Therapeutic Communication

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

PHASE

(Teach them!)

WORKING PHASE

(Provide therapeutic

experience)

TERMINATION PHASE

(Take Pride!)

Trust and

Rapport

Environment

(Therapeutic)

Assess client’s

strength and

weakness

Contract

(therapeutic)

Help

communicate

Promote Positive self

concept

Realistic goal setting

Organize support system

Verbalize feelings

(encourage)

Implement action plan

Develop positive coping

behaviors

Evaluate the results of

plan of actions

Promote self care

Recognize increasing anxiety

Increase independence

Demonstrate emotional

stability

Environmental support

• 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 INTERACTION

THERAPEUTIC RELATIONSHIP

Characteristics Personal and intimate Personal but NOT intimate

Goal Doing favor for mutual benefit

Promoting functional use 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 interaction

Specialized professional 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 with the client and either talk or just sit quietly.

“Let me sit with you for 15 minutes and read a story.” “I’d like to eat lunch with you.” “Let’s walk to the cafeteria together.”

Providing broad openings

The nurse invites the client to select a topic.

“Where would you like to begin?” “Talk more about…” “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 observation

The nurse acknowledges that something or someone exists or has changed in some way.

“You appear anxious. I noticed that you have been coming to lunch with the group.” “You have drawn a picture.” “That’s a new hairstyle, isn’t it?” “I noticed on the chart that today is your birthday.”

Suggesting collaboration

The nurse makes an offer to work together with the client.

“Let’s try to figure this out together.” “Let’s talk and see if we can work together to understand this.” “Perhaps we can discuss this and see what offended you.” ”Perhaps you and I can discover the triggers of your anxiety

Providing silence

The nurse allows the verbal conversation to stop to provide a time for quiet contemplation of what has been discussed, for formulation

(Silence)

Providing general leads

The nurse provides brief interjections that let the client know that he or she is on the right track and should continue.

“Go on…” “Talk more about…” “Then what?” “Please go on.” “And…?”

Exploring The nurse asks the client to describe something in more detail or to discuss it more fully.

“You said you liked Carl best. Can you tell me about Carl?” “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 from among several possible topics presented by the client.

“Give an example of what you mean.” “Let’s look at this more closely.” “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 clarification

The nurse lets the client know that what was said was unclear. If necessary, the nurse asks for clarification or provides input regarding how to make the message clearer. (further elaboration)

“I’m not sure that I understand what you’re saying.” “Do you mean…?” “I didn’t understand what you meant then. Can you say that in different words?” “Let me repeat back to you what I think I heard you say.”

Restating The nurse paraphrases what the client has said. This paraphrased message may be fed back to the client in the form of a statement or a question to provide the client the opportunity to agree or to disagree and clarify further.

Client: I can’t sleep, I stay awake all night” Nurse: “you have difficulty sleeping?” Adult: “I’m down.” Nurse: “You feel depressed?”

Seeking consensual validation

The nurse attempts to verify with the client that a certain term means the same thing to both parties.

“You want ‘moo moo’? Does ‘moo moo’ mean milk? “When you say your brother is crazy, does the word crazy mean ‘kind of wild’?” “Tell me if we both understand that word the same way.”

Placing events in time or sequence

The nurse asks the client to explain more about when an event occurred (placing the event in time) or to explain the sequence of a series of events.

“Were you frightened before or after the movie?” “Tell me what went on before the fight broke out in the gym?"

Summarizing Do this at end of conversation, for you & client, to feel you have accomplished something

“ During the past hour, you and I have discussed…”

Confrontation If there are contradiction in the clients behavior or feeling that sending mixed messages to others

“You said that you love your sister but you refuse to reconcile with her” “You say you’re not nervous, yet you are pacing”

Presenting reality

The nurse indicates reality when the client is misinterpreting it

Client: ”I see a man” 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 description of perception

Having client describe his or her view of an event

Client: “I hear voices” Nurse:” what kind of voice?”

Giving information

The nurse provides facts or information that the client requests

“You cant take this medication unless you take your meal, this drug can cause hyperacidity”

Reflecting Nurse reflects back to the client the feeling or thought message that the client expressed to help him/her identify the emotions and events that trouble him

Client: “do you think I should tell the doctor?” Nurse: “You think you should?”

ALPHABET OF THERAPEUTIC COMMUNICATION Accepting Opening leads Broad opening Present reality Clarifying Questions not answerable by yes

or no Demonstrate unconditional positive regard

Reflecting

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 avoided

eXplore alternatives rather than answer of solutions

Keep respect You are interested to listen Listen to what the person is not saying

Zest up-show interest

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 reassurance

Trying to make the client better superficially and not to worry or be anxious

“Don’t worry; you will be better in a few weeks. “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 that he or she is incapable of solving own problem

“What you should do is…” “If I were you, I would do…”

3. Rejecting An angry or punitive response to clients action, thoughts or feelings

“I don’t like it when you…” “Please, don’t ever talk about…”

4. Belittling The nurse discounts the client’s feeling and experiences as not being valuable or worthwhile

“Everybody feels that way.” “Why, shouldn’t feel that way.”

5. Probing Persistent questioning of the client or asking unrelated topics

“Tell me more about your relationship with other men.” 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 a patients cant handle

“Hi, I am Joann, your student nurse. How old are you? 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 meaning is clear; withholding information.”

“I’ll give you some medication, later”

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 feelings or needs

“It is silly to think that people want to hurt you?” “You’re crazy”

8. Literal response “Dealing with abstract symbols or metaphors in a concrete manner”

“Gee, the weather is beautiful outside.”

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 clientAccept client as she/he isBe honest and consistentAttempt to establish good relationship (rapport)Allow client then family to make decisionAnswer according to nursing actionDo not provide response that implies that the client

is unworthySelect the most comprehensive (global) answerFocus on the feelings of client

• Thank you.