- Open ended questions
- Focus on feelings
- State behaviors observed
- Reflect, restate, rephrase verbalization of patient
- Neutral responses
Therapeutic relationship – is a relationship that is established between a health care professional and a client for the purpose of assisting the client to solve his problems.
Components of a Therapeutic Relationship
One of the most important skills of a nurse is developing the ability to establish a therapeutic relationship with clients. For interventions to be successful with clients in a psychiatric facility and in all nursing specialties it is crucial to build a therapeutic relationship. Crucial components are involved in establishing a therapeutic nurse-patient relationship and the communication within it which serves as the underpinning for treatment and success. It is essential for a nurse to know and understand these components as it explores the task that should be accomplish in a nurse-client relationship and the techniques that a nurse can utilize to do so.
Without trust a nurse-client relationship would not be established and interventions won’t be successful. For a client to develop trust, the nurse should exhibit the following behaviors:
- Treating the client as human being
- Suggesting without telling
- Keeping promises
- Providing schedules of activities
Another essential factor to build a therapeutic nurse-client relationship is showing a genuine interest to the client. For the nurse to do this, he or she should be open, honest and display a congruent behavior. Congruence only occurs when the nurse’s words matches with her actions.
For a nurse to be successful in dealing with clients it is very essential that she empathize with the client. Empathy is the nurse’s ability to perceive the meanings and feelings of the client and communicate that understanding to the client. It is simply being able to put oneself in the client’s shoes. However, it does not require that the nurse should have the same or exact experiences as of the patient. Empathy has been shown to positively influence client outcomes. When the nurse develops and utilizes this ability, clients tend to feel much better about themselves and more understood.
Some people confuse empathizing with sympathizing. To establish a good nurse-patient relationship, the nurse should use empathy not sympathy. Sympathy is defined as the feelings of concern or compassion one shows for another. By sympathizing, the nurse projects his or her own concerns to the client, thus, inhibiting the client’s expression of feelings. To better understand the difference between the two, let’s take a look at the given example.
“I am so sad today. I just got the news that my father died yesterday. I should have been there, I feel so helpless.”
Nurse’s Sympathetic Response:
“I know how depressing that situation is. My father also died a month ago and until now I feel so sad every time I remember that incident. I know how bad that makes you feel.”
Nurse’s Empathetic Response:
“I see you are sad. How can I help you?”
When the nurse expresses sympathy for the client, the nurse’s feelings of sadness or even pity could influence the relationship and hinders the nurse’s abilities to focus on the client’s needs. The emphasis is shifted from the client’s to the nurse’s feelings thereby hindering the nurse’s ability to approach the client’s needs in an objective manner.
In dealing with clients their interest should be the nurse’s greatest concern. Thus, empathizing with them is the best technique as it acknowledges the feelings of the client and at the same time it allows a client to talk and express his or her emotions. Here a bond can be established that serves as a foundation for the nurse-client relationship.
Clients are unpredictable. There are times that they outburst with anger or act out their inappropriate desires. A nurse, who does not judge the client or person no matter what his or her behavior, is showing acceptance. Acceptance does not mean accepting all the inappropriate behavior but rather acceptance of the person as worthy. When the client displays an improper behavior, the nurse can communicate with the client by being firm and clear without anger or judgment. In this way, the nurse allows the client to feel intact but at the same time aware that his certain behavior is unacceptable. Let’s take a look at the given example.
Situation: A client tries to kiss the nurse.
Inappropriate response: What the hell are you doing?! I’m leaving maybe I’ll see you tomorrow.
Appropriate response: Adam, do not kiss me. We are working on your relationship with your girlfriend and that does not require you to kiss me. Now let us continue.
Positive regard is an unconditional and nonjudgmental attitude where the nurse appreciates the client as a unique worthwhile human being that shows respect for the client regardless of his or her behavior background and lifestyle. The following ways are example of how to promote respect and positive regard to a client:
- Calling the client by name
- Spending time with the client
- Listening to the client
- Responding to the client openly
- Considering the client’s ideas and preferences when planning care
Self-awareness is the process of understanding one’s own values, beliefs, thoughts, feelings, attitudes, motivations, prejudices, strengths and limitations. Before a nurse can understand clients he or she should be able to understand him or herself. The first step in preparing oneself to build a therapeutic nurse-patient relationship is to understand oneself.
