Interpersonal Relationship Notes

Interpersonal Relationship

• Involves social associations, connections, or affiliations between 2 or more people.
• The goal of nurses is to promote interpersonal relationships with their clients.
• A conceptual framework involves the nurse looking into themselves for values, beliefs, attitudes, self-awareness, body image and self-image.
• The patient also looks into themselves for values, beliefs, and attitudes to promote a good interpersonal relationship with the nurse, hoping for good caring care from illness to an optimum level of function.

Therapeutic Relationship

• A dynamic, ever-changing relationship between a health professional and a patient.
• Focus on the welfare, needs, experience, feelings, and ideas of the patient.
• Begins with examining, understanding, and affirming oneself and individual life, both from the professional health provider and the patient.

Non-Therapeutic Relationship

• Utilizes techniques that hinder or damage professional relationships.
• Discourages further expression of feelings and ideas.
• May engender negative responses or behaviors in others.

Self Awareness

• A process of being aware of one’s own feelings, assets, skills, and abilities.
• Can be used to help nurses recognize their own stereotypes and biases about clients who are culturally different.
• Can be achieved through reflection.

Body Image

• How one views oneself physically and one’s view of his/her appearance.
• Body image disturbance could be a problem for some people.

Self Image

• One’s conception of oneself or of one’s role.
• The collection of notions, feelings, and beliefs about ourselves with which we identify and through which we relate and communicate with others and interact with the environment.

*Interpersonal Relationships Means Between Persons.
*Therapeia: Greek word meaning care.
*Relatus: Latin word donating connection.
*Reciprocal: Give and take.

Core of Nursing

• Caring relationships formed between the nurse and those affected by the nursing practice.
• This could be nurse-client, nurse-to-nurse, or nurse-to-other-healthcare providers.

Nurse-Client Interaction

• Any process in which a nurse and a client exchange or share information, verbally or nonverbally
• No emotional involvement is purely professional.
• Essential component of the nursing assessment

Nurse-Client Relationship

• Built on a series of nurse-client interactions.
• Develops over time; the longer the client stays in a hospital, a relationship is built.
• Differs from a social relationship; designed to meet the needs only of the client and promote self-care and independence.

Hildegard Peplau (1909-1999)

• Theorist who promoted interpersonal relationships.
• Saw the role of the nurse as a participant observer.
• Shifted focus from what nurses do to the client to what nurses do WITH clients.
• The interpersonal relationships theory by Hildegard Peplau involves the healthcare professional or the nurse working to understand their own behavior:
  • values
  • culture
  • race
  • beliefs
  • past experiences
  • expectations
  • preconceived ideas
• Understand the values, culture, race, beliefs, and past experiences, and what these clients expect of the care that is being given is how the interpersonal relationships by Hildegard Peplau is being promoted.

Types of Relationship

1. Social Relationship

• Primarily initiated for the purpose of friendship, socialization, companionship, or accomplishment of a task.
• Usually focuses on sharing ideas, feelings, and experiences.
• Meets the basic need for people to interact.
• Serious work that moves the client forward may not be done.

2. Intimate Relationship

• Involves two people who are emotionally committed to each other.
• Concern: meeting each other’s needs.
• May include sexual or emotional intimacy as well as sharing of mutual goals.
• Has no place in the nurse-client interaction.

3. Therapeutic Relationship

• Also called the helping relationship.
• Focuses on the needs, experiences, feelings, and ideas of the client only, not the nurse.
• The nurse and client agree about the areas to work on and evaluate the outcomes.
• The nurse is not concerned about whether or not the client likes him or her or is grateful.
• There is an explicit time frame, a goal-oriented approach, and a high expectation of confidentiality.
• The nurse’s level of self-awareness can either benefit or hamper the therapeutic relationship.

