BUILDING THE NURSE CLIENT
RELATIONSHIP
KATRINA BENTAIN
DREXLER BUENAFE
COMPONENTS OF A THERAPEUTIC RELATIONSHIP
• Trust
• To develop acceptance of assistance being offered.
• Congruence
• When words and actions match
• Genuine Interest
• A client with mental illness can detect when someone is exhibiting dishonest or
artificial behavior.
• Empathy
• Ability of the nurse to perceive the meanings and feelings of the client and to
communicate that understanding to the client
• Sympathy
• Understanding between people; common feeling
• Acceptance
Does not become upset or responds negatively to outbursts or anger
Must set boundaries for behavior in the nurse-client relationship.
• Positive Regard
Unconditional non judgment attitude
• Self-Awareness and Therapeutic Use of Self
-The nurse must know him/herself before understanding the clients
-Self-awareness
-Values
-Beliefs
-Attitude
-Therapeutic Use of Self
By developing self-awareness and beginning to understand his/her attitude the nurse can
begin to use aspects of his/her experiences, personalities, values, feelings, skills and etc.
-Johari window
Quadrant 1
Open/public
Quadrant 2
Blind/unaware
Quadrant 3
Hidden/private
Quadrant 4
Unknown
Patterns of Knowing
-Hildegard Peplau, (1952) Identify ways one person expects another to behave or speak, as
a roadblock to the formation or an authentic relationship
Carper (1978) identified Four Patterns of Knowing:
-Empirical knowing
-Personal knowing
-Ethical knowing
-Aesthetic knowing
Munhall (1993) Unknowing:
The nurse in a state of unknowing is open to seeing and hearing the client's view without
imposing any of his or her values or viewpoints.
Types of Relationships
• Social Relationship
Initiated for the purpose of friendship, socialization, companionship or accomplishment of a
task
• Intimate Relationship
Involves two people who are commonly committed to each other
• Therapeutic Relationship
Focuses on the needs, experiences, feelings and ideas of the client only
Establishing the Therapeutic Relationship
• Phases
Orientation phase
-Begins when the nurse and client meet and ends when the client begins to identify
problems to examine
-Nurse-Client Contracts
-Confidentiality
-Self-Disclosure
Working
Divided into two phases:
-Problem identification
-Exploitation
Resolution or Termination
-Begins when the problems are resolved, and it ends when the relationship is ended
Avoiding Behaviors that Diminish the Therapeutic Relationship
• Inappropriate Boundaries
The nurse must maintain professional boundaries to ensure the best therapeutic outcomes
• Feelings of Sympathy and Encouraging Client Dependency
The nurse must not let feelings of empathy turns into sympathy for the client
• Non Acceptance and Avoidance
The relationship can be jeopardized if the nurse finds the client's behavior unacceptable or
distasteful and allows those feelings to show
Roles of the Nurse in a Therapeutic Relationship
Teacher
The nurse may teach the client new methods of coping and solving problems
Caregiver
Implementation of the therapeutic relationship to build trust, explore feelings, assist
client in problem solving, and help the client meet psychosocial needs
Advocate
The nurse informs the client and support in whatever decision they make
Parent Surrogate
When a client exhibits childlike behavior or when a nurse is required to provide
personal care, the nurse may be tempted to assume the parenteral role
Therapeutic Communication
-An interpersonal interaction between the nurse and the client during which the
nurse focuses on the client's specific need to promote an effective exchange of
information
-Two levels of communication:
Verbal communication
Nonverbal communication
Privacy and Respecting Boundaries
Proxemics
-Is the study of distance zones between people during communication
• Intimate zone
0-18 inches between people
Comfortable for parents with young children, people who mutually desire personal
contact, or people whispering
• Personal zone
18-36 inches
Comfortable between family and friends who are talking
• Social zone
4-12 feet
Acceptable for communication in social, work, and business settings
• Public zone
12-25 feet
Acceptable distance between speaker and an audience, small groups, and other formal
functions
Touch
Can be comforting and supportive when it is welcome and permitted
-Knapp (1980) identified five types of touch
Functional-professional touch
1. Social-polite touch
2. Friendship-warmth
3. Love-intimacy
4. Sexual-arousal
Active Listening and Observation
-Refraining from other internal mental activities and concentrating exclusively on what
the client says
Active observation
-Watching the speaker's nonverbal actions as he or she communicates
Verbal Communication Skills
• Using concrete messages
-Use words as clear as possible
• Abstract messages
-Unclear patterns of word that often contain figures of speech that are difficult to interpret
Using Therapeutic Communication Techniques
-The nurse can use many therapeutic techniques to facilitate the interaction and enhance
communication with the client
Avoiding Nontherapeutic Communication
-These responses cut off communication and make it more difficult for the interaction to
continue
Interpreting Signals of Cues
-The nurse watches and listens carefully for cues
-Overt cues
-Are clear, direct statements of intent
-Covert cues
Are vague or indirect messages that need interpretation and exploration
Nonverbal Communication Skills
-Is the behavior a person exhibits while delivering verbal content
