Therapeutic Nurse–Patient Relationship



Therapeutic Nurse–Patient Relationship


Gail W. Stuart





The therapeutic nurse–patient relationship is a mutual learning experience and a corrective emotional experience for the patient. It is based on the humanity of the nurse and patient, mutual respect, and acceptance of sociocultural differences. In this relationship the nurse uses personal qualities and clinical skills in working with the patient to effect insight and behavioral change. Most importantly, the core of mental health nursing is providing hope for a better future to patients and their families (Stuart, 2010).



Characteristics of the Relationship


The goals of a therapeutic relationship are directed toward promoting the patient’s growth and well-being and include the following dimensions:



To achieve these goals, various aspects of the patient’s life experiences are explored. The nurse allows the patient to express thoughts and feelings and relates these to observed and reported behaviors, clarifying areas of conflict and anxiety. The nurse identifies and maximizes the patient’s ego strengths and encourages socialization and family relatedness. Together the patient and nurse correct communication problems and modify maladaptive behavior patterns by testing new patterns of behavior and more adaptive coping mechanisms (Wheeler, 2011). In the nurse-patient relationship, differing values are respected. The two communicate through a dialogue or discussion, affirming the patient’s reality and worth and allowing the patient to more fully define ego identity.


Rogers (1961) summarizes the characteristics of a helping relationship that facilitate growth (Box 2-1). All nurses working with patients should ask themselves these questions because the answers will determine the progress of the relationship. The therapeutic nurse-patient relationship is complex, but evidence shows that a strong therapeutic alliance has a positive effect on patient outcomes (Norcross et al, 2006; Miner-Williams, 2007). This chapter examines the personal qualities of the nurse as helper, the phases of the relationship, facilitative communication, responsive and action dimensions, therapeutic impasses, and therapeutic outcomes (Figure 2-1). Each of these factors influences the nurse’s effectiveness.





Personal Qualities of the Nurse


Research suggests that some essential qualities are needed if one is to help others. These qualities are necessary for all nurses who wish to be therapeutic. They also help the nurse set goals for future growth. The key therapeutic tool of the psychiatric nurse is the use of oneself. Thus self-analysis is the first building block in providing quality nursing care.




Awareness of Self


Effective helpers must be able to answer the question, Who am I? Nurses who care for the biological, psychological, and sociocultural needs of patients see a broad range of human experiences. They must learn to deal with anxiety, anger, sadness, and joy in helping patients throughout the health-illness continuum. Self-awareness is a key part of the psychiatric nursing experience, and the nurse’s goal is to achieve authentic, open, and personal communication (LaTorre, 2005; Vandemark, 2006; Scheick, 2011). The nurse must be able to examine personal feelings, actions, and reactions. A good understanding and acceptance of self allow the nurse to acknowledge a patient’s differences and uniqueness.


A holistic nursing model of self-awareness consists of four interconnected components: psychological, physical, environmental, and philosophical (Campbell, 1980):



Together these components provide a model that can be used to promote the self-awareness and self-growth of nurses and the patients for whom they care.



Increasing Self-Awareness


No one ever completely knows the inner self, as shown in the Johari window (Figure 2-2).




Taken together, these quadrants represent the total self. The following three principles help explain how the self functions:



The goal of increasing self-awareness is to enlarge the area of quadrant 1 while reducing the size of the other three quadrants. To increase self-knowledge, it is necessary to listen to the self. This means the individual allows genuine emotions to be experienced; identifies and accepts personal needs; and moves the body in free, joyful, and spontaneous ways. It includes exploring personal thoughts, feelings, memories, and actions.


The next step in the process is to reduce the size of quadrant 2 by listening to and learning from others. Knowledge of self is not possible alone. As we relate to others, we broaden our perceptions of self, but such learning requires active listening and openness to the feedback others provide. The final step involves reducing the size of quadrant 3 by self-disclosing, or revealing to others important aspects of the self. Self-disclosure is both a sign of personality health and a means of achieving healthy personality.


