Building Therapeutic Relationships

nurse-client relationship

A relationship between the nurse and client that is founded upon trust, respect, and professionalism.

theory of Interpersonal Relationships

1. pre-interaction:

   1. self- evaluate of needs, beliefs and behaviors before interaction

2. orientation

   1. build trust/ rapport

   2. place boundaries

   3. collect data, assess, works w/ client for goals, and identify barriers

   4. account for health literacy

3. working

   1. progress towards the goal

   2. help pt have a plan to solve the problem → sense of autonomy

4. termination phase

   1. goals have been met → new goals developed

building trust and rapport

rapport build up when pt feels understood, and tx is transparent

employ honesty, fidelity, respect, understanding

barriers: socioeconomic status, education, cultural and racial differences, language backgrounds, and gender.

transference

client experiences feelings or emotions from a person or object and displaces those feelings or emotions toward the nurse.

if negative→ talk to supervisor

countertransference

The unconscious effort on behalf of the nurse to redirect their previously experienced feelings or emotions toward the client.

motivational interviewing

A communication strategy that assists clients in developing motivation to resolve insecurities and ambivalent feelings toward behavior change.

congruence

When a client’s expressed mood matches their affect.

SOLER

therapeutic non verbal communication

• S: Sit squarely to the client

• O: Open posture

• L: Lean forward

• E: Eye contact​​​​​​​

• R: Relax

SURETY

therapeutic non verbal communication

• sit at an angle

  • sitting across might appear like confrontation

• uncross legs and arms

• relax,

• eye contact,

• touch:

  • hand, lower arm, sholder

• your intuition.

non verbal cues

• Affect: frowning; lack of expression; grimacing; pursed lips; raised or lowered eyebrows; biting, licking, smacking lips; nose scrunching

• Appearance: sudden disrobing; clothing that is incongruent to current temperature; disheveled grooming

• Autonomic Response: visible brow or palm perspiration; pupil dilation; facial flushing or paleness; increased respirations

• Body Behaviors: gait; posture; hand clenching; rocking; psychomotor agitation

• Eye Movement: suspicious; squinting; open with minimal blinking

open ended

“ tell me more ….”

affirmations

used when the nurse feels like the client is making real progress in conversation or treatment.

state what the pt did and then affirm

If the nurse does not feel genuine about the affirmation, they should not say it. The nurse’s body language and the tone of their voice are cues when they do not feel genuine about what they are saying.

simple reflection

uses some element of what the client said.

complex reflection

taking educated guess on how the pt is feeling

“So you are saying...,” “It sounds like…,” or “I get the impression that you….”

summaries

restate major key concepts in a conversation about change

OARS

• Open-ended

• Affirmations

• Reflections

• Summaries

non therapeutic communication

• giving advice or opinions

• health literacy: avoid jargon

• disagreeing: confrontation, makes pt defensive

• primary language

• reassuring: will minimize how the pt is feeling

• why questions: pt feel the need to defend ideass

• disapproval

• anxiety, pain, and physical discomfort:

  • pharmacological and non pharmacological interventions

Socratic questioning types

• Clarification: “Tell me more about your current thought.”

• Questions about the question: “How were you feeling when you asked that question?”

• Probe assumptions: “I wonder how someone would explain this belief?”

• Probe reasons: “What do you think causes this to happen?”

• Probe viewpoints: “What are the strengths and weaknesses for...”

• Probe implications: “What might be the consequences of…”

Active listening

• look interested

• respond

• stay on task

• respond by summarizing

• evaluate message

• neutralize feeling: w/o judgment

LISTEN

• Look interested

• Involve

• Stay on task

• Test

• Evaluate

• Neutralize

transtheoretical model of change

integrative, biopsychosocial model to conceptualize the process of intentional behavior change.

1. precontemplation,

2. contemplation,

3. preparation,

4. action, and

5. maintenance

Precontemplation

pt lacks insight or demonstrates defense mechanism of denial.

The client does not recognize the benefit of change or may have previously attempted change and failed to maintain healthy behaviors.

Contemplation

ambivalence

see themselves making a change or understand the change’s importance.

→ aim to explore the positives and negatives of current and proposed behavior changes​​​​​​​.

Preparation

pt demonstrate adjustments or minor changes to their current habits.

may have yet to fully commit to a changed lifestyle or is having difficulties overcoming barriers to change.

→ aim to identify the client's current coping skills and possible support systems​​​​​​​.

action

by the client experiencing changed behaviors.

• behavior: changed when the previous behavior has not been experienced for more than 180 days.

→ identify positive outcomes of making the behavior change and develop contingencies if planned coping or support systems fail​​​​​​​.

maintenance

the change is second nature and actively working to prevent relapse.

• behavior for more than six months and no longer feels like change is necessary.

→ aim to help the client identify triggers for relapses like people, places, or objects that are associated with the old behavior. 

therapeutic window

psychological state in which therapeutic interventions are believed to be most beneficial.

need to be culturally considerate

culturally competent care (6)

1. awareness

   1. self-reflection

2. knowledge:

   1. life-long learning and actively seeking knowledge

3. sensitivity:

4. skill:

   1. Giger and Davidhizar Transcultural Assessment Model: cultural differences in communication, space, time, social organization, environmental control, and biological variations.

5. proficiency

6. dynamicity

Transcultural Nursing Theory

Madeleine Leininger

pt culture develops their values and beliefs that can impact their health and lifestyle decisions.

whole body approach + autonomy

maintenance

cultural preservations: Care considerations to retain the client’s core cultural beliefs and values related to health care.

negotiation

cultural accommodations: help the client adapt or negotiate with other cultures while in treatment

cultural repatterning

supports the client who is changing a culturally related behavior in an effort to improve health outcomes.

cultural formulation interview

1. cultural def of the problem

2. cultural perceptions of cause, context, support

3. cultural factors that affect self-cope and past help-seek

4. cultural factors affecting current help-seek

organizational culture

the values, attitudes, beliefs, psychology, and experiences that influence daily operation.

DEI

Diversity: refers to the qualities of a client that differs from that of the nurse.

equity: ensures that the client has an equal opportunity to initiate and continue fair treatment.

inclusion: the ability of all care team members, including the client, to voice their concerns with treatment and influence the decision-making process.

Bias free language

• avoid generalization

• be specific

• if unsure how to address pt, ask for pronouns

• don’t use “normal”

telehealth

cost-effective and increasingly accessible in rural areas​​​​​​​

motivational interview process

• engaging: allow pt to discuss their concern and major importance in life

  • helps build trust and rapport while supporting client autonomy

• focus: identify unhealthy behaviors → analyze alternatives

  • expert trap: when a clinician prescribes advice without consent or solicitation from the client.

  • always ask for consent

• evoke:

  • importance, or confidence, ruler statements: statement designed to evoke motivation by focusing on the client’s strengths.

• plan: works with the client to develop a plan for behavior change.

SMART

goal plan

• Specific:

• Measurable:

• Achievable:

• Realistic:

• Time:

occupational role of nurse

The occupational role of a nurse includes education, group facilitation, and care management.