on a single point, which may prevent a multitude of factors or problems from overwhelming the client. It is also a useful technique when a client jumps from one topic to another. Informing the client of facts increases his or her knowledge about a topic or lets the client know what to expect. The nurse is functioning as a resource person. Giving information also builds trust with the client. 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. When clients deal with topics superficially, exploring can help them examine the issue more fully.

Silenceabsence of verbal communication, which provides time for the client to put thoughts or feelings into words, regain composure, or continue talking

Nurse says nothing but continues to maintain eye contact and conveys interest.

Offering selfmaking oneself available

Ill sit with you awhile. Ill stay here with you. Im interested in what you think. This point seems worth looking at more closely. Of all the concerns youve mentioned, which is most troublesome? My name is . . . Visiting hours are . . . My purpose in being here is . . .

Focusingconcentrating on a single point

Giving information making available the facts that the client needs

Broad openings allowing the client to take the initiative in introducing the topic Exploringdelving further into a subject or idea

Is there something youd like to talk about? Where would you like to begin? Tell me more about that. Would you describe it

Prepared by Dra Anna Katharina G Pena 4

more fully? What kind of work?

General leadsgiving encouragement to continue

Go on. And then? Tell me about it.

Giving recognition acknowledging, indicating awareness

Good morning, Mr. S . . . Youve finished your list of things to do. I notice that youve combed your hair. I see no one else in the room. That sound was a car backfiring. Your mother is not here; I am a nurse.

Presenting reality offering for consideration that which is real

Restatingrepeating the main idea expressed

Client: I cant sleep. I stay awake all night. Nurse: You have difficulty sleeping. Client: Im really mad, Im really upset. Nurse: Youre really mad and upset. Have I got this straight? Youve said that . . . During the past hour, you and I have discussed . . .

Summarizingorganizing and summing up that which has gone before

Any problem or concern can be better understood if explored in depth. If the client expresses an unwillingness to explore a subject, however, the nurse must respect his or her wishes. General leads indicate that the nurse is listening and following what the client is saying without taking away the initiative for the interaction. They also encourage the client to continue if he or she is hesitant or uncomfortable about the topic. Greeting the client by name, indicating awareness of change, or noting efforts the client has made all show that the nurse recognizes the client as a person, as an individual. Such recognition does not carry the notion of value, that is, of being good or bad. 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 nurses perceptions or the facts not by way of arguing with the client or belittling his or her experience. The intent is to indicate an alternative line of thought for the client to consider, not to convince the client that he or she is wrong. The nurse repeats what the client has said in approximately or nearly the same words the client has used. This restatement lets the client know that he or she communicated the idea effectively. This encourages the client to continue. Or if the client has been misunderstood, he or she can clarify his or her thoughts. Summarization seeks to bring out the important points of the discussion and to increase the awareness and understanding of both participants. It omits the irrelevant and organizes the pertinent aspects of the interaction. It allows both client and nurse to depart with the same ideas and provides a sense of closure at the completion of each discussion.

Prepared by Dra Anna Katharina G Pena 5

How do I use Therapeutic Communication to Help Problem Solve?? Goals are often achieved through use of the problem-solving model: Identify the clients problem. Promote discussion of desired changes. Discuss aspects that cannot realistically be changed and ways to cope with them more adaptively. Discuss alternative strategies for creating changes the client desires to make. Weigh benefits and consequences of each alternative. Help client select an alternative. Encourage client to implement the change. Provide positive feedback for clients attempts to create change. Help client evaluate outcomes of the change and make modifications as required.

How do I set limits on inappropriate behavior? Best approach is to be firm, but accepting Reject the behavior Accept the person Mr D, I really enjoy playing monopoly with you, but I dont like when you swear. I am wondering if you can express your angry feeling in another manner? Active Listening To listen actively is to be attentive to what client is saying, both verbally and nonverbally. Several nonverbal behaviors have been designed to facilitate attentive listening. S Sit squarely facing the client. O Observe an open posture. L Lean forward toward the client. E Establish eye contact. R Relax. Process Recordings Written reports of verbal interactions with clients A means for the nurse to analyze the content and pattern of interaction A learning tool for professional development How do I give a Patient Feedback Feedback is useful when it is descriptive rather than evaluative and focused on the behavior rather than on the client is specific rather than general is directed toward behavior that the client has the capacity to modify imparts information rather than offers advice Nontherapeutic Communication Techniques Prepared by Dra Anna Katharina G Pena 6

