Ch. 9 Communication and the Therapeutic Relationship Flashcards
Professional Core Belief
Nurses need to communicate assertively and responsibly w/ clients and colleagues to demonstrate caring
Patients request
- -Understanding
- -Action
- -Information
- -Comfort
You may need to validate w/ them what they are requesting if it is not clear
Responsible Communication
willing to answer for ones own conduct instead of blaming situations or other people
Caring Communication
focusing on the relationship w/ the client instead of the procedure you are doing. Having meaningful connections w/ clients. Creating hope and trust
Assertive Communication
being clear about your needs and respectful in language and behavior, striving for win-win situations. This is in contrast to passive or aggressive.
Assertive Communication: Passive
does not state needs, lets others make decisions and choices, frustrating to others
Assertive Communication: Aggressive
wants to win at all costs, defeat others, makes choices for others
Assertion
3 criteria for success in assertiveness:
–doing it when there is adequate time, respectfully phrasing your needs, and doing it when the person is receptive to discussion
To improve your assertiveness:
- Determine what rights you are giving up
- Identify what irrational belief you have
- Use DESC
- -Describe situation
- -Express what you think and feel
- -Specify your request
- -State consequences
Therapeutic Use of Self
Application of nurse’s own personality and characteristics w/in the interaction to facilitate hearing
Open-ended process, continues to develop throughout life as we learn new ways to relate to others
Basic concept involves understanding of self and others
Nurse-Patient Relationship
Pre-orientation phase
-get report
Orientation phase
- First meeting
- Confidentiality
- Testing the relationship
- Ends when patient begins identifying problems
Working phase
- Identification of problems
- Problem solving
Resolution phase
- Problems resolve
- Relationship ends
Therapeutic impasses are usually in what phase?
Working phase
Therapeutic Impasses: Transference
Unconscious response of client
Client: inappropriate intensity of feelings: hostility, anger, love, dependence
Nurse: confront distortions of reality gently, facilitate client awareness
Therapeutic Impasses: Countertransference
Inappropriate intensity of nurse’s feelings
Nurse must increase self-awareness and access supervision to assist in dealing w/ client more effectively
Resistance - Testing Behaviors
Normal response to anxiety-provoking thoughts and feelings - afraid of self-exploration
Client: avoidance, acting out, forgetting, silence, lateness
Nurse: make observations, support client to deal w/ anxiety
Self-Awareness
The process of understanding one’s own beliefs, thoughts, motivations, biases, and limitations, and recognizing how they affect others
The development of self-awareness requires a willingness to be introspective
Includes:
Biologic, Psychological, and Social
Self-Awareness: Biologic
- Gender, age, body weight, height, and other physical characteristics
- Genetic makeup, chronic illness, or physical disability
Self-Awareness: Psychological
- Psychological makeup
2. Traumatic experiences
Self-Awareness: Social
- Sociocultural values
2. Acknowledge cultural heritage
Johari’s Window: Quadrant 1
Open quadrant known to self and known to others
Johari’s Window: Quadrant 2
Blind quadrant known to others but not known by self
Johari’s Window: Quadrant 3
Hidden quadrant private life space personal secrets
Johari’s Window: Quadrant 4
Unknown quadrant unconscious self and unknown to others
Goals of Self-Awareness
Increase size of quadrant 1
- -Learn more about yourself, reveal more about yourself to others
- -Represents free and spontaneous interaction, easier to relate to others
- -Increased self-concept increases confidence, insight produces growth
As quadrant 1 grows, quadrants 2, 3, and 4 shrink accordingly
Reduce size of quadrant 3
–Freer to be yourself
Tiny quadrant 4
Johari Window
The 4 quadrants represent total self
A change in any quadrant affects all other quadrants
The smaller quadrant 1, the poorer the communication
Interpersonal learning means that a change has taken place so quadrant 1 is larger and one or more of the other quadrants is smaller
Increasing Self-Awareness and Changing Behavior
Begin by listening to yourself - experience emotions, explore thoughts, feelings, and impulses
Listen and learn from others, be open to feedback
