The Nurse-Client Relationship
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Outline
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- The nurse-client relationship is the primary vehicle for assisting people to engage in positive health practices for our goal of health promotion.
Health promotion efforts
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Nurse-client relationship
Absence of nurse-client relationship
Effective
Severely limited
Friendly advice
- Assisting a person to adopt health promoting behaviors requires more than giving information, it requires effective communication.
- Successful health promotion involves interpersonal skills, personal insight, accountability, mutual respect, and supportive working milieu.
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Interpersonal context
Essential components:
1. Values clarification
2. Communication
3. Helping relationship
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�Values clarification�
. Values are qualities, principles, attitudes, or beliefs about the inherent worth of an object, behavior, or idea.
Value :
1. Cognitive : ascribed to verbally and intellectually.
Example: claim you believe in “ prevention is better than treatment”
2. Active: physically acted out.
Example: do exercises to prevent heart disease
- Values color an individual’s identity, goal, and sense of personal meaning. Its passed from one generation to another; they are imbedded in the culture; taught within a family and social context; culture-bound (linked to culture).
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Values clarification
- Nurse must understand cultural values, traditions, and practices influence on caregiving in a multicultural society
partnership with clients.
Nursing care provided
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Interaction
Client’s beliefs
Nurse’s beliefs
Values clarification
Therapeutic nurse-client relationship requires:
√ Sensitivity to discrepancies (differences) in values.
√ Respect for client’s values.
Purposes of V.C:
(1) to examine personal values and their influence on nursing care.
(2) to assist clients in identifying their own values and reflecting on their connection to health-related behaviors.
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Con…
Values clarification becomes a clinical aim when clients’ values lead to behaviors that conflict with the nurse’s value of promoting health.
Example: Health education (pregnancy and smoking):
[ conflict in values ]
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Values clarification process:
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Therapeutic use of self
- It is the application of one’s cognitions, perceptions, and behaviors to create interpersonal encounters that promote health in another person, family, group, or community.
- Self-concept: a mental picture of the self, a composite view of personal characteristics, abilities, limitations, and aspirations.
- Self-esteem: the effective component of self-perception, refers to how individuals feel about the way that they see themselves. It is learned from experience.
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Therapeutic use of self
- Self-concept; self-esteem: a person’s judgment and attitude toward her/himself.
- Positive self-concept: confidence; acceptance by others.
Negative self-concept: shame.
- Self-concept evolves throughout life. Avoid focusing excessively on negatives; give feedback on abilities.
- Positive, rewarding, anxiety-free interactions security, esteem, and positive self-view.
- Negative experiences sense of incompetence, insecurity, and negative self-concept.
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outcome
outcome
Self??
- Self is dynamic, changing through interaction with the outside world and in response to the various maturational and situational crises of life.
- Self-awareness “the dynamic, conscious, and active gaining of knowledge about the psychological, physical, environmental, and philosophical components of the inner self;” interactions between self and external world and symbolic connections created by the person.
- Unconscious self: partially accessible; influences behavior.
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Self??
Johari window
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(1) Public self (known to self and others) | (2) Semi-public self (known only to others) |
(3) Private self (known only to self) | (4) Inner self (known neither to self nor to others) |
* How self functions:
1. Change in one portion influences all other portions.
2. The smaller the 1st portion, the poorer communication will be.
3. Interpersonal learning enlarges 1st portion and decreases the size of others.
* Self-awareness goal: increase the size of (1) while reducing the size of the other 3 areas.
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Self??
Self??
Achieve high self-awareness…How?
1. Listen to oneself, pay attention to emotions, thoughts, memories, reactions, and impulses (self reflection).
2. Listen to and learn from others (feedback). Feedback from others that conflicts with self-image can produce anxiety.
3. Self-disclosure: sharing aspects of the self enriches interpersonal life.
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Self??
Self-disclosure…cont
- A symptom of a healthy personality and the means to achieve it.
- Through self-disclosure, people come to know themselves better because they have held thoughts, actions, and feelings up to the light for examination with others.
- Self-disclosure by one person tends to trigger self-disclosure by another in a reciprocal pattern (a pattern of interaction in which the two participants-nurse and client-perform similar activities within the same or subsequent time intervals).
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Self-disclosure
Nurses are not blank screens, robots, or technicians delivering care; individuals value nurses who engage in interactions as real people and who are willing to share information about themselves.
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Self-disclosure
Why should nurses clarify personal values and increase self-awareness?
- Self is the nurse’s greatest tool that nurse must be fully aware of how it functions in order to use it effectively.
- Self-awareness and acceptance of personal beliefs free the nurse to direct energy toward meeting the client’s needs.
- Openness to self generates openness to others and acceptance of differences among people.
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Communication
- A process by which information is exchanged between individuals through a common system of symbols, signs, or behavior: spoken and written word as well as nonverbal communication-gestures, facial expressions, movement, body messages or signals, and artistic symbols.
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Con…
Functions of Communication?
- Obtain and send messages and to retain information.
- Use information to arrive at new conclusions, to reconstruct the past, and look forward to future.
- Begin and modify physiological processes.
Influence others and outside events.
- Influence others and outside events
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Components of communication process
1. Input: taking in information from outside the individual or group. Input information must be transformed in some manner to be used.
2. Flow: the way information is analyzed and stored within the individual; the way information is transmitted from person to person within a human system (group, family) before communication with the external environment occurs.
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Con…
3. Output- further exchange with environment or other person.
4. Feedback- person or group controls the internal and external responses to behavior (output) and accommodates appropriately. Positive (encourage change); negative (encourage homeostasis or no change).
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Communication…Types
I. Verbal: spoken or written words; signs for deaf or hard of hearing people; Braille for blind and visually challenged people.
II. Nonverbal: movement, facial, and eye expressions, gestures, appearance, and vocalization (paralanguage-crying, groaning, gasping), sign language (also verbal).
“Actions speak louder than words”
III. Metacommunication: even in silence, the person is transmitting a message about what is being communicated-reading between the lines, going past the surface content of the message.
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Functional communication
1. State the case firmly:- make content and metacommunication congruent (words are congruent with actions).
2. Clarify and qualify the message:- sender must give a complete message; I statement (I felt happy when you remembered my birthday last month).
3. Seek feedback:- both sender and receiver understand the same information.
Example: “What is your understanding of what I said?”
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How to achieve a functional communication
A. Effective listening:- actively focusing attention on the message and not only passive taking in information; listening activities are not universal and are culturally determined (direct gazing, eye contact, head nodding, leaning forward, smiling, statements such as “Please go on”).
- Nurse’s failure to listen effectively to the client may be due to anxiety; lack of experience; or preoccupation with personal thoughts.
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Con…
B. Flexibility:- a balance between control (monitoring every message) and permissiveness (anything can be communicated in any way).
C. Silence:- allows clients to reflect on what is being discussed or experienced; when a client is seeking a verbal response, silence can be perceived as a lack of interest.
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How to achieve a functional communication
D. Humor:- relieves tension, reduces aggression, and creates a climate of sharing; can block communication when used to avoid subjects that might be uncomfortable. No jokes concerning race, ethnicity, country of origin, age, gender…etc.
E. Touch:- nurse’s concern can be expressed by a gentle or soothing application of touch except in acutely disturbed psychiatric and very anxious clients.
F. Space:- intimate (up to 18 inches); personal (18 inches-4 feet); social-consultative (9-12 feet); public (12 feet and over).
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The helping relationship
- A process in which one person promotes the development of another by fostering the latter’s maturation, adaptation, integration, openness, and ability to find meaning in the present situation.
Guidelines:
- Purposeful communication.
- Rapport:- harmony and affinity between people in a relationship.
- Trust:- affective experience that evolves from rapport; involves a sense of certainty that the other will carry out responsibilities and promises and an expectation that the outcome of interaction need not to be afraid of.
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The helping relationship
- Empathy:- feeling with another person and understanding the dynamic meaning of behavior; involves the ability to understand another’s feelings without losing one’s own identity and perspectives; nurse’s expression of empathy reduces patient’s distress.
- Goal direction:- helping relationship meets some need or promotes the growth of the client (client centered); goals should be stated in measurable terms, focus on a positive change or on the decrease of a problematic behavior.
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Therapeutic techniques
1. Focus on the client:- nurses are to answer or respond to obvious questions and to switch the focus back to the client when the other questions are asked.
2. Help the client to describe and clarify content and meaning:- assist the client in describing a particular experience or concern; avoid threatening, detective-like questions (limit “Why” questions).
3. Reflection:- restatement of what the client has said in the same or different words; no frequent, parrotlike repetition of client’s statements.
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Therapeutic techniques
4. Constructive confrontation:- the nurse points out a specific behavior and then helps the client to examine its meaning or consequences.
5. Use nouns and pronouns correctly:- such as you and I rather than let’s or we; maintains personal boundaries.
6. Silence:- helpful to depressed or physically ill persons by reducing pressure and conserving energy.
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Con…
7. Accept communication:- allowing the client to communicate verbally and nonverbally in his/her own fashion makes the client feel safe and respected; nurse does not always agree with the client or tolerates inappropriate behavior, such as verbal or physical abuse.
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Barriers to effective communication
a) Ineffective techniques:- nurse’s failure to use the therapeutic techniques; failure to send a clear message, receive and interpret the message correctly, or provide useful feedback.
b) Anxiety:- anxiety and use of defense mechanisms (denial, projection) distort reality and lead to ill communication.
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Con…
c) Attitudes:- biases and stereotyped notions can limit the ability to relate.
d) Gaps between the nurse and client:- gender, age, socioeconomic background, race, and religion cause differences in perception and block mutual understanding
e) Resistance:- all phenomena that inhibit the flow of thoughts, feelings, and memories in an interpersonal encounter as well as behaviors that interfere with therapeutic goals.
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Barriers to effective communication
f) Transference (reacting to another person in an exchange as if that person were someone from the past-mother, father, or all authority figures; love, anger, dislike) and countertransference (nurse encourages a childlike dependency, and interferes with the person’s progress).
g) Sensory barriers:- lack of access to interpreters for deaf clients and visual aides.
h) Failure to address concerns or needs:- inadequate assessment, lack of knowledge, inability to separate own needs from client’s needs, confusion between friendship and helping relationship.
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Nurse-client relationship...stages!!
1. Introductory (orientation) phase:- begins when the nurse and client meet; feelings of anxiety; neither knows what to expect.
2. Working phase:- begins when the nurse and client collaborate as partners in promoting the client’s health; goals are set, mutual work toward accomplishment of the goals; tool for effective nursing intervention.
3. Termination phase:- can cause anxiety (client and nurse); feelings of sadness, frustration, and anger because of loss; helps nurse and client gain practice in ending relationships and in exploring reactions, which can be most helpful when losses occur.
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The End
Thank You
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