3- Therapeutic Communication Part 1

What is a Nurse-Client Relationship?

An interaction between a nurse and "client" aimed at enhancing the well-being of the client, who may be an individual, a family, a group, or a community

Nurse client-relationships vs Personal relationships

• Nurse client-relationships

  • The nurse establishes, directs and takes responsibility

  • Client needs are the priority

  • Defined Boundaries

  • Length of the relationship is related to the client's need for nursing care and is time limited

  • Unequal power related to the nurse's position within the care team

• Personal Relationships

  • Equal responsibility to establish and maintain relationship

  • Focuses on the interest or pleasure of all individuals involved

  • Can occur anywhere

  • May last a lifetime

  • Relatively equal power, each may shift

5 Components to the Nurse-Client Relationship

• Trust

• Respect

• Professional Intimacy

• Empathy

• Power

Trust

• Most important

• Trust in a relationship is fragile

• Once broken difficult to re- establish

• Clients are in a vulnerable position

• How do we build trust?

• The art of making promises

Respect

The recognition of the inherent dignity, worth and uniqueness of every individual

How can we show respect?

• Walking in and introducing yourself

• Active listening without interupting

To respect a client is to what?

have the humility to appreciate that the patient is more than a set of symptoms or a diagnosis

Professional Intimacy

• Present in the type of care and services nurse provide

• May be physical activities (ex: bathing, toileting)

• Also involves the psychological, social and spiritual care that we provide

• Having access to patient’s personal information is also a form of professional intimacy

What is the difference between Empathy and Sympathy?

Empathy: understanding, resonating, validate

Sympathy: feeling sorry

Empathy

• Understanding, validating, and resonating with the meaning that the healthcare experience holds for client

• Important to maintain appropriate emotional distance to ensure objectivity and appropriate professional response

The nurse-client relationship is one of _____ power

unequal

As nurses we have more:

• Knowledge

• Authority

• Influence present info and let them make the decision

• Access to information

• Ability to advocate

Power

• Important to use the power in an appropriate manner

• A misuse of power is considered abuse

College of Nurses Standards and Guidelines purpose

to support nurses in providing safe & ethical nursing care.

Practice Standards

• Expectations for nurses that contribute to public protection

  • Outline accountabilities to the profession

  • Outline what the public can expect from nurses.

• Apply to all nurses, regardless of where we work, what job we hold or what area of practice we are in.

• Code of Conduct

• Confidentiality & Privacy: Person Health Information

• Discontinuing or Declining to Provide Care

• Documentation

• Medication

• Nurse Practitioner

• RN Prescribing

• Scope of Practice

• Professional Boundaries & Nurse-Client Relationships

Practice Guidelines

• Help nurses understand their responsibilities

• Assist in making safe and ethical decisions

• Associated with practice related issues.

• Aesthetic Services

• Conflict Prevention & Management

• Consent

• Directives
  Guidance on Nurses' Roles in Medical assistance in dying

• Independent Practice

• Virtual Care

• Working with Unregulated Care Providers

College of Nurses of Ontario (CNO)

• Governing body for Registered Nurses, Registered Practical Nurses and Nurse Practitioners.

• CNO's purpose is to protect the public by promoting safe nursing practice

• CNO aims to prevent harm by identifying potential problems and addressing them before they can harm the public. We are committed to a whole-system approach to nursing regulation and working with nurses and other system partners to make a greater collective impact on the patient care system.

CNO fulfils its role by what?

• Establishes entry to practice requirements

• Creates & promotes practice standards nurses must follow

• Administers it Quality Assurance Program

• Enforces standards of practice & conduct to protect the public.

Therapeutic Communication

Nurses use a wide range of effective communication strategies and interpersonal skills to appropriately establish, maintain, re-establish and terminate the nurse-client relationship.

Introduce, use names client prefers, allow client to explain themselves, listen with intent, inform information shared with health care team, modify communication style as needed, provide information, respect client's values, opinions and ethnocultural beliefs, recognize behaviours have meaning and seek to understand the cause, listen to concerns of family members, refrain from self-disclosure.

Client-centered care

Nurses work with the client to ensure that all professional behaviours and actions meet the therapeutic needs of the client.

