Interpersonal relationship and communication skills

INTERPERSONALRELATIONSHIP AND

COMMUNICATION SKILLS

By:- Firoz QureshiDept. Psychiatric Nursing

INTRODUCTION

• The therapeutic nurse - patient relationship is complex.

• It has a positive effect on patient’s outcomes. • The relationship between the nurse and the client

is voluntary based on principles of contracting. • The goal directed characteristic of the one to one

relationship. • The clients expectations arrives from life

experiences, desires and levels of personal believes.

INTRODUCTION

• The nurses expectations arise from what she considers to be helpful.

• Therapeutic goals aimed at client’s growth and developments through elements of relationship itself.

• The concepts of mutual collaboration, the basic to this concept are issues of responsibility and accountability.

• Both the nurses and client bring personal abilities and capacities to the relationships.

MEANING

• Communication stems from the Latin word, “to impart, participate, convey, and share information about” Webster’s New Collegiate Dictionary, (1974).

• Communication- Communication refers to the reciprocal exchange of information, ideas, beliefs, feelings and attitudes between persons or among a group of persons. It is a goal- directed process in which people use a system of symbols and signs to convey a message

MEANING• Interpersonal relationship-The nurse-client

relationship is a dynamic partnership that defines, directs, and evaluates treatment outcomes.(Antai-Otong and Wasserman 2003)

• Therapeutic Relationship- An interaction between two people (usually a caregiver and a care receiver) in which input from both participants contributes to a climate of healing, growth promotion, and/or illness prevention.

MEANING

• Nurse-patient relationship-it is an interpersonal process between a professional nurse and a client that helps the client to foster and promote growth of personality, to help the client improve in construction and productive way of living.

DEFINITIONS• Communication- It is the act or reciprocal process of

imparting or interchanging thoughts, attitudes, emotions, opinions, or information by speech, writing, or signs. Nurses can use this dynamic and interactive process to motivate, influence, educate, facilitate mutual support, and acquire essential information necessary for survival, growth, and an overall sense of well-being (Howells, 1975; Kleinman, 2004).

• Communication- Communication as a process by which information is exchanged between individuals through a common systems, signs or behavior.- Webster’s Dictionary.

DEFINITIONS• Therapeutic communication- It is a process in

which the nurse consciously influences a client or helps the client to a better understanding through verbal or nonverbal communication. Therapeutic communication involves the use of specific strategies that encourage the patient to express feelings and ideas and that convey acceptance and respect. - Mosby's Medical Dictionary (2009).

DEFINITIONS

• Interpersonal relationships refer to reciprocal social and emotional interactions between the patient and other persons in the environment.

• Nurse - patient relationship it is a mutual learning experience and a corrective emotional experience for the patient. the nurse uses personal attributes and specified clinical techniques in working with the patient to bring about behavioral change.

JOHARI WINDOW• A Johari window is a cognitive psychological tool

created by Joseph Luft and Harry Inghamin 1955 in the United States, used to help people better understands their interpersonal communication and relationships.

• The Johari Window is a communication model that can be used to improve understanding between individuals and increase self-awareness.

JOHARI WINDOWTwo key ideas behind the tool:

• Individuals can build trust between themselves by disclosing information about themselves.

• They can learn about themselves and come to terms with personal issues with the help of feedback from others.

• Using the Johari model, each person is represented by their own four-quadrant, or four-pane, window. Each of these contains and represents personal information - feelings, motivation - about the person, and shows whether the information is known or not known by themselves or other people.

JOHARI WINDOW

JOHARI WINDOWThe four quadrants are:• Quadrant 1: Open Area What is known by the person about him/herself and is also known by others.• Quadrant 2: Blind Area, or "Blind Spot“ What is unknown by the person about him/herself but which others know.

This can be simple information, or can involve deep issues (for example, feelings of inadequacy, incompetence, unworthiness, rejection) which are difficult for individuals to face directly, and yet can be seen by others.

• Quadrant 3: Hidden or Avoided Area What the person knows about him/ herself that others do not.• Quadrant 4: Unknown Area What is unknown by the person about him/herself and is also unknown by

others.

THERAPEUTIC COMMUNICATION IN PSYCHIATRIC NURSING

• The nurse-client relationship is the foundation on which psychiatric nursing is established.

• The therapeutic interpersonal relationship is the process by which nurses provide care for clients in need of psychosocial intervention.

THERAPEUTIC COMMUNICATION IN PSYCHIATRIC NURSING

• Mental health care providers need to know how to gain trust and gather information from the patient, the patient's family, friends and relevant social relations, and to involve them in an effective treatment plan.

