Nurse-Patient

Interaction
 Therapeutic Use of Self
• By developing SELF-AWARENESS and
beginning to understand his or her attitudes,
the nurse can begin to use aspects of his/her
personality, experiences, values, feelings,
intelligence, needs, coping skills, and
perceptions to establish relationships with
clients.
 Therapeutic Relationship
• Differs from the social or intimate relationship
in many ways:
• SOCIAL RELATIONSHIP- primarily initiated for
the purpose of friendship, socialization,
companionship, or accomplishment of a task.
• INTIMATE RELATIONSHIP – involve two people
who are emotionally committed to each other.
 Therapeutic Relationship
• It focuses on the needs, experiences, feelings,
and ideas of the client only
• The nurse and the client agree about the areas
to work on and evaluate the outcomes
• The nurse uses COMMUNICATION SKILLS,
personal strengths, and understanding of
human behavior to interact with the client
Focus in the client’s needs,
NOT the nurse’s
• The nurse should not be concerned about
whether or not the client likes him or her or is
grateful
• The nurse must guard against allowing the
therapeutic relationship to slip into a more
social relationship.
• The nurse must constantly focus on the
client’s needs, not his or her own.
Communication Skills
 Therapeutic
Communication
Technique
• Accepting
• Broad Openings
• Consensual Validation
• Encouraging Comparison
• Encouraging Description of Perceptions
• Encouraging Expression
• Exploring
• Focusing
• Formulating a Plan of Action
• General Leads
• Giving Information
• Giving Recognition
• Making Observations
• Offering Self
• Placing Events in Time or Sequence
• Presenting Reality
• Reflecting
• Restating
• Seeking Information
• Silence
• Suggesting Collaboration
• Summarizing
• Translating into Feelings
• Verbalizing the Implied
• Voicing Doubt
Nontherapeutic
Communication
Techniques
• Advising
• Agreeing
• Belittling Feelings Expressed
• Challenging
• Defending
• Disagreeing
• Disapproving
• Giving Approval
• Giving Literal Response
• Indicating the Existence of External Source
• Interpreting
• Introducing an Unrelated topic
• Making Stereotype Comments
• Probing
• Reassuring
• Rejecting
• Requesting an Explanation
• Testing
• Using Denial
Establishing the Therapeutic
Relationship
 Phases
• ORIENTATION PHASE
• WORKING PHASE
• TERMINATION PHASE
ORIENTATION PHASE
Begins when the nurse and client meet
and ends when the client begins to
identify problems to examine.
 Activities
• establishes nurses roles
• purpose of meeting
• Parameters of subsequent meetings
• Identifies the client’s problems
• Clarifies expectations
 Activities
• Reads background materials available on the
client
• Becomes familiar with the clients medication
• Gathers necessary paperwork
• Arranges for a quiet, private, comfortable
setting
 Activities
• Time for “self-assessment”
• Begins to build trust
• Share appropriate information about self:
– Name
– Reason for being on the unit
– Level of schooling
 Activities
• Outlines nurse’s responsibilities and client’s
responsibilities
• The contract should state:
– Time, place and length of sessions
– When sessions will terminate
– Who will be involved in the treatment plan (family
members, health team members)
 Activities
– Nurses’ responsibilities
• arrive on time
• end on time
• maintain confidentiality at all times
• evaluate progress with client
• document sessions
SAMPLE CONVERSATION COMMUNICATION SKILL
NURSE: “Hello, Mr. O’ Malley. I Establishing trust; placing
am Anndra Margareth Dumo, a boundaries on the relationship
3rd year nursing student from and first mention of
Don Mariano Marcos Memorial termination in 4 weeks.
State University, Agoo, La
Union. I will be coming to the
hospital for the next 4 weeks
from Monday to Wednesday. I
would like to meet with you
each time I am here to help
support you as you work on
your treatment goals.”
SAMPLE CONVERSATION COMMUNICATION SKILL
NURSE: “Mr. O’ Malley, we Establishing specifics of the
will meet every Monday to relationship time, date,
Wednesday from March 1 place, and duration of
to March 30 at 10 am – meetings (can be written
11:30 am in conference as a formal contract or
room #2. We can use that stated as an informal
time to work on your contract)
feelings of loss since the
death of your wife.”
SAMPLE CONVERSATION COMMUNICATION SKILL
NURSE: “Mr. O’ Malley, it is Establishing confidentiality
important that I tell you I will
be sharing some of what we
talk about with my instructor,
peers, and staff at clinical
conference. I will not be
sharing any information with
your family without your
permission. If I feel a piece of
information may be helpful, I
will ask you first if I may share it
with your family.
