Ch. 5 Therapeutic Communication Flashcards
Which is the primary nursing goal when establishing a therapeutic relationship with a patient?
A. To promote patient growth
B. To develop the nurse’s personal identity
C. To establish a purposeful social interaction
D. To develop communication skills
A. The goal of a therapeutic nursing interaction is to promote patient insight and behavioral change directed toward patient growth.
What is the therapeutic interpersonal relationship and therapeutic use of self? What does interpersonal communication techniques have to do with them?
Therapeutic interpersonal relationship is the process by which nurses provide care for patients in need of psychosocial intervention.
Therapeutic use of self is the instrument for the delivery of that care. It is the ability to use one’s personality consciously and in full awareness in an attempt to establish relatedness and to structure nursing interventions. Nurses must possess self-awareness, self-understanding, and a philosophical belief about life, death, and the overall human condition.
Interpersonal communication techniques are the tools of psychosocial intervention
What are the conditions essential to the development of a therapeutic relationship?
Rapport, trust, respect, genuineness, empathy
Describe rapport in a therapeutic relationship
Getting acquainted and establishing rapport is the primary task in relationship development.
Rapport implies special feelings on the part of both the patient and the nurse based on acceptance, warmth, friendliness, common interest, a sense of trust, and a nonjudgmental attitude
[To establish rapport] is to create a sense of harmony based on knowledge and appreciation of each individual’s uniqueness.
Describe trust in a therapeutic relationship
To trust another, one must feel confidence in that person’s presence, reliability, integrity, veracity, and sincere desire to provide assistance when requested.
Trust cannot be presumed; it must be earned. Trustworthiness is demonstrated through nursing interventions that convey a sense of warmth and caring to the patient.
Examples of nursing interventions that would promote trust in an individual that is thinking concretely include”
- Providing a blanket when the patient is cold
- Providing food when the patient is hungry
- Keeping promises
- Being honest (e.g., saying, “I don’t know the answer to your question, but I’ll try to find out”) and then following through
- Simply and clearly providing reasons for certain policies, procedures, and rules
- Providing a written, structured schedule of activities
- Attending activities with the patient if he or she is reluctant to go alone
- Being consistent in adhering to unit guidelines
- Listening to the patient’s preferences, requests, and opinions and making collaborative decisions concerning his or her care
- Ensuring confidentiality; providing reassurance that what is discussed will not be repeated outside the boundaries of the healthcare team
Describe respect in a therapeutic relationship
What are ways a nurse can convey respect?
To show respect is to believe in the dignity and worth of an individual regardless of his or her unacceptable behavior.
Also called unconditional positive regard.
- Calling the patient by name (and title, if he or she prefers)
- Spending time with the patient
- Allowing for sufficient time to answer the patient’s questions and concerns
- Promoting an atmosphere of privacy during therapeutic interactions with the patient or when the patient may be undergoing physical examination or therapy
- Always being open and honest with the patient, even when the truth may be difficult to discuss
- Listening to the patient’s ideas, preferences, and requests, and making collaborative decisions concerning his or her care whenever possible
- Striving to understand the motivation behind the patient’s behavior, regardless of how unacceptable it may seem
Describe genuineness in a therapeutic relationship
Refers to the nurse’s ability to be open, honest, and “real” in interactions with the patient. To be real is to be aware of what one is experiencing internally and to allow the quality of this inner experiencing to be apparent in the therapeutic relationship.
The nurse who possesses the quality of genuineness responds to the patient with truth and honesty rather than with responses that he or she may consider more “professional” or that merely reflect the “nursing role.”
May call for a degree of self-disclosure on the part of the nurse
Describe empathy in a therapeutic relationship
What is the difference between empathy and sympathy?
Empathy is the ability to see beyond outward behavior and to understand the situation from the patient’s point of view.
With empathy, the nurse can accurately perceive and understand the meaning and relevance of the patient’s thoughts and feelings.
The major difference is that with empathy the nurse “accurately perceives or understands” what the patient is feeling and encourages the patient to explore these feelings. With sympathy the nurse actually “shares” what the patient is feeling and experiences a need to alleviate distress
Phases of a therapeutic nurse-patient relationship
- Preinteraction phase
- Orientation (introductory) phase
- Working phase
- Termination phase
Describe the pre-interaction phase in the therapeutic nurse-patient relationship
Obtain information about the patient from the chart, significant others, or other health team members.
Examine one’s own feelings, fears, and anxieties about working with a particular patient.
The nurse needs to be aware of how these preconceptions may affect his or her ability to care for individual patients.
Describe the orientation phase in a therapeutic nurse-patient relationship
- Create an environment for trust and rapport.
- Establish contract for intervention that details the expectations and responsibilities of both nurse and patient
- Gather assessment data to build a strong database
- Identify the patient’s strengths and limitations.
- Formulate nursing diagnoses.