Compare panels A and B of Figure 2-3. Panel A represents a person with little self-awareness whose behaviors and feelings are limited. Panel B, however, shows an individual with great openness to the world. Much of this person’s potential is being developed and realized. Panel B represents an individual who has an increased capacity for experiences of all kinds: joy, hate, work, and love. This person also has few defenses and can interact more spontaneously and honestly with others. It is a worthy goal for the nurse to pursue.





The Nurse and Self-Growth


Nurses need time to explore and define the many parts of their personalities. If their nursing experiences involve perceiving, feeling, and thinking, then nursing students should be given the time and opportunity to study these experiences. Authenticity in relationships must be learned, and nurses must first experience openness and authenticity in relationships with instructors and supervisors. The student and instructor can participate in a relationship that accepts and respects their individual differences. Instructors can help students by facilitating students’ self-awareness, increasing their level of functioning, stimulating more self-direction, and helping them cope with stressors.


Authenticity involves being open to self-exploration of thoughts, needs, emotions, values, defenses, actions, communications, problems, and goals. Nursing students have many new experiences that provide opportunities for self-learning. The student will be faced with disease, bizarre behavior, complex problems, and even death. Feelings related to these experiences should be discussed. For example, students might enter clinical settings with high ideals and unrealistic images. Perhaps they view nurses as all-knowing, all-caring “miracle workers.” During initial encounters, students may feel fearful, anxious, and inadequate, wondering how a nurse gains the necessary knowledge.


Nursing students might devalue their abilities and feel like an imposition on patients, or they may identify closely with patients and feel anger toward the impersonal system and unresponsive personnel. The feelings involved in all these situations should be identified, discussed, and analyzed. Only then can nurses resolve them in a constructive manner.


Throughout the growing process the student needs the support and guidance of a noncritical but challenging instructor. Together they can analyze the student’s behavior, and the student can assess personal strengths and limitations. It is often helpful if students share these experiences with a peer group. Students can empathize, critique, and support each other while they learn more about themselves. Another effective tool is the use of a journal to express and explore one’s thoughts and impressions. Finally, objective self-examination is not easy or pleasant, particularly when findings conflict with self-ideals. However, like many painful experiences, discovering self-awareness presents a challenge—that of accepting self-limitations or changing the behaviors that support them.




Clarification of Values


Nurses should be able to answer the question, What is important to me? Awareness of one’s own values helps the nurse to be honest, to better accept differences in others, and to avoid the unethical use of patients to meet personal needs. Nurses should avoid the temptation to use patients for their personal satisfaction or security. If nurses do not have personal fulfilment, they need to realize that fact. Their sources of dissatisfaction should be clarified to prevent them from interfering with the success of the nurse-patient relationship.



Value Systems


Values are concepts that are formed as a result of life experiences with family, friends, culture, education, work, and relaxation. The word value has positive connotations of worth or significance, but values also can imply negatives. If we value honesty, then it follows that we do not value dishonesty. People are likely to hold strong values related to religious beliefs, family ties, sexual preferences, other ethnic groups, and gender role beliefs. One of the many challenges facing nurses today is the need to provide care for patients from diverse backgrounds. Because the goals of treatment are determined greatly by beliefs and values, establishing a therapeutic relationship with patients from different backgrounds requires particular skill and sensitivity. This is discussed in Chapter 7.


Value systems provide the framework for many daily decisions and actions. By being aware of their value systems, nurses can identify situations in which value systems are in conflict. Clarification of values also provides some insurance against the tendency to project values onto other people. Many therapeutic relationships test the nurse’s values. For example, a patient may describe a sexual behavior that the nurse finds unacceptable; a patient may talk about divorce, whereas the nurse may strongly believe that marriage contracts should not be broken; or a patient may be a “born-again” Christian, but the nurse may not believe in God or religion.




Value Clarification Process


The value clarification process allows individuals to discover their values by assessing, exploring, and determining what those values are and how they influence their own thoughts, attitudes, and behaviors. Value clarification does not determine what the individual’s values should be or what values should be followed. Value clarification focuses only on the process of valuing, or on how people come to have the values they hold.