WORKING PHASE
 2 Phases
1. Problem Identification
– The client identifies the issues or concerns
causing problems
2. Exploitation
– The nurse guides the client to examine feelings
and responses and to develop better coping skills
and a more positive self image
– Encourages behavior change and develop
independence
 Activities
• Maintaining the relationship
• Gathering more data
• Exploring perceptions of reality
• Developing positive coping mechanisms
• Promoting a positive self concept
• Encouraging verbalization of feelings
• Facilitating behavior change
 Activities
• Working through resistance
• Evaluating progress and redefining goals as
appropriate
• Providing opportunities for the client to
practice new behaviors
• Promoting independence
 Hot Spots!
• Transference
• Countertransference
 Example
Sample Conversation Communication Skill
Client: Nurse, I miss my Gathering data
wife Meredith so much.
Nurse: Mr. O’Malley,
how long have you
been without your
wife?
 Example
Sample Conversation Communication Skill
Client: Without my Promoting self-esteem
wife, I am not half the
person I was.
Nurse: Mr. O’Malley,
let’s look at the
strengths you have.
 Example
Sample Conversation Communication Skill
Client: Oh, why talk about Overcoming resistance
me. I’m nothing without
my wife.
Nurse: Mr. O’Malley, you
are a person in your own
right. I believe working
together we can identify
strengths you have. Will
you try with me?
Termination Phase/Resolution
Phase

Final Stage in the Nurse-Client relationship.

Begins when the problems are resolved and
it ends when the relationship is ended.
• Both nurse and client usually have feelings
about ending the relationship; the client
specially may feel the termination as an
impending loss
• Client tries to reopen and discuss old resolved
issues
• The nurse can acknowledge the client’s angry
feelings and assure the client that this
response is normal to ending the relationship
• Identify the client’s stalling maneuvers and
refocus the client on newly learned behaviors
and skills to handle the problem
• It is appropriate to tell the client that the
nurse enjoyed the time spent with the client
and will remember him or her
• It is inappropriate for the nurse to agree to see
the client outside the therapeutic relationship
 Example
Sample Conversation Communication Skill
Nurse: Well, Mr. O’Malley, Sharing of the termination
as you know I only have 1 experience with the client
week left to meet with demonstrates the
you. partnership and the caring
Client: I am going to miss of the relationship.
you. I feel better when you
are here.
Nurse: I will miss you also
Mr. O’Malley.
 Example
Sample Conversation Communication
Skill
Client: Oh, you have been so helpful to me. I refocus the
just know I will go back to my old self without client on newly
you here to help me. learned
Nurse: Mr. O’Malley, I think we’ve had a very behaviors and
productive time together. You have learned so skills to handle
many new ways to cope with your loneliness the problem
and I know you will go home and be able to
use those skills. When you come back for your
follow-up visit, I will want to hear all about
how things have changed at home.
Sampl
e NPI
 A Person With Depression
• Scenario: After a medical workup revealed no physical
symptoms, Nadia, a 39 year old mother of 3, admitted
herself voluntarily to the in-patient psychiatric unit,
stating she no longer have the energy to care for her
children, her marriage, saying, I am not fit to be a
mother or wife. I saw Nadia 3 days later and set up a
contract with her for after breakfast, expecting that
later we would attend group therapy, then meet for 1-
to-1. Instead, Nadia, after missing group, reluctantly
met me in the day room.
• Therapeutic Goal: By the conclusion of this
interaction, Nadia will state that she
understands that depression is a treatable
disorder and that her symptoms were the
cause of her despondent behavior.
 Student-Patient Interaction
CLIENT NURSE COMMUNICATION RATIONALE
TECHNIQUE
Speaking slowly, “Your looking down Translating into Often what the
eyes downcast. “I like you are sad.” feelings client says, when
couldn’t face all No response from taken literally,
those people.” Nadia. “I wonder seems meaningless
what facing the or far removed
group means to from reality . To
you”. understand, the
Student’s Feelings: nurse must
I should have concentrate on
stayed with “sad”. I what the client
aimed for her might be feeling to
feelings, then did express herself this
not wait for her to way.
share any feelings.
CLIENT NURSE COMMUNICATION RATIONALE
TECHNIQUE
Slowly shakes her With a concerned Silence Silence: Often
head back and look. “You shake Restatement encourages the
forth. Silent for 3 your head as if you client to verbalize,
minutes. No eye are saying no” provided that she is
contact. Student’s Feelings: interested and
I know it’s the right expectant. Silence
thing to do, but gives the client time
waiting during the to organize
silence makes me thoughts, direct the
so anxious. I need topic of interaction,
to stay mindfully or focus on issues
alert and attentive. that are most
I can endure the important.
silence for Nadia’s Restatement: Lets
sake. the client know that
she communicated
the idea effectively.
This encourages the
client to continue.
