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Behaviour change

Miljana Stamenkovic

St. Lawrence College/Laurentian University

LUSL 1207: Relational Practice 2

Professor Susan Ogilvie

April 19, 2021

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Relational practice takes the art of nursing and applies it as a client-centered and holistic

approach (Zou, 2016, p. 1). Relational practice is an essential part of nursing practice (Zou, 2016, p. 1). It

focuses on the clients’ lived experiences and their health care needs (Zou, 2016, p. 1). The ability to

practice relational practice, requires nurses to be genuinely concerned in the client’s well-being,

establish trust, actively listen and evaluate their own values, beliefs and assumptions (Zou, 2016, p. 2).

When this is established, nurses have a better ability to meet challenges and provide a higher quality of

health care (Zou, 2016, p. 1). Along with relational practice, it is essential for nurses to develop a

therapeutic nurse-client relationship. It is important for nurses to use therapeutic communication when

establishing relationships with clients’ (CNO, 2006). This allows for effective communication and

interpretation of client messages and healthcare needs (CNO, 2006). Nurses must understand how the

client feels to help them in developing an effective plan of care (CNO, 2006).

The relationship in terms of its therapeutic effectiveness is described as appropriately and

effectively establishing, maintaining and terminating a nurse-client relationship (CNO, 2006). The

purpose of this paper is to gain insight on my therapeutic communication by watching, reflecting and

identifying areas for self-improvement by watching my performance as the role of the nurse. This paper

will outline a therapeutic nurse-client relationship during a nurse-client interaction in a video. It will

focus on analysis of nurses’ relational practice in terms of strengths and areas for development.

Description of nurse-client interaction

The reason the nurse-client came together in this scenario was regarding the clients’ decision to

self-isolate and request trays in his room due to his hearing impairment. The purpose of the interaction

was to establish a therapeutic nurse-client relationship, using active listening and empathetic responses

to assess how the nurse can better assist the client. In the video, I played the nurse, and I was trying to

accomplish a better understanding into the client’s feelings and decisions towards self-isolating and

requesting trays in his room. I was using empathetic, active listening and therapeutic communication to
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establish trust and a positive behaviour change. The particular issues that were assessed as priorities for

the client included, reasons for self-isolating, when did he come to the decision to have trays in his

room, what brought on these decisions, and does he have difficulty or lack of knowledge in using his

hearing aids. Engaging in effective teaching and learning may increase his willingness to wear hearing

aids in the future.

Analysis of nurse’s relational practice

My student nursing abilities demonstrated and managed the phases of the relationship. These

phases include orientation phase, working phase and termination phase. The first phase is the

orientation phase. This phase involves beginning to establish trust by providing a brief introduction of

myself and some basic information (Arnold & Boggs, 2020, p. 190). An example from the video was a

simple introduction: “Hello, Mr. Smith, my name is Miljana. I will be your student nurse today.” This

gave the client an idea of who I am and my role. My non-verbal behaviour included eye contact, open

posture and leaning in (Arnold & Boggs, 2020, p. 190). The next phase demonstrated in the video is the

working phase. The working phase was used to establish relevant problem solving that were assessed as

health care needs of the client (Arnold & Boggs, 2020, p. 194). I focused on health goals and behaviour

changes relevant to the client, that would promote his health and well-being. This was evidenced by the

phrase, “What brought on these feelings of having trays in your room?” and “Is there something I can do

to help?” and “Would you allow me to assist you with your hearing aids?” This opens opportunity for

trust and communication and genuine concern of the clients’ needs. This also allows the client to

explore feelings and solutions to his healthcare needs. The final phase is the termination phase. The

termination phase was established when teaching has been achieved (Arnold & Boggs, 2020, p. 197).

The nurse-client evaluate the relationship and the goals that have been achieved (Arnold & Boggs, 2020,

p. 197). The termination phase also involves client-centered plans for the future (Arnold & Boggs, p.

