THERAPEUTIC COMMUNICATION AND NURSE-PATIENT-RELATIONSHIP.pdf

THERAPEUTIC
COMMUNICATION AND
NURSE – PATIENT
RELATIONSHIP

COMMUNICATION
• Communication refers to the giving and receiving of
information.
• Communication is the means by which people
influence the behavior of another, leading to
successful outcome of Nursing intervention.
• It is a vehicle used to establish therapeutic relationship
involving the elements like the sender, the message,
the receiver, and the feedback .

THERAPEUTIC COMMUNICATION
• Therapeutic Nurse – Patient interaction is a
mutual learning experience and corrective
emotional experience for the client .
• In this relationship , the Nurse uses personal
attributes and clinical techniques while working with
the client to bring about insight and behavioral
change.
• The general goal of nurse- client interaction is to
help the client to grow.
• All Nurses need skills in therapeutic communication
to effectively apply the nursing process and to meet
standards of care for their clients .

GOALS OF THERAPEUTIC
COMMUNICATION.
• Toestablish a therapeutic nurse – patient relationship.
• Toidentify client’s most important needs .
• To assess client’s perception and the problem.
• Tofacilitate client’s expression of emotions or feelings.’s
needs
• To implement interventions designed to address the
patient
• It helps in realization, self acceptance and anincreased
genuine self respect.
• Helps in problem solving.
• Clarifies the area of conflict and anxiety.
• Toidentify client’s strengths and weaknesses.

YOU MUST KNOW……….
• Tohave an effective therapeutic communication,
the Nurse must consider privacy and respect of
boundaries , use of touch and active listening
and observation .

COMMUNICATION TYPES .
I ) Verbal Communication.

II ) Non – verbal communication.
1. Vocal Cues . = Are also known as
Paralinguistic cues . They include all the noises
and extra speech sounds .
EXAMPLE = Tone of voice, pitch, Nervous
coughing.
COMMUNICATION TYPES .

II ) NON – VERBAL COMMUNICATION.
2. Action Cues = Are mainly body movements.
Like, expression , mannerisms, actions etc.
Facial movements and postures particularly
significant in interpreting the speaker’s mood.

3. Object Cues = Are dress, furnishings and
possessions. They communicate something to
the observer about the speaker’s feelings.
4. Space = Provides another cue to the nature of
the relationship between two people .

5. Touch= Is the most personal of the non-
verbal messages . It involves both personal
space and action . Most often in nursing, we
use touch with therapeutic goal . We lay
hands on the body of an ill person for the
purpose of comforting him/her .

THERAPEUTIC COMMUNICATION
TECHNIQUES
1. LISTENING
2. BROAD OPENINGS – Encouraging the client
to select topics for discussion. Eg : What are
you thinking about ?

OBSERVING AND LISTENING SKILLS.
LADDER
L = Look at others, keep good eye contact.
A = Ask appropriate questions only.
D = Do not interrupt.
D= Do not change the subject.
E = Express emotions with control.
R= Responsively listen.

3. RESTATING– Repeating the main thought
expressed by the client . Eg : Yousay that your
Mother left you when you were 5 years old.
4. CLARIFICATION – Attempting to put vague
ideas or unclear thoughts of the client into
words to enhance nurse’s understanding or
asking the client to explain what he/she
means. Eg: “I am not sure about what you
mean; could you tell me again” ?

5. REFLECTION. – Directing back the client’s
ideas, feelings, questions and content. Eg :
Youare feeling anxious and tense and it is
related to a conversation you had with your
husband last night?
6. HUMOR – The discharge of energy through
the comic enjoyment of the imperfect. That
gives a whole new meaning to the word
‘nervous’ , said with shared kidding between
nurse and the patient.
7. INFORMING – The skill of information
sharing. Eg: “I think you need to know
more about your medications . ”

8.FOCUSING – Questions or statements that help
the patient expand on a topic of importance .
Eg : “I think we should talk more about your
relationship with your Father . “
9.SHARING PERCEPTIONS – Asking the client to
verify nurse’s understanding of what the client is
thinkingor feeling. Eg: “You are smiling, but I sense
that you are really very angry with me.”
10.THEME IDENTIFICATION – This involves
identification of underlying issue or problems
experienced by the client that emerge repeatedly
during the course of the nurse-client relationship . Eg
: “I noticed that you said, you have been hurt or
rejected by the man. Do you think this is an
underlying issue?”