Seven criteria are used to determine a value. These criteria should be considered in relation to a person’s strongest value and tested against the person’s own definition of a value. The seven criteria are grouped into the three steps listed in Table 2-1. The three criteria of choosing rely on the person’s cognitive abilities; the two criteria of prizing emphasize the emotional or affective level; and the two criteria of acting have a behavioral focus. A change takes place when certain contradictions are perceived in the person’s value system. To eliminate the distress that follows such a realization, the person realigns values to coincide with the new view of self.




The Mature Valuing Process


The valuing process in the mature person is complex, and the choices are often difficult. There is no guarantee that the choice made will be self-actualizing. The valuing process in the mature person has the following characteristics (Kirschenbaum and Simon, 1973):





Exploration of Feelings


Some people think that helping others requires complete objectivity and detachment. This is definitely not true. Complete objectivity and detachment describe someone who is unresponsive, unapproachable, impersonal, and self-alienated—qualities that block the establishment of a therapeutic relationship. Rather, nurses should be open to, aware of, and in control of their feelings so that they can be used to help patients. The feelings that nurses have serve an important purpose as barometers for feedback about themselves and their relationships with others.


In helping others, nurses have many feelings: satisfaction at seeing a patient improve, disappointment when a patient regresses, distress when a patient refuses help, and anger when a patient is demanding or manipulative. Nurses who are open to their feelings understand how they are responding to patients and how they appear to patients. The nurse’s feelings are valuable clues to the patient’s problems. For example, despite the patient’s statement that “things are going real well,” the nurse might perceive a strong sense of despair or anger. So too, nurses should be aware of the feelings they convey to the patient. Is the nurse’s mood one of hopelessness or frustration? If nurses view feelings as feedback mechanisms, their effectiveness as helpers will improve.



Serving as Role Model


Formal helpers have a strong influence on those they help, and nurses function as role models for their patients. Research has shown the power of role models in molding socially adaptive, as well as maladaptive, behavior. Thus a nurse has an obligation to model adaptive and growth-producing behavior. If a nurse has a chaotic personal life, it will show in the nurse’s work with patients, thereby decreasing the effectiveness of care. The nurse’s credibility as a helper also will be questioned. The nurse may think that it is possible to separate one’s personal life from one’s professional life, but in caring for patients this is not possible because psychiatric nursing is the therapeutic use of self. This does not mean that the nurse must be a model citizen or must live a fully contented life. What it does mean is that the effective nurse has a fulfilling and satisfying personal life that is not dominated by conflict, distress, or denial, and that the nurse’s approach to life conveys a sense of growing, hopefulness, and adapting.




Altruism


It is important for nurses to have an answer to the question, Why do I want to help others? An effective helper is interested in people and tends to help out of a love for humanity. It also is true that everyone seeks a certain amount of personal satisfaction and fulfillment from work. The goal is to maintain a balance between these two needs. Helping motives can become destructive tools in the hands of naive or zealous users.


Another danger lies in adopting an extreme view of altruism. Altruism is concern for the welfare of others. It does not mean that an altruistic person should not expect adequate compensation and recognition or must practice denial or self-sacrifice. Only if personal needs have been appropriately met can the nurse expect to be maximally therapeutic. Finally, a sense of altruism also can apply to changing social conditions to meet human welfare needs. One goal of all helping professionals should be to create a people-serving and growth-facilitating society. Thus a necessary role for the nurse is to work to change the larger structure and process of society in ways that will promote the individual’s health and well-being.



Ethics and Responsibility


Personal beliefs about people and society can serve as guidelines for action. The Code for Nurses with Interpretive Statements (American Nurses Association, 2001) reflects common values regarding nurse-patient relationships and responsibilities and serves as a frame of reference for all nurses in their judgments about patient welfare and social responsibility. Responsible ethical choice involves accountability, risk, commitment, and justice. Related to the nurse’s sense of ethics is the need to assume responsibility for one’s own behavior. This means knowing one’s limitations and strengths and being accountable for them. Ethical issues related to psychiatric nursing are discussed in Chapter 8.