Characteristics of a Therapeutic (Helping) Relationship

• Intellectual and emotional bond between the nurse and the client.
• Focused on the client and his/her well-being.
• Respects the client as an individual.
• Maximizes client’s decision-making and treatment.
• Considers ethnic and cultural aspects, family relationships, and values.
• Respects client confidentiality.
• Mutual trust, respect, and acceptance.

Aspect Comparison

Types of a Therapeutic (Helping) Relationship

1. Nurse-Client Relationship
2. Nurse-Family Relationship
3. Nurse-Community Relationship
4. Nurse-Health Team Relationship

Components of a Therapeutic (Helping) Relationship

1. Trust
   • Trust builds when the client is confident in the nurse and the nurse’s presence conveys integrity and reliability
   • Congruence: Consistency in words and actions
   • Maintaining confidentiality
2. Genuine Interest
   • Nurse is comfortable with himself or herself, aware of his or her strengths and limitations, and is clearly focused, therefore able to show genuine interest
3. Empathy
   • Ability of the nurse to perceive the meanings and feelings of the client and to communicate that understanding to the client
   • Putting oneself in another’s shoes
   • Does not mean that the nurse has had the same exact experiences as the client
4. Acceptance
   • The nurse who does not become upset or respond negatively to a client’s outbursts, anger, or acting out conveys acceptance to the client
   • Avoiding judgmental behavior
   • Does not mean acceptance of inappropriate behavior but acceptance of the person as worthy
5. Positive Regard
   • Appreciating the client as a unique, worthwhile human being can respect the client regardless of his or her behavior, background, or lifestyle
6. Self-Awareness
   • Process of developing an understanding of one’s own values, beliefs, attitudes, thoughts, feelings, motivations, prejudices, strengths, and limitations and how these qualities affect others
   • Allows the nurse to observe, pay attention to, and understand the subtle responses and reactions of clients when interacting with them
7. Therapeutic Use of Self
   • By developing self-awareness and understand his or her attitudes, the nurse can begin to use aspects of his or her personality, experiences, values, feelings, intelligence, needs, coping skills, and perceptions to establish relationships with clients

Nursing Attitudes That Promote Therapeutic (Helping) Relationship

*Warmth: Be genuine, true, open to taking care of the client
*Respect: Treat each person as a unique human being, equally, regardless of their race, color, or region.
*Hope: Hope for a brighter tomorrow, especially when the client is losing hope; inspire and motivate them.
*Compassion: A primary quality or attitude that the nurse should have; be a compassionate person.

Effective Listening

SOLER

• S - Sit
• O – Open posture
• L – Lean Forward
• E – Eye contact
• R - Relax

Factors in a Therapeutic (Helping) Relationship

*Age: Consider dealing with pediatric vs. geriatric patients differently.
*Sex/Gender: Be very careful with female, male, and LGBTQ2+ individuals.
*Age: Considerations of beauty, ugliness, etc.
*Diagnosis: Terminal vs. ordinary; consider the prognosis.
*Education: How they are able to relate to what you are saying. No medical jargon for the understanding of the client
*Values: Your values against the values of the client
*Ethnic and Cultural Background: Race, Color, Religion
*Personality
*Expectations
*Professional Characteristics: Acting in a professional way.

Phases of the Nurse-Client Relationship

Rapport

• Creating a sense of harmony between individuals
• Finding common interests and experiences
• Establish rapport so that your client will be able to trust you and so this should be created from the very beginning

I. Pre-Interaction Phase

Planning Stage

• Nurse must identify specific information to be discussed in order to achieve positive outcome

Tasks:

• SELF-ASSESSMENT: explore personal beliefs, values, attitudes, and feelings
• Analyze own strengths and limitations
• Read and review available client history data
• Review on appropriate theoretical concepts that could help achiever your goal in the rendering of car
• PLAN for the initial interaction

II. Introductory / Orientation / Pre-Helping Phase

• Begins when the nurse and client meet and ends when the client begins to identify problems to examine
• Sets the tone for the rest of the relationship
• Observes one another
• Getting to know each other and developing trust (building RAPPORT)

3 Stages of Introductory Phase:

A. Opening the Relationship

B. Clarifying the Problem

C. Structuring and Formulating the Contract

III. Working Phase

• The nurse and client begin to view each other as unique individuals and work toward the goal.
• Client begins to overcome resistive behavior.