11.SILENCE – Lack of communication for a
therapeutic reason. Eg : Sitting with a client
and non-verbally communicating interest and
involvement .
12.SUGGESTING - Presentation of alternative
ideas for the client’s consideration relating to
Problem solving .
Eg : “ Have you thought about responding to your
bose in a different way when he raises that issue
with you? "

TYPES OF RELATIONSHIPS.
• SOCIAL RELATIONSHIP
A social relationship can be defined as a relationship
that is primarily initiated with the purpose of
friendship , socialization, enjoyment or
accomplishing a task .
Mutual needs are met during social interaction.
There is no predetermined goals or focus in the
relationship, and the continuation of the relationship
is not determined at the onset .

TYPES OF RELATIONSHIPS .
• INTIMATE RELATIONSHIP
• An intimate relationship is a relationship between
two individuals committed to one another , caring
for and respecting each other .
• Those in an intimate relationship usually react
naturally with each other . Often the relationship
is a partnership between each member cares
about the other’s need for growth and
satisfaction .
• According to Erikson , the intimate relationship
focus the basis for marriage and other partner-
type relationships .

TYPES OF RELATIONSHIPS .
• THERAPEUTIC RELATIONSHIP
• The therapeutic relationship between nurse and the
client differs from both a social and an intimate
relationship in that the nurse maximizes inner
communication skills , understanding of human
behavior and personal strengths in order to
enhance the client’s growth.
• The focus of this interaction is on the client’s ideas,
experiences and feelings .
• In this the interaction is purposefully established ,
maintained and carried out with the anticipated
outcome of helping the client to gain new coping
and adaptation skills.

GOALS OF THERAPEUTIC
RELATIONSHIP
• Facilitating communication of distressing thoughts and
feelings
• Assisting the patient with problem-solving
• Helping patients examine self-defeating behaviors and
test alternatives
• Promoting self care and independence

COMPONENTS / ELEMENTS OF
NURSE-CLIENT RELATIONSHIP
• Rapport.
• Empathy.
• Warmth.
• Genuineness.

RAPPORT
• Getting
acquainted and
establishing
rapport is the
primary task in
relationship
development.

TRUST
• To trust another, one
must feel confidence
in that person’s
presence, reliability,
integrity, veracity, and
sincere desire to
provide assistance
when requested.

CONT…
• Examples of nursing interventions
that would promote trust:
• Providing a blanket when the
client is cold
• Providing food when the client
is hungry

CONT…
• Being consistent in adhering to
unit guidelines
• Taking the client’s preferences,
requests, and opinions into
consideration when possible in
decisions concerning his or her
care

CONT…
• Ensuring
confidentiality

RESPECT
• To show respect is
to believe in the
dignity and worth of
an individual
regardless of his or
her unacceptable
behavior.

CONT…
• The nurse can convey an attitude of respect with the
following interventions:
• Calling the client by name
• Spending time with the client
• Allowing for sufficient time to answer the client’s
questions and concerns
• Promoting an atmosphere of privacy
• Always being open and honest

CONT…
• Taking the client’s ideas,
preferences, and opinions into
considerations when planning care
• Striving to understand the
motivation behind the client’s
behavior, regardless of how
unacceptable it may seem

CONT…
• To be “real” is to be aware of
what one is experiencing
internally and to express this
awareness in the therapeutic
relationship.

CONT…
• Empathy is the ability to see beyond
outward behavior and to understand the
situation from the client’s point of view.
• The nurse must also be able to
communicate this perception to the client
by attempting to translate words and
behaviors into feelings.

CONT…
• It is not uncommon for the concept of empathy
to be confused with that of sympathy.
• The major difference is that with empathy the
nurse “accurately perceives or understands”
what the client is feeling and encourages the
client to explore these feelings.

CONT…
• With empathy, while understanding
the client’s thoughts and feelings, the
nurse is able to maintain sufficient
objectivity to allow the client to
achieve problem resolution with
minimal assistance.

CONT…
• With sympathy, the nurse actually feels
what the client is feeling, objectivity is
lost, and the nurse may become focused
on relief of personal distress rather than
on helping the client resolve the
problem at hand.

PHASES OF A THERAPEUTIC NURSE – CLIENT
RELATIONSHIP
• Use interpersonal relationship
development as the primary intervention
• Role of the nurse in psychiatry becomes
especially meaningful and purposeful.
• It becomes an integral part of the total
therapeutic regimen.

CONT…
• Tasks of the relationship have been
categorized into four phases:
1. The preinteraction phase,
2. The orientation (introductory) phase,
3. The working phase, and
4. The termination phase.