Reveal to others important aspects about self (self-disclosure)
Through self-awareness and conscious effort, the nurse can change learned behaviors to engage effectively in therapeutic relationships
Communication
Verbal communication (7% of communication) --Spoken word, underlying emotion, context, connotation
Nonverbal communication (93% of communication) --Gestures, expressions, body language
Therapeutic communication
–Ongoing process of interaction in which meaning emerges
Transactional Analysis Model - Eric Berne
Parent: attitudes and behaviors taught
Adult: logic, rational, realistic
Child: feelings from childhood
Three types of transactions:
- Complementary (ex: adult to adult)
- Crossed (ex: one party speaking as an adult and the other as a parent)
- Ulterior (ex: appears to be adult to adult but in reality the client is asking for parenting from the nurse, but does not really want it so rejects all ideas suggested)
Principles of Therapeutic Communication
- The patient should be the primary focus
- A professional attitude sets the tone
- Use self-disclosure only when disclosure has a therapeutic purpose
- Avoid social relationships with patients
- Maintain patient confidentiality
- Assess the patient’s intellectual competence
- Implement interventions from a theoretic base
- Maintain a nonjudgemental attitude
- Avoid giving advice
- Guide the patient to reinterpret his or her experiences rationally
- Track the patient’s verbal interaction through the use of clarifying statements
Using Verbal Communication
Self-disclosure
Verbal communication techniques
- -Science and listening
1. Passive listening
2. Active listening
Communication Process
Sender of message
–Incongruent verbal and non-verbal
Message not transmitted
–Not relevant, nor enough info
Receiver is perceiver of message
–Misinterpretation
Feedback is response of receiver
–Failure to give feedback
Context is the setting
–Noise, temperature, or distractions
Selecting Communication Techniques
Choosing the best response begins with assessing and interpreting the meaning of patient’s communication - both verbal and nonverbal
The next step is identifying the desired patient outcome
Focus on the patient’s feelings
Applying Communication Concepts: Rapport
interpersonal harmony characterized by understanding and respect
Applying Communication Concepts: Validation
explicitly checking out one’s own thoughts or feelings w/ another person
Applying Communication Concepts: Empathy
ability to experience, in the present, the situation as another did at some time in the past
Applying Communication Concepts: Boundaries
the defining limits of persons, objects, or relationships
Biopsychosocial Boundaries and Body Space Zones
Personal boundaries:
- Four body zones [from closest to farthest away from person]
1. Intimate zone
2. Personal zone
3. Social Zone
4. Public Zone
The patient will allow the nurse to enter the personal zone, but will express discomfort is the nurse breaches the intimate zone
For the nurse, the difficulty lies in differentiating the personal zone from the intimate zone for each patient
Nonverbal Behaviors
Space
Vocal cues
-Tone, loudness, rate, laughing
Action cues
-Body movement, gestures, facial movements, posture
Object cues
-Dress, furnishings, possessions
Professional Boundaries and Ethics
Be aware of professional boundaries to avoid exploitation of the patient
When concerns arise related to therapeutic boundaries, the nurse must seek clinical supervision or transfer the care of the patient immediately
Potential Boundary Violations
Role: firm limits
Time: odd, unusual treatment time
Place and space: lunch
Money: compensation, free therapy
Gift and service: consider the reason; obligation, manipulation, gift to the organization for excellence of care
Clothing: revealing vs. professional
Language: first/last name, off color jokes
Self disclosure: use only for patient benefit
Post discharge social: confuse social w/ professional support
Physical boundaries: touch, space, sexual
Defense Mechanisms
Automatic psychological processes protecting the individual against anxiety (denial, splitting, altruism)
Individuals often are unaware
Some defense mechanisms are maladaptive
Others may be either maladaptive or adaptive
The nurse evaluates the purpose of a defense mechanism and then determines whether or not it should be discussed w/ the patient
Analyzing Interactions
Process recordings - will do in mental health class
Role play
Exam questions
Analysis:
- Symbolism
- Content themes
- Communication blocks