2 Stages of Working Phase:

1. Problem Identification
   • Exploring and understanding thoughts and feelings

    Needed Skills:

2. Exploitation
   • Facilitating and taking action
   • Nurse guides the client to examine feelings and responses and to develop better coping skills and a more positive self-image
   • Responsibility for action belongs to the client
   • Nurse only provides support, collaborate in these decisions, and may offer options or information

Tasks:

*Maintaining the relationship
*Gathering more data
*Facilitating behavior change
*Developing positive coping mechanisms, self-concept, and independence
*Providing opportunities for the client to practice new behaviors
*Evaluating progress and redefining goals

*Transference: Client unconsciously transfers to the nurse feelings he or she has for significant others
*Countertransference: Nurse transfers the feelings towards the client

IV. Termination Phase / Resolution

• Ending of the contract or termination of the relationship
• Planning for termination is actually done during the beginning of the relationship
• Evaluation

Roles of a Nurse in a Therapeutic (Helping) Relationship

1. Caregiver / giver of care
   • Caregivers can work independently or for a healthcare facility providing personal care to patients
2. Teacher
   • They do health teachings
3. Advocate
   • A nurse advocate is a nurse who works on behalf of patients to maintain quality of care and protect patients’ rights
   • They intervene when there is a care concern and they follow proper channels to work and solve any patient care issues
4. Manager
   • The nurse becomes a manager not only because she manages her time but she also manages people around
   • There are nurses who are head nurses who manage nurses who are under their unit
5. Evaluator
   • They evaluate the care. They evaluate the client healthcare plan. They have a lot to evaluate as a nurse

Behaviors That Diminish a Therapeutic (Helping) Relationship

*Lack of Care: As nurses, the number one we should do is to care for the clients or the patients that we are tending to
*Inappropriate Boundaries: This involves a disregard for your own and others' values, for example, one’s needs and limitations
*Overinvolvement: Dictating what the client should do or imposing your own rules.
*Anxiety: The environment should be relaxing.
*Stereotyping: For example, stereotyping the elderly as very hard to please or difficult to care for.
*Feelings of SYMPATHY: Differentiate empathy from sympathy; empathy is good, but control feelings of sympathy. Sympathy describes sharing the feelings of another person; empathy indicates less emotional closeness.
*Encouraging Client Dependency: Interdependence is the healthy state of equilibrium, so avoid encouraging dependency on the nurse's care or drugs.
*Nonacceptance and Avoidance: Avoiding issues. Always be nonjudgmental, open, and discuss issues further with the client.

Tools That Promote IPR in Nursing

*Self-Awareness: Understanding one’s own values, beliefs, thoughts, feelings, attitudes, motivations, prejudices, strengths, and limitations, and how these qualities affect others.
*Values: Principles that influence the development of beliefs and attitudes and indirectly affect behavior. Gives a sense of right and wrong and establishes a code of conduct.

Values and Beliefs

• are derived from a range of choices
• reflect our own culture
• are those we have chosen for ourselves from a variety of influences-role models
• as nurses, we not only understand and accept our own values and beliefs but are sensitive to and accepting of the unique values of others

Values Clarification

1. Choosing
   • a person considers a range of possibilities and freely chooses the value that feels right
2. Prizing
   • a person considers the value, cherishes it, and publicly attaches it to himself or herself
3. Acting
   • a person puts the value into action

Johari’s Window

• A psychological tool created by Joseph Luft and Harry Ingham
• Used to help people better understand their interpersonal communications and relationships
• Creates a “word portrait” of a person in four areas and indicates how well that person knows himself or herself and communicates with others

