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Therapeutic nurse-patient relationship

• Concept developed by Hildegard Peplau


• In which the client accomplishes certain
tasks and relationship changes that help
the healing process
• Includes four phases:
 Orientation phase
 Identification phase
 Exploitation phase
 Resolution phase
(or 3 phases: orientation, working and termination)
Stages or Phases of
Therapeutic NPR

ORIENTATION WORKING PHASE


PHASE (Provide therapeutic TERMINATION PHASE
(Teach them!) experience) (Take Pride!)
Trust and Promote Positive self Promote self care
Rapport concept Recognize increasing anxiety
Environment Realistic goal setting Increase independence
(Therapeutic) Organize support system Demonstrate emotional
Assess client’s Verbalize feelings stability
strength and (encourage) Environmental support
weakness Implement action plan
Contract Develop positive coping
(therapeutic) behaviors
Help Evaluate the results of
communicate plan of actions
• THERAPEUTIC NURSING PROCESS
• The nurse promotes goal-directed activities
that help to alleviate the discomfort of the
client by promoting growth and satisfying
interpersonal relationships.
Characteristics:
• Goal directed
• Understanding, emphatic
• Concreteness
• Honest, open communication
• Acceptance; nonjudgmental attitude
Differentiating SOCIAL
and THERAPEUTIC Relationship

Differentiation SOCIAL THERAPEUTIC


INTERACTION RELATIONSHIP
Characteristics Personal and intimate Personal but NOT intimate
Goal Doing favor for Promoting functional use
mutual benefit of one’s latent inner
resources
Termination Not defined Defined in the beginning
Identification of needs May not occur By client with help of the
nurse
Resources used Variety during Specialized professional
interaction skills for intervention
Focus of therapeutic
relationship is in helping
clients (RELEASE):
• Reinforce self-worth
• Enhance self-concepts and confidence
• Learn coping strategies
• Examine relationship
• Achieve Growth
• Solve Problems
• Extinguish (let go) of unwanted behavior
NURSE PATIENT RELATIONSHIP (NPR)
• an interpersonal process
• Therapeutic
• BLOCKS to NPR
1. Resistance – refusal of client to submit to care
2. Transference – Client’s unconscious assignment
to the therapist of feelings and attitude originally
associated with importance in his or her early life.
• Creates dependence
• can be (+) or (- )
• form of resistance
3. Counter transference-emotional reaction to the
client based on the therapist’s unconscious needs
and conflict
• Self Awareness – process of developing an
understanding of one’s own values, beliefs,
thoughts, feelings, attitudes, motivations,
prejudices, strengths and limitations and how
one’s thought and behaviors affect others
• Therapeutic use of self – Using one’s
humanity- personality, experiences, values,
feelings, intelligence, needs, skills, and
perceptions - to help client grow and change
• Communication
- is a personal interactive system between a
sender and receiver.
- through the feedback process, persons in
the transaction convey meaning through the
transmission of verbal and non-verbal cues.
3 Essential Components Of Communication
Process:

• encoding of information
• meaning of the transmission
• behavioral effect of information
• VARIABLES THAT
INFLUENCE COMMUNICATION:

• Perception
- the experience of sensing, interpreting
and comprehending the world in which
one lives.
- it is highly personal and internal act
- influences behavior
• Values/Beliefs

- past experiences prepare us to see things


people and events in particular way.
• Culture
- each culture provides its member with ideas
of how the world is structured and what it
means
- stereotyping may have a profound effect on
relationships with others
• Gender
- differences in personality and temperament
are found between sexes

• Age and Developmental Level


- has effect on communication skills
• Environmental Factors
- external influences have impact on
communication, which may include lighting of
the room, outside temperature, noise and
level of privacy
Types of Communication
• A. Non-verbal
-action or behavior that communicates a
message without speaking

ex. facial expression, body language, hand


gestures, etc.
• B. Verbal

-transmission of messages using the spoken


and written language.
A. Nonverbal Communication

General principles
• it is multichanneled
• is relatively spontaneous
• is relatively ambiguous
• may contradict verbal messages
• it is very culture-bound
Definition of Terms :
• Kinetics
- the study of communication through body
language or movement

• Proxemics
- the study of people’s use of interpersonal
space
• Personal space
- is a zone of space surrounding a person
that is felt to ‘belong’ to that person

• Territoriality
- the marking off and defending of certain
areas as their own

• Paralanguage
- refers to how something is said rather
than what is said
Interpersonal Distance Zone:

• Public distance –12 ft and beyond (for


actors, total strangers, important officials)
• Social distance – 4-12 ft (for social
gathering, friends and work situation)
• Personal distance – 18 in-4ft (close
friends)
• Intimate distance – 0-18 in (parents and
children, lovers, husband and wife)
• Therapeutic Communication

– is an interpersonal interaction between


the nurse and the client during which the
nurse focuses on the specific needs of
the client to promote an effective
exchange of information between the
nurse and the client
Therapeutic Communication

– intended to help client to practice new ways


of feeling and acting gradually, leading to
the development of both courage and the
ability to take responsibility for their action
in socially acceptable ways.
Essential Conditions
For Therapeutic Communication:

• Genuineness
- being as one appears, sincere, honest

• Respect
- a relationship in which one considers the
other in high esteem or regard
• Rapport
- interpersonal relationship characterized by a
spirit of cooperation, confidence, and harmony

• Empathy - the ability to recognize and share to


some extent the feelings and state of mind of
another person
• Active listening
- attentiveness to the client in physical and
psychological manner

e.g. position facing client


open posture
leaning forward toward the client
establishing of eye contact language
• Acceptance
- avoiding judgments of the person, no
matter what the behavior

• Trust
- a risk-taking process whereby a person’s
situation and feeling of well-being depend
on the action of another.
THERAPEUTIC COMMUNICATION TECHNIQUES

Technique Description/Definition Example


Offering self The nurse offers to stay “Let me sit with you for 15 minutes and read a story.”
with the client and either “I’d like to eat lunch with you.”
talk or just sit quietly. “Let’s walk to the cafeteria together.”
Providing The nurse invites the “Where would you like to begin?”
broad client to select a topic. “Talk more about…”
openings “What would you like to tell me about yourself?”
“Tell me what’s been in your mind?”
“I’m interested in hearing about issues of concern to you.”
Making an The nurse acknowledges “You appear anxious. I noticed that you have been
observation that something or coming to lunch with the group.”
someone exists or has “You have drawn a picture.”
changed in some way. “That’s a new hairstyle, isn’t it?”
“I noticed on the chart that today is your birthday.”
Suggesting The nurse makes an offer “Let’s try to figure this out together.”
collaboration to work together with the “Let’s talk and see if we can work together to understand
client. this.”
“Perhaps we can discuss this and see what offended
you.”
”Perhaps you and I can discover the triggers of your
anxiety

Providing The nurse allows the (Silence)


silence verbal conversation to
stop to provide a time for
quiet contemplation of
what has been
discussed, for formulation
Providing The nurse provides brief interjections that “Go on…”
general leads let the client know that he or she is on the “Talk more about…”
right track and should continue. “Then what?”
“Please go on.”
“And…?”
Exploring The nurse asks the client to describe “You said you liked Carl best. Can you tell me about
something in more detail or to discuss it Carl?”
more fully. “You say you get more satisfaction out of helping
out at the flower shop. I’d like to hear more about
that.”
“These dreams you mentioned. What are they like?”
“What seems to be the problem?”
“Tell me more about…”
Focusing The nurse selects one topic for exploration “Give an example of what you mean.”
from among several possible topics “Let’s look at this more closely.”
presented by the client. “You said you hate all your brothers. Tell me about
Carlo first.”
“You’ve briefly mentioned three different suicide
attempts. For now, I’d like to focus on just what was
going on with you at the time of the first attempt.”
“Let’s return to the last point you made and talk
more about that.”
Asking for The nurse lets the client know that what was “I’m not sure that I understand what you’re saying.”
clarification said was unclear. If necessary, the nurse “Do you mean…?”
asks for clarification or provides input “I didn’t understand what you meant then. Can you
regarding how to make the message say that in different words?”
clearer. (further elaboration) “Let me repeat back to you what I think I heard you
say.”
Restating The nurse paraphrases what the client has Client: I can’t sleep, I stay awake all night”
said. This paraphrased message may be Nurse: “you have difficulty sleeping?”
fed back to the client in the form of a
statement or a question to provide the client Adult: “I’m down.”
the opportunity to agree or to disagree and Nurse: “You feel depressed?”
clarify further.
Seeking The nurse attempts to verify with the client “You want ‘moo moo’? Does ‘moo moo’ mean milk?
consensual that a certain term means the same thing to “When you say your brother is crazy, does the word
validation both parties. crazy mean ‘kind of wild’?”
“Tell me if we both understand that word the same
way.”
Placing events The nurse asks the client to explain more “Were you frightened before or after the movie?”
in time or about when an event occurred (placing the “Tell me what went on before the fight broke out in
sequence event in time) or to explain the sequence of the gym?"
a series of events.
Summarizing Do this at end of conversation, for you & “ During the past hour, you and I have discussed…”
client, to feel you have accomplished
something

