1 Communications that contribute to trust and mistrust of providers

2 Trust… Trust is defined as an individual’s expectation that the communication behaviors of other s are reliable Trust is to rely on the veracity and integrity of another individual Evidence of trust occurs in patient’s perception that providers are sincere, honest, benevolent (caring), and credible in what they do

3 Trust is not something that is just absent or present It is a complex phenomena that is manifested differently in interpersonal relationships, in particular situations

Establishing trust is important… trust allows many things to happen: Important to successful patient assessment where pt.’s disclosure is more complete Identification with the nurse and the helping relationship enable pt to experiment and become adept at aspects of self-care

Pt. learn to: -cope with their limitations -Master skills -Resolve problems and frustrations related to their health conditions 5

Trust potentiates change and patients are more likely to attempt new health related behavior Establishing trust is felt to be an influential factor and important behind the patient’s acceptance of provider opinion 6

7 Levels of trust… General trust: is the trust that the individuals have of other people in a global sense. This kind of trust is consistent (trait) Specific trust: is the trust an individual has of another person in a specific relationship

Trust occur when 2 conditions are met… When patient perceive that nurses have their best interest in mind When patient s perceive that the same nurse is capable and competent to help

Trust, respect and genuineness… Acknowledging the value of patients and accepting their individuality (listening to pt. acknowledging their preferences, giving choices where possible

10 The process of establishing trust… While it is true that trust is “earned”, it also true that some individuals have difficulty trusting under any circumstances Patients’ personal health and social histories will reveal clues about their level of trust and the likelihood that trust will come easily

Trust like other aspects of interpersonal relationships is best viewed on a continuum High level of trust or low level of trust, and somewhere in the middle a healthy appropriate level of trust

Trust and Mistrust… Early origins of trust emanate from infancy from learning that a person will receive or have done what is needed In time self-confidence results from perceiving that one is self-reliant The process that patients go through in becoming confident in their abilities to render self-care parallel this primary experience

Clients who have healthy level of trust are more open and responsive They are likely to communicate hope and faith and willing to take risk under provider guidance 13

Clients who mistrust behaves differently, they might communicate with defensiveness They might be guarded with speech, exhibiting suspiciousness and caution 14

15 The nurse-client relationship an interactive process between nurse and client that is goal-directed to help the client overcome temporary stress, to get along with other people, to adjust to the unalterable, and to overcome psychological blocks which stand in the way of self-realization

16 1.To allow the client to express thoughts, feelings, behaviors and life experiences, and life experiences in a meaningful way in order to promote healthy growth 2.To understand the significance of the client’s problems and the role of the client and the significant people in his or her life 3.To assist in the identification and resolution processes of the client’s problem areas

The process of establishing trust Phases of therapeutic relationship 17

Nurse-client relationship is goal-directed and go through 3 or 4 phases. These phases are interrelated and each describes the responsibilities and task of the nurse and the client….

19 Orientation, initiation, introductory... The very first contact between provider and patient, whether through telephone or actual face to face encounter This contact sets the tone and climate for the relationship, a statement of nurse’s name should be accompanied by an explanation of the role particularly in relation to the client

20 It is the provider’s obligation to establish a climate that is conducive of trust through: - The contract (working agreement) including distribution of responsibilities, usually verbal one, location, frequency and length of meetings - Overall purpose of the relationship, what the client should or should not expect

21 -Way in which confident material will be handled (confidentiality), the client information will only be shared with appropriate others It is helpful to summarize elements of agreement at the end of interaction, this may include writing.

Developing rapport: Observing patient’s communication pattern starts the minute the nurse interacts with him or her. It shows if the person is interested. A cue is a unit of sensory input; a sight, sound, smell, taste or touch that is perceived as important to be noticed

An inference is the conclusion drawn from cues. Must be based on knowledge, previous experience, expectations and needs Inferences are usually formed on the basis of more than one cue

Communication cues: verbal and non- verbal cues that are elicited because the exploration itself triggers the cues Patient tone of voice may change, rate of speech may accelerate Patient questions as cues; often come in form of question asked of the nurse

Cue perception: involves noticing how the patient is responding, and trusting, your intuitions that the patient is trying to tell something Cue exploration: sharing perceptions.

A goal of this phase is to put patient at ease. The patient’s comfort is crucial for the therapeutic process, create an accepting atmosphere that nurtures and supports the patient. Responding to patients as people first and as patients second enhances the possibility of establishing a meaningful rapport.

27 Beginning client assessment: This is a major task of this phase -The nurse is organizing the information gathered about the client through the process of nursing assessment -The client might do some “testing” a way of measuring nurse’s sincerity and interest

28 By the end of the end of the orientation phase the participants are no longer strangers, trust is beginning to develop (a degree of mutuality by agreeing on terms and purpose of the relationship They begin to care for each other, the potential for empathy grows

Collecting information: Exploring Patient cues can be explored using any of the skills that will be discussed in the incoming slides Patient present cues in an attempt to communicate with nurses, so do not fall into the trap of looking for hidden meaning or motives

The process of exploration is one of searching, carried out for the purpose of discovery, detection, recognition and identification Successful exploration results in greater understanding between patient and nurse Nevertheless, effective exploration in the nursing context involves more than the collection of specific facts from patients

Planned Exploration, Probing skills: The techniques of asking questions, Carefully warded and well timed. Provide the base of effective exploration and interviewing Spontaneous Exploration, prompting skill: the nurse follows pt’s lead instead of pt. following the nurse’s lead, it affirms that the nurse is is attending and listening

Planned versus Spontaneous Exploration… Direct Nurse-led Prescribed format Information solicited Topic areas determined by the nurse More questioning techniques (probes) used Responsive Patient-led No prescribed format Meaning sought Topic areas introduced by the patient More exploratory statements (prompts) used

33 Therapeutic responding techniques related to assessment and orientation phase: Introducing self Offering self Active listening Questioning Waiting in silence listening Empathizing Reality orientation/ providing information Summarizing Reflection Restating Clarifying Stating observations Fostering description of perception Voicing doubt Identifying themes Encouraging comparison focusing

Planned Exploration, Probing skills… The techniques of asking questions Carefully warded and well timed Provide the base of effective exploration and interviewing 34

Closed questions… Those are answered yes, no or other one- word response of information Control the direction of conversation and limit the amount of information that is shared or obtained 35

Open-ended… Are those require more than one-word response Questions that are open-ended often yield more information because their replies include more detailed expansion and elaboration in response Patient can highlight what is more relevant to his/her experience and retain sense of control in the interaction 36

كيف كان نومك امبارح؟ ايش اكثر اشي بيثير قلقك (بتفكر فيه) بالنسبة للعملية؟ ايش اصناف الاكل اللي بتحبها وتستمتع فيها؟ كيف كانت زيارتك لعيادة الطبيب؟ 37

Pitfalls in the use of probing skills… Overuse of questions Continuous multiple questions The why? Question The leading question 38

Spontaneous Exploration, prompting skills… Minimal encouragement such as آه، انا معك، احكي لي اكثر او بتفصيل اكثر One-ward/phrase accents The repetition of key ward to extend and focus the interaction 39

Gentle commands ( allow the patient to determine direction and flow of information) خبرني او احكي لي تفاصيل اكثر، خلينا نحكي بهذا الموضوع اكثر، استمر احكي اللي يجول في خاطرك Open-ended statements) a broad introduction to topics indicate to a patient indicate that you would like to hear more about something هذه اول مرة تخضع فيها لعملية جراحية، اتساءل كيف كونك مريض الان بالرغم انك كنت تتمتع بالصحة طوال حياتك سابقا 40

Self-disclosure (nurse opens an area for exploration by stating their own reactions, feelings, or thoughts. Must be honest). It shows that nurse is not afraid to be open لو كنت مكانك لعصبت برضو، انا ما بتحمل الالم بصورة جيدة، بعتقد اني راح اتساءل عن اللي بيصير 41

42 Working, implementing phase… The nurse-client relationship enters period of time during which interaction is maintained for the purpose of accomplishing the tasks that have been mutually agreed on

Growth and resistance…. During this phase nurse and client know each other and some degree of predictability has developed However it’s time of intensive work There will be periods of growth by positive behavioral changes These periods of growth alternate with episodes of resistance expression of feelings of vulnerability, shame, anger, fear, sadness, hostility, dislike and sexuality is expected 43

Responding to client’s feelings… Self disclosure, immediacy and confrontation as well as self-awareness are valuable tools for the nurse as she/he assists client to deal with their feelings 44

Termination… The end of a successful helping relationship is always met with ambivalence Termination and interpersonal growth Both nurse and client may experience anxiety as they anticipate termination 45

Special communication techniques… Self-disclosure Touch humor 46

Non therapeutic communication techniques False reassurance not listening (selective listening) Offering approval Minimizing the problem Advice Giving literal information Changing the topic 47

Obstacles to therapeutic communication… Resistance Transference Counter transference Boundary violation 48