4 Quadrants:

1. Open
   • Known to self and known to others
   • Qualities one knows about oneself and others also know
   • What are the qualities that you know you possess and what you know what others also know about you
2. Blind spot
   • Not known to self
   • Qualities known only to others
   • There are times that you do not know your qualities, instead, other people know about it
3. Hidden
   • Not known to others
   • Qualities known only to oneself
   • Qualities that you know by yourself; you are the only one who knows about it and no other people
4. Unknown
   • An empty quadrant to symbolize qualities as yet undiscovered by oneself or others

Creating a Johari’s Window:

I. Nurse to appraise his or her own qualities by creating a list of them: values, attitudes, feelings, strengths, behaviors, accomplishments, needs, desires, and thoughts

II. Find out the perceptions of others by interviewing them and asking them to identify qualities, both positive and negative, that they see in the nurse.

III. Compare lists and to assign qualities to the appropriate quadrants

• Quadrant 1 is the longest list = Nurse is open to others
• Smaller Quadrant 1 = Nurse shares little about himself or herself with others
• Quadrants 1 and 3 are both small = person demonstrates little insights
• Any change in one quadrant will be reflected by changes in other quadrants
• The goal is to work toward moving qualities from quadrants 2, 3, and 4 into quadrant 1 (qualities known to self and others)
• Doing so allows the nurse to gain self-knowledge and awareness

Transactional Analysis

• A psychoanalytic theory of psychology and psychotherapy developed by a psychiatrist named Eric Berne during the late 1950’s
• Concentrated on the content of the people’s interaction with each other rather than believing that increasing awareness of the contents of unconsciously held ideas was the therapeutic path
• Eric Berne was focused on the present interaction rather than trying to understand what is the receiver’s understanding viewpoint or preconceptions

Importance:

I. Improves communication

II. Shows how one communicates and behaves with others

III. Helps us to understand what happens in human interactions

IV. Shows whether a communication is destructive or constructive

V. Increases self-awareness

3 Ego States

A. Parent (Exteropsychic)

• Rules, judgments, decisions, counsel, care, and punishment
• The parent is like a tape recorder. The parent decides without reasoning - how to react to situations, what is good and bad, and how people should live
• The parent judges for or against or and can be controlling or supportive
• A parent acts like a critical parent or a nurturing parent. It all depends on the situation
• Incorporate the feelings and behaviors learned from the parents or authority figures
• Resembles closely behavior of human parents
• All wise, all knowing, benevolent, prim, critical, or righteous attitude
• Part of me that feeds, cuddles, and nurtures others

B. Adult (Neopsychic)

• Information’s, sensory perception facts, no emotional aspect
• The adult is like a human computer. There is logical thinking
• Objective appraisal of reality and the capacity to process data
• Perceptive skills, data processing, sociability and communicativeness
• Has no emotion of its own but pays attention to feelings from the parent and child and logically deals with them
• The ability to see, hear, read, observe, collect information, and evaluate them
• “it appears”, “I think”,” why”, “when”, “how”

C. Child (Archaeopsychic)

• Creativity, play, self- expression, obedience, compliance, rebellion
• The child is sensual, impulsive, and feelings are being reflected in how they respond
• The responses of a little child to what he sees and hears
• Immature, need gratifying aspect
• Full of bright ideas, spontaneous
• Part of me that wants what I want when I want it
• Giggles, coyness, naïve, boisterousness, whining
• “I want” , “gosh!” , “me” , “dunno”

In the Parent Ego State, you could be:

*Critical Parent

• Monitors adherence to rules, should, and musts, and expectations of self and others
• Largely automatic

*Nurturing Parent

• Voice of unconditional acceptance, hope, and optimism
• The source of self-soothing and self-recognition

In the Adult Ego State:

• The planner, observer, organizer, and analyzer
• The part of self that can think logically and rationally and act accordingly

In the Child Ego State, one could be:

*Adaptive Child

• The part of self that makes emotional decisions about self and the world based on past and present drivers, injunctions, biology, and environment