Include the client as a partner, gain an understanding of their abilities and limitations, discuss expectations, negotiate roles, acknowledge biases and feelings that have developed, demonstrate sensibility, acknowledge difficulty in establishing a therapeutic relationship and request a transfer of care.

Maintaining boundaries

Nurses are responsible for effectively establishing and maintaining the limits or boundaries in the therapeutic nurse-client
relationship

Help client to understand when requests are beyond the limits, develop and follow a comprehensive care plan, ensure an activity that could be perceived as boundary crossing is included in the care plan for all health care members (having coffee with a client that all nurses will participate in). Recognize the setting may increase the need for vigilance in boundaries (client's home), no disclosing personal information, ensuring co-relationships do not undermine the judgment and objectivity in the therapeutic nurse-client relationship (caring for a friend's child or parent). Consulting as needed when unclear if behaviour may cross boundary (gift giving), relationship developed for purpose of promoting the health and well-being of the client, documenting any concerns, consider cultural values of the client

Protecting the client from abuse

• Nurses protect the client from harm by ensuring that abuse is prevented, or stopped or reported.

• Intervening and reporting incidents of verbal and non-verbal behaviours that demonstrate disrespect for the client, reporting behaviours or remarks that can be perceived as violent, threatening, sexually suggestive or abusive, not entering a friendship or relationship with a client when a therapeutic relationship exists.

• Ensuring after termination of therapeutic relationship no personal, romantic or sexual relationship exists.

  • May after 1 year engage in this type of relationship if it does not have a negative impact on well being of client.

• Not engaging in any behaviours toward a client or make remarks that may reasonably be perceived by others to be sexually suggestive, exploitive or sexually abusive.

• Not neglecting a client by failing to meet or withhold his/her basic assessed needs.

Person Centred Care

• A subset in which nurses and other health providers engage with people in need of care.

• Based on the premise that each person's personalized experience of an illness, injury, or disease is a total human experience.

Four components of PCC

• Holistic

• Respectful

• Individualized

• Empowering

Elements of Person-Centred Care Relationships

• Considers the person foremost, with distinctive personally held values, beliefs, cultural contexts, and life goals.

• A person with a health issue or disease requires health care and professional support in addressing the health issues.

• Respect for the person's values, preferences, and expressed needs

• Coordination and integration of care through collaboration and teamwork Accessibility and free flow of information, communication, and education

• Physical comfort

• Sensitivity to the nonmedical and spiritual dimension of care

• Emotional support

• Involvement of family and friends; no one in isolation of each other

Phases of a Person-Centred Relationship

• PRE-INTERACTION

• ORIENTATION

• WORKING

• TERMINATION

Pre-Interaction Phase

• Self-Management Strategies

  • Authenticity

  • Presence

• Setting Realistic Goals

• Preparing to meet the person and family

• *Information gathering: get info prior to understand them and what needs to happen next

Orientation phase

• Clarifying the purpose of the relationship

• Establishing trust

• Where to start with assessment

  • Current health situation -good place to start

  • Use questions that follow a normal logical sequence

• Sharing information

  • Open and honest

  • Ask if they have any questions along the way

• Using empathetic responses

  • 'I can only imagine how hard this must be for you'

• Defining the problem(s)

  • Nurses act as sounding boards

  • Ask for specific details to help explore the issue

  • Time allowed for person to respond fully

• Understanding the person's perspective

  • Life history; family history; employment/school; cultural context, financial resources.

• Defining goals

  • Based on person's values, preferences, resources and capabilities

  • Chosen goals have meaning to the person

• *Listen to the patients words and what they say

Working phase

• Supporting the person's self-management strategies

  • Identify the focus of action plans for health issues

  • Breaking down into steps (i.e. eating 3 meals a day) to make manageable

• Tuning in to the person's response patterns

  • Emphasizes shared information and joint actions that connect, collaborate and create new possibilities for health and well-being.

  • Older people may require a slower pace; people in crisis need simple, structured levels of support.

  • Watch for changes in body language

• Shared decision making

  • Choice talk; option talk; Decision talk.

• Defusing challenging behaviours

  • Look beyond own emotions to better understand what the person is conveying in their behaviours.

  • Active listening.

• Giving constructive feedback

Termination phase

• When treatment outcomes are achieved, or the person is discharged or transferred to another health care provider or setting.

