therapeutic relationship

1. PRESENTAION ON THERAPEUTIC
COMMUNICATION &
INTERPERSONAL RELATIONSHIP
Presented To: Presented By:
Dr. Monika Dutta Miss Pratibha
(Lecturer NINE ) M.Sc. Nursing 1st Year

2. LEARNING OBJECTIVE:
• Definition of therapeutic communication.
• Techniques of therapeutic communication
• Forms and stages of achieving therapeutic
communication
• Barrier of therapeutic communication
• Model of therapeutic communication
&
• Definition of interpersonal relationship
• Forms of interpersonal relationship
• Phases of interpersonal relationship
• Model of interpersonal relationship

3. THERAPEUTIC COMMUNICATION

4. INTRODUCTION:
 The therapeutic communication
(also therapeutic alliance, the helping alliance,
or the working alliance) refers to the relationship
between a healthcare professional and
a client (or patient).
 Therapeutic communication involves a wide range of
different types of communication with the user of
health care in the treatment process .

5. DEFINITION
“Promotes mutual understanding, establishes a
constructive relationship between the nurse and
the client”.
(Kozier, 2004)
“It is the process, in which the nurse utilizes a
planned approach to learn about the client”.
(Potter A, 1997)

6. TECHNIQUES OF THERAPEUTIC
COMMUNICATION
 Using Silence
Providing general leads
 Being specific and tentative
Using tentative questions
 Restating and paraphrasing

7. Cont…
Offering self
 Giving information
 Presenting reality
 Reflecting
 Summarizing and planning

8.  Using silence: Accepting pauses or silences that
may extend for several seconds or minutes without
interjecting any verbal response.
Example : Sitting quietly (or walking with the
client)waiting attentively until the client is able to put
thoughts and feelings into words.

9. Cont….
 Providing general leads: Using statements or
questions that –
(a) Encourage the client to verbalize
(b) Choose a topic of conversation
(c) Facilitate continued verbalization
Example:
 “Can you tell me how it is for you?”
 “Perhaps you would like to talk about. . . .”
 “Would it help to discuss your feelings?”
 “Where would you like to begin?”
 “And then what?”

10. Cont…
Being specific and tentative: Making
statements that are specific rather than general,
and tentative rather than absolute.
Example:
 “Rate your pain on a scale of zero to ten.” (specific
statement)
 “Are you in pain?” (general statement)
 “You seen unconcerned about your diabetes.”
(tentative statement)”

11. Using open-ended questions: Asking broad
questions that lead or invite the client to explore
(elaborate, clarify, describe, compare, or illustrate)
thoughts or feelings.
 Open-ended questions specify only the topic to be
discussed and invite answers that are longer than one
or two words.
Example:
 “I’d like to hear more about that.”
 “Tell me more. . . .”
 “What brought you to the hospital?”
 “What is your opinion?”
 “You said you were frightened yesterday. How do you
feel now?

12. Cont…
Restating or paraphrasing
Actively listening for the client’s basic message and
then repeating those thoughts and/or feelings in
similar words. This conveys that the nurse has
listened and understood the client’s basic message
and also offers clients a clearer idea of what they
have said.
Example:
 Client: “I couldn’t manage to eat any dinner last
night— not even the dessert.”
 Nurse: “You had difficulty eating yesterday.”
 Client: “Yes, I was very upset after my family left.”

13. Cont…
 Offering self:
Suggesting one’s presence, interest, or wish to
understand the client without making any demands
or attaching conditions that the client must comply
with to receive the nurse’s attention.
Example
 “I’ll stay with you until your daughter arrives.”
 “We can sit here quietly for a while; we don’t need to
talk unless you would like to.”

14. Cont…
 Giving information :
Providing, in a simple and direct manner,
specific factual information the client may or
may not request. When information is not
known, the nurse states this and indicates who
has it or when the nurse will obtain it.
Example:
 “Your surgery is scheduled for 11 am tomorrow.”
 “You will feel a pulling sensation when the tube
is removed from your abdomen.”
 “I do not know the answer to that, but I will find
out from Mrs. King, the nurse in charge.”

15. Cont…
 Presenting reality :
Helping the client to differentiate the real from the
unreal.
Example:
 “That telephone ring came from the program on
television.”
 “Your magazine is here in the drawer. It has not
been stolen.”