*Free Child

• The spontaneous, emotive, creative, and in-the- moment part of self

Example 1:
Nurse: why didn’t you take your medicine (Harsh voice, beetle brows) (parent/child)
Patient: Please… I don’t want to take it. (Wobbly voice, shy looks) (child/parent)

Example 2:
Patient: When does the visit start? (With a calm voice, eye to eye communication) (Adult/Adult)
Nurse: At 1 pm (calm voice, neutral face expression) (Adult/Adult)

Example 3:
Nurse: You are again late for this shift delivery time (harsh voice, eye to eye communication with beetle brows) (Parent/child)
Nurse: I am sorry… (Wobbly voice, bowed posture) (child/parent)

Example 1:
Nurse: why didn’t you take your medicine (Harsh voice, beetle brows) (parent/child)
Patient: I’m not going to ask you for permission for when to take my medicine. (Harsh voice, holding up one’s hand) (parent/adult)

Transactions

• The unit of social intercourse
• Exchange of interaction, verbal or non-verbal, between 2 or more persons
• The “sender” is always the one who initiates the “transaction” or the communication interaction. There is always a “receiver” of the communication.
• The overall reaction is either Complementary (Straight) or Crossed (Transverse)

Generally speaking, transactions follow three rules:

I. The more comprehensive the transactions are, the more chances of survival they have (such as adult- adult ego state transactions).

II. If there is a change towards transverse transaction in communication (Parent ego state/child, child ego state/parent), it is interrupted and a problem occurs.

III. The results of hidden transactions are determined at a psychological level rather than social level.

Complementary (Straight) Transactions

• Occurs when a stimulus gets the expected response from another person
• The response must go back from the receiving ego to sending ego
• Transactional vectors are parallel
• They are easy to understand, and the message is clear
• The messages are either straight or parallel

Best type:

• Parent – Child
• Parent – Parent
• Child – Child
• Adult – Adult

Transverse (Crossed) Transactions

• An individual sends a message to the person that is contacted from any ego state, however, the other person replies from another ego state than the ego state that is targeted by the message sender
• Transverse transactions generally result in misunderstanding

Example 2:
Patient: When does the visit start? (With a calm voice, eye to eye communication) (Adult/Adult)
Nurse: why do you always ask me things? (Cynical voice, making a grimace) (child/Adult)

Example:
Salesman: That one is actually better, but you can’t afford it (A-A but actually A-C)
Client: That’s the one. I’ll take it! (A-A) (thought) I’ll show that arrogant guy. (C-A)

Example:
Patient: I’m not ready to go back to work and I need your help
Doctor: I’ll take care of you and give you extra time

Ulterior Transactions

Two types:

*Angular Transactions
*Duplex Transactions

Angular Transaction

• It is a two-level transaction in which beyond the obvious transaction, there is a hidden transaction between two different ego-states of the persons concerned
• A non-verbal message is sent along with the spoken words
• A message conveyed in the social level as Adult ego-state, but it contains a hidden psychological message intended for the Child ego-state of the recipient

Duplex Transaction

• Beyond the obvious transaction, there is a hidden transaction between the two ego states of the persons concerned

Psychological Games

• Berne indicated that psychological games are formed as a result of hidden transactions and play a role in the unconsciousness of the Adult ego state
• Games are learnt behaviors
• A person who is unconsciously overwhelmed with the weight of an unsolved problem either faces one’s problem or manipulates others in order to get support.

Life Positions

Refers to the specific behavior towards others that an individual learns on the basis of certain assumptions made very early in the life

1. “I’m not okay. You’re okay.”
   • The futility, helpless position
   • Depressive. Helplessness
2. “I’m not okay. You’re not okay.”
   • The depressive, despair position
3. “I’m okay. You’re not okay.”
   • The destructive, arrogant position / paranoid
4. “I’m okay. You’re okay”
   • The healthy, mature person