PHASES OF RELATIONSHIP DEVELOPMENT
AND MAJOR NURSING GOALS
Phases Goals
1.Preinteraction Explore self-perceptions
2.Orientation
(Introductory)
Establish trust
Formulate contract for
intervention
3.Working Promote client change
4.Termination Evaluate goal attainment
Ensure therapeutic closure

THE PREINTERACTION PHASE
• The preinteraction phase involves preparation for the
first encounter with the client

CONT…
• Tasks include the following:
1. Explore own feelings, fantasies and fears
2. Analyze own professional strengths and
limitations
3. Gather data about patient whenever possible
4. Plan for first meeting with patient

PROBLEMS ENCOUNTERED
• Difficulty in self-analysis and self-acceptance
• Anxiety
• Apart from anxiety, the nurse may also
experience boredom, anger, indifference, and
depression

THE ORIENTATION (INTRODUCTORY) PHASE

IN THIS TASKS INCLUDE…
• Creating an
environment
for the
establishment
of trust and
rapport.

• Establishing a
contract for
intervention that
details the
expectations and
responsibilities of
both nurse and client.

• Gathering
assessment
information to
build a strong
client data base

•Identifying the
client’s
strengths and
limitations

•Formulating nursing diagnosis

• Setting goals
that are
mutually
agreeable to
the nurse and
client

•Developing a
plan of action
that is realistic
for meeting the
established
goals

•Exploring
feelings of
both the
client and
nurse

• The major problem encountered during this
phase is related to the manner in which the
nurse and patient perceive each other
• Problems related to establishing an
agreement or pact between the nurse and
patient

FORMULATING A CONTRACT
• It is a mutual process
• It begins with the introduction of the nurse and
patient, exchange names, and explanation of roles.
• An explanation of roles includes the responsibilities
and explanations of the patient and nurse, with a
description of what the nurse can and cannot do

ELEMENTS OF NURSE-PATIENT CONTRACT
• Exchanging names of nurse and patient
• Explanation of roles of nurse and patient
• Explanations of responsibilities of nurse and patient
• Discussion of purpose
• Discussion of date, time and place
• Description of meeting conditions for termination
• Confidentiality

CONT…
•Tasks include in this:
•Maintaining the trust and
rapport that was established
during the orientation phase.

CONT…
• Promoting the client’s
insight and perception of
reality.

CONT…
• Overcoming resistance behaviors on
the part of the client as the level of
anxiety rises in response to
discussion of painful issues.

CONT…
• Continuously evaluating progress
toward goal attainment.

• Testing of the nurse by the patient
• Progress of the client
• The nurse’s fear of closeness
• Life stresses of the nurse
• Resistance behaviours
• Transference and counter transference reactions

CONT…
•Tasks include bringing a
therapeutic conclusion to the
relationship and this occurs
when:

• Progress has
been made
toward
attainment of
mutually set
goals.

• A plan for continuing
care or for assistance
during stressful life
experiences is mutually
established by the
nurse and client

• Feelings about
termination of
the relationship
are recognized
and explored

• Through these interactions, the client learns
that it is acceptable to have these kinds of
feelings at a time of separation.
• Through this knowledge, the client
experiences growth during the process of
termination.

• Patients may perceive termination as
desertion and may demonstrate angry
behaviour
• Some patients attempt to punish the
nurse
• Other patients react to the threatened loss
by becoming depressed or assuming an
attitude of not caring

•Fault finding behaviour
•Resistance
•Flight to illness

CRITERIA FOR DETERMINING CLIENT’S READINESS
FOR TERMINATION.
Patient experiences relief from presenting problem.
Patient’s social functions has improved and
isolation has decreased.
Patient’s ego functions are strengthen and has
attained a sense of identity .
Patient employs more effective and productive
defense mechanisms.
Patient has achieved the planned treatment goals .

DYNAMICS OF THERAPEUTIC NURSE-
PATIENT RELATIONSHIP.
Forces that change the nurse-patient
relationship:
1. The therapeutic use of self.
2. Gaining Self Awareness. (Johari Window.)
3. Power
4. Trust
5. Intimacy
6. Respect

DYNAMICS OF THERAPEUTIC NURSE-
PATIENT RELATIONSHIP.
1. THE THERAPEUTIC USE OF SELF.

1. THE THERAPEUTIC USE OF SELF = Is defined as
the “ability to use one’s personality, consciously
and in full awareness in an attempt to establish
relatedness and to structure nursing
interventions.”
Peplau ( 1952 ) described that Nurses must
clearly understand themselves to promote
client’s growth, change and heal .