16. Cont…
Reflecting : Directing ideas, feelings, questions, or
content back to clients to enable them to explore
their own ideas and feelings about a situation.
Example:
 Client: “What can I do?”
 Nurse: “What do you think would be helpful?”
 Client: “Do you think I should tell my husband?”
 Nurse: “You seem unsure about telling your
husband.”

17. Cont…
 Summarizing and planning:
Stating the main points of a discussion to clarify
the relevant points discussed. This technique is
useful at the end of an interview or to review a
health teaching session. It often acts as an
introduction to future care planning.
Example:
 “During the past half hour we have talked about. . .”
 “Tomorrow afternoon we may explore this further.”
 “In a few days I’ll review what you have learned
about the actions and effects of your insulin.”

18. The division of stages of therapeutic
communication has primarily didactic
importance and its primary function is to make
guidelines for achieving favourable therapeutic
communication in health care system .There are
three stages of therapeutic communication these
are :

19. Stage 1st : Beginning from
conversation
Greet the user by name
Offer the user to sit
Introduce oneself
Explain the purpose of the interview
Loudly indicate the planned duration of the
interview
Turn off the phone
Do not start a conversation by criticism

20. Stage 2nd : conducting a flow of
conversation
Provide privacy
Start a conversation with open questions
Use closed questions only when necessary
Do not ask too many questions
Maintain eye contact
Encourage and stimulate the user
Listen carefully
Perceive the user’s non-verbal communication
Express support, understanding and
compassion

21. Stage 3rd : End of conversation
 Repeat in front of the user everything
important what they said.
Check with the user whether all is well
understood.
Ask the user if she/he missed something and
whether she/he wants to say something else.
thank the user for the interview, greet, escort
them to the door.

22. The Importance of Feedback in
Therapeutic Communication
Feedback is extremely important in all aspects
of communication, and therefore in the
therapeutic one also.
 The five main categories of feedback that occur
when conducting therapeutic communication;
categories and their characteristics are given
here:

23. S.No.
Categories Characteristic
1. Evaluation Making opinion about value of
interviewee’s statement.
2. Interpretation
(Paraphrasing)
Intention to explain the meaning of the
sent message.
3. Supporting Giving support to the interviewee.
4. Examination Intention do find out further information,
develop discussion or clarify conclusion.
5. Understanding Intention to fully reveal the interviewee’s
message.

24. BARRIER OF THERAPEUTIC
COMMUNICATION
 Stereotyping
 Being defensive
 Challenging
 Testing
 Rejecting
Changing topic and subjects
 Giving common advice

25. Stereotyping :
Offering generalized and oversimplified beliefs about
groups of people that are based on experiences too
limited to be valid. These responses categorize clients
and negate their uniqueness as individuals.
Example :
 “Women are complainers.”
 “Men don’t cry.”
 “Most people don’t have any pain after this type of
surgery”

26. Cont…
Being defensive :
Attempting to protect a person or health care services
from negative comments. These responses prevent the
client from expressing true concerns. The nurse is
saying, “You have no right to complain.” Defensive
responses protect the nurse from admitting weaknesses
in the health care services, including personal
weaknesses.
Example:
 Client: “Those night duty nurses just sit around and
talk all night. They didn’t answer my questions for over
an hour.”
 Nurse: “Let me know you we literally run around
whole night. You’re not the only client, you know.”

27. Cont…
Challenging:
Giving a response that makes clients prove their
statement or point of view. These responses
indicate that the nurse is failing to consider the
client’s feelings, making the client feel it necessary
to defend a position.
Example :
 Client: “I felt nauseated after that red pill.”
 Nurse: “Surely you think I gave you the wrong
pill?”
 Client: “I feel as if I am dying.”
 Nurse: “How can you feel that way when your
pulse is 70?”

28. Cont…
Testing :
Asking questions that make the client admit to
something. These responses permit the client only
limited answers and often meet the nurse’s need
rather than the client’s.
Example:
 “Who do you think you are?” (forces people to admit
their status is only that of client)
 “Do you think I am not busy?” (forces the client to
admit that the nurse really is busy)

29. Cont…
Rejecting :
Refusing to discuss certain topics with the client.
These responses often make clients feel that the
nurse is rejecting not only their communication but
also the clients themselves.
Example:
 “Let’s discuss other areas of interest to you rather
than the two problems you keep mentioning.”

