Ch. 9 Communication and the Therapeutic Relationship Flashcards Preview

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Flashcards in Ch. 9 Communication and the Therapeutic Relationship Deck (40):

Professional Core Belief

Nurses need to communicate assertively and responsibly w/ clients and colleagues to demonstrate caring

Patients request

You may need to validate w/ them what they are requesting if it is not clear


Responsible Communication

willing to answer for ones own conduct instead of blaming situations or other people


Caring Communication

focusing on the relationship w/ the client instead of the procedure you are doing. Having meaningful connections w/ clients. Creating hope and trust


Assertive Communication

being clear about your needs and respectful in language and behavior, striving for win-win situations. This is in contrast to passive or aggressive.


Assertive Communication: Passive

does not state needs, lets others make decisions and choices, frustrating to others


Assertive Communication: Aggressive

wants to win at all costs, defeat others, makes choices for others



3 criteria for success in assertiveness:
--doing it when there is adequate time, respectfully phrasing your needs, and doing it when the person is receptive to discussion

To improve your assertiveness:
1. Determine what rights you are giving up
2. Identify what irrational belief you have
3. Use DESC
--Describe situation
--Express what you think and feel
--Specify your request
--State consequences


Therapeutic Use of Self

Application of nurse’s own personality and characteristics w/in the interaction to facilitate hearing

Open-ended process, continues to develop throughout life as we learn new ways to relate to others

Basic concept involves understanding of self and others


Nurse-Patient Relationship

Pre-orientation phase
-get report

Orientation phase
-First meeting
-Testing the relationship
-Ends when patient begins identifying problems

Working phase
-Identification of problems
-Problem solving

Resolution phase
-Problems resolve
-Relationship ends


Therapeutic impasses are usually in what phase?

Working phase


Therapeutic Impasses: Transference

Unconscious response of client

Client: inappropriate intensity of feelings: hostility, anger, love, dependence

Nurse: confront distortions of reality gently, facilitate client awareness


Therapeutic Impasses: Countertransference

Inappropriate intensity of nurse’s feelings

Nurse must increase self-awareness and access supervision to assist in dealing w/ client more effectively


Resistance - Testing Behaviors

Normal response to anxiety-provoking thoughts and feelings - afraid of self-exploration

Client: avoidance, acting out, forgetting, silence, lateness

Nurse: make observations, support client to deal w/ anxiety



The process of understanding one’s own beliefs, thoughts, motivations, biases, and limitations, and recognizing how they affect others

The development of self-awareness requires a willingness to be introspective

Biologic, Psychological, and Social


Self-Awareness: Biologic

1. Gender, age, body weight, height, and other physical characteristics
2. Genetic makeup, chronic illness, or physical disability


Self-Awareness: Psychological

1. Psychological makeup
2. Traumatic experiences


Self-Awareness: Social

1. Sociocultural values
2. Acknowledge cultural heritage


Johari's Window: Quadrant 1

Open quadrant known to self and known to others


Johari's Window: Quadrant 2

Blind quadrant known to others but not known by self


Johari's Window: Quadrant 3

Hidden quadrant private life space personal secrets


Johari's Window: Quadrant 4

Unknown quadrant unconscious self and unknown to others


Goals of Self-Awareness

Increase size of quadrant 1
--Learn more about yourself, reveal more about yourself to others
--Represents free and spontaneous interaction, easier to relate to others
--Increased self-concept increases confidence, insight produces growth

As quadrant 1 grows, quadrants 2, 3, and 4 shrink accordingly

Reduce size of quadrant 3
--Freer to be yourself

Tiny quadrant 4


Johari Window

The 4 quadrants represent total self

A change in any quadrant affects all other quadrants

The smaller quadrant 1, the poorer the communication

Interpersonal learning means that a change has taken place so quadrant 1 is larger and one or more of the other quadrants is smaller


Increasing Self-Awareness and Changing Behavior

Begin by listening to yourself - experience emotions, explore thoughts, feelings, and impulses