197). In the video, the termination phase involved a focus on teaching the client about hearing aids, so
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that he will be able to know how to use them in the future. Although, as the nurse on duty, it is my

responsibility to assist the resident if he continues to have difficulty with the hearing aids. This is stated

as, “Okay, Mr. Smith I will be back in a few minutes to see how your hearing aids feel.” “Would that be

alright?” This allowed him time to explore wearing his hearing aids and the knowledge that I will be back

to see if the teaching was effective.

The contextual variables that may have impacted on the interaction were the environmental

setting and technology in communicating, since we were in different rooms communicating through a

screen. This gave the impression that our closeness and proximity to each other was affected. Also, since

the client is hearing impaired, I was initially unable to get clients’ attention due to the environmental

setting. I would have initial tried to get the clients’ attention when entering the room, with a therapeutic

touch or coming to face him, since he probably could not hear me come in. Another contextual variable

was the dim lighting in the room, this would have an impact on the communication since the client

would need better lighting to see my facial expressions or read my lips since he is hearing impaired.

I went into the scenario thinking it would be difficult to communicate with the client regarding

behaviour change, however, I found the client to be trusting, receptive and eager to learn. I believe that

my paraverbal components of pitch, tone and pace, not speaking too fast or too slow, set the

atmosphere for a positive teaching environment. I utilized the non-verbal communication skill of SOLER

(Stickley, 2011, p. 395). I considered this a useful tool to establish trust, active listening and effective

communication (Stickley, 2011, p. 395). I exhibited this by being present with the client (Stickley, 2011,

p. 396). I sat facing the client, I had open posture, no crossed arms and I was leaning in towards the

client to show that I am interested in what he is telling me (Stickley, 2011, p. 396). I maintained eye

contact, although my eyes averted at times, but sometimes it is reasonable to have social breaks in eye

contact, so that it does not seem that I am staring. I maintained a relaxed position and did my best not

to fidget or become nervous (Stickley, 2011, p. 396). The conversation maintained an overall good flow. I
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also used non-verbal communication of nodding my head when the client was speaking, this allowed

him to know that I am actively listening and interested in the conversation without interrupting him. My

verbal communication used conversational talk, which establishes physical and mental well-being

(Keutchafo et al, 2020). When speaking with my client I used open ended questions such as, “Can you

tell me more about how you came to the decision to have trays in your room?” and “What brought on

these feelings?” These types of questions encouraged the client to express reasons how he came to this

decision. I used clarifying phrases such as, “If I am understanding correctly you wish to have trays in your

room?” I also used closed ended questions to clarify answers from the client such as, “Are you

interested in trying your hearing aids again?” and “Would you allow me to assist you with your hearing

aids?” I used closed ended questions to clarify, focus and validate his thoughts. This made it easier for

the client to express his point of view. I also used teaching to help the client learn about hearing aids

and engage in applying his own hearing aids. This allows the client to maintain his independence. I also

used focused communication, where I focused on client’s priorities, such as “Do you find it difficult to

apply your hearing aids?” and “How often do you wear your hearing aids?” This helps the client focus on

the problem, reasons and possible solutions for the client. By using verbal and non-verbal

communication it helps the nurse-client build their therapeutic relationship.

I demonstrated two relational capacities which were trust and caring by using an empathetic

approach. Trust was established by ensuring the clients’ safety and acting in the clients’ best interest

(Gholamzadeh et al, 2018, p. 2). Having a positive attitude towards the client determines the quality of

the nurse-client therapeutic relationship (Gholamzadeh et al, 2018, p. 2). Establishing the trust between

older clients’ and the nurse is important in achieving health care goals (Gholamzadeh et al, 2018, p. 2).

There is a significant increase in positive healthcare outcomes when there is a warm, friendly and

reassuring encounter that enables a trusting relationship to develop (Vogel et al, 2018, p. 2). The second

relational capacity is empathy. Empathy is a care component of enhancing a therapeutic relationship

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(Mercer & Reynolds, 2002, p. 9). Empathy enhances the nurse-client relationship and improves nurse-

client satisfaction (Mercer & Reynolds, 2002, p. 9). I was able to exhibit empathy by stating, “I can

understand how that would be difficult” and “I can understand how your frustrated” and “I know it must

be difficult for you to be in a noisy environment.” By acknowledging these feelings, it can reduce clients’

frustration and anxiety (Mercer & Reynolds, 2002, p. 9). Using these expressions initiates support and

interpersonal communication to better understand the needs of the client (Mercer & Reynolds, 2002, p.