30. • Cont…
Changing topics and subjects:
Directing the communication into areas of self-interest
rather than considering the client’s concerns is often
a self-protective response to a topic that causes
anxiety. These responses imply that what the nurse
considers important will be discussed and that clients
should not discuss certain topics.
Example:
 Client: “I’m separated from my wife. Do you think I
have to make sexual relationship with another
woman?”
 Nurse: “I see that you’re 36 and that you like
gardening. I have a beautiful rose garden.”

31. Cont…
Giving common advice
Telling the client what to do. These responses deny
the client’s right to be an equal partner. Note that
giving expert rather than common advice is
therapeutic.
Example:
 Client: “Should I move from my home to a nursing
home?”
 Nurse: “If I were you, I’d go to a nursing home,
where you’ll get your meals cooked for you.”

32. MODEL OF THERAPEUTIC
COMMUNICATION
MODEL
SOLER SBAR

33. SOLER: Stands for
S • Sit facing the client
O • observe an open posture
L • Lean towards
E • Eye contact
R
• Relaxed
•Active listening shows respect towards the person who is speaking and powerful as it reinforces the relationship ; allows the client to talk more ope
•Active listening shows respect towards the person who is speaking and powerful as it reinforces the relationship ; allows the client to talk more ope
•Active listening shows respect towards the person who is speaking and powerful as it reinforces the relationship ; allows the client to talk more ope

34. S- Sit facing the client – It depicts Nurse is interested
in listening to the client.
O- observe an open posture- Adopt an open posture.
The non defensive position is one in which neither
arms nor legs are crossed. It conveys that the person
wishes to listen to what the other has to say.
L- Lean towards – Lean toward the person. People
move naturally toward one another when they want
to say or hear something—by moving to the front of a
class, by moving a chair nearer a friend, or by leaning
across a table with arms propped in front. The nurse
conveys involvement by leaning forward, closer to the
client.

35. E- Maintain good eye contact- The interest is further
enhanced by eye contact. Maintaining eye contact
shows interest and concern. However, it is
important to vary the eye contact so that the other
party does not feel threatened or intimidated.
R- Relaxed-client will be relaxed and comfortable
when the Nurse is actively listening to them .

36. This model depicts that active listening shows
respect towards the person who is speaking and
powerful as it reinforces the relationship ; allows
the client to talk more openly without any
inhibitors or bias; It wins the trust or
confidentiality ; establishes therapeutic nurse
patient relationship. Promotes effective
communication.

37. SBAR: Stands for
S •Situation
B •Background
A •Assessment
R •Recommendation

38. • This communication model has gained popularity
in healthcare settings, especially among
professionals such as physicians and nursing. It is
a way for health care professionals to communicate
effectively with one another, and also allows for
important information to be transferred accurately.
The format of SBAR allows for short, organized and
predictable flow of information between
professionals.

39. S- Situation: Clearly and briefly describe the
current situation.
B- Background: Provide clear, relevant background
information of the patient.
A- Assessment: State your professional conclusion,
based on the situation and background.
R- Recommendation: Tell the person with whom
you’re communicating what you need from him or
her, in a clear and relevant way.

40. Example : Example of SBAR being used in a phone
call between a nurse and a physician.
“Dr. Rajesh, this is Priya RN, I am calling from ABC
Hospital about your patient Riya.”
Situation : “Here’s the situation: Mrs. Riya is
having increasing dyspnea and is complaining of
chest pain.”
 Background: “The supporting background
information is that she had a total knee replacement
two days ago. About two hours ago she began
complaining of chest pain. Her pulse is 140b/min
and her blood pressure is 128 /54mmhg. She is
restless and short of breath.”

41.  Assessment: “My assessment of the situation is
that she may be having cardiac event or a
pulmonary embolism”.
 Recommendation: “I recommend that you see
her immediately and that we start her on O2 stat.
Do you agree?”

42. The introduction of SBAR increased the experience of having a well-
functioning structure for oral communication among health care
professionals regarding patients’ conditions. Qualitative findings
revealed the categories: Use of SBAR as a structure, Reporting time,
Patient safety, and Personal aspects

43. INTERPERSONAL RELATIONSHIP

44. INTRODUCTION:
Interpersonal relationship is also defined as the
close association between the individuals who
share common interest and goals.
 A strong bond between two or more people
refers to interpersonal relationship. Attraction
between individuals brings them close to each
other and eventually results in a strong
interpersonal relationship

45. DEFINITION:
Interpersonal relationships refer to reciprocal
social and emotional interactions between two
or more individuals in an environment.
Any or all behavior which a person undertake in
the presence of others (Jourald).

