1. Carolyne Richardson-Phillips, MS, RN PNU 145 Fall Term 2015 Pages 94 - 104 Fostering Communication: The Nurse-Client Relationship

2. Learning Outcomes By the end of this session, PN students will be able to: 1. List & describe the 4-basic roles that a nurse performs in a nurse-client relationship 2. Describe the current role expectations for clients 3. List at least 5-principles that form the basis of the nurse-client relationship 4. Identify three phases of the nurse-client relationship 5. Describe the barriers to a therapeutic relationship 6. Explain the concept of communication 7. Explain the difference btwn social & therapeutic verbal communication 8. Discuss therapeutic & non-therapeutic communication techniques; provide examples of each 9. List five factors that affect oral communication 10. Explain non-verbal communication 11. Describe 4 nonverbal techniques 12. Define communication zones 13. Discuss the difference between task-oriented touch & affective touch 14. List at least 5-situations in which affective touch may be appropriate 15. Discuss general cultural & gerontologic considerations in a nurse-client relationship

3. Nursing Roles within the Nurse-Client Relationship Relationship- between two or more people over time Established between nurse & client-when nursing services provided Requires nurse to respond to client’s needs Nurses provide services-skills for clients Promotes or restores health Cope with disorders that do not improve Helps client die with dignity

4. National Council of State Boards of Nursing (NCLEX-PN) Four categories established for client needs as structure for test plan 1. Safe & effective care environment 2. Health promotion & maintenance 3. Psychosocial integrity 4. Physiologic integrity How does the nurse meet the client needs?

5. Nurses’ Roles within the Nurse-Client Relationship (cont’d) Nurse performs 4 basic roles Caregiver Educator Collaborator Delegator

6. Nurse as Caregiver Performs health-related activities that a sick client cannot perform independently Provide physical/emotional services so to restore or maintain functional independence Involves developing close emotional relationships-Become guide, companion, interpreter-Establishes trust, help to reduce fear Uses empathy-determine emotional state-need for support Look at Box 7-1, page 95

7. Nurse as Educator Provides information Provides health teaching pertinent to each one’s needs and knowledge base Examples: Diagnostic procedures Self-administration of medications Techniques for managing wound care Restorative exercises Diet Avoid giving advise Reserve the right of each person to make his/her own decisions (health & illness care) Share information on potential alternatives & promote one’s freedom to choose Support one’s ultimate decision Nursing extends beyond original treatment facility: nurses –resources for information about community health services which empowers clients to become involved with their care

8. Nurse as Collaborator Work with others to achieve a common goal Collaboration-Responsible for managing care and those that the nurse delegates to give that care Collaboration-When nurse –physician share information, exchange findings with other health care workers

9. Nurse as Delegator One who assigns a task to someone Need to know what tasks are legal & appropriate for particular health care workers to perform Responsible for checking that the task was completed- determine resulting outcome Accountable for inadequate care

10. Therapeutic Nurse-Client Relationship Desired outcome- moving toward improving health Therapeutic relationship: patient-centered with focus on goal achievement Time-limited goals Relationship ends when goals achieved Nurse encourages- patients to be actively involved, communicate, question, assist in plan of care See Box 7-2, page 96 Note difference between therapeutic relationship v. social relationship

11. Underlying Principles of a Therapeutic Nurse Nurse: Treats patient as unique person Respects patient’s feelings Strives to promote physical, emotional, social spiritual well being Encourages one’s decision making/problem solving Accepts patient’s growth and change Communicates with words client understands Uses nursing process-individualize care Incorporates others for support Implements health care techniques –compatible with each one’s values and cultural heritage

12. Phases of Nurse-Client Relationship Three Phases: Introductory phase- Period of getting acquainted Positive first impression: dress appropriately, being well- groomed, smiling, making eye contact, greeting with a handshake if acceptable, projecting confidence, avoid odors Client then initiates-identifies health issues Nurse demonstrates courtesy, active listening, empathy, competency, appropriate communication skills Working phase: mutually enacting a plan Period during which tasks are performed Promotes independence-Participation of both sides Terminating phase-Period when relationship ends Both agree that health problems have improved Note that client can terminate

13. Barriers to A Nurse-Client Relationship Appearing unkempt Failing to identify oneself Mispronouncing or avoiding client’s name Using client’s first name without permission Sharing personal or work related problems Using crude or distasteful language Talking with someone in room as if client not there Reveal confidential information Focus on nursing tasks rather than client’s responses Being inattentive to client’s requests Abandoning the client Failure to keep promises Going on break without delegating care Never treat adults as if they are children

15. Communication Process Exchange of information Involves both sending & receiving messages between two or more people Followed by feedback, indicating that the information was understood or requires further clarification Takes place simultaneously verbal & nonverbal communication

16. Verbal Communication Attention & concentration Language compatibility Verbal skills Hearing & visual acuity Environment Motor function Sensory distractions Interpersonal attitudes Literacy Culture Communication- uses words- Includes speaking, reading, writing Helps nurse & client –gather facts Used to instruct, clarify & exchange ideas Affected by