2. GAINING SELF AWRENEESS=
Is the process of understanding
one’s own beliefs thoughts,
motivations and limitations
and recognizing how they
affect others . Without self
awareness , nurse will find it is
impossible to establish and
maintain therapeutic
relationship with clients.
Johari Window is a
representation of the self
and a tool that can be used
to increase self awareness.

Johari Window = Johari Window is based on the concept
of “no one ever completely knows his/her inner self”. Self
awareness is a key component of the psychiatric nursing
experience. The goal of increasing self awareness by
using Johari Window is to increase the size of the
quadrant that represents the open or public self .
The individual who is open to self and others has the
ability to be spontaneous and share emotions and
experiences with others.
Increased self awareness allows an individual to interact
with others comfortably, to accept the differences in
others and to observe each person’s right to respect and
dignity .

In creating Johari Window , first step is for the
nurse to appraise / evaluate their own qualities
by creating a list of them ; Values, attitudes,
feelings, strengths , behavior, accomplishments,
need, desires and thoughts.
Second step is to find out the perceptions of others
by interviewing them and asking them to identify
the qualities, both positive and negative thy see in
the nurse .
The third step is to compare list and assign qualities
to appropriate quadrants.

JOHARI WINDOW
…CONT….
1 2
3 4
Person with little self understanding
1 2
3 4
Person with great self awareness

3. POWER
• The appropriate use of power in a
caring manner enables the nurse to
work with the patient towards the
patient's goals and to ensure that the
patient's vulnerable position in the
nurse-patient relationship is not taken
advantage of.

4. TRUST
• To maintain trust in the relationship,
it is important that the nurse keeps
promises to patients.
• If trust is breached, then it becomes
very difficult to re-establish it

5. INTIMACY
• In this context, intimacy relates to the
kinds of activities nurses perform for
the patients that create personal and
private closeness on many levels.
• This can involve physical, psychological,
spiritual and social elements.

6. RESPECT
• Respect for the dignity and worth of the
patient is fundamental to the relationship.
• The nurse needs to know and understand
the culture and other aspects of the patient's
individuality and to take these into account
when providing service.

Therapeutic
impasses
Resistance
transference
Countertransfe
rence
Boundary
violations

RESISTANCE
• Resistance is the patient’s attempt to remain unaware of
anxiety producing aspects within himself.
• It is a natural learned reluctance to avoidance of
verbalizing or even experiencing troubled aspects of self
• Resistance is often caused by the patient’s unwillingness
to change when the need for change is recognizing

HOW CLIENT SHOWS RESISTANCE???

• Suppression and
repression of relevant
information
• Intensification of
symptoms
• A helpless outlook on
the future

• Breaking appointments,
coming late to his sessions,
being forgetful, silent, and
sleepy during the interaction
• Acting out or irrational behavior

• Reporting physical symptoms which may occur only
during the time the patient with the nurse
• Expressing on excessive liking for the nurse and
claiming that nobody can replace her

• Hostility, dependence, provocative remarks,
sexual interest in the nurse

MANAGEMENT
• Active listening
• Clarification- give for focused ides of what is
happening

• Reflection- helps
the patient to
become aware of
what has been
going in his mind
• Explore behaviour to find possible reason
• Maintain open communication with supervisor

TRANSFERENCE
• Transference is an unconscious response in which
the patient experiences feelings and attitudes
toward the nurse that were originally associated
with significant figures in the patient’s early life.
• For example, a patient perceives the nurse as acting
the way that his mother did, regardless of how the
nurse is truly acting.

• Transference can be positive if patient views
the nurse as a helpful and caring.
• Negative transference is more difficult because
of unpleasant emotions that interfere with
treatment such as anger and fear.
• Transference occurs when the client
unconsciously displaces (or “transfers”) to the
nurse, feelings formed toward a person from
the past

• Transference can interfere with the
therapeutic interaction when the feelings
being expressed include anger and hostility.

• Anger toward the
nurse can be
manifested by
uncooperativeness
and resistance to
the therapy.

• Transference can
also take the form of
overwhelming
affection for the
nurse or excessive
dependency on the
nurse.

• The nurse is
overvalued and
the client forms
unrealistic
expectations of
the nurse.

MANAGEMENT
• No need to terminate relationship unless poses a
serious barrier to therapy or safety
• Nurse should work with patient in sorting out past
from the present
• Assist patient in identifying the transference &
reassign a new & more appropriate meaning to
the current nurse-patient relationship

• The goal is to guide the patient to
independence by teaching them assume
responsibility for their own behaviours,
feelings & thoughts & to assign the correct
meaning to the relationship based on the
present circumstances instead of past

COUNTERTRANSFERENCE
• Countertransference refers to the nurse’s behavioral
and emotional response to the client.
• These responses may be related to unresolved
feelings toward significant others from the nurse’s
past, or they may be generated in response to
transference feelings on the part of the client.