• Therapeutic use of self is the instrument for delivery of care to clients in need of psychosocial intervention. Interpersonal communication techniques are the “tools” of psychosocial intervention.

THERAPEUTIC NURSE-CLIENT RELATIONSHIP

• Therapeutic relationships are goal- oriented and directed.

Components of Therapeutic Relationship• Rapport – harmonious relationship, growth towards

mutual acceptance, promotes self disclose.• Trust - presence of reliability, integrity, & sincere

desire to provide assistance when desired.• Respect- Non possessive warmth or unconditional

positive regards without criticism & ridicule.contd…

THERAPEUTIC NURSE-CLIENT RELATIONSHIP

• Genuineness- being ones own self, aware of her thoughts, feelings, values, its relevance in interaction with a client.

• Empathy- ability to feel with the patient, oneself in another person circumstances & feelings

• Concreteness- use of specific terminology easy to understand, rather than abstraction, it avoids vagueness and ambiguity.

PHASES OF A THERAPEUTIC NURSE-CLIENT RELATIONSHIP

• Pre-interaction phase- this phase begins when the nurse is assigned to initiate a therapeutic relationship and this includes obtaining information about the patient from charts, significant others or health team members.

• In this phase the nurse starts with initial assessment, she evaluate her own feeling, explore fantasies, fears and ambivalence, strengths and limitations and she plan her first meeting.

• In this phase she feels difficulty in self analysis, self acceptance, anxiety, boredom, anger, indifference and depression.


• Orientation/Introductory Phase- Nurse and patient meets for the first time.

• The task involves in this phase are to establish trust and rapport, establish a contract for intervention, assessment and examination of the patients problems and needs, identifies the patients strengths and limitations.

• Then she sets realistic goals mutually agreeable by patient and the nurse. Developing a plan of action. Both explore the feelings of each other


• Working Phase- therapeutic work is carried out in this phase.

• The nurse maintains the trust and rapport. • She uses the problem solving approaches to over

come the resistances. • She continuously evaluates and explore for

stressors. • She promotes Insight and constructive coping

mechanism to overcome the patients problems.


• Termination- it is a difficulty phase. • The nurse should recognize that the patients functioning

has improved, relief from the problems, the patient has increased self esteem and a strong sense of identity and has achieved the planned treatment outcomes.

• Nurse has to establish reality of separation, mutually explore feeling of rejection, loss, sadness, anger and related behavior.

• She review the progress of therapy and attainment of goals. She have to formulate plans for meeting future therapy needs and plan for continuing care.

INTERPERSONAL COMMUNICATION

• Interpersonal communication is a transaction between the sender and the receiver.

• Both participants perceive each other, listen to each other, and simultaneously engage in the process of creating meaning in a relationship, focusing on the patients’ issues and assisting them learn new coping skills.

• Both sender and receiver bring certain preexisting conditions to the exchange that influence the intended message and the way in which message is interpreted.

THERAPEUTIC COMMUNICATION TECHNIQUES

1. Using silence - allows client to take control of the discussion, if he or she so desires

2. Accepting - conveys positive regard3. Giving recognition - acknowledging,

indicating awareness4. Offering self - making oneself available5. Giving broad openings - allows client to

select the topic


6. Giving broad openings - allows client to select the topic

7. Offering general leads - encourages client to continue8. Placing the event in time or sequence - clarifies the

relationship of events in time9. Making observations - verbalizing what is observed

or perceived10.Encouraging description of perceptions - asking

client to verbalize what is being perceived


11. Restating - lets client know whether an expressed statement has or has not been understood

12. Reflecting - directs questions or feelings back to client so that they may be recognized and accepted

13. Focusing - taking notice of a single idea or even a single word

14. Exploring - delving further into a subject, idea, experience, or relationship

15. Seeking clarification and validation - striving to explain what is vague and searching for mutual understanding


16. Presenting reality - clarifying misconceptions that client may be expressing

17. Voicing doubt - expressing uncertainty as to the reality of client’s perception

18. Verbalizing the implied - putting into words what client has only implied

19. Attempting to translate words into feelings - putting into words the feelings the client has expressed only indirectly

20. Formulating plan of action - striving to prevent anger or anxiety escalating to unmanageable level when stressor recurs

NONTHERAPEUTIC COMMUNICATION TECHNIQUES OR BARRIERS

1. Giving reassurance - may discourage client from further expression of feelings if client believes the feelings will only be downplayed or ridiculed