• Jointly evaluate the person's response to the care provided and what goals have been achieved.

• Where possible, ending the relationship should be identified well before it actually occurs

Linear communication model

• Sender

• Message

• Receiver

• Communication channels

• Context

Transactional communication model

• More complex

• Reciprocal interaction process

• Input, throughout, output

• Feedback loops

Forms of communication

• Verbal

• Non-verbal

• Written

• Visual

• Listening

Verbal communication

• Use of medical

• Tone

• Formal or informal

Non-verbal communication

• Facial Expressions

• Body Language

• Appearance

• Posture

• Eye Contact

• Touch (when appropriate)

Written communication

• Documentation

• Use of acronyms

• Writing emails

• Providing written instructions

• Research Papers

• Social Media

Visual communication

• Visual Aids

• Demonstrations

• Physical models

• Illustrations

Listening communication

• Active Listening

• Listening responses:

  • Clarifying

  • Restating

  • Paraphrasing

  • Reflection

  • Summarizing

  • Silence

Active listening

• Being fully present in the moment and listening without distraction or interruptions

• Involves processing and reflecting throughout an interaction; moves beyond hearing to understanding

• Begin to realize what is said (and not said in some cases) and why it matters to that person

• Active listening is connected, conscious, and intentional

• It is a full body activity, expressed in verbal and non-verbal signs of full engagement

Why are Active Listening Skills Important to Develop?

• They are Important for:

  • Relationships: In order to nurture trust and demonstrate respect for people we must hear them and learn who they are.

  • Problem Solving: Asking purposeful questions can reveal deeper, hidden matters that often get missed.

  • Collaboration: Through active listening, we can strengthen mutual understanding and learn to work collaboratively

  • Negotiation: When we can reduce misunderstandings through active listening, we can pursue common interests and goals

Strategies for Active Listening

• Provide authentic and timed nonverbal cues to show that you are listening.

• Natural but direct eye contact

• Facial expression

• Head movement when appropriate (nodding, shaking, lowering, etc.)

• Body and face turned toward the person

• Minimize distractions

• Put your phone away or silence notifications

• Close your computer or turn it off

• Keep fidgeting to a minimum

• Pause taking notes when/if possible

• Minimize noise

Nonverbal communication- SOLER

S = Sit facing the person

O = Keep an open posture

L = Lean toward the person

E = Initiate and maintain eye contact

R = Relax

Types of questions to ask clients

• Open ended questions

• Focused questions

• Close ended questions

Open Ended Questions

• Questions that are open to interpretation

• Cannot be answered by "Yes" "No" or one-word response

• Allows patient to express their problems in their own words

• Usually begin with words such as "What" "How" "Can you describe for me"

• Are likely to yield more complete information

• *Start with this

Focused questions

• Require more than a yes or no answer, but place limitations on the topic to be addressed

• Helpful in emergencies or situations where immediate concise information is required

• For example, when did the symptoms begin?

• Patients with limited verbal skills sometimes respond better to focused questions because they require less interpretation

Close ended questions

• Narrowly focused questions for which a single answer is a valid response (yes or no)

• Useful in emergency situations, when the goal is to obtain information quickly

How to build rapport

• Begin with asking routine questions, about the reason for admission and other common information

• Sequence questions to go from easy to more complex, allowing for open ended questions

• Being attentively present and actively listening to patient concerns helps to build rapport

• Patients who feel safe, validated and accepted by their health care providers find it easier to collaborate with them

• Remember patients are not only looking to you for competence, but sincerity and genuine interest in them as a person

• When you have rapport with someone, you are better able to influence, learn and teach as the trust that you have built means the other person is more likely to accept your ideas, share ideas and collaborate

Context for Communication

• Environment

• Reason for interaction

• Take into consideration:

  • Culture

  • Age

  • Gender

  • Social Status

  • Values, beliefs, attitudes (of yourself as well as the person you are communicating with)

  • Past experiences with the health care system

  • Language and literacy level

Adapting communication- Being aware of what?

• how person is receiving the message

• how they are choosing to communicate

• their non-verbal cues and comfort level of the conversation

• the power dynamics you hold as a nurse

• power of listening vs. talking

• maintaining the concept of person centeredness in communication