The Nurse Client Relationship

The Nurse Client Relationship


What is the nurse-client relationship?
– Main tool of psychiatric nursing
– Safe
– Confidential
– Reliable
– Consistent
– With clear boundaries

Social Relationships
• Initiated for the purpose of friendship, socialization or task accomplishment.
• Mutual needs are met during interaction.
• Communication includes giving advice and ask for or provide help with jobs.
• Content of communication may be superficial, roles may shift.
• No evaluation

Intimate Relationships
• Individuals have an emotional
commitment
• Often a partnership where mutual needs are met
• Short and long term goals are mutual
• Personal and intimate information are shared
• Emotional satisfaction, security, sex, procreation, etc.

Therapeutic Relationships
• Relationship consistently focused on the client s problems and needs
• Potential solutions to problems discussed
• Client chooses and implements plans
• New coping skills develop
• Behavioral change encouraged
Nurse’s Behaviors that Facilitated
Growth and Change in Clients
• Genuineness “Being yourself”
– Self-awareness of one s feelings
– Ability to communicate one s feelings when appropriate
– Key ingredient in building trust
• Empathy
– Understanding the client’s feelings and ideas accurately
– Accurate understanding of client s communication
– Communicating understanding to the client and check for accuracy
– Acting on “this understanding” in a helpful way

Nurse’s Behaviors that Facilitated
Growth and Change in Clients
• Positive self-regard
– Respect communicated indirectly
by actions
– Help client to develop own personal resources and actualize his living potential
– Nonjudgmental focus on client s thoughts, feelings to understand behaviors
– Cultural sensitivity

Boundaries of the
Nurse-Client Relationship

• Client s needs are separated from the nurse s needs

• Client s role is different from that of the nurse

Boundaries Blurred
• Nurses’ actions are overly helpful, controlling, or narcissistic
• Transference- Client’s feelings and behaviors from childhood are displaced onto another person (nurse).
• Counter-transference- Nurse displaces onto client feelings related to people in the nurse’s past.
Phases of Nurse-Client Relationship

• Orientation
• Working
• Termination
Orientation Phase
• Establish
– Trust
– Parameters of the relationship
– Formal or informal contract
– Confidentiality
• Termination begins
• Assessment, nursing diagnosis, mutually agreed goals, plan of actions

Working Phase

• Maintain relationship
• Gather further data
• Promote clients
– Problem-solving skills
– Self-esteem
– Use of language

Working Phase - Continued

• Facilitate behavioral change
• Overcome resistant behaviors
• Evaluate problems and goals
– Redefine them as necessary
• Promote practice and expression
of alternative adaptive behaviors

Termination Phase
• Nurse and client express feelings about termination
• Evaluating outcomes, goals and interventions
• Summarize goals and objectives achieved
• Review client s plans for future
• Finalize termination


Factors Facilitating the
Nurse-Client Relationship


• Consistent, regular, and private interactions with client
• Being honest and congruent
• Letting client set the pace
• Listening to client s concerns
Factors Facilitating the
Nurse-Client Relationship

• Positive initial attitudes and preconceptions
• Promoting client comfort and balancing control
• Client demonstrating trust and active participation in relationship


How to Begin Communication

• Setting

• Seating

• Introductions

Helpful Guidelines
• Speak briefly
• When you do not know what to say,
say nothing
• When in doubt focus on feelings
• Avoid giving advice
• Do not rely on asking questions
• Pay attention to nonverbal clues
• Focus on the client

Client’s Behaviors
• Cries
• Asks nurse to keep a secret
• Leaves before a session is over
• Interrupted by another client
• Communicates thoughts of suicide

Client’s Behaviors

• Does not want to talk
• Seeks to prolong the interview
• Gives the nurse a present
• Asks the nurse a personal question

Factors that Affect Communication
• Personal
– Emotional
– Social
– Cognitive
• Environmental
– Physical
– Societal determinants

Therapeutic Communication
• Verbal- all words a person speaks
– Communicates- Beliefs, values, perceptions
– Convey- interest, understanding or the opposite, clear or distorted

• Non-Verbal- 95% of a message
– Kinesics - Proxemics - Verbal tracking
– Silence - Touch - Paralanguage
– Eye contact - Culture
Therapeutic Techniques
• Silence
• Accepting
• Giving recognition
• Offering self
• General leads
• Broad opening
• Making observations
• Restating
• Reflecting

• Focusing
• Exploring
• Giving information
• Clarification
• Presenting reality
• Voicing doubt
• Encouraging evaluation
• Summarizing
• See table 11-4 p.187
Detrimental Nurse-Client Relationship
• Nurse tries to get his or her own needs met by wanting the client to like them
• Nurse tries to solve the client s problems
• Expects the client to do as suggested
• Nurse takes the role of a friend or family member of the client
• Lack of boundaries in the relationship

Factors Hindering
Nurse-Client Relationship

• Lack of nurse availability or lack
of contact
• Lack of nurse self-awareness
• Nurse s negative feelings about client

Blocks to Therapeutic Communication

• Obstructive techniques
– Asking excessive questions
– Giving approval or disapproval
– Advising
– Asking "why" questions

Blocks to Therapeutic Communication Table 11-5 p.191
• Giving advice
• Minimizing feelings
• False reassurance
• Showing non-verbal signs of boredom
• Making value judgments
• Changing the subject
• Asking “Why” questions
• Asking excessive questions
• Giving approval, agreeing
• Disapproving, disagreeing