Bridges & Barriers in the Therapeutic Relationship

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Bridges & Barriers in the Therapeutic Relationship:

Bridges & Barriers in the Therapeutic Relationship 1


Objectives Identify concepts that enhance development of therapeutic relationships: caring, empowerment, trust, empathy, mutuality, and confidentiality Describe nursing actions designed to promote trust, empathy, mutuality and confidentiality Describe barriers to the development of therapeutic relationships: anxiety, stereotyping, and lack of personal space 2

Objectives (cont.):

Objectives (cont.) Identify nursing actions that can be used to reduce anxiety and respect personal space and confidentiality Identify research-supported relationships between communication outcomes, such as client empowerment, and improvements in self-care 3

Can you detect therapeutic relationship?:

Can you detect therapeutic relationship? A nurse’s actions convey a therapeutic relationship Implementing actions that convey therapeutic relationships is an interpersonal skill that requires practice 4


Bridges Caring Empowerment Trust Empathy Mutuality Confidentiality Veracity (truthfulness) Respecting client’s autonomy Treating client in just & beneficent manner 5


Barriers Anxiety Stereotyping Violation of personal space or confidentiality 6

1. Caring:

1. Caring According to Leninger: Caring is essence of nursing There can be no cure without caring, but there may be caring without cure According to Watson: Caring is central to nursing Caring actions include: communication, positive regard for patient, support and physical intervention by the nurse 7

1. Caring:

1. Caring Behavior of “caring” is not an emotional feeling, rather a chosen response to client’s need Caring is act of giving freely and willingly of oneself to another thru compassion, warmth, concern and interest Caring is visible when we explain to patient about condition in terms that patient can understand (nurse as patient advocate) To care for client is to make him involved in health care rather than just do for client 8

1. Caring:

1. Caring Caring is an ethical responsibility In caring relationship, clients can focus on accomplishing goals of health care instead of worrying about whether care is forthcoming Nurse gains by experiencing satisfaction of meeting client’s needs Families also need to experience a sense of caring from the nurse, of the problems they encounter while caring for their ill family member 9


10 Don’t tell me that you understand, Don’t tell me that you know. Don’t tell me that I will survive, How I will surely grow. Don’t tell me this is just a test, That I am surely blessed, That I am chosen for this task, Apart from all the rest. Don’t come at me with answers That can only come from me, Don’t tell me how my grief will pass… That I will soon be free. Don’t stand in pious judgment Of the bonds I must unite. Don’t tell me how to suffer, And don’t tell me how to cry. My life is filled with selfishness, My pain is all I see, But I need you, and I need your love… Unconditionally. Accept me in my ups and downs, I need someone to share, Just hold my hand and let me cry, And say, “My friend, I care.”

Barrier: Lack of Caring:

Barrier: Lack of Caring Nurse meeting her own needs rather than client’s needs Nurse so rushed to meet multiple demands that she forgets to focus on client 11

Group Work:

Group Work In groups, identify some aspect of caring that might be applied to nursing practice. Write on the white board and discuss Examples: involving client in own care, explaining about disease process in terms patient can understand, to families for difficulties they go thru in caring for patient, etc. 12

2. Empowerment:

2. Empowerment Dictionary definition of empower is enable Empowerment has to do with people power In contrast to “I know what is best for you”. Assist people to develop knowledge, skills and resources they need to: take primary role in their care, and to take control over their decisions about their lives Empowerment is important aim in every nurse-client relationship and addressed by nursing theories, such as Orem's theory of self-care Recent studies demonstrate that the more involved a client is in his care, the better is his health outcome 13

Barrier: Lack of Empowerment:

Barrier: Lack of Empowerment Failure to allow the client to assume personal responsibility or failure to provide him with appropriate information and resources or your ongoing support, weakens empowerment 14

3. Trust:

3. Trust Trust is foundation of all relationships Development of a sense of trust, a sense of feeling safe, is key in nurse-client relationship Trust provides a non-threatening climate in which client feels comfortable to reveal own needs to nurse This trust is crucial to allow you to make accurate assessment of client's needs According to Erikson (1963), “Trust is the reliance on the consistency, sameness and continuity of experiences that are provided by known caregivers”. 15

3. Trust:

3. Trust Techniques that promote trust Convey respect Consider client’s uniqueness Show warmth and caring Use client’s proper name Use active listening Give sufficient time to answer question Maintain confidentiality Show congruence between verbal and nonverbal behaviors Use warm, friendly voice Use appropriate eye contact Techniques that promote trust Smile Be flexible Provide for allowed preferences Be honest and open Give complete info Provide consistency Plan schedules Follow thru on commitments Set limits Use an attending posture; arms, legs, and body relaxed; leaning slightly forward 16

Barrier: Mistrust:

Barrier: Mistrust Examples of mistrust: A nurse who treats a client as though he/she is a misbehaving child; such as if client fails to follow treatment regimen “noncompliant” Nurse inconsistent with her appointments Pediatric nurse who indicates to child that an injection will not hurt Client who provides false misleading information 17

4. Empathy:

4. Empathy Empathy is important in therapeutic relationship; it demonstrates respect and understanding of the client’s feelings Expert nurses feel the emotions a client feels, but maintain their own separate identities Do not try to over-identify with your client because you would lose: your objectivity, and your ability to help the client deal with his feelings Recognize that client’s feelings belong to client, not to you 18

4. Empathy:

4. Empathy Carkhuff (1969) identified five levels of empathy: Level 1 : Unawareness of the client’s message of feelings (no active listening of client's feelings, nurse’s response communicates significantly less than client’s) Level 2: Superficial acknowledgement of the client’s message (Superficial acknowledgement of the client’s message, response ignores and minimizes the client’s feelings; nurse responds to content of statement but not to the feelings) 19

4. Empathy:

4. Empathy Carkhuff (1969) identified five levels of empathy: Level 3: Recognition of the client’s message and some of the client’s feelings (nurse responds to client’s emotions, verbal and nonverbal behaviors congruent) Level 4: Acknowledgment of the message and obvious feelings (nurse probes for info to expand client’s awareness and nurse’s understanding of situation, still there are deep, hidden feelings of which the nurse is unaware ) 20

4. Empathy:

4. Empathy Carkhuff (1969) identified five levels of empathