The Therapeutic Nurse-The Therapeutic Nurse-Client RelationshipClient Relationship

Use of Therapeutic Use of Therapeutic CommunicationCommunication

Self Awareness & Nurse - Client Self Awareness & Nurse - Client RelationshipRelationship

• Quad I • Open to self/public –• What you know about self• And what others also

know about you

• Quad 2 • Blind – the unaware self• Qualities others know

about you –but you are unaware of.

• Quad 3 • The hidden /private self• Qualities only you know

• Quad 4• Unknown self• EMPTY quad – the

undiscovered self- Qualities not known by self/ others

Components of the Nurse-Client Components of the Nurse-Client RelationshipRelationship

• Trust

• Genuine interest

• Empathy

• Acceptance

• Positive Regard

• Therapeutic Use of Self

Types of relationshipsTypes of relationships

Social

Friendship

Companion

Use small talk

superficial

Intimate

Emotional commitment

May be sexual/

emotional

Intimacy

Therapeutic

Focus on client needs

Experiences,

Feelings, ideas

Goal oriented

Phases of the Nurse-Client Phases of the Nurse-Client Relationship:Relationship:

• Pre-Orientation- Self assessment

examine own feelings, fears, anxieties.

• Orientation – Introductory Phase

establish trust, share information with client; discrete self-disclosure.

convey support, facilitate healing

educate

Phases of Therapeutic Nurse-Phases of Therapeutic Nurse-Client Relationship—Client Relationship—cont’d.cont’d.

• The Working Phase – Problems identified

Exploration- guide client to examine feelings/responses, develop new coping skills

Termination Phase – Resolution phase

Examine goals achieved;

Explore feelings regarding termination

Establish plan for continuing assistance

Obstacles to the Therapeutic Obstacles to the Therapeutic Relationship:Relationship:

• Inappropriate Boundaries

• Encouraging dependence

• Non acceptance/Avoidance

• Resistance

Roles of the Nurse:Roles of the Nurse:

• Teacher

• Caregiver

• Advocate

• Parent- Surrogate

Therapeutic CommunicationTherapeutic Communication

• Boundaries:Intimate

Personal

Social

Public

Non Verbal CommunicationNon Verbal Communication

• Eye ContactEye Contact

• Body LanguageBody Language

• BoundariesBoundaries

• Facial ExpressionsFacial Expressions

• SilenceSilence

• Vocal cuesVocal cues

Non Verbal CommunicationNon Verbal Communication

• SpaceSpace ((comfort zone)comfort zone)

• Touch ( Touch ( action/personal space – used action/personal space – used cautiously)cautiously)

• AppearanceAppearance – communicates a particular – communicates a particular image/one’s mental status ( use of image/one’s mental status ( use of clothing, make-up etc.)clothing, make-up etc.)

Be aware of own non-verbal cues!!Be aware of own non-verbal cues!!

Traits of Therapeutic Traits of Therapeutic CommunicationCommunication

• GenuinenessGenuineness

• Positive RegardPositive Regard

• EmpathyEmpathy

• TrustworthinessTrustworthiness

• ClarityClarity

• ResponsibilityResponsibility

• AssertivenessAssertiveness

Active Listening!!Active Listening!!

• S – S – Sit facing the clientSit facing the client

• O – O – Open PostureOpen Posture

• L – L – Lean forward towards clientLean forward towards client

• E – E – Establish eye contactEstablish eye contact

• R- R- Relax!!Relax!!

Conditions Affecting Conditions Affecting CommunicationCommunication

• ValuesValues• AttitudesAttitudes• BeliefsBeliefs• PerceptionsPerceptions• Culture or ReligionCulture or Religion• Social StatusSocial Status• GenderGender• Age or developmental levelAge or developmental level• EnvironmentEnvironment

Enhancing CommunicationEnhancing Communication

• SilenceSilence

• Support/reassuranceSupport/reassurance

• Sharing ObservationsSharing Observations

• Acknowledge feelingsAcknowledge feelings

• Broad – open ended statementsBroad – open ended statements

• Information givingInformation giving

• InterpretationInterpretation

Enhancing CommunicationEnhancing Communication

• Restating• Reflecting• Clarification• Confrontation• Offering Alternatives• Voicing doubt• Role-playing• Use of Humor – use cautiously/discretely

Non-therapeutic responsesNon-therapeutic responses

• Advising• Agreeing• Belittling feelings• Challenging• Defending• Disagreeing• Disapproving • Probing

Caring for clients from different Caring for clients from different socio-cultural backgroundssocio-cultural backgrounds

• Important !! – Analyze self! – know your own beliefs/values/customs/behaviors

• Avoid being judgmental• Rules for communication vary since they arise

from cultural norms!• Understand differences in communication

among various cultures• Ask families for assistance re: their culture• Reflect on your emotions/journal write feelings

Therapeutic communication ?’sTherapeutic communication ?’s1. The nurse is meeting a new client on

the unit.Which action, by the nurse, is most effective in initiating the nurse-client relationship?

