The Therapeutic NurseClient Relationship

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The Therapeutic Nurse-Client Relationship

• Use of Therapeutic Communication

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Self Awareness Nurse - Client Relationship

• Quad I
• Open to self/public
• What you know about self
• And what others also know about you

• Quad 2
• Blind the unaware self
• Qualities others know about you but you are
  unaware of.

• Quad 3
• The hidden /private self
• Qualities only you know

• Quad 4
• Unknown self
• EMPTY quad the undiscovered self- Qualities not
  known by self/ others

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Components of the Nurse-Client Relationship

• Trust
• Genuine interest
• Empathy
• Acceptance
• Positive Regard
• Therapeutic Use of Self

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Types of relationships
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Phases of the Nurse-Client Relationship

• Pre-Orientation- Self assessment
• examine own feelings, fears, anxieties.
• Orientation Introductory Phase
• establish trust, share information with
  client discrete self-disclosure.
• convey support, facilitate healing
• educate

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Phases of Therapeutic Nurse-Client
Relationshipcontd.

• The Working Phase Problems identified
• Exploration- guide client to examine
  feelings/responses, develop new coping skills
• Termination Phase Resolution phase
• Examine goals achieved
• Explore feelings regarding termination
• Establish plan for continuing assistance

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Obstacles to the Therapeutic Relationship

• Inappropriate Boundaries
• Encouraging dependence
• Non acceptance/Avoidance
• Resistance

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Roles of the Nurse

• Teacher
• Caregiver
• Advocate
• Parent- Surrogate

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Therapeutic Communication

• Boundaries
• Intimate
• Personal
• Social
• Public

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Non Verbal Communication

• Eye Contact
• Body Language
• Boundaries
• Facial Expressions
• Silence
• Vocal cues

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Non Verbal Communication

• Space (comfort zone)
• Touch ( action/personal space used
  cautiously)
• Appearance communicates a particular
  image/ones mental status ( use of clothing,
  make-up etc.)
• Be aware of own non-verbal cues!!

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Traits of Therapeutic Communication

• Genuineness
• Positive Regard
• Empathy
• Trustworthiness
• Clarity
• Responsibility
• Assertiveness

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Active Listening!!

• S Sit facing the client
• O Open Posture
• L Lean forward towards client
• E Establish eye contact
• R- Relax!!

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Conditions Affecting Communication

• Values
• Attitudes
• Beliefs
• Perceptions
• Culture or Religion
• Social Status
• Gender
• Age or developmental level
• Environment

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Enhancing Communication

• Silence
• Support/reassurance
• Sharing Observations
• Acknowledge feelings
• Broad open ended statements
• Information giving
• Interpretation

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Enhancing Communication

• Restating
• Reflecting
• Clarification
• Confrontation
• Offering Alternatives
• Voicing doubt
• Role-playing
• Use of Humor use cautiously/discretely

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Non-therapeutic responses

• Advising
• Agreeing
• Belittling feelings
• Challenging
• Defending
• Disagreeing
• Disapproving
• Probing

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Caring for clients from different socio-cultural
backgrounds

• Important !! Analyze self! know your own
  beliefs/values/customs/behaviors
• Avoid being judgmental
• Rules for communication vary since they arise
  from cultural norms!
• Understand differences in communication among
  various cultures
• Ask families for assistance re their culture
• Reflect on your emotions/journal write feelings

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Therapeutic communication ?s

• 1. The nurse is meeting a new client on the
  unit.Which action, by the nurse, is most
  effective in initiating the nurse-client
  relationship?
• Introduce self and explain the purpose and the
  plan for the relationship.
• Describe the nurses family and ask the client to
  describe his/her family.
• Wait until the client indicates a readiness to
  establish a relationship.
• Ask the client why he/she was brought to the
  hospital.

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• 2. Mrs. F. has remained close to the nurse all
  day. When the nurse talked with other clients
  during dinner, Mrs. F. tried to regain the
  nurses attention and began to shout, Youre
  just like my mother. You pay attention to
  everyone but me! The best interpretation of
  this behavior is that
• Mrs. F. is exhibiting resistance.
• Mrs. F. has been spoiled by her family.
• The nurse has failed to meet Mrs. Fs needs.
• Mrs. F. is demonstrating transference.

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• 3. The nurse is caring for a Native American
  client who says, I dont want you to touch
  me.Ill take care of myself. Which nursing
  response is most therapeutic?
• Okay, if thats what you want.Ill just leave
  this cup for you to collect your urine.
• If you dont want our care, why did you come
  here?
• Why are you being so difficult? I only want to
  help you.
• It sounds as though you want to take care of
  yourself. Lets work together so you can do
  things for yourself.

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• 4. The client says to the nurse I am going to
  die, I wish my family would stop hoping for a
  cure! I get so angry when they carry on like
  this! After all, Im the one whos dying. The
  most therapeutic response is
• Youre feeling angry that your family continues
  to hope for you to be cured.
• I think we should talk more about your anger
  with your family.
• Well, it sounds like youre being pessimistic.
  After all, years ago people died of pneumonia.
• Have you shared your feelings with your family?

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• 5. The nurse employed in a mental health clinic
  is greeted by a neighbor in a local grocery
  store. The neighbor says to the nurse, How is
  Carol doing? She is my best friend and is seen
  at your clinic every week. The most appropriate
  nursing response is which of the following?
• Im not supposed to discuss this, but because
  you are my neighbor, I can tell you that she is
  doing great!
• Im not supposed to discuss this, but because you
  are my neighbor, I can tell you that she really
  has some problems!
• If you want to know about Carol, you need to ask
  her yourself.
• I cannot discuss any client situation with you.

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• 6. The nurse is preparing the client for the
  termination phase of the nurse-client
  relationship. The nurse prepares to implement
  which nursing task is most appropriate for this
  phase?
• Identifying expected outcomes
• Planning short term goals
• Making appropriate referrals
• Developing realistic solutions

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• 7. During the termination phase of the
  nurse-client relationship, the clinic nurse
  observes that the client continuously
  demonstrates bursts of anger. The most
  appropriate interpretation of the behavior is
  that the client
• Requires further treatment and is not ready to be
  discharged.
• Is displaying typical behaviors that can occur
  during termination.
• Needs to be admitted to the hospital.
• Needs to be referred to the psychiatrist as soon
  as possible.

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• 8. A client looks at a mirror and cries out, I
  look like a bird. This is not my face. The nurse
  responds therapeutically by saying
• What kind of a bird do you think you are?
• That must be very distressing to you, your face
  does not look different to me.
• Maybe the light is playing tricks on you.
• Why do you think that you look like a bird?

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• 9. A 32 year old mother of 2 young children
  diagnosed with cervical cancer with metastacies,
  tells her nurse Im going to die, arent I ?
  The nurses most appropriate response would be
• No, you are not . After all you are receiving
  the latest treatment available, and your doctor
  is one of the best in this area.
• We are all going to die sometime.
• What did your doctor tell you?
• I dont know. You have a serious illness. Do
  you have feelings that you would like to talk
  about?

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• A client relates angrily to the nurse that his
  wife says he is selfish. Which response by the
  nurse would be most helpful?
• Thats just her opinion.
• I dont think that you are selfish.
• Everyone is a little bit selfish.
• You sound angry tell me more about what went
  on.

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• 11. The most therapeutic response a nurse could
  make to a student who begins to cry upon learning
  that a failing grade was received on a final exam
  is
• Youll make it next time.
• Failing an exam is an upsetting thing to
  happen.
• How close were you to passing?
• It wont seem so important 5 years from now.

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