Therapeutic Relationships & Communication

Pschy

Patient Centered Care

• Dignity and respect

• Information sharing

• Patient and family participation

• Collaboration in policy and program development

• Clear and appropriate boundarie

Therapeutic Use of Self

• Safe, confidential, reliable, and consistent

• Use personality consciously and in full awareness

• Attempt to establish relatedness

• Structure nursing interventions

Goals & Functions

• Facilitate communication of distressing thoughts and feelings

• Assist patient with problem solving

• Help patient examine self-defeating behaviors and test alternatives

• Promote self-care and independence

• Provide education about disorders and treatments

Building Healthy Relationships

When you build healthy relationships, you:

• Assess the needs of the patient

• Determine any unmet needs

• Find de-escalation strategies

Maslow’s Hierarchy

5. Self-actualization

4. Esteem: respect

3. Love + Belonging: connection

2. Safety: security, health

1. Physiological: food, shelter, warmth

Personal Relationships

• Initiated for the purpose of friendship, socialization, enjoyment, or accomplishment of a
  task

• Mutual needs are met

• Communication to give advice, give, or ask for help

• Content of communication superficial

Therapeutic Relationship

• Needs of patient identified and explored

• Clear boundaries established

• Problem-solving approaches taken

• New coping skills developed

• Behavioral change encouraged

Necessary Behaviors for Nurses

• Accountability

• Focus on the patient’s needs

• Clinical competence

• Delaying judgement

• Supervision

Goals & Function of the Therapeutic Relationship

• Facilitate communication of distressing thoughts and feeling

• Assist patient with problem solving

• Help patient identify distressing thoughts and feelings

• Promote self-care and independence

Relationship Boundaries & Roles

Boundaries

• The expected and accepted legal, ethical, and professional standards that separate
  nurses from patients

• Boundaries provide a safe space in which the patient can explore feelings and
  treatment concerns.

• Professional and ethical boundaries involve maintaining a professional role helping
  meet patient goals and never personal goals of the nurse

Over-involvment

Increases the risk of:

• Boundary crossings

• Boundary violations

• Professional sexual misconduct

• Blurring of Roles

Box 8.1

Transference

Patient unconsciously and inappropriately displaces onto nurse feelings and behaviors related to significant figures in patient’s past

Countertransference

Nurse unconsciously displaces feelings related to significant figures in the nurse’s past onto the patient

A Focus on Self-Awarness

The Nurses values and beliefs

• Reflect own culture/subculture

• Derived from range of choices

• Chosen from a variety of influences and role models

Preorientation Phase

Preparing for your assignment

• Researching the patient’s history

• Recognizing one’s own thoughts and feelings about meeting this patient

• Anticipating and setting ground rules before the first meeting

Orientation Phase

• Establishing rapport

• Parameters of the relationship

• Formal or informal contract

• Confidentiality

• Terms of termination

Working Phase

• Maintain relationship

• Gather further data

• Promote patient’s
  - Problem-solving skills
  - Self-esteem
  - Use of language

• Facilitate behavioral change

• Overcome resistant behaviors

• Evaluate problems and goals
  - Redefine them as necessary

• Promote practice and expression of alternative adaptive behaviors

Termination Phase

1. Summarize goals & objectives achived

2. Discuss ways for patient to incorporate new coping strategies learned

3. Review situations of relationship

4. Exchange memories

Factors that Promote Patient Growth

• Genuineness

• Empathy (not sympathy)

• Positive regard
  - Attitudes
  - Actions
  - Attending

• Suspending value judgments

• Helping patients develop resources

Therapeutic Communication

• Is crucial to the formation of a patient-centered therapeutic relationship.

• Therapeutic communication is a professional ability that you learn and practice

- Patient-centered refers to the patient as a full partner in care whose values, preferences. and needs are respected.

- Goal directed

- Scientifically based

• Saying the Wrong Thing

- There’s very little chance it will be harmful. Making mistakes helps us to find more useful and effective ways of helping individuals reach their goals.

Benefits of Therapeutic Communication

• the patient feeling safer and protected

• the patient being more satisfied with the care

• increased recovery rates

• improved adherence to treatment

• Death

• Malpractice claims

• Increased malpractice costs

Poor communication can create serious problems such as:

The Transactional Model

• Communicator:

- are senders & recievers

• Message

- the information sent to another, the clearer the message the better recieved

• Channel

- message can go through channels (auditory, visual, tactile, olfactory, or combination)

• Feedback

- person recieving message then interprets the message & responds to the sender & give feedback. feedback for one is the message for the other

• Encoding/Decoding

- individuals encode or develop the message & send to other and then decode to determine the meaning

• Context

• Environmental Noise

Peplau’s Interpersonal Theory

Encouraged non-directive listening. This allows nurses to provide reflective and non-judgmental feedback and thereby enables patients to clarify their thoughts.

• Guiding Principles in Communication
  ❖ Clarity: Ensures that the meaning of the
  message is accurately understood by both parties
  ❖Continuity: Promotes connections among ideas,
  feelings, events, and themes

Factors that Affect Communication

Personal factors

• Depression

• Cognition

• Language/cultural barriers

Environmental factors
• The setting

Relationship factors
• Level of equality within the relationship

Verbal Communication

Consists of the words a person speaks. Words are a symbol for emotions and
mental images

• Communicates
  - Beliefs and values
  - Perceptions and meaning

• Can convey
  - Interest and understanding
  - Insult and judgment
  - Clear or conflicting messages
  - Honest or distorted feelings

Nonverbal Communication

• Tone of voice

• Emphasis on certain words

• Physical appearance

• Facial expressions

• Body posture

• Amount of eye contact

• Hand gestures

Interaction of Verbal & Nonverbal Communication

• Messages can appear to be one thing when in fact they are another.

• People are often less aware of their nonverbal messages and behaviors.

• Verbal message can be called the content, while e the nonverbal behavior is the process

• Double-bind message: Mutually contradictory messages, usually given by a person in power.

Communication Skills for Nurses

• Silence

• Active listening

• Clarifying techniques

• Questions
  - Open-ended
  - Closed-ended
  - Projective
  - The miracle question

Barriers to Effective Communication

• Excessive questioning

• Giving approval or disapproval

• Giving advice

• Asking “why” questions

Cultural Considerations

• Communication style

• Use of eye contact

• Perception of touch

• Cultural filters—form of bias or prejudice

Tactics to Avoid

• Arguing, minimizing, or challenging the patient

• Giving false reassurance

• Interpreting or speculating

• Probing into sensitive areas the patient doesn’t want to discuss

• Trying to “sell” the patient on accepting treatment

• Joining in attacks patients launch on others

• Participation in criticizing other staff members

Behaviors that Support Counseling: Attending Behaviors

• Kinetic communication

• Vocal quality (called paralanguage)

• Proxemics: The study of personal space
  - Intimate distance (United States): 0 to 18 inches
  - Personal distance: 18 inches to 4 feet
  - Social distance: 4 to 12 feet
  - Public distance: 12 feet or more