Phases of the Relationship


A vital characteristic of the nurse-patient relationship is the sharing of behaviors, thoughts, and feelings that is based on clear role expectations. The support requested and provided should be within the boundaries of the nurse’s role as a professional caregiver. The elements of a therapeutic nurse-patient relationship apply to all clinical settings and can be adapted to settings in which the patient is only seen for a brief period of time (Spiers and Wood, 2010). Nurses working in medical, surgical, obstetrical, oncological, and other specialty areas need to understand and be able to use therapeutic nurse-patient relationship skills. Four phases of the nurse-patient relationship have been identified: preinteraction phase; introductory, or orientation, phase; working phase; and termination phase. Each phase builds on the preceding one and has specific tasks.



Preinteraction Phase


Concerns of New Nurses


The preinteraction phase begins before the nurse’s first contact with the patient. The nurse’s initial task is one of self-exploration. This is no small task because psychiatric nursing clinical experience can bring both stress and challenge to the student (Happell and Gough, 2009). In the first experience of working with psychiatric patients, the nurse brings the misconceptions and prejudices of the general public, in addition to feelings and fears common to all novices (Halter, 2008; Webster, 2009) (Box 2-2). A major one is anxiety or nervousness, which is common to new experiences of any kind. Another feeling is ambivalence or uncertainty because nurses may see the need for working with these patients but feel uncertain about their ability to do so.



The informal nature of psychiatric settings may threaten the nurse’s role identity. A common first reaction among students is a feeling of panic when they realize that they “can’t tell the patients from the staff.” It is unsettling for some students to give up their uniforms, stethoscopes, and scissors, which emphasizes that, in this nursing setting, the most important tools are the ability to communicate, empathize, and solve problems. Without a physical illness to manage, new students may feel self-conscious and hesitant about introducing themselves to a patient and starting a conversation.


Some nurses express feelings of inadequacy and fears of hurting or exploiting the patient. They worry about saying the wrong thing, which might drive the patient “over the brink.” With their limited knowledge and experience, they doubt that they will be of any value. They wonder how they can help or whether they can really make a difference. Some nurses perceive the plight of psychiatric patients as hopeful; others perceive it as hopeless. A common fear of nurses is related to the stereotype of psychiatric patients being violent. Because this is the picture portrayed by the media, many nurses are afraid of being physically hurt by a patient. Other nurses fear being psychologically hurt by a patient through rejection or silence. A final fear is related to nurses’ questioning their own mental health. Nurses may worry about how working with psychiatric patients might affect their own psychological struggles.


The following clinical example contains many of the feelings and fears expressed by one nursing student in the preinteraction phase of self-analysis, as reported in the notes from her journal of her psychiatric rotation.



Clinical Example


When first told that I would have a clinical psychiatric nursing experience, I received this information with a blank mind. Mental overload, denial, repression, or whatever it was made me hear the words but put off dealing with it. Then, when given a chance to sort through my thoughts and feelings, I thought more about what this experience would be like. Having never been personally involved with anyone who was hospitalized for a psychiatric illness, I was unable to rely on past personal experiences. I did, however, have quite a number of impressions from novels, television, and the movies.


As I thought more about it, I realized that three things scared me the most about this experience. First, I felt that the behavior of psychiatric patients is quite unpredictable. Would they get violent or aggressive without any warning? Would this aggression be directed toward me? If so, would I be hurt? Second, related to the first, is my feeling of inadequacy. I’ve been exposed to physically ill people and have learned how to respond to them. But not the psychiatrically ill. How can I help? What if I do or say something that offends them? Will I have the patience to persevere? I just don’t know, and my not knowing makes me even more nervous. My third fear is how seeing and being in contact with the psychiatrically ill will affect me. Although I know it’s not contagious, will I begin to doubt my own stability and sanity? I mean, adolescence hasn’t been easy for me, and I feel like I’m just now beginning to see things more clearly and feel better about myself. Will this experience stir up my fears and doubts, and, if so, how will I handle it? I am beginning to realize that there is a fine line between health and illness and that the psychiatric patients we’ll meet have been unable to gather enough resources from within to cope with their problems. Help, reassurance, and understanding are their needs. I’m hoping I can help them… but, honestly, I’m just not sure.