Listen and learn from others, be open to feedback

Reveal to others important aspects about self (self-disclosure)

Through self-awareness and conscious effort, the nurse can change learned behaviors to engage effectively in therapeutic relationships



Verbal communication (7% of communication)
--Spoken word, underlying emotion, context, connotation

Nonverbal communication (93% of communication)
--Gestures, expressions, body language

Therapeutic communication
--Ongoing process of interaction in which meaning emerges


Transactional Analysis Model - Eric Berne

Parent: attitudes and behaviors taught

Adult: logic, rational, realistic

Child: feelings from childhood

Three types of transactions:
1. Complementary (ex: adult to adult)
2. Crossed (ex: one party speaking as an adult and the other as a parent)
3. Ulterior (ex: appears to be adult to adult but in reality the client is asking for parenting from the nurse, but does not really want it so rejects all ideas suggested)


Principles of Therapeutic Communication

1. The patient should be the primary focus
2. A professional attitude sets the tone
3. Use self-disclosure only when disclosure has a therapeutic purpose
4. Avoid social relationships with patients
5. Maintain patient confidentiality
6. Assess the patient’s intellectual competence
7. Implement interventions from a theoretic base
8. Maintain a nonjudgemental attitude
9. Avoid giving advice
10. Guide the patient to reinterpret his or her experiences rationally
11. Track the patient’s verbal interaction through the use of clarifying statements


Using Verbal Communication


Verbal communication techniques
--Science and listening
1. Passive listening
2. Active listening


Communication Process

Sender of message
--Incongruent verbal and non-verbal

Message not transmitted
--Not relevant, nor enough info

Receiver is perceiver of message

Feedback is response of receiver
--Failure to give feedback

Context is the setting
--Noise, temperature, or distractions


Selecting Communication Techniques

Choosing the best response begins with assessing and interpreting the meaning of patient’s communication - both verbal and nonverbal

The next step is identifying the desired patient outcome

Focus on the patient’s feelings


Applying Communication Concepts: Rapport

interpersonal harmony characterized by understanding and respect


Applying Communication Concepts: Validation

explicitly checking out one’s own thoughts or feelings w/ another person


Applying Communication Concepts: Empathy

ability to experience, in the present, the situation as another did at some time in the past


Applying Communication Concepts: Boundaries

the defining limits of persons, objects, or relationships


Biopsychosocial Boundaries and Body Space Zones

Personal boundaries:
-Four body zones [from closest to farthest away from person]
1. Intimate zone
2. Personal zone
3. Social Zone
4. Public Zone

The patient will allow the nurse to enter the personal zone, but will express discomfort is the nurse breaches the intimate zone

For the nurse, the difficulty lies in differentiating the personal zone from the intimate zone for each patient


Nonverbal Behaviors


Vocal cues
-Tone, loudness, rate, laughing

Action cues
-Body movement, gestures, facial movements, posture

Object cues
-Dress, furnishings, possessions


Professional Boundaries and Ethics

Be aware of professional boundaries to avoid exploitation of the patient

When concerns arise related to therapeutic boundaries, the nurse must seek clinical supervision or transfer the care of the patient immediately


Potential Boundary Violations

Role: firm limits

Time: odd, unusual treatment time

Place and space: lunch

Money: compensation, free therapy

Gift and service: consider the reason; obligation, manipulation, gift to the organization for excellence of care

Clothing: revealing vs. professional

Language: first/last name, off color jokes

Self disclosure: use only for patient benefit

Post discharge social: confuse social w/ professional support

Physical boundaries: touch, space, sexual


Defense Mechanisms

Automatic psychological processes protecting the individual against anxiety (denial, splitting, altruism)

Individuals often are unaware

Some defense mechanisms are maladaptive

Others may be either maladaptive or adaptive

The nurse evaluates the purpose of a defense mechanism and then determines whether or not it should be discussed w/ the patient


Analyzing Interactions

Process recordings - will do in mental health class

Role play

Exam questions

-Content themes
-Communication blocks