1. Lecture 4 Community and Mental Health Nursing-NUR 472 Relationship Development and Therapeutic Communication

2. Introduction  The nurse-client relationship is the foundation on which psychiatric nursing is established.  The therapeutic interpersonal relationship is the process by which nurses provide care for clients in need of psychosocial intervention.

3. Introduction (cont.)  Therapeutic use of self is the instrument for delivery of care to clients in need of psychosocial intervention.  Interpersonal communication techniques are the “ tools ” of psychosocial intervention.

4. The Therapeutic Nurse-Client Relationship  Therapeutic relationships are goal- oriented and directed at learning and growth promotion.  Goals are often achieved through use of the problem-solving model

5. The Therapeutic Nurse-Client Relationship (cont.) The Problem Solving process consists of a sequence of sections that fit together depending on the type of problem to be solved. These are:  Problem Definition.  Problem Analysis.  Generating possible Solutions.  Analyzing the Solutions.  Selecting the best Solution(s).

6. Conditions Essential to Development of a Therapeutic Relationship  Rapport  Trust  Respect  Genuineness  Empathy

7. Phases of a Therapeutic Nurse-Client Relationship Pre-interaction phase  Obtain information about the client from chart, significant others, or other health team members and emphasis is on the self- analysis of the nurse.

8. Phases of a Therapeutic Nurse-Client Relationship (cont.) Orientation (introductory) phase  Create an environment for trust and rapport.  Gather assessment data.  Identify client ’ s strengths and weaknesses.

9. Phases of a Therapeutic Nurse-Client Relationship (cont.) Orientation phase (cont.)  Formulate nursing diagnoses.  Set mutually agreeable goals.  Develop a realistic plan of action.  Explore feelings of both client and nurse.

10. Phases of a Therapeutic Nurse-Client Relationship (cont.) Working phase  Maintain trust and rapport.  Promote client ’ s insight and perception of reality.  Use problem-solving model to work toward achievement of established goals.  Overcome resistance behaviors.  Continuously evaluate progress toward goal attainment.

11. Phases of a Therapeutic Nurse-Client Relationship (cont.) Termination phase  Therapeutic conclusion of relationship occurs when:  Progress has been made toward attainment of the goals  A plan of action for more adaptive coping with future stressful situations has been established  Feelings about termination of the relationship are recognized and explored  Patient anxieties reappear

12. Interpersonal Communication  Interpersonal communication is a transaction between the sender and the receiver. Both persons participate simultaneously.  In the transactional model, both participants perceive each other, listen to each other, and simultaneously engage in the process of creating meaning in a relationship.

13. The Impact of Preexisting Conditions (cont.)  There are four kinds of distance in interpersonal interactions:  Intimate distance - the closest distance that individuals allow between themselves and others  Personal distance - the distance for interactions that are personal in nature, such as close conversation with friends  Social distance - the distance for conversation with strangers  Public distance - the distance for speaking in public or yelling to someone some distance away

14. Nonverbal Communication Components of nonverbal communication  Physical appearance and dress  Body movement and posture  Touch  Facial expressions  Eye behavior

15. Therapeutic Communication Techniques  Using silence - allows client to take control of the discussion, if he or she so desires  Formulating plan of action - striving to prevent anger or anxiety escalating to unmanageable level when stressor recurs  Offering self - making oneself available  Giving broad openings - allows client to select the topic

16. Therapeutic Communication Techniques (cont.)  Offering general leads - encourages client to continue  Placing the event in time or sequence - clarifies the relationship of events in time  Exploring - delving further into a subject, idea, experience, or relationship

17. Therapeutic Communication Techniques (cont.)  Encouraging comparison - asking client to compare similarities and differences in ideas, experiences, or interpersonal relationships  Restating - lets client know whether an expressed statement has or has not been understood  Focusing - taking notice of a single idea or even a single word

18. Nontherapeutic Communication Techniques  Rejecting - refusing to consider client ’ s ideas or behavior  Approving or disapproving - implies that the nurse has the right to pass judgment on the “ goodness ” or “ badness ” of client ’ s behavior

19. Nontherapeutic Communication Techniques (cont.)  Agreeing or disagreeing - implies that the nurse has the right to pass judgment on whether client ’ s ideas or opinions are “ right ” or “ wrong ”  Probing - pushing for answers to issues the client does not wish to discuss causes client to feel used and valued only for what is shared with the nurse  Introducing an unrelated topic - causes the nurse to take over the direction of the discussion

20. Nontherapeutic Communication Techniques (cont.)  Defending - to defend what client has criticized implies that client has no right to express ideas, opinions, or feelings  Belittling feelings expressed - causes client to feel insignificant or unimportant  Using denial - blocks discussion with client and avoids helping client identify and explore areas of difficulty

21. Active Listening  To listen actively is to be attentive to what client is saying, both verbally and nonverbally.  Several nonverbal behaviors have been designed to facilitate attentive listening.

22. Active Listening (cont.) SOLER acronym  S – Sit squarely facing the client.  O – Observe an open posture.  L – Lean forward toward the client.  E – Establish eye contact.  R – Relax.

23. Feedback  Feedback is useful when it  is descriptive rather than evaluative and focused on the behavior rather than on the client  is specific rather than general  is directed toward behavior that the client has the capacity to modify  imparts information  is well-timed