Confrontation If there are contradiction in the “You said that you love your sister but you refuse to
clients behavior or feeling that reconcile with her”
sending mixed messages to “You say you’re not nervous, yet you are pacing”
others

Presenting The nurse indicates reality when the client is Client: ”I see a man”
reality misinterpreting it Nurse: ”I see no one here but you and me”
Do not argue, client may become defensive
Purpose: To tell client you do not share his
thoughts
Encouraging Having client describe his or her view of an Client: “I hear voices”
description of event Nurse:” what kind of voice?”
perception
Giving The nurse provides facts or information that “You cant take this medication unless you take your
information the client requests meal, this drug can cause hyperacidity”

Reflecting Nurse reflects back to the client the feeling Client: “do you think I should tell the doctor?”
or thought message that the client Nurse: “You think you should?”
expressed to help him/her identify the
emotions and events that trouble him
ALPHABET OF THERAPEUTIC COMMUNICATION
Accepting Opening leads
Broad opening Present reality
Clarifying Questions not answerable by yes
or no
Demonstrate unconditional Reflecting
positive regard
Exploring Sharing of observation
Focusing Trust
General leads Using silence
Here and now behavior Validating
Informing What is said is more important
than why it is said
Jargon, figure of speech eXplore alternatives rather than
avoided answer of solutions
Keep respect You are interested to listen
Listen to what the person is Zest up-show interest
not saying
Master active listening
Never advise
• Non-therapeutic
- communication that is barrier to free
expressions of feelings
- provides a disruption of the treatment
process

ex. giving false assurance


using close ended questions
NON-THERAPEUTIC COMMUNICATION (Barriers)

RESPONSE Description/Definition EXAMPLE


1.False Trying to make the client better superficially “Don’t worry; you will be better in a few weeks.
reassurance and not to worry or be anxious “Don’t worry; I had an operation just like it; it was a
snap.”
2. Giving advice The nurse gives advice to the client indicating “What you should do is…”
that he or she is incapable of solving own “If I were you, I would do…”
problem
3. Rejecting An angry or punitive response to clients “I don’t like it when you…”
action, thoughts or feelings “Please, don’t ever talk about…”
4. Belittling The nurse discounts the client’s feeling and “Everybody feels that way.”
experiences as not being valuable or “Why, shouldn’t feel that way.”
worthwhile
5. Probing Persistent questioning of the client or asking “Tell me more about your relationship with other men.”
unrelated topics Client: “ And so my wife and I split up
Nurse: “So tell me about your mother”
6. Overloading Giving so much information or questions that “Hi, I am Joann, your student nurse. How old are you?
a patients cant handle What brought you to the hospital? How many children do
you have?
Do you want to fill out your menu right now?”
7. Under loading “Not giving enough information so that the “I’ll give you some medication, later”
meaning is clear; withholding information.”
8. Agreeing Indicating agreement with the client “That’s right.”
“ I agree”

9. Disagreeing Opposing the clients idea “That’s wrong”


“I don’t believe that”
10. Approval Sanctioning the patients ideas or behavior “You were good to have done that”

11. Disapproval Denouncing the clients actions, thoughts “It is silly to think that people want to hurt you?”
feelings or needs “You’re crazy”
8. Literal response “Dealing with abstract symbols or metaphors “Gee, the weather is beautiful outside.”
in a concrete manner”
NOTES IN THERAPEUTIC COMMUNICATION TECHNIQUES

• Best responses are those that:


Encourage clients to express themselves
more fully
Reflect or re-state what the client has
earlier said
Reflect the feelings that are identified and
encourage expression of these feelings
Encourage hopes (never with false assurance)
Clarify client’s statement
Acknowledge client’s non verbal behavior
Use silence but expresses being there
Inform
Clarify and validate
• Never:
Give response that belittles, negate or devalue
Advise or show approval or disapproval
Ask for explanation or “why”
Avoid
Be defensive
• Remember to:
Focus on client
Accept client as she/he is
Be honest and consistent
Attempt to establish good relationship (rapport)
Allow client then family to make decision
Answer according to nursing action
Do not provide response that implies that the client
is unworthy
Select the most comprehensive (global) answer
Focus on the feelings of client
• Thank you.

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