THERAPEUTIC USE OF SELF
A nurse can only use his or her personality, experiences, values, feelings, intelligence, needs, coping skills and perceptions to build a relationship with clients (therapeutic use of self) when he or she has developed self-awareness and self-understanding.
1. Offering Self
- making self-available and showing interest and concern.
- “I will walk with you”
2. Active listening
- paying close attention to what the patient is saying by observing both verbal and non-verbal cues.
- Maintaining eye contact and making verbal remarks to clarify and encourage further communication.
- “Tell me more about your son”
4. Giving broad openings
- What do you want to talk about today?
- Planned absence of verbal remarks to allow patient and nurse to think over what is being discussed and to say more.
6. Stating the observed
- verbalizing what is observed in the patient to, for validation and to encourage discussion
- “You sound angry”
7. Encouraging comparisons
- · asking to describe similarities and differences among feelings, behaviors, and events.
- · “Can you tell me what makes you more comfortable, working by yourself or working as a member of a team?”
8. Identifying themes
- asking to identify recurring thoughts, feelings, and behaviors.
- “When do you always feel the need to check the locks and doors?”
- reviewing the main points of discussions and making appropriate conclusions.
- “During this meeting, we discussed about what you will do when you feel the urge to hurt your self again and this include…”
10. Placing the event in time or sequence
- asking for relationship among events.
- “When do you begin to experience this ticks? Before or after you entered grade school?”
11. Voicing doubt
- voicing uncertainty about the reality of patient’s statements, perceptions and conclusions.
- “I find it hard to believe…”
12. Encouraging descriptions of perceptions
- asking the patients to describe feelings, perceptions and views of their situations.
- “What are these voices telling you to do?”
13. Presenting reality or confronting
- stating what is real and what is not without arguing with the patient.
- “I know you hear these voices but I do not hear them”.
- “I am Lhynnelli, your nurse, and this is a hospital and not a beach resort.
14. Seeking clarification
- asking patient to restate, elaborate, or give examples of ideas or feelings to seek clarification of what is unclear.
- “I am not familiar with your work, can you describe it further for me”.
- “I don’t think I understand what you are saying”.
15. Verbalizing the implied
- rephrasing patient’s words to highlight an underlying message to clarify statements.
- Patient: I wont be bothering you anymore soon.
- Nurse: Are you thinking of killing yourself?
- throwing back the patient’s statement in a form of question helps the patient identify feelings.
- Patient: I think I should leave now.
- Nurse: Do you think you should leave now?
- repeating the exact words of patients to remind them of what they said and to let them know they are heard.
- Patient: I can’t sleep. I stay awake all night.
- Nurse: You can’t sleep at night?
18. General leads
- using neutral expressions to encourage patients to continue talking.
- “Go on…”
- “You were saying…”
19. Asking question
- using open-ended questions to achieve relevance and depth in discussion.
- “How did you feel when the doctor told you that you are ready for discharge soon?”
- recognizing and acknowledging patient’s feelings.
- “It’s hard to begin to live alone when you have been married for more than thirty years”.
- pursuing a topic until its meaning or importance is clear.
- “Let us talk more about your best friend in college”
- “You were saying…”
- providing a view of the meaning or importance of something.
- Patient: I always take this towel wherever I go.
- Nurse: That towel must always be with you.
23. Encouraging evaluation
- asking for patients views of the meaning or importance of something.
- “What do you think led the court to commit you here?”
- “Can you tell me the reasons you don’t want to be discharged?
24. Suggesting collaboration
- offering to help patients solve problems.
- “Perhaps you can discuss this with your children so they will know how you feel and what you want”.
25. Encouraging goal setting
- asking patient to decide on the type of change needed.
- “What do you think about the things you have to change in your self?”
26. Encouraging formulation of a plan of action
- probing for step by step actions that will be needed.
- “If you decide to leave home when your husband beat you again what will you do next?”
27. Encouraging decisions
- asking patients to make a choice among options.
- “Given all these choices, what would you prefer to do.
28. Encouraging consideration of options
- asking patients to consider the pros and cons of possible options.
- “Have you thought of the possible effects of your decision to you and your family?”
29. Giving information
- providing information that will help patients make better choices.
- “Nobody deserves to be beaten and there are people who can help and places to go when you do not feel safe at home anymore”.
30. Limit setting
- discouraging nonproductive feelings and behaviors, and encouraging productive ones.
- “Please stop now. If you don’t, I will ask you to leave the group and go to your room.
31. Supportive confrontation
- acknowledging the difficulty in changing, but pushing for action.
- “I understand. You feel rejected when your children sent you here but if you look at this way…”
32. Role playing
- practicing behaviors for specific situations, both the nurse and patient play particular role.
- “I’ll play your mother, tell me exactly what would you say when we meet on Sunday”.
- asking the patient for a verbal description of what will be said or done in a particular situation.
- “Supposing you meet these people again, how would you respond to them when they ask you to join them for a drink?”.
- pointing out specific behaviors and giving impressions of reactions.
- “I see you combed your hair today”.
35. Encouraging evaluation
- asking patients to evaluate their actions and their outcomes.
- “What did you feel after participating in the group therapy?”.
- giving feedback on positive behaviors.
- “Everyone was able to give their options when we talked one by one and each of waited patiently for our turn to speak”.
- Giving advise
- Talking about your self
- Telling client is wrong
- Entering into hallucinations and delusions of client
- False reassurance
- Giving approval
- Asking WHY?
- Changing subject
- Defending doctors and other health team members.
- talking rapidly, changing subjects too often, and asking for more information than can be absorbed at one time.
- “What’s your name? I see you like sports. Where do you live?”
2. Value Judgments
- giving one’s own opinion, evaluating, moralizing or implying one’s values by using words such as “nice”, “bad”, “right”, “wrong”, “should” and “ought”.
- “You shouldn’t do that, its wrong”.
- sending verbal and non-verbal messages that contradict one another.
- The nurse tells the patient “I’d like to spend time with you” and then walks away.
- remaining silent and unresponsive, not picking up cues, and failing to give feedback.
- The patient ask the nurse, simply walks away.
5. False reassurance/ agreement
- Using cliché to reassure client.
- “It’s going to be alright”.
- Ignoring or denying another’s presence, thought’s or feelings.
- Client: How are you?
- Nurse responds: I can’t talk now. I’m too busy.
7. Focusing on self
- responding in a way that focuses attention to the nurse instead of the client.
- “This sunshine is good for my roses. I have beautiful rose garden”.
8. Changing the subject
- introducing new topic
- inappropriately, a pattern that may indicate anxiety.
- The client is crying, when the nurse asks “How many children do you have?”
9. Giving advice
- telling the client what to do, giving opinions or making decisions for the client, implies client cannot handle his or her own life decisions and that the nurse is accepting responsibility.
- “If I were you… Or it would be better if you do it this way…”
10. Internal validation
- making an assumption about the meaning of someone else’s behavior that is not validated by the other person (jumping into conclusion).
- The nurse sees a suicidal clients smiling and tells another nurse the patient is in good mood.
Other ineffective behaviors and responses:
- Defending – Your doctor is very good.
- Requesting an explanation – Why did you do that?
- Reflecting – You are not suppose to talk like that!
- Literal responses – If you feel empty then you should eat more.
- Looking too busy.
- Appearing uncomfortable in silence.
- Being opinionated.
- Avoiding sensitive topics
- Arguing and telling the client is wrong
- Having a closed posture-crossing arms on chest
- Making false promises – I’ll make sure to call you when you get home.
- Ignoring the patient – I can’t talk to you right now
- Making sarcastic remarks
- Laughing nervously
- Showing disapproval – You should not do those things.