46. FROMRS OF INTERPERSONAL
RELATIONSHIP:
An interpersonal relationship can develop
between any of the following:
 Individuals working together in the same
organization.
 People working in the same team.
 Relationship between a man and a woman (Love,
Marriage).
 Relationship with immediate family members
and relatives.
 Relationship of a child with his parents.

47. Different Types of Interpersonal
Relationships:
• Friendship
• Love
• Family Relationship
• Professional Relationship (Work Relationship).

48. PHASES OF INTERPERSONAL
RELATIONSHIP
PREINTERACTION PHASE
INTRODUCTORY PHASE
WORKING PHASE
TERMINATION PHASE

49. PREINTERACTION PHASE
Tasks:
The nurse reviews pertinent assessment data and
knowledge, considers potential areas of concern,
and develops plans for interaction.
Skills:
Organized data gathering; recognizing limitations
and seeking assistance as required.

50. INTRODUCTORY PHASE
Opening the relationship:
Tasks: Both client and nurse identify each other by
name. When the nurse initiates the relationship, it
is important to explain the nurse’s role to give the
client an idea of what to expect. When the client
initiates the relationship, the nurse needs to help
the client express concerns and reasons for seeking
help. Vague, open-ended questions, such as “What’s
on your mind today?” are helpful at this stage.
Skills: A relaxed, attending attitude to put the client
at ease.

51.  Clarifying the problem :
Tasks: Because the client initially may not see the
problem clearly, the nurse’s major task is to help
clarify the problem.
Skills: Attentive listening, paraphrasing, clarifying,
and other effective communication techniques as
discussed before . A common error at this
stage is to ask too many questions of the client.
Instead focus on priorities.

52.  Structuring and formulating the contract
(obligations to be met by both the nurse
and client):
Tasks: Nurse and client develop a degree of trust
and verbally agree about :
(a) location, frequency, and length of meetings.
(b) overall purpose of the relationship.
(c) how confidential material will be handled.
(d) tasks to be accomplished.
(e) duration and indications for termination of
the relationship.
Skills: Communication skills listed above and ability
to overcome resistive behaviors if they occur.

53. WORKING PHASE :
Tasks: Nurse and client accomplish the tasks
outlined in the introductory phase, enhance trust
and rapport, and develop caring.
Skills: Listening and attending skills, empathy,
respect, genuineness, concreteness, self-disclosure.
Skills acquired by the client are Non defensive
listening and self-understanding

54. Cont…
1. Exploring and understanding thoughts and
feelings:
The nurse assists the client to explore thoughts
and feelings and acquires an understanding of the
client. The client explores thoughts and feelings
associated with problems, develops the skill of
listening, and gains insight into personal behavior.

55. Cont…
2. Facilitating and taking action:
Tasks : The nurse plans programs within the client’s
capabilities and considers long- and short term
goals. The client needs to learn to take risks (i.e.,
accept that either failure or success may be the
outcome). The nurse needs to reinforce successes
and help the client recognize failures realistically.
Skills:
Decision-making and goal-setting skills. Also, for
the nurse: reinforcement skills; for the client: risk
taking.

56. TERMINATION PHASE :
Tasks: Nurse and client accept feelings of loss. The
client accepts the end of the relationship without
feelings of anxiety or dependence.
Skills: For the nurse: summarizing skills; for the
client: ability to handle problems independently.

57. REDE MODEL OF HEALTH CARE
SYSTEM:
REDE:
 The REDE model is a conceptual framework for
teaching relationship-centered healthcare
communication.
 The REDE model applies effective communication
skills to optimize personal connections in three
primary phases of Relationship Establishment,
Development and Engagement (REDE). The REDE
model and its application to a typical provider-
patient interaction.