-Knapp and Hall (2013) listed the ways in which nonverbal messages accompany verbal
messages
-Accent
-Complement
-Contradict
-Regulate
-Repeat
-Substitute
Facial Expressions
-Can affect the listener's response
-3 categories
[Link] face
[Link] face
[Link] facial expression
Body Language
-A nonverbal form of communication
-Closed body position
-Accepting body position
Vocal Cues
-Nonverbal sound signals transmitted along with the content: voice volume, tone, pitch,
intensity, emphasis, speed and pauses augment the sender's message
Eye Contact
-Is used to assess the other person and the environment and to indicate whose turn it is to
speak
Silence
-It is important to allow client sufficient time to respond, even if it seems like a long time
Understanding the Meaning of Communication
-Messages often contain more meaning than just the spoken words (DeVito 2013)
Understanding Context
-Gives the nurse more information and reduces the risk for assumptions
Understanding Spirituality
-The nurse must be aware and respect the client's cultural, religious and spiritual
beliefs
The Therapeutic Communication Session
-Goals
-Uses therapeutic communication techniques and skills to help achieve goals
-Nondirective Role
-Uses broad openings and open-ended questions to collect information and to help
the client to identify and discuss the topic of concern
Directive Role
-Asking direct yes/no questions and using problem solving to help the client develop
new coping mechanisms to deal with present here-and-now issues
Asking Clarification
-Nurses should always be able to understand what the client is saying
Client's Avoidance of the Anxiety-Producing Topic
- Clients begin to discuss a topic in minimal importance because it is less threatening
than the issue that is increasing the client's anxiety.
- Listening and observing to nonverbal cues will help the nurse to get a sense of what's
going on
Guiding the Client in Problem Solving and Empowering
-Virginia Satir (1967) explained how important the client participation is to finding effective
and meaningful solution to problems
-It involves several steps:
A. Identify the problem
B. Brainstorm all possible solutions
C. Select the best alternative
D. Implement the selected alternative
E. Evaluate the situation
F. If dissatisfied with the results, select another alternative and continue the process
Assertive Communication
-Ability to express positive and negative ideas and feelings in an open and honest, and
direct way.
-Four types of responses that can have to this situation:
A. Aggressive
B. Passive-aggressive
C. Passive
D. Assertive
Community-based Care
-The nurse may become the major caregiver and resource person for increasingly high-risk clien
treated at home and their families and may become more responsible for primary prevention in
wellness and health maintenance
CLIENT’S RESPONSE TO
ILLNESS
-it examines some of the personal, interpersonal, and cultural factors that create the unique
individual response to both illness and treatment.
CULTURE
- is all the socially learned behaviors, values, beliefs, customs and ways of thinking of a
population that guide its members’ views of themselves and the world.
INDIVIDUAL FACTORS:
AGE, GROWTH AND DEVELOPMENT
-This can affect how a person copes and expresses illness. Younger patients have not had
experiences of successful independent living or the opportunity to work and be self-sufficient
and have a less well-developed sense of personal identity than older patients. According to
Erikson’s theory, people may get “stuck” at any stage of development.
[Link] AND BIOLOGIC FACTORS
-not under voluntary control. We cannot change these factors. Genetic makeup
tremendously influences a person’s response to illness and perhaps even to
treatment. It is an essential part of the nursing assessment.
[Link] HEALTH AND HEALTH PRACTICES
-The healthier a person is, the better he or she can cope with stress or illness.
4. RESPONSE TO DRUG
-When evaluating the efficacy of psychotropic medications, the nurse must be alert
to side effects and serum drug levels in the clients from different ethnic
backgrounds.
5. SELF-EFFICACY
-Is a belief that personal abilities and efforts affect the events in our lives (Bandura,1997).
4 main ways to do so are as follows:
A. Experience of success
B. Social modeling (observing successful people instills the idea that one can also succeed).
C. Social persuasion
D. Reducing stress, building physical strength, and how to interpret physical sensations
positively.
6. HARDINESS
-Ability to resist illness, when under stress. First described by Kobasa (1979).
3 COMPONENTS:
A. COMMITMENT: active involvement in life’s activities.
B. CONTROL: ability to make appropriate decisions in life activities
C. CHALLENGE: ability to perceive change as beneficial rather than just stressful
7. RESILIENCE AND RESOURCEFULNESS
-Resilience: defined as having healthy responses to stressful circumstances or risky
situations (HILL, 1998).
-Resourcefulness: involves using problem-solving abilities and believing that one can
cope with adverse or novel situations.
8. SPIRITUALITY
-involves the essence of a person's being and his or her beliefs about the meaning of life
and the purpose for living.
INTERPERSONAL FACTORS.
1. SENSE OF BELONGING
-Feeling of connectedness with or involvement in a social system or environment in
which a person feels an integral part.
2. SOCIAL NETWORKS AND SOCIAL SUPPORT
-Social networks: groups of people whom one knows and with whom one feels
connected.
