Communications that contribute to trust and mistrust of providers

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

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: 1. Important to successful patient assessment where pt.’s disclosure is more complete 2. Identification with the nurse and the helping relationship enable pt to experiment and become skilled at aspects of self-care because trust is an influential factor and important behind the patient’s acceptance of provider opinion 3. Pt. learn to: cope with their limitations, Master skills and resolve problems and frustrations related to their health conditions

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

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

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

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

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

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 To understand the significance of the client’s problems and the role of the client and the significant people in his or her life To assist in the identification and resolution processes of the client’s problem areas

The process of establishing trust Phases of therapeutic relationship

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….

Stages of the Nurse-Client Relationship Pre-orientation phase Orientation phase Working phase Termination phase

Preorientation Phase Obtaining available information about the client from his or her chart, significant others, or other health team members. From this information, the initial assessment is begun. Examining one’s feelings, fears, and anxieties about working with a particular client. All individuals bring attitudes and feelings from prior experiences to the clinical setting. The nurse needs to be aware of how these preconceptions may affect his or her ability to care for individual clients.

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

The Orientation (Introductory) Phase Tasks include: Creating an environment for the establishment of trust and rapport Establishing a contract for intervention that details the expectations and responsibilities of both the nurse and client Gathering assessment information to build a strong client database Identifying the client’s strengths and limitations Formulating nursing diagnoses Setting goals that are mutually agreeable to the nurse and client Developing a plan of action that is realistic for meeting the established goals Exploring feelings of both the client and nurse

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

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

Working, implementing phase… The therapeutic work of the relationship is accomplished during this phase. Tasks include: Maintaining the trust and rapport that was established during the orientation phase Promoting the client’s insight and perception of reality Problem-solving. Overcoming resistance behaviors on the part of the client as the level of anxiety rises in response to discussion of painful issues Continuously evaluating progress toward goal attainment

Termination… Termination of the relationship may occur for a variety of reasons: the mutually agreed-on goals may have been reached; the client may be discharged from the hospital; or, in the case of a student nurse, it may be the end of a clinical rotation. Termination can be a difficult phase for both the client and nurse. The main task involves: Progress has been made toward attainment of mutually set goals. A plan for continuing care or for assistance during stressful life experiences is mutually established by the nurse and client. Feelings about termination of the relationship are recognized and explored. Both the nurse and client may experience feelings of sadness and loss.

Special communication techniques… Self-disclosure Touch humor

Obstacles to therapeutic communication… Resistance Transference Counter transference Boundary violation

Resistance occurs in clients who consciously or unconsciously maintain a lack of awareness of problems they are having to avoid anxiety. Eg. A nurse can assure a client who resist discharge because of fear of failure or loneliness that such fears are not uncommon at the time of termination. The nurse can then remind the patient with his progress.

Transference Is the unconscious response whereby clients associate the nurse with someone significant in their lives. Feelings and attitudes about the other person are transferred to the nurse.

Countertransfernce Is initiated by the nurses’ emotional response to a specific client. Is is simply the nurse own transference. To deal with, the nurse should conduct honest self-appraisal.

Boundary violations Occurs when the nurse goes beyond the established therapeutic relationship and enters into social or personal relationship with the client. Eg. A client may ask the nurse “ are you married” Eg. The nurse accepts compensation or gifts for treatment.