CONT…
•These feelings can interfere with
the therapeutic relationship
when they initiate the following
types of behaviors

CONT…
• The nurse over
identifies with the
client’s feelings, as they
remind his or her of
problems from the
nurse’s past or present.

CONT…
• The nurse and the client develop a social or
personal relationship.

CONT…
•The nurse begins
to give advice or
attempts to
“rescue” the client

CONT…
•The nurse
encourages and
promotes the
client’s
dependence

CONT…
• The nurse’s anger
engenders
feelings of disgust
toward the client

CONT…
•The nurse feels
anxious and
uneasy in the
presence of the
client.

CONT…
•The nurse is
bored and
apathetic in
sessions with
the client.

CONT…
• The nurse has
difficulty setting
limits on the
client’s behavior

CONT…
•The nurse
defends the
client’s behavior
to other staff
members

MANAGEMENT
• Support the nurse
• Assist her identifying counter transference
• Discuss with superiors
• Self examination
• Pursue to find out source of problem
• Exercise control counter transference
• Peer consultation & professional meetings

BOUNDARY VIOLATION
• Boundary Violation occurs when a
nurse goes outside the boundaries of
the therapeutic relationship and
establishes a social, economic or
personal relationship with a patient

POSSIBLE BOUNDARY VIOLATIONS
• Nurse accepts free gifts from the patient
• Having personal or social relationship with the
patient

• Nurse attends social functions of the patient

• Nurse regularly reveals personal
information of the patient
• Nurse routinely hugs or has physical
contact with the patient
• Nurse does business with or purchases
services from the patient

• Nurse must have knowledge of the impasses and
recognize behaviors that indicate their existence.
• Nurse must reflect on feelings, explore reasons
behind such behaviors.
• Co-workers are most likely than others to
recognize the phenomenon initially and give a
feedback to the nurse about it.

• Nurse must examine their strengths, weaknesses,
prejudices and values before they can interact more
appropriately with patients.
• The transference reactions of patients must also be
examined, gently but directly.
• Nurse must be open and clear about their genuine
reactions when patients misperceive behavior.

• Nurse should also state actions that they can and
cannot take to meet patient’s needs.
• Limit setting is useful when patients act
inappropriately towards the nurse.
• Maintain open communication with her supervisor,
who can then guide her in making adequate
progress in handling such resistance reactions.

DEFINITION
• Process recording is a written account or verbatim
recording of all that transpired, during and
immediately following the nurse-patient interaction.
• In other words, it is the recording of the
conversation during the interaction or the interview
between the nurse and the patient in the psychiatric
setup with the nurse's inference.

PURPOSE AND USES
• The aim of process recording is to
improve the quality of the interaction
for better effect to the patient and as a
learning experience for the nurse to
continuously improve her clinical
interaction pattern.

WHEN CORRECTLY USED, IT-
• Assists the nurse or student to plan, structure
and evaluate the interaction on a conscious
rather than an intuitive level
• Assists her to gain competency in interpreting
and synthesizing raw data under supervision
helps to consciously apply theory to practice

• helps her to develop an increased awareness of her
habitual, verbal and non verbal communication
pattern and the effect of those patterns on others
• helps the nurse to learn to identify thoughts and
feelings in relation to self and others
• helps to increase observational skills, as there is a
conscious process involved in thinking, sorting and
classifying the interaction under the various
headings
• helps to increase the ability to identify problems
and gain skills in solving them.

PROCESS RECORDING IS
• Educative tool
• Teaching tool
• Diagnostic tool
• Therapeutic tool, and a prerequisite for
nursing process

PREREQUISITES FOR
PROCESS RECORDING
• Physical setting
• Getting consent of the patient for
the possibility of cassette recording
• Confidentiality

SUGGESTED OUTLINES FOR
PROCESS RECORDING
• Introductory Material
• Objectives
• Context of the Interaction
• Record of Interaction between Nurse and the
Patient
• Analysis of the Interaction

FORMAT FOR PROCESS
RECORDING
• Name of the patient:
• Place (ward / OPD):
• Name of the hospital
• DOA:
• Day 1:
• Objectives:
1.
2.
3.

NURSE CLIENT
THERAPEUTIC
COMMUNICATI
ON TECHNIQUE
INFERENCE
VERBAL
RESPONSE
NON
VERBAL
RESPONSE
VERBAL
RESPONSE
NON
VERBAL
RESPONSE

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