9). It also empowers the client to learn and cope with their environment and come to resolutions to the

clients’ problems (Mercer & Reynolds, 2002, p. 9).

My relational practice strengths included empathetic tone of voice and pace, speech was clear,

not too fast or slow. It set a good pace for communication especially with a client who has hearing

impairment. I faced the client so that he was able to watch my lips move. I used pauses and simple

sentences to allow client time to think and interpret questions. Hearing impairment can have an impact

and “decrease communicative relationships and social interactions” (Lotfi et al, 2009, p. 367). This is why

it is important to maintain eye contact, reduce distractions, noises and have good lighting so the client

can see facial expressions. I did well in educating the client on the importance of hearing aids, how to

use and how to store them. Hearing aids can have a positive effect on the older adults’ social

relationships and their quality of life (Lotfi et al, 2009, p. 366). My areas for development were smiling

more, using more hand gestures and maintaining eye contact. I noticed that my eyes would avert from

the client. Although, I find it difficult to maintain eye contact especially when I feel it becomes too

awkward during the conversation. With the loss of eye contact, while taking notes or looking down at

notes, it reduces the “emotional aspects of client disclosure and decreases the clients’ historical details”

(Vogel et al, 2018, p. 2). Also, using more hand gestures would have been useful especially for a client

with hearing impairment.

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Therapeutic nurse-client relationship is an important part of communication and building trust

with the client. The importance of trust, respect, empathy and balance of power affect the nurse-client

relationship (CNO, 2006). I learned the importance of pauses in the conversation and using simple

sentences. This allowed me to actively listen and allow the client time to think and answer the

questions. I learned the importance of respect and trust, and how verbal, paraverbal and non-verbal

components effect the whole interaction. This experience has helped me learn active listening, empathy

and establishing a trusting therapeutic relationship. These skills that I have gained will help me maintain

therapeutic nurse-client relationship through therapeutic communication, client-centered care and

maintaining boundaries (CNO, 2006). My skills will be enhanced and used throughout my nursing career

to make me a better communicator with my clients.

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References

Arnold, E, and Boggs, K. (2020). Interpersonal relationships: professional communication skills for nurses.

Elsevier. 190-197

College of Nurses of Ontario (CNO). (2006). Therapeutic nurse-client relationship practice standard:

Therapeutic communication and client-centered care. The Standard of Care.

http://www.cno.org/globalassets/4-learnaboutstandardsandguidelines/prac/learn/modules/

tncr/pdf/tncr-chapter3.pdf

Gholsmzadeh, S., Khastavaneh, Z., Khademian, Z., and Ghadakpour, S. (2018). The effects of empathy

skill training on nursing students’ empathy and attitudes toward elderly people. BMC Medical

Education, 18(1), 1-7. http://dx.doi.org.librweb.laurentian.ca/10.1186/s12909-018-1297-9

Keutchafo, E.L.W., Kerr, J., and Jarvis, M.A. (2020). Evidence of nonverbal communication between

nurses and older adults: A scoping review. BMC Nursing. https://doi.org/10.1186/s12912-020-

00443-9

Lotfi, Y., Mehrkian, S., Moossavi, A., and Faghih-Zadeh, S. (2009). Quality of life improvement in hearing-

impaired elderly people after wearing a hearing aid. Archives of Iranian Medicine, 12(4), 365-

370.

Mercer, S., and Reynolds, W. (2002). Empathy and quality of care. British Journal of General Practice, 52,

s9-s13.