Self-Assessment

Experienced nurses benefit by asking themselves the following questions:



The nurse’s self-analysis in the preinteraction phase is a necessary task. To be effective, nurses should have a reasonably stable self-concept and an adequate amount of self-esteem. They should engage in positive relationships with others and face reality to help patients do the same. If they are aware of and in control of what they convey to their patients verbally and nonverbally, nurses can function as role models. Some nurses, however, abandon their personal strengths and assume a mask of “professionalism” that is not true to their authentic self. This acts as a barrier to establishing mutuality with patients.


Other tasks of this phase include gathering data about the patient if information is available and planning for the first interaction with the patient. The nursing assessment is begun, but most of the work related to it is done with the patient in the second phase of the relationship.



Introductory, or Orientation, Phase


It is during the introductory phase that the nurse and patient first meet. One of the nurse’s primary concerns is to find out why the patient sought help (Table 2-2). The reason for seeking help forms the basis of the nursing assessment, helps the nurse focus on the patient’s problem, and determines the patient’s motivation for treatment. It is important for the nurse to realize that help-seeking varies among different cultures, social, and ethnic groups. Another task is for the patient and nurse to establish their partnership and agree on the nature of the problem and the patient’s treatment goals. The focus is on the patient’s goals and not what the nurse believes should be done. Both the nurse and the patient may experience some degree of discomfort and nervousness in the introductory phase. Reasons that patients may have difficulty receiving help are listed in Box 2-3.




TABLE 2-2


ANALYSIS OF WHY PATIENTS SEEK PSYCHIATRIC HELP













































REASONS FOR PATIENTS SEEKING PSYCHIATRIC CARE APPROPRIATE NURSING APPROACH SAMPLE RESPONSE
Environmental Change from Home to Treatment Setting
They desire protection, comfort, rest, and freedom from demands of their home and work environments. Emphasize the ability of the environment to provide protection and comfort while the healing process of the mind occurs. “Tell me what it was at home/on the job that made you feel so overwhelmed.”
Nurturance
They wish for someone to care for them, cure their illness, and make them feel better. Acknowledge their nurturance needs, and assure them that help and caring are available. “I’m here to help you feel better.”
Control
They are aware of their destructive impulses directed toward themselves or others but lack internal control. Offer sources of internal control, such as medication, if prescribed; reinforce external controls available through the staff. “We’re not going to let you hurt yourself. Tell us when these thoughts come to mind, and someone will stay with you.”
Psychiatric Symptoms
They describe symptoms of depression, nervousness, or crying spells and actively want to help themselves. Ask for clarification of symptoms, and strive to understand life experiences of the patient. “I can see that you’re nervous and upset. Can you tell me about how things are at home/on the job so I can better understand?”
Problem Solving
They identify a specific problem or area of conflict and express desire to reason it out and change. Help patient look at problem objectively; use problem-solving process. “How has drinking affected your life?”
Advised To Seek Help
Family member, friend, or health professional has convinced them to get treatment. They may feel angry, ambivalent, or indifferent. Confirm facts surrounding seeking of help, and set appropriate limits. “I see that you’re angry about being here. I hope that after we talk you might feel differently.”


image


Modified from Burgess A, Burns J: Am J Nurs 73:314, 1973.



Forming a Contract


The tasks in this phase of the relationship are to establish a climate of trust, understanding, acceptance, and open communication and formulate a contract with the patient. Establishing a contract is a mutual process in which the patient participates as fully as possible. Box 2-4 lists the elements of a nurse-patient contract. The contract begins with the introduction of the nurse and patient, exchange of names, and explanation of roles. An explanation of roles includes the responsibilities and expectations of the patient and nurse, with a description of what the nurse can and cannot do.