58. Phase 1: Establishment
 Convey & respect with the welcome
 Review chart in advance and comment on their
history.
 Knock and inquire before entering room
 Greet patient and companions formally with
smile and handshake .
 Introduce self team, clarify role.
 Position self at patient’s eye level
 Recognize and respond to signs of physical or
emotional distress

59.  Collaboratively set the agenda :
 Orient patient to elicit a list of their concerns.
 Use a open ended question to initiate survey.
 Ask “ What else?” until all concerns are identified
 Summarize list of concerns to check accuracy ; ask
patient to prioritize.
 Demonstrate empathy using SAVE:
 Recognize emotional cues & respond “in the
moment”.
 Allow space to be with the patient & their emotion
with judgment.
 Clarify the emotions if needed .

60.  Demonstrate verbally with SAVE
 S- Support- “Let’s work together…”
 A- Acknowledge- “This has been hard on you .”
 V- Validate – “Most people would feel the way
you do.”
 E- Emotional naming – “ You seem sad.”
 Nonverbally – doing only that which feels natural
and authentic to you.

61. Phase 2 : Development
 Engage in reflective listening :
 Nonverbally – e.g. , direct eye contact, forward
lean, nodding .
 Verbally using continue such as
 “What I hear you saying is ……” or “ Sounds like…”
 Avoid expressing judgment , getting distracted ,
or redirecting.
 Express appreciation for sharing.

62.  Elicit the patient narrative :
 Use transition statement to orient patient to the
history of present illness.
 Use open- ended questions (s) to initiate patient
narrative.
 Maintain the narrative with verbally & nonverbal
continuers –
 “Tell me more…..” or
 “What next?”
 Summarize patient narrative to check accuracy .

63.  Explore the patient’s perspective using
VIEW
 V- Vital activities :
 “ How does it disrupt your daily activity?”
or
 “How does it impact your functioning ?”
 I- Ideas:
“What do you think is wrong ?”
 E- Expectations:
“ What are you hoping I can do for you today?”
 W- Worries :
“What worries you most about it?”

64. Phase 3 : Engagement
 Share diagnosis & information:
 Oriented patient the education & planning portion
of the visit.
 Present a clear , concise diagnosis
 Pause necessary
 Provide additional education, if desired & helpful
to the patient.

65.  Collaboratively develop the plan
 Describe treatment goals and options including
risks , benefits ,& alternatives.
 Elicit patient’s preferences & interrogate into a
mutually agreeable plan.
 Check for mutual understanding
 Confirm patient’s commitment to plan
 Identify potential treatment barriers & need for
additional resources .

66.  Provide closure:
 Alert patient that the visit is ending
 Affirm patient’s contributions and collaboration
during visit.
 Arrange follow up with patient and consultation
with other team members
 Provide handshake & a personal good-bye.
 Dialogue throughout using ARIA
 A- Assess using open – ended questions
 What the patient knows about diagnosis &
treatment.

67. Cont…
 How much & what types of education the patient
desires/needs.
 Patient treatment preferences
 Health literacy
 R- Reflect patient meaning emotion
 I- Inform
 Tell information to patient
 Speak slow & provide small chunks of information
at a time.
 Use understandable language & visual aids.
 A- Assess patient understanding & emotional
reaction to the information provided.

68. The REDE model builds on a significant research base including
placebo, therapeutic alliance, communication skills and patient-
centeredness that recognizes the healing potential of the healthcare
relationship for not only patients but also providers. The REDE model
helps frame the specific communication strategies that optimize their
effect(s) on processes, outcomes of care and the patient-provider
relationship itself. It is hoped that such system wide efforts will result
in improved experience of care and self-efficacy for patients, and
increased confidence, emotional connectedness and resiliency for
providers

69. Summarization:
Definition of Therapeutic communication
 Technique of therapeutic communication
 Forms and stages of therapeutic communication.
 Barrier of therapeutic communication
 Model of therapeutic communication
&
 Definition of Interpersonal relationship
 Phases if interpersonal relationship
 REDE model of health care system .

70. References:
1. B. Audrey, S.J. Shirlee , F. Geralyn. Kozier &
Erb’s fundamentals of nursing:Integral Aspects
of Nursing.10TH ed. United States of
America:Julie Levin Alexander;2016
2. Available from
https://www.managementstudyguide.com/typ
es-of-interpersonal-relationships.htm on date
12/09/2020
3. WK Amy. A Boissy. R Thomas. The REDE
Model of Healthcare Communication:
Optimizing Relationship as a Therapeutic
Agent.USA: SAGE Publication;2014