-Social support: emotional sustenance that comes from friends, family members,
and even health care providers who help a person when a problem arises.
CULTURAL FACTORS:
-Culture: has the most influence on aperson’s health beliefs and practices
(CAMPINHA-BACOTE, 2002).
2 prevalent types of beliefs:
A. Personalistic beliefs attribute the cause of illness to the active, purposeful
intervention of an outside agent, spirit, or supernatural force or deity.
B. Naturalistic view is rooted in a belief that natural conditions or forces, such as cold,
heat, wind, or dampness, are responsible for the illness.
Important factors in cultural assessment:
-COMMUNICATION
-PHYSICAL DISTANCE OR SPACE
-SOCIAL ORGANIZATION
-TIME ORIENTATION
-ENVIRONMENTAL CONTROL
-BIOLOGIC VARIATIONS
NURSE’S ROLES IN WORKING WITH CLIENT
1. SELF-AWARENESS ISSUES - The nurse must be aware of the factors that influence a
client’s response to illness including the individual, interpersonal, and cultural factors.
ASSESSMENT
FACTORS INFLUENCING ASSESSMENT
[Link] participation/feedback
[Link]’s health status
[Link]’s previous experiences/ misconceptions about health care
[Link]’s ability to understand
[Link]’s attitude and approach
HOW TO CONDUCT THE INTERVIEW:
-ENVIRONMENT: the nurse should conduct the psychosocial assessment in an
environment that is comfortable, private and safe for both the client and nurse.
-INPUT FROM FAMILY AND FRIENDS: the nurse should obtain their
perceptions of the client’s behavior and emotional state.
HOW TO PHRASE QUESTIONS:
-The nurse should use open-ended questions to start the assessment.
CONTENT OF ASSESSMENT:
-The nurse should use some organizing framework so that he or she can assess the client
in a thorough and systematic way.
Components:
• History
-background assessments includes client’s history, age, and developmental stage,
cultural and spiritual beliefs about health and illness.
• General appearance and motor behavior
-The nurse assesses the client’s overall appearance, including dress, hygiene, and
grooming.
• Mood and affect
-Mood refers to the client’s pervasive and enduring emo-tional state. Affect is the
outward expression of the client’s emotional state.
• Thought process and content
-Thought process refers to how the client thinks. The nurse can infer a client’s thought
process from speech and speech patterns. Thought content is what the client actually
says.
Sensorium and intellectual processes.
-Orientation: refers to the client’s recognition of person, place, and time—that is,
knowing who and where he or she is and the correct day, date, and year.
-Memory: The nurse directly assesses memory, both recent and remote, by asking
questions with verifiable answers.
-Ability to Concentrate
The nurse assesses the client’s ability to concentrate by asking the client to perform
certain tasks:
· Spell the word world backward.
· Begin with the number 100, subtract 7, subtract 7 again, and so on. This is called
“serial sevens.”
· Repeat the days of the week backward.
· Perform a three-part task, such as “Take a piece of paper in your right hand, fold it in
half, and put it on the floor.” (The nurse should give the instructions at one time.)
• Judgment and insight
-Judgment refers to the ability to interpret one’s environment and situation correctly
and to adapt one’s behavior and decisions accordingly. Insight is the ability to
understand the true nature of one’s situation and accept some personal responsibility
for that situation.
• Self-concept
-Self-concept is the way one views oneself in terms of per-sonal worth and dignity.
• Roles and relationships
-The nurse assesses the roles the client occupies, client satisfaction with those roles,
and whether the client believes he or she is fulfilling the roles adequately.
• Physiologic and self-care concerns
-Although a full physical health assessment may not be indicated, emotional prob-
lems often affect some areas of physiologic function.
DATA ANALYSIS
After completing the psychosocial assessment, the nurse analyzes all the data that he or she
has collected. Data analysis involves thinking about the overall assessment rather than
focusing on isolated bits of information.
Psychological Tests
Psychological tests are another source of data for the nurse to use in planning care for the
client. Two basic types of tests are intelligence tests and personality tests. Intelligence tests
are designed to evaluate the client’s cognitive abilities and intellectual functioning.
Personality tests reflect the client’s personality in areas such as self-concept, impulse control,
reality testing, and major defenses (Adams & Culbertson, 2005).
Psychiatric Diagnoses
Medical diagnoses of psychiatric illness are found in the Diagnostic and Statistical Manual of
Mental Disorders, 4th edition, Text Revision (DSM-IV-TR). This taxonomy is uni-versally
used by psychiatrists and by some therapists in the diagnosis of psychiatric illnesses.
The DSM-IV-TR uses a multiaxial system to provide the format for a complete psychiatric
diagnosis
· Axis I: clinical disorders, other conditions that may be a focus of clinical
attention
· Axis II: personality disorders, mental retardation
· Axis III: general medical conditions
· Axis IV: psychosocial and environmental problems
· Axis V: global assessment of functioning (GAF).