17. Verbal Communication (cont’d) Nurses need to consider when speaking Pace-rhythm & intonation: indicate interest, anxiety, boredom, fear Simplicity of words Clarity & brevity Timing & relevance Adaptability Credibility: always be honest Humor

18. Therapeutic Verbal Communication Using words & gestures to accomplish objectives Helps nurse when exploring problems or encouraging feelings Never assume a quiet uncommunicative client is problem-free or understands everything; Don’t probe or pry-wait/be patient and may respond Emotionally charged clients should be allowed to express their emotions w/o fear of retaliation; approach delicately-remain non- judgmental, come back later to talk w/ them about their concerns Listening: very important part of communication Active listening: includes attending to and becoming fully involved in the conversation-both verbal and nonverbal Requires energy & concentration Allows for a meaningful interaction Avoid signals of boredom, impatience, or the pretense of listening

19. Therapeutic Verbal Communication (cont’d), p. 98 Silence: allows time for considering how to proceed or arouses client’s anxiety to the point that it stimulates more verbalization Encourages one to participate in verbal conversations Helps in relieving anxiety-by having a personal presence Offers a brief period – so able to process information received May be used as a camouflage for fear, or to express contentment Used for introspection when need to explore feelings or to pray Broad opening Giving information Direct questioning Open-ended questioning Reflecting Paraphrasing Verbalizing what has been implied

20. Non-therapeutic Verbal Communication Techniques Giving false reassurance: trivializing patient’s feelings-& discourages further discussion -everything will work out just fine- You’ve got nothing to worry about Using clichés: worthless advice, “Keep a stiff upper lip” Giving approval or disapproval: holds client to a rigid standard Agreeing: does not allow pt to change his/.her mind- Disagreeing: may intimidates client-makes pt feel foolish-That’s not true-Where did you get this information Demanding an explanation: puts client on defensive Giving advice: discourages independence-=problem solving and decision making Defending: strong allegiance and any disagreement is unacceptable Belittling: disregards how pt responds as an individual Patronizing: treats client condescendingly --like they can’t make a decision Changing the subject: alters direction of client’s thought system

21. Nonverbal Communication Exchange of information without using words-spoken or written Body language-gestures, body movements, use of touch, physical appearance Less control over non-verbal than verbal Messages communicated more accurately thru non-verbal

23. Nonverbal Communication -Kinesics Body language Facial expressions Posture Gestures Body movements Clothing style & accessories

24. Nonverbal Communication-Paralanguage Vocal sounds that are not actually words Taking a deep breath to indicate surprise Clucking the tongue-indicates disappointment Whistling-get someone’s attention Crying, laughing, moaning

25. Nonverbal Communication-Proxemics Use and relationship of space to communication Varies among people from different cultural backgrounds 4 Space Zones: Intimate space = within 6 inches Personal space = 6 inches to 4 feet Social space = 4 to 12 feet Public space = more than 12 feet

26. Nonverbal Communication-Touch Can be task-oriented, affective or both Task-oriented-personal contact required when performing nursing procedures Affective- demonstrate caring & concern Nurse needs to be sensitive to how clients respond Therapeutic use for lonely-uncomfortable, near death, anxious, insecure, frightened, disoriented, visually impaired, sensory deprived

27. Task- Orientated & Affective Touch

28. Cultural Communication Considerations Language: Speech patterns and habits; determine if client understands English Styles of speech and expression Eye contact Touch Space Concept of time View of Health and health care

29. Communicating with Special Populations The Joint Commission is adamant that Nurses-need to find ways to communicate with clients Clients: Verbally impaired-deaf-cognitive deficits-dementia, stroke, Alzheimer’s disease, artificial airways, wired jaws Verbally Impaired: provide paper & pencil/pen or “magic slate”, cards, charts, communication boards Hearing Impaired: may be able to write information, and the materials above or those born deaf-may use American Sign Language (ASL), webcam-video camera

30. Communicating: Alzheimer’s Disease Progressive, deteriorating brain disorder Memory loss-classic symptom, also disturbances in behavior, & loss of ability to care for self Problems –speaking, difficulty expressing one-self, reading, writing Techniques to use: gain client’s attention-use name and approach from the front Smile, maintain eye contact, be relaxed, Speak naturally, avoid long words, sentences Wait for a response, rephrase information, show patience Use visual cues, pantomimes Avoid correcting or arguing with client

31. Gerontologic Considerations Show Respect Approach slowly Exchange names-utilizing client’s last name Do not use demeaning terms Do not ignore client & talk to someone else in room (act as if client is not there) Do not treat like a child Utilize touch & eye contract appropriately Sit face to face Provide good lighting Inquire about whether or not client has any special needs- Hearing (hearing aids, sit closer, sit on the best side, vision (glasses) Speak in a normal tone with distinct pronunciation of words Promote as much control over decisions as possible Encourage reminiscing Allow the older clients the ability to pace their care

32. Nursing Process Assessment Diagnosis Planning Interventions Evaluation

33. References Pictures retrieved from web site on June 12, 2015 from http:// oogleimages.com Timby, B. K. (2013), (10 th ed.). Fundamental Nursing Skills and Concepts. Philadelphia, PA: Lippincott Williams & Wilkins