Stickley, T. (2011). From soler to surety from effective non-verbal communication. Nurse Education in

Practice, 11(6), 395-398. https://doi.org/10.1016/j.nepr.2011.03.021

Vogel, D., Meyer, M., and Herendza, S. (2018). Verbal and non-verbal communication skills including

empathy during history taking of undergraduate medical students. BMC Medical Education, 18,

1-7. https://doi.org/10.1186/s12909-018-1260-9
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Zou, P. (2016). Relational practice in nursing: A case analysis. Nursing and Healthcare, 1(1), 1-5.

http://edelweisspublications.com/edelweiss/article/Relational-Practice-Nursing-Case-Analysis-

NHC-16-102.pdf
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Appendix A
Appraisal of a Therapeutic Relationship Marking Scheme (30%)
This marking scheme will be used to evaluate the learner’s portrayal of the student nurse
within the Video-Recorded Nurse-Patient Interaction. This section to be included as Appendix
A in student paper
Weight (%) Assessment Criteria Does not Below Approaching Meets Exceeds
meet requirements requirements requirements requirements
requirements
(0-49%) (50-59%) (60-69%) (70-79%) (80-100%
Indicate your level of self- 1 2 3 4 5
assessment in each box
Provide examples to support your
assessment of each criteria.
10% Welcomes Client (Orientation Level: 4
phase): (e.g. introduces self to Examples: I introduced myself and my role by stating, “Hello,
client, uses client’s name and states Mr. Smith, My name is Miljana, and I will be your student
professional roles (demonstration of nurse today.”
warmth, caring behaviours
evident)
10% Structures & Manages Level: 4
interaction (e.g., provides Examples: I focused the conversation on the priorities for my
information about time client, such as “Tell me more about how you came to this
commitment & purpose, decision to have trays in your room?” and “Would you allow
interruptions deferred, me to assist you with your hearing aids?”
conversation flow maintained) Maintained a good flow of conversation throughout.
15% Priorities for engagement Level: 4
established & demonstrated in Examples: I was able to set a goal with client by using teaching
working phase (e.g., corresponding and I demonstrated sensitivity to clients’ needs by stating,
to the ‘what is’; setting goals with “Tell me how you are feeling?” and “I understand it must be
client/support person, difficult for you to be in a noisy environment” and “Would you
demonstrates sensitivity to allow me to assist you with your hearing aids?”
client, mutuality)
15% Demonstrates Use of Level: 4
Appropriate Non-Verbal skills (e.g., Examples: I was able to use SOLER, active listening and using
SURETY, active listening, use of pauses and silence throughout conversation. I also used head
silence, acknowledging (nodding nodding to show interest in what the client was saying.
head/interest); using
touch appropriately)
15% Demonstrates Use of Verbal & Level: 4
Paraverbal communication skills: Examples: I used open-ended questions such as, “Tell me
(e.g., open-ended questions, what you are feeling today?” and “What brough on these
paraphrasing, reflecting, clarifying, feelings?” and “Tell me more about how you came to the
focusing, summarizing, verbal decision to have trays in your room?”
acknowledging etc.) I used clarifying by stating, “If I am understanding this
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correctly you wish to have trays in your room?”

I used focusing, “How often do you wear your hearing aids?”
and “Do you find it difficult to apply your hearing aids?”
15% Demonstrates behaviours to Level: 4
promote sense of engagement (i.e., Examples: I leaned in to show interest, I was present with the
maintaining eye contact, leaning in, client and had empathetic communication
appropriate level of interest and
concern; presence; respect and
genuineness; compassion and
empathy)
10% Responds to client/support Level: 4
person’s cues to facilitate Examples: Able to acknowledge clients’ frustration such as, “I
therapeutic interaction (eg. adapts can hear how frustrating this must be for you”
interaction to client cues, responses
& affect)
10% Terminates the relational Level: 3
interaction with patient/support Examples: focused on the teaching of client in regard to
person in a caring supportive hearing aids and using them so he can enjoy socializing with
manner (e.g. summarizes co-residents.
interaction & caring handoff)
Overall Summary of things done Active listening
well: Building trust
Empathetic communication
Good tone of voice and pace, not too slow or fast
Allowed for pauses and silence

Overall Summary of areas for Smiling more

growth: Using hand gestures, especially since client has hearing
impairments
Maintain eye contact throughout conversation, noticed that I
was averting my eyes.
Use less closed-ended questions