This is followed by a discussion of mutually agreed on specific goals, in which the nurse focuses on what the patient identifies as important problems to be resolved. Because establishing the contract is a mutual process, it is a good opportunity to clarify misperceptions held by either the nurse or the patient. The issue of confidentiality is an important one to discuss with the patient at this time. Confidentiality involves the disclosure of certain information only to another specifically authorized person (Chapter 8). This means that information about the patient will be shared only with people who are directly involved in the patient’s care in the form of verbal reports and written notes. This is important in providing for the continuity and comprehensiveness of patient care and should be clearly explained to the patient.





Termination Phase


Termination is one of the most difficult but most important phases of the therapeutic nurse-patient relationship. It is a time to exchange feelings and memories and to evaluate mutually the patient’s progress and goal attainment. Levels of trust and intimacy are heightened, reflecting the quality of the relationship and the sense of loss experienced by both nurse and patient. Box 2-5 lists criteria that can be used to determine whether the patient is ready to terminate.



Together the nurse and the patient review the progress made in treatment and the attainment of specified goals. It is appropriate to make referrals at this time for continued care or treatment. Successful termination requires that the patient work through feelings related to separation from emotionally significant people. The nurse can help by allowing the patient to experience and feel the effects of the anticipated loss, to express the feelings generated by the impending separation, and to relate those feelings to former symbolic or real losses. Helping the patient work and grow through the termination process is an essential goal of each relationship.


Learning to bear the sorrow of the loss while integrating positive aspects of the relationship into one’s life is the goal of termination for both the nurse and the patient. The patient’s response will be affected by the nurse’s ability to remain open, sensitive, empathic, and responsive to the patient’s changing needs. The impending termination can be as difficult for the nurse as for the patient. Nurses who can begin this process by reviewing their thoughts, feelings, and experiences will be more aware of personal motivation and more responsive to patients’ needs. The major tasks of the nurse during each phase of the nurse-patient relationship are summarized in Table 2-3.





Facilitative Communication


Communication, which takes place on two levels (verbal and nonverbal), can either facilitate the development of a therapeutic relationship or serve as a barrier to it (Shattell and Hogan, 2005; Sheldon et al, 2006). Everyone communicates constantly from birth until death. All behavior is communication, and all communication affects behavior. Communication is critical to nursing practice because of the following:




Verbal Communication


Verbal communication occurs through words, spoken or written. Taken alone, verbal communication can convey factual information accurately and efficiently. It is a less effective means of communicating feelings or subtle meanings. It represents only a small part of total human communication. Another limitation of verbal communication is that words can change meaning with different social or cultural groups because words have both denotative and connotative meanings. The denotative meaning of a word is its actual or concrete meaning. For example, the denotative meaning of the word bread is “a food made of a flour or grain dough that is kneaded, shaped, allowed to rise, and baked.”


The connotative meaning of a word, in contrast, is its implied or suggested meaning. Thus the word bread can suggest many different connotative or personalized meanings. Depending on a person’s experiences, preferences, and present frame of reference, the person may think of French bread, rye bread, or pita bread. When used as slang, “give me some bread” may mean “give me some money.” Thus the characteristics of the speaker and the context in which the phrase is used influence the specific meaning of verbal language.


When communicating verbally, many people assume that they are “on the same wavelength” as the listener; but because words are only symbols, they seldom mean precisely the same thing to two people. And if the word represents an abstract idea such as “depressed” or “hurt,” the chance of misunderstanding or misinterpretation may be great. In addition, many feeling states or personal thoughts cannot be put into words easily. Nurses should try to overcome these problems by checking their interpretation and incorporating information from the nonverbal level as well.


Today more than ever before, nurses need to be prepared to communicate effectively with people from a variety of socioeconomic and ethnocultural backgrounds. For example, psychiatric patients may be evaluated in their second language, such as English, but competence in a second language varies depending on the individual and the stage of illness. In addition, cultural nuances in language often are not conveyed in translation, even when the patient uses similar words in the second language. Patients also may use a second language as a form of resistance to avoid intense feelings or conflicting thoughts, and events that may have occurred before a person learned English, if that is the second language, may not be easily communicated. The effective psychiatric nurse uses verbal communication sensitively to promote mutual respect based on understanding and acceptance of cultural differences. The nurse also may communicate respect for the patient’s dialect by adapting to the patient’s linguistic style by using fewer words, more gestures, or more expressive facial behaviors or by obtaining a trained interpreter.




Nonverbal Communication


Nonverbal communication includes all relayed information that does not involve the spoken or written word, including cues from all five senses. It has been estimated that about 7% of meaning is transmitted by words, 38% is transmitted by paralinguistic cues such as vocal tones, and 55% is transmitted by body cues. Nonverbal communication is often unconsciously motivated and may more accurately indicate a person’s meaning than the words being spoken. People tend to say what they think the receiver wants to hear, whereas less acceptable or more honest messages may be communicated by the nonverbal route.



Types of Nonverbal Behaviors


The various types of nonverbal behaviors are all influenced by one’s sociocultural background. Following are brief descriptions of five categories of nonverbal communication.


Vocal cues include all the nonverbal qualities of speech. Some examples include pitch; tone of voice; quality of voice; loudness or intensity; rate and rhythm of talking; and unrelated nonverbal sounds, such as laughing, groaning, nervous coughing, and sounds of hesitation (“um,” “uh”). These are vital cues of emotion and can be powerful communicators of information.


Action cues are body movements, sometimes referred to as kinetics. They include automatic reflexes, posture, facial expression, gestures, mannerisms, and actions of any kind. Facial movements and posture can be particularly significant in interpreting the speaker’s mood.


Object cues are the speaker’s intentional and unintentional use of all objects. Dress, furnishings, and possessions all communicate something about the speaker’s sense of self. These cues often are consciously selected by the individual and therefore may be chosen specifically to convey a certain look or message. Thus they can be less accurate than other types of nonverbal communication.


Space provides another clue to the nature of the relationship between two people. It must be examined based on sociocultural norms and customs. The following four zones of space are evident interpersonally in typical Western culture:



Observation of seating arrangements and use of space by patients can provide valuable information to the nurse, clarifying not only the nurse’s assessment of the patient but also the way in which the nursing intervention should be implemented.


Touch involves both personal space and action. It is possibly the most personal of the nonverbal messages. A person’s response to it is influenced by setting, cultural background, type of relationship, gender of communicators, ages, and expectations. It can be supportive or threatening. Touch can express a desire to connect with another person, as a way of meeting them or relating to them (holding hands). It can be a way of expressing a feeling of concern, empathy, or caring (patting a shoulder). There also is the concept of therapeutic touch—the nurse lays her hands on or close to the body of an ill person for the purpose of helping or healing. Touch continues to be the hallmark of nursing with its therapeutic, comforting effects. It is a universal and basic aspect of all nurse-patient relationships. It is often described as the first and most fundamental means of communication.




Interpreting Nonverbal Behavior


All types of nonverbal messages are important, but interpreting them correctly can present problems for the nurse. It is impossible to examine nonverbal messages out of context, and sometimes the individual’s body reveals a number of different and perhaps conflicting feelings at the same time.


Sociocultural background is a major influence on the meaning of nonverbal behavior. In the United States, with its diverse communities, messages between people of different upbringing can easily be misinterpreted. For instance, Arab Americans tend to stand closer together when speaking, and Asian Americans tend to touch more; touching in the United States is often minimized because of perceived sexual overtones. Because the meaning attached to nonverbal behavior is so subjective, it is essential that the nurse check and evaluate its meaning carefully.