2. Rejecting - refusing to consider client’s ideas or behavior3. Approving or disapproving - implies that the nurse has the right

to pass judgment on the “goodness” or “badness” of client’s behavior

4. Agreeing or disagreeing - implies that the nurse has the right to pass judgment on whether client’s ideas or opinions are “right” or “wrong”

5. Giving advice - implies that the nurse knows what is best for client and that client is incapable of any self-direction


6. Giving reassurance - may discourage client from further expression of feelings if client believes the feelings will Probing - pushing for answers to issues the client does not wish to discuss causes client to feel used and valued only for what is shared with the nurse

7. Defending - to defend what client has criticized implies that client has no right to express ideas, opinions, or feelings

8. Requesting an explanation - asking “why” implies that client must defend his or her behavior or feelings

9. Indicating the existence of an external source of power - encourages client to project blame for his or her thoughts or behaviors on others

10. Belittling feelings expressed - causes client to feel insignificant or unimportant


11.Making stereotyped comments, clichés, and trite expressions - these are meaningless in a nurse-client relationship

12.Using denial - blocks discussion with client and avoids helping client identify and explore areas of difficulty

13.Interpreting - results in the therapist’s telling client the meaning of his or her experience

14.Introducing an unrelated topic - causes the nurse to take over the direction of the discussion

THERAPEUTIC IMPASSES

• Therapeutic impasses are blocks in the progress of the nurse-patient relationship.

• Five specific therapeutic impasses and ways to overcome are to be learnt to develop therapeutic nurse-patient relationship.• Resistance.• Transference.• Counter transference.• Gift giving.• Boundary violations.

• RESISTANCE- it is the patients’ attempts to remain unaware of anxiety-producing aspects within him.

• It is natural or learned reluctance to avoidance of verbalizing or even experiencing troubled aspects of self.

• It is caused by the patients’ unwillingness to change when the need for change is recognized or secondary gain.

• It occurs in working phase and as this phase encompasses problem-solving process.

• Resistance occurs due to over involvement of nurse, lack of respect, nurses’ inappropriate role model behavior.


• TRANSFERENCE- it is an unconscious response of the patient in which he experience feelings and attitudes towards the nurse that were originally associated with significant figures, in his early life.

• It reduces the patient’s self-awareness and the nurse is viewed as an authority figure from the past, such as a parent, lost loved object, former spouse.

• It may be hostile and dependent reaction transference.


INTERVENTIONS TO RESOLVE RESISTANCE AND TRANSFERENCE

• The nurse must be prepared to be exposed to powerful negative and positive emotional feelings coming from the patient.

• Make therapeutic contracts, develop a mutually acceptable goals or plan of action, defining the goals, purpose and roles of the nurse and patient in the relationship.

• The appropriate action is to return to clarifying the goals, purposes and roles of the nurse and patient in the relationship.

INTERVENTIONS TO RESOLVE RESISTANCE AND TRANSFERENCE

• Listen to patient’s analysis of the resistance or transference. • Use clarification and reflection of feelings.• Clarification gives the nurse more focused idea of what is

happening. • Reflection of the content may help the patients become aware of

what has been going on in their own minds. Reflection of feelings acknowledges the resistance and mirrors it to the patient.

• For example the nurse may say, “I sense that you are struggling with yourself. Part of you wants to explore the issue of your marriage and another part says ’No- am not ready yet.”

• Explore the possible reasons for resistance.

COUNTER TRANSFERENCE• Counter transference is a therapeutic impasse created by the

nurse. It refers to the specific emotional response generated by the qualities of the patient.

• Counter transference is the transference applied to the nurse. • In this case the nurse identifies the patient with individuals

from his or her past, and the personal needs will interfere with therapeutic effectiveness.

• It is natural, for example, that the nurse will feel warmth toward or liking for some patients more than others, and the nurse will be genuinely angry at times in regard to the actions of certain patients.

COUNTER TRANSFERENCE

Types of counter transference 1. Reactions of intense love or caring.2. Reactions of intense hostility or hatred.3. Reactions of intense anxiety often in response

to resistance by patient.Through the use of immediacy, the nurse canidentify counter transference in of its variousforms.


Forms of Counter Transference displayed by nurses1. Inability to empathize with the patient in certain

problem areas.2. Depressed feelings during or after the session.3. Carelessness about implementing the contract by

being late, running overtime etc.4. Drowsiness during sessions.5. Feeling of anger or impatience because of the

patient’s unwillingness to change.


Forms of Counter Transference Displayed by Nurses6. Encouragement of the patient’s dependency, praise or

affection.7. Arguing with the patient or a tendency to push the

patient before he is ready.8. Trying to help the patient in matters not related to the

identified nursing goals.9. Involvement with the patient on a personal or social

level.10. Dreaming about or preoccupation with the patient.


Forms of Counter Transference Displayed by Nurses11.Sexual or aggressive fantasies towards the patient.12.Recurrent anxiety, unease or guilt feelings about

the patient.13.A tendency to focus repeatedly on only one aspect

or way of looking at the information presented by the patient.

14.A need to defend nursing interventions used with the patient to others.


Advantages of Counter Transference • Powerful tool in exploration and potent instruments in

uncovering inner states. They are destructive only if they are brushed aside, ignored or not taken seriously.

• Counter transference can lead to further information, can bring to light new materials, and help in developing insight.

• Nurse understanding of counter transference and her own feelings help to maintain a working relationship with the patient.


Interventions to Counter Transference1. Experience of working with psychiatric patients.2. Constantly lookout for counter transference.3. Hold counter transference in abeyance or utilize it for

promoting therapeutic goals.4. Apply self-examination throughout the course of

relationship, particularly when the patient attacks or criticizes. Asking oneself the following questions may be helpful:

5. How do I feel about the patient?


Interventions to Counter Transference6. Do I look forward to seeing the patient?7. Do I feel sorry for or sympathetic toward the

patient?8. Am I bored with the patient and believe that we

are not progressing?9. Am I afraid of the patient?10.Do I get extreme pleasure out of seeing the

patient?


Interventions to Counter Transference11.Do I want to protect, reject or punish the patient?12.Do I dread meeting with the patient and feel

nervous during the sessions?13.Am I impressed by or try to impress the patient?14.Does the patient make me very angry or

frustrated?15.Pursue to find out the source of the problem.


Interventions to Counter Transference16.Exercise control over counter transference.17.Have individual or group supervision.18.Weekly clinical seminars, peer consultation,

and professional meetings can also offer emotional support.

GIFT GIVING

• Gift is that of something of value is voluntarily offered to another person, usually to convey a gratitude.

• Receiving a gift from the patients make the nurse to inhibit independent decision-making, create a feeling of anxiety or guilt.

GIFT GIVING

• Gifts can be divided into following five types (Morse, 1991).– Gifts to reciprocate for care given.– Gifts intended to manipulate or change the quality of

care given or the nature of nurse-patient relationship.– Gifts given as perceived obligation by the patient.– Serendipitous gifts or gifts received by chance.– Gifts given to organization to recognize excellence of

care received.

GIFT GIVING

• Gifts can be tangible or intangible; Lasting or temporary.

• Tangible gifts may include box of sweets, a bouquet of flowers or hand painted picture.

• Intangible gifts can be expression of thanks to a nurse by a patient who is about to be discharged or a family members gratitude at being able to share an emotional burden with another caring person.

GIFT GIVING• Occasionally it may be most appropriate and therapeutic for

the nurse to accept a patient’s gift; on other occasions it may be quite inappropriate and detrimental to the relationship.

• In the orientation phase of the relationship, gift giving can be harmful if it meets personal needs rather than therapeutic goals.

• In the working phase gift giving may take on a different significance.

• As an isolated incident, the nurse’s acceptance of it can enhance the patient’s confidence, self esteem, and a sense of responsibility.

GIFT GIVING• Gift giving most often arises in the termination phase of

relationship, At this time gifts can reflect a patient’s need to make the nurse feel guilty, delay the termination process, compensate for feelings of inadequacy or an attempt to transform the therapeutic nurse-patient relationship in to social one that can go on indefinitely.

• The nurse can initiate gift giving for similar reasons. If feelings are identified and clarified, then a small gift that reflects gratitude and remembrance can be exchanged, accepted and valued.

BOUNDARY VIOLATIONS

A boundary indicates a border or a limit. It determines the extent of acceptable limits. Many types of boundaries exist. Examples include the following:– Material boundaries – Social boundaries – Personal – Professional boundaries (College and Association of

Registered Nurses of Alberta [CARNA], 2005).

BOUNDARY VIOLATIONS

Concerns regarding professional boundaries are commonly related to the following issues:– Self-disclosure. – Gift-giving. – Touch. – Friendship or romantic association.

CONCLUSION

Effective communication is the core skill in mental health care in primary care settings.

Self-awareness and ability to collaborate with other health care providers are also skills that

will facilitate accurate inquiry into the patient's true concerns and the context in

which they occur.

Interpersonal relationship and communication skills

Healthcare

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