A. Introduce self and explain the purpose and the plan for the relationship.

B. Describe the nurse’s family and ask the client to describe his/her family.

C. Wait until the client indicates a readiness to establish a relationship.

D. Ask the client why he/she was brought to the hospital.

2. Mrs. F. has remained close to the nurse all day. When the nurse talked with other clients during dinner, Mrs. F. tried to regain the nurse’s attention and began to shout, “You’re just like my mother. You pay attention to everyone but me!” The best interpretation of this behavior is that

A. Mrs. F. is exhibiting resistance.

B. Mrs. F. has been spoiled by her family.

C. The nurse has failed to meet Mrs. F’s needs.

D. Mrs. F. is demonstrating transference.

3. The nurse is caring for a Native American client who says, “I don’t want you to touch me.I’ll take care of myself.” Which nursing response is most therapeutic?

A. “Okay, if that’s what you want.I’ll just leave this cup for you to collect your urine.”

B. “If you don’t want our care, why did you come here?”C. “Why are you being so difficult? I only want to help

you.”D. “It sounds as though you want to take care of

yourself. Let’s work together so you can do things for yourself.”

4. The client says to the nurse “I am going to die, I wish my family would stop hoping for a cure! I get so angry when they carry on like this! After all, I’m the one who’s dying.” The most therapeutic response is:

A. “You’re feeling angry that your family continues to hope for you to be cured.”

B. “I think we should talk more about your anger with your family.”

C. “Well, it sounds like you’re being pessimistic. After all, years ago people died of pneumonia.”

D. “Have you shared your feelings with your family?”

5. The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, “How is Carol doing? She is my best friend and is seen at your clinic every week.” The most appropriate nursing response is which of the following?

A. “I’m not supposed to discuss this, but because you are my neighbor, I can tell you that she is doing great!”

B. I’m not supposed to discuss this, but because you are my neighbor, I can tell you that she really has some problems!”

C. “If you want to know about Carol, you need to ask her yourself.”

D. “I cannot discuss any client situation with you.”

6. The nurse is preparing the client for the termination phase of the nurse-client relationship. The nurse prepares to implement which nursing task is most appropriate for this phase?

A. Identifying expected outcomesB. Planning short term goalsC. Making appropriate referralsD. Developing realistic solutions

7. During the termination phase of the nurse-client relationship, the clinic nurse observes that the client continuously demonstrates bursts of anger. The most appropriate interpretation of the behavior is that the client

A. Requires further treatment and is not ready to be discharged.

B. Is displaying typical behaviors that can occur during termination.

C. Needs to be admitted to the hospital.

D. Needs to be referred to the psychiatrist as soon as possible.

8. A client looks at a mirror and cries out, “I look like a bird. This is not my face.” The nurse responds therapeutically by saying:

A. “What kind of a bird do you think you are?”

B. “That must be very distressing to you, your face does not look different to me.”

C. “Maybe the light is playing tricks on you.”

D. “Why do you think that you look like a bird?”

9. A 32 year old mother of 2 young children diagnosed with cervical cancer with metastacies, tells her nurse “I’m going to die, aren’t I ?” The nurse’s most appropriate response would be:

A. “No, you are not . After all you are receiving the latest treatment available, and your doctor is one of the best in this area.”

B. “We are all going to die sometime.”C. “What did your doctor tell you?”D. “I don’t know. You have a serious illness. Do you have

feelings that you would like to talk about?”

10.A client relates angrily to the nurse that his wife says he is selfish. Which response by the nurse would be most helpful?

A. “That’s just her opinion.”B. “I don’t think that you are selfish.”C. “Everyone is a little bit selfish.”D. “You sound angry – tell me more about

what went on.”

11. The most therapeutic response a nurse could make to a student who begins to cry upon learning that a failing grade was received on a final exam is:

A. “You’ll make it next time.”

B. “Failing an exam is an upsetting thing to happen.”

C. “How close were you to passing?”

D. “It won’t seem so important 5 years from now.”