Giving reassurance - may discourage client from further expression of feelings if client believes the feelings will only be downplayed or ridiculed Rejecting - refusing to consider clients ideas or behavior Approving or disapproving - implies that the nurse has the right to pass judgment on the goodness or badness of clients behavior Agreeing or disagreeing - implies that the nurse has the right to pass judgment on whether clients ideas or opinions are right or wrong Giving advice - implies that the nurse knows what is best for client and that client is incapable of any self-direction Probing - pushing for answers to issues the client does not wish to discuss causes client to feel used and valued only for what is shared with the nurse Defending - to defend what client has criticized implies that client has no right to express ideas, opinions, or feelings Requesting an explanation - asking why implies that client must defend his or her behavior or feelings Indicating the existence of an external source of power - encourages client to project blame for his or her thoughts or behaviors on others Belittling feelings expressed - causes client to feel insignificant or unimportant Making stereotyped comments, clichs, and trite expressions - these are meaningless in a nurse-client relationship Using denial - blocks discussion with client and avoids helping client identify and explore areas of difficulty Interpreting - results in the therapists telling client the meaning of his or her experience Introducing an unrelated topic - causes the nurse to take over the direction of the discussion

QUESTIONS: I. CONDITIONS ESSENTIAL TO DEVELOPMENT OF A THERAPEUTIC RELATIONSHIP Situation: Pam comes to the psychiatric clinic for assistance with more adaptive coping. Nurse Jones will be her therapist. Match the behaviors described on the right with the essential condition for therapeutic relationship development listed . RAPPORT; TRUST; RESPECT; GENUINENESS; EMPATHY _____1. Nurse Jones does not approve of Pams gay lifestyle but accepts her unconditionally nonetheless. _____2. Nurse Jones and Pam develop an immediate mutual regard for each other. _____3. Pam knows that Nurse Jones is always honest with her and will tell her the truth even if it is sometimes painful. _____4. Pam knows that Nurse Jones will not tell anyone else about what they discuss in therapy. _____5.When Pam talks about her problems, Nurse Jones listens objectively and encourages Questions: Phases of the Relationship Prepared by Dra Anna Katharina G Pena 7

Identify the appropriate phase of relationship development for each of the following tasks. The four phases include: a. Pre-interaction phase: b. Orientation phase c. Working phase; d. Termination phase _____ 1. Pam and Nurse Jones set goals for their time together. _____ 2. Nurse Jones reads Pams previous medical records. _____ 3. Having identified Pams problem, they discuss aspects for possible change and ways to accomplish them. _____ 4. They establish a mutual contract for intervention. _____ 5. The established goals have been met. What technique is being used? 1. Ct: The FBI wants to kill me. Ns: I find that hard to believe. __________________________ 2. Ns Asst: Mr. J. always calls me sweetie pie. I get so angry when he does that. Ns: Perhaps you should consider how he is feeling. ____________________________________ 3. Ct: My daddy always tucked me into bed at night. Ns: Id like to talk more about your relationship with your father.________________________ 4. Ns to Ct: Good morning, Sue. I see you are wearing the hair bow you made in OT.____ 5. Ct: I didnt really mean it when I said I wanted to die. Ns: What makes you say those kinds of things?\_____________________________________

Prepared by Dra Anna Katharina G Pena 8

PROCESS RECORDING (in nursing education) a system used for teaching nursing students to understand and analyze verbal and nonverbal interaction. The conversation between nurse and patient is written on special forms or in a special format. The student nurse is instructed to record observations, perceptions, thoughts, and feelings, as well as conversations. The student also is asked to analyze his or her communication, determining and naming both therapeutic and nontherapeutic techniques used within an interaction. The process recording is then studied by the nursing instructor to discover patterns of difficulty in communicating with the patient and to help the student nurse identify them.

A verbatim between nurse and the patient-Walker An exact written report of conversation between the nurse and the patient during the time they were together.-Hudson MENTAL HEALTH NURSING PROCESS RECORDING FORMAT Bio Data Description of patient Setting of interaction Description of environment Nurses feelings & thoughts before interaction Reasons for selecting the patient Goal of interaction Date & Time

Prepared by Dra Anna Katharina G Pena 9

Nurses Statement Verbal & Nonverbal

Verbal & Nonverbal Clients Statement

Therapeutic Technique Use by the nurse

Analysis and discussion Inference

Prepared by Dra Anna Katharina G Pena 10