CLIENT NURSE COMMUNICATION RATIONALE
TECHNIQUE
“Everybody in the “Sinking deeper?” Restatement Restatement: Lets
group makes the client know that
progress. I just keep she communicated
sinking deeper.” the idea effectively.
This encourages the
client to continue.
Or if the client has
been
misunderstood she
can clarify her
thoughts.
CLIENT NURSE COMMUNICATION RATIONALE
TECHNIQUE
“into depression. I “You care about Translate into Often what the
can’t pull it your children” she Feelings client says, when
together even nods. “Sounds like taken literally,
though I know my you find it difficult seems meaningless
kids need me.” at this time to care or far removed
Makes eye contact. about yourself very from reality . To
much” understand, the
Student’s Feelings: nurse must
I know from concentrate on
experience that it’s what the client
hard to pull might be feeling to
anything together express herself this
when you feel way.
depressed
CLIENT NURSE COMMUNICATION RATIONALE
TECHNIQUE
Sustaining eye “Think about what you’ve Giving approval and Giving approval
contact. “I accomplished! You have advice tends to limit the
can’t do your children, your (nontherapeutic) client’s freedom to
anything marriage, your teaching think, speak or act
right. I have career.” Nadia shrugs, in a certain way.
nothing to eyes downcast. This can lead to the
show for my Student’s Feelings: client’s acting in a
life” She has so much going particular way just
for her. Why can’t she see to please the nurse.
that? My response causes Giving advice
Nadia to pull away by implies that only
withdrawing eye contact. the nurse knows
I need to remember that what is best for the
support and client.
nonjudgmental
acceptance provide the
foundation for the nurse-
patient relationship.
CLIENT NURSE COMMUNICATION RATIONALE
TECHNIQUE
After waiting for 2 Offering Self The nurse offer her
minutes. “Nadia, I Acceptance presence, interest
am here to be with and desire to
you right where you understand. It is
are this moment. important that this
No pressure” offer is
unconditional, that
is, the client does
not have to respond
verbally to get the
nurse attention.
An accepting
response indicates
the nurse has heard
and followed the
train of thought. It
does not indicate
agreement but is
nonjudgmental.
CLIENT NURSE COMMUNICATION RATIONALE
TECHNIQUE
Looking up, “thank Nods, “you want to Restating Restatement: Lets
you, you don’t get better. You were Reflecting the client know that
know how much able to take the first she communicated
that means. I do courageous step. In the idea effectively.
want to get better deciding to get This encourages the
and not feel like admitted, you client to continue.
depression acknowledge your Reflecting:
consumes who I symptoms are a Reflection
am” problem and they encourages the
are the symptoms client to recognize
of depression, a and accept her own
disorder” feelings. The nurse
Student’s Feelings: indicates that the
Nadia feels client’s point of
swallowed up by view has value, and
the depression. I that the client has
want her to know the right to have
that depression opinions, make
need not be her decisions and think
life. independently.
CLIENT NURSE COMMUNICATION
TECHNIQUE
RATIONALE
“Oh, I never Nods. “A Accepting An accepting response indicates the
thought of it treatable Silence nurse has heard and followed the
that way… as disorder.” I Giving train of thought. It does not indicate
a first step, continued to Information agreement but is nonjudgmental.
not a sign of sit with Nadia Silence: Often encourages the client
failure. My in silence for a to verbalize, provided that she is
symptoms are short while. interested and expectant. Silence
from the gives the client time to organize
depression” thoughts, direct the topic of
interaction, or focus on issues that are
“Yes, most important.
depression is Informing the client of facts increases
a disorder, not her knowledge about a topic or lets
all that I am” the client know what to expect. The
nurse is functioning as a resource
person. Giving information also builds
trust with the client.
COMMON PATIENT BEHAVIORS &
NURSE RESPONSES
What to do if the patient says he
or she wants to kill himself or
herself?
 Possible Reaction by Nurse
• The nurse may feel overwhelmed or
responsible for talking the patient out of it
• The nurse may pick up some of the patient’s
feelings of hopelessness
 Useful Responses by Nurse
• The nurse assess whether the patient has a
plan and the lethality of the plan
• The nurse tells the patient that this is serious,
that the nurse does not want harm to come to
the patient, and that this information needs to
be shared with other staff
 Useful Responses by Nurse
• “This is very serious Lamb. I do not want any
harm to come to you. I will have to share this
with the other staff”
• The nurse can then discuss with the patient
the feelings and circumstances that led up to
this decision (strategies in suicide
intervention)
What to do if the patient asks
the nurse to keep a secret?
 Possible Reactions by Nurse
• The nurse may feel conflict because the nurse
wants the patient to share important
information but is unsure about making such a
promise
 Useful Responses by Nurse
• The nurse can not make such a promise. The
information may be important to the health or
safety of the patient or others “I cannot make
that promise. It might be important for me to
share it with other staff”
• The patient then decides whether to share the
information
What to do if the patient asks
the nurse a personal question?