Nurses should note and respond to the variety of nonverbal behaviors displayed by the patient, particularly voice inflections, body movements, gestures, facial expressions, posture, and physical energy levels. Incongruent behavior and contradictory messages are especially significant communications. The nurse should refer to the specific behavior observed and try to confirm its meaning and significance with the patient. The nurse may use the following three kinds of responses to the patient:




The nurse’s first possible response is a reflection of and an attempt to validate the patient’s feelings. The purpose is to communicate to the patient the nurse’s awareness of his feelings, to show acceptance of those feelings, and to request that he focus on them and elaborate on them. The nurse’s second possible response deals with the content of the patient’s message. The nurse clarifies what the patient is trying to say. The third possible response shares both the nurse’s perception of her patient’s feelings and the personal disclosure that she has some of those same feelings. This type of response may help the patient feel that the nurse accepts and understands him.



Implications for Nursing Care


Besides responding to patients’ nonverbal behavior, nurses should incorporate aspects of it into patient care. For example, patients who resist closeness will be disturbed by entry into their intimate space. The nurse can assess the patient’s level of spatial tolerance by observing the distance the patient maintains with other people. The nurse also can be alert to the patient’s response during their interaction. If the nurse sits next to the patient on the sofa, does the patient get up and move to a chair? If the nurse moves closer to the patient, does the patient move away to reestablish the original space? Sometimes increasing the space between the nurse and an anxious patient can reduce the anxiety enough to allow the interaction to continue. A decrease in the distance the patient chooses to maintain from others may indicate a decrease in interpersonal anxiety.


Height may communicate dominance and submission. Communication is made easier when both participants are at similar eye levels. Orientation of the participants’ body positions also is significant. Face-to-face confrontation is more threatening than oblique (sideways) body positions. The physical setting also has spatial meaning. Control issues are minimized when communication takes place in a neutral area that belongs to neither participant. However, people quickly identify their own turf, even in unfamiliar settings, and then begin to exert ownership rights over this area. A common example of this can be seen in most classroom settings. At the beginning of the semester, people sit randomly, but the arrangement usually solidifies after a couple of classes. Students then feel vaguely annoyed if they arrive in class to find another person in “their seat.” They are experiencing an invasion of personal space.


Touch also should be used carefully. Patients who are sensitive to issues of closeness may experience a casual touch as an invasion or an invitation to intimacy, which may be even more frightening. If procedures requiring physical contact must be carried out, careful explanations should be given both before and during the procedure. In addition, the nurse should always be aware of the potential for touch to be interpreted in a sexual way, thus creating problems related to the sexual conduct of the nurse within the nurse-patient relationship. Despite these issues, touch is a significant part of psychiatric nursing practice. Reasons that nurses use touch include the following:



Finally, nurses must be aware not only of patients’ nonverbal cues but also of their own. The nurse’s nonverbal cues can communicate interest, respect, and genuineness or disinterest, annoyance, and lack of respect. Positive nonverbal behaviors include smiles, head nods, gestures, eye contact, and leaning one’s body forward.




The Communication Process


The three elements of the communication process are perception, evaluation, and transmission. Perception occurs when the sensory end organs of the receiver are activated. The impulse is then transmitted to the brain. Human beings mostly rely on visual and auditory stimuli for communications.


When the sensory impulse reaches the brain, evaluation takes place. Personal experience allows for the evaluation of the new experience. If the person encounters a new experience for which there is no frame of reference, confusion results. Evaluation results in two responses: a cognitive response related to the informational part of the message and an affective response related to the relationship aspect of the message. Most messages stimulate both types of responses.


When the evaluation of the message is complete, transmission takes place that the sender receives as feedback. This feedback influences the continued course of the communication cycle. It is impossible not to transmit some kind of feedback. Even lack of any visible response is feedback to the sender that the message did not get through, was considered unimportant, or was an undesirable interruption. Feedback stimulates perception, evaluation, and transmission by the original sender. The cycle continues until the participants agree to end it or one participant physically leaves the setting.



Structural Model


Theoretical models of the communication process show visual relationships more clearly and can help in finding and correcting communication breakdowns or problems. The structural model of communication has five components: the sender, the message, the receiver, the feedback, and the context (Figure 2-4):


Feb 25, 2017 | Posted by in NURSING | Comments Off on Therapeutic Nurse–Patient Relationship
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