- Set mutually agreeable goals.
- Develop a realistic plan of action for meeting the established goals
- Explore feelings of both patient and nurse.
Describe the working phase of a therapeutic relationship
- Maintain trust and rapport.
- Promote patient’s insight and perception of reality.
- Use problem-solving model to work toward achievement of established goals.
- Overcome resistance behaviors as the level of anxiety rises in response to discussion of painful issues.
- Continuously evaluate progress toward goal attainment.
Describe the problem-solving model in the therapeutic nurse-patient relationship
Therapeutic relationships are goal-oriented and directed at learning and growth promotion. Goals are often achieved through use of the problem-solving model.
- Identify the patient’s problem.
- Promote discussion of desired changes
- Discuss aspects that cannot realistically be changed and ways to cope with them more adaptively.
- Discuss alternative strategies for creating changes that the patient desires to make.
- Weigh benefits and consequences of each alternative.
- Help patient select an alternative.
- Encourage patient to implement the change.
- Provide positive feedback for patient’s attempts to create change.
- Help patient evaluate outcomes of the change and make modifications as required.
What is transference? What are some interventions for transference?
Occurs when the patient unconsciously displaces (or “transfers”) to the nurse feelings formed toward a person from the past
Can interfere with the therapeutic interaction when the feelings being expressed include anger and hostility
Can also take the form of overwhelming affection for the nurse or excessive dependency on the nurse. Patient forms unrealistic expectations for the nurse
Interventions: The nurse should
- Work with the patient in sorting out the past from the present
- Assist the patient into identifying the transference
- Reassign a new and more appropriate meaning to the current nurse-patient relationship
What is countertransference? How can countertransference interfere with the therapeutic nurse-patient relationship?
Refers to the nurse’s behavioral and emotional response to the patient.
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 patient.
- The nurse overidentifies with the patient’s feelings because they remind him or her of problems from the nurse’s past or present.
- The nurse and patient develop a social or personal relationship.
- The nurse begins to give advice or attempts to “rescue” the patient.
- The nurse encourages and promotes the patient’s dependence.
- The nurse’s anger engenders feelings of disgust toward the patient.
- The nurse feels anxious and uneasy in the presence of the patient.
- The nurse is bored and apathetic in sessions with the patient.
- The nurse has difficulty setting limits on the patient’s behavior.
- The nurse defends the patient’s behavior to other staff members.
What are some interventions for countertransference?
- The nurse or staff member experiencing the countertransference should be supportively assisted by other staff members to identify his or her feelings and behaviors and recognize the occurrence of the phenomenon.
- It may be helpful to have evaluative sessions with the nurse after his or her encounter with the patient, in which both the nurse and other staff members (who are observing the interactions) discuss and compare the exhibited behaviors in the relationship.
Describe the termination phase of the nurse-patient relationship
Therapeutic conclusion of a relationship occurs when…
- Progress has been made toward attainment of the goals.
- A plan of action for more adaptive coping with future stressful situations has been established
- Feelings about termination of the relationship are recognized and explored.
- Through these interactions, the patient learns that it is acceptable to have feelings at a time of separation. Through this knowledge, the patient experiences growth during the process of termination.
- This is also a time when both nurse and patient may evaluate and summarize the learning that occurred as an outgrowth of their relationship.
A patient threatens to kill himself, his wife, and their children if the wife follows through with divorce proceedings. During the pre-interaction phase of the nurse–patient relationship, which interaction should the nurse employ?
A. Acknowledging the patient’s actions and encouraging alternative behaviors
B. Establishing rapport and developing treatment goals
C. Providing community resources on aggression management
D. Exploring personal thoughts and feelings that may adversely impact the provision of care
D. In the pre-interaction phase, the nurse must clarify personal attitudes, values, and beliefs to become aware of how these might affect the nurse’s ability to care for various patients. This occurs before the nurse meets the patient.
Types of boundaries in the nurse-patient relationship
- Material: These are physical property that can be seen.
- Social: These boundaries are established within a culture and define how individuals are expected to behave in social situations.
- Personal: These are boundaries that individuals define for themselves. These include physical distance boundaries, or just how close individuals will allow others to invade their physical space and emotional boundaries, or how much individuals choose to disclose of their most private and intimate selves to others.
- Professional: : Limit and outline expectations for appropriate professional relationships with patients. “Professional boundaries are the spaces between a nurse’s power and the patient’s vulnerability”. Nurses must recognize that they have an imbalance of power with their patients by virtue of their role and the patient information to which they have access. They must be consistently conscientious in avoiding any circumstance in which they might achieve personal gain within that relationship.
Professional boundary concerns commonly include issues such as:
Self-disclosure
Gift-giving
Touch
Friendship or romantic association
Describe how self-disclosure is a professional boundary concern
Self-disclosure on the part of the nurse may be appropriate when it is judged that the information may therapeutically benefit the patient. It should never be undertaken for the purpose of meeting the nurse’s needs.
Describe how gift-giving is a professional boundary concern
- Those who are receiving care often feel indebted toward healthcare providers.
- Gift giving may even be part of the therapeutic process.
- Cultural belief and values may also enter into the decision of whether to accept a gift from a patient. In some cultures, failure to do so would be interpreted as an insult.\
- Accepting financial gifts is never appropriate, but in some instances, nurses may be permitted to suggest instead a donation to a charity of the patient’s choice
- . If acceptance of a small gift of gratitude is deemed appropriate, the nurse may choose to share it with other staff members who have been involved in the patient’s care.
- Attention should be given not only to what the gift giving means to the patient but also to institutional policy
Describe how touch is professional boundary concern
- Touching or hugging can be beneficial when it is implemented with therapeutic intent and patient consent
- When using caring touch, make sure it is appropriate, supportive, and welcomed
- Caring touch may provide comfort or encouragement, but some vulnerable patients may misinterpret the meaning of touch.
- In some cultures, touch is not considered acceptable unless the parties know each other very well
- Additionally, patients who are experiencing high levels of anxiety, suspiciousness, or psychosis. These are times when touch should be avoided or considered with extreme caution.
Describe how friendship or romantic association is a professional boundary concern
- When a nurse is acquainted with a patient, the relationship must move from one of a personal nature to professional. If the nurse is unable to accomplish this separation, he or she should withdraw from the nurse-patient relationship.
- Nurses must guard against personal relationships developing as a result of the nurse-patient relationship
- Romantic, sexual, or similar personal relationships are never appropriate between nurse and patient
Warning signs that indicate that professional boundaries of the nurse–patient relationship may be in jeopardy
- Favoring one patient’s care over another’s
- Keeping secrets with a patient
- Changing dress style when working with a particular patient
- Swapping patient assignments to care for a particular patient
- Giving special attention or treatment to one patient over others
- Spending free time with a patient
- Frequently thinking about the patient when away from work
- Sharing personal information or work concerns with the patient
- Receiving of gifts or continued contact and communication with the patient after discharge
Describe interpersonal communication
- Interpersonal communication is a transaction between the sender and the receiver. Both persons participate simultaneously.
- In the transactional model, both participants perceive each other, listen to each other, and simultaneously engage in the process of creating meaning in a relationship.
In all interpersonal transactions, both the sender and receiver bring certain pre-existing conditions to the exchange that influence both the intended message and the way in which it is interpreted. These conditions include….
Values, attitudes, and beliefs
Culture and religion
Social status
Gender
Age or developmental level
The environment in which the transaction takes place
Describe how values, attitudes, and beliefs influence communication
- Learned ways of thinking
- Children generally adopt the value systems and internalize the attitudes and beliefs of their parents. They may retain this way of thinking into adulthood or develop a different set of attitudes and values as they mature
- Ex: Prejudice is expressed verbally through negative stereotyping
- One’s value system may be communicated with behaviors that are more symbolic in nature. Ex: An individual who values youth may dress and behave in a manner that is characteristic of one who is much younger
Describe how culture and religion influence communication
- Cultural mores, norms, ideas, and customs provide the basis for our way of thinking.
- Cultural values are learned and differ from society to society. Ex: In some European countries, men may greet each other with hugs and kisses; in the US or England, shaking hands is a more culturally accepted style of greeting among men.
- Religion. Ex: Priests and ministers who wear clerical collars publicly communicate their mission in life. The collar also may influence the way in which others relate to them, either positively or negatively.
- Other symbolic gestures, such as wearing a cross around the neck or hanging a crucifix on the wall, also communicate an individual’s religious beliefs.
Describe how social status influences communication
- Studies of nonverbal indicators of social status or power have suggested that high-status persons are associated with gestures that communicate their higher-power position
- Ex: They use less eye contact, have a more relaxed posture, use louder voice pitch, place hands on hips more frequently, are “power dressers,” have greater height, and maintain more distance when communicating with those of lower social status
Describe how gender influences communication
- Most cultures have gender signals that are recognized as either masculine or feminine and provide a basis for distinguishing between members of each gender.
- Ex: differences in posture: Men usually stand with thighs 10-15 degrees apart, the pelvis rolled back, and the arms slightly away from the body. Women stand with legs close together, the pelvis tipped forward, and the arms close to the body. When sitting, men may lean back in the chair with legs apart or may rest the ankle of one leg over the knee of the other. Women tend to sit more upright in the chair with legs together, perhaps crossed at the ankles, or one leg crossed over the other at thigh level.
- Roles have historically been identified as either male or female. Male: husband, father, breadwinner, doctor, lawyer, engineer. Female: wife, mother, homemaker, nurse, teacher, secretary
- Words such as unisex communicate a desire by some individuals to diminish the distinction between the genders and minimize the discrimination of either.