 Possible Reactions by Nurse
• The nurse may think that it is rude not to
answer the patient’s question
• A new nurse might feel relieved to put off
having to start the interview
• The nurse may feel put on the spot and want
to leave the situation
• New nurses are often manipulated by patients
into changing roles. This keeps the focus of the
patient and prevents the building of a
relationship
 Useful Responses by Nurse
• The nurse may or may not answer the patients
query. If the nurse decides to answer a natural
question, he or she answers in a word or two,
then refocuses back on the patient.
• Patient: Are you married?
• Nurse: Yes. Do you have a spouse?
• Patient: Do you have any children?
• Nurse: This time is for you, tell me about yourself.
• Patient: You can just tell me if you have any
children.
• Nurse: This is your time to focus n your concerns.
Tell me something about your family.
What to do if the patient makes
sexual advances?
 Possible Reactions by Nurse
• The nurse feels uncomfortable but may feel
conflicted about rejecting the patient or
making him or her feel unattractive or not
good enough
 Useful Responses by Nurse
• The nurse needs to set clear limits on
expected behaviors.
• “I am not comfortable having you touch (kiss)
me. This time is for you to focus on your
problems and concerns.”
• Frequently restating the nurses role
throughout the relationship can help maintain
boundaries
• If the patient doesn’t stop the nurse might say,
“If you can’t stop this behavior, I’ll have to
leave. I’ll be back at _____ to spend time with
you then”
• Leaving gives the patient time to gain control.
The nurse returns at the stated time.
What to do if the patient cries?
 Possible Reactions by Nurse
• The nurse may feel uncomfortable and
experience increased anxiety or feel somehow
responsible for making the person cry
 Useful Responses by Nurse
• The nurse should stay with the patient and
reinforce that it is alright to cry. Often it is at
that time that feelings are closest to the
surface and can be best identified
• “you seem ready to cry”
• “you are still upset about your brother’s
death”
• “what are you thinking right now
• The nurse offers tissues when appropriate
What to do if the patient leaves
before the session is over?
 Possible Reactions by Nurse
• The nurse may feel rejected, thinking it was
something he/she did. The nurse may
experience increased anxiety or feel
abandoned by the patient
 Useful Responses by Nurse
• Some patients are not able to relate for long
periods without experiencing an increase in
anxiety. On the other hand, the patient may be
testing the nurse.
• “I will wait for you here for 15 minutes, until
our time is up”
• During this time the nurse does not engage in
conversation with any other patient or even
with the staff
• When the time is up, the nurse approaches
the patient, says the time is up, and restates
the day and time the nurse will see the patient
again
What to do if the patient say
he/she does not want to talk?
 Possible Reactions by Nurse
• The nurse new to this situation may feel
rejected or ineffectual
 Useful Responses by Nurse
• At first, the nurse might say something to this
effect: “it’s alright. I would like to spend time
with you. We don’t have to talk
• The nurse might spend short frequent periods
(e.g. 5 minutes) with patient throughout the
day
• “Our 5 minutes is up. I’ll be back at 10 am and
stay with you 5 more minutes”
• This gives the patient the opportunity to
understand that the nurse means what he/she
says and is back on time consistently. It also
gives the patient between visits to assess how
he/she feels and what he/she thinks about the
nurse, and perhaps to feel less threatned
What to do if the patient leaves
the nurse a present?
 Possible Reactions by Nurse
• The nurse may feel uncomfortable when
offered a gift
• The meaning needs to be examined. Is the gift:
1. A way of getting better care
2. A way to maintain self-esteem
3. A way of making the nurse feel guilty
4. A sincere expression of thanks
5. A cultural expectation
 Useful Responses by Nurse
• Possible Guidelines:
– If the gift is expensive the only policy is to
graciously refuse
– If it is inexpensive:
1. If it is given at the end of hospitalization when a
relationship has develop, graciously accept
2. If it is given at the beginning of the relationship,
graciously refuse and explore the meaning behind the
present
• “Thank you, but it is our job t care for our
patients. Are you concerned that some
aspects of your care will be overlooked?”
• If the gift is money, it is always graciously
refused.
What to do if another patient interrupts
during time with your selected patient?
 Possible Reactions by Nurse
• The nurse may feel a conflict. The nurse does
not ant to appear rude. Sometimes the nurse
tries to engage both patients in conversation
 Useful Responses by Nurse
• The time the nurse had contracted with a
selected patient is that patients time. By
keeping his/her part of the contract, the nurse
demonstrates that the nurse means what
he/she says and views the sessions important.
• “I am with Mr. Rob for the next 20 minutes. At
10 am after our time is up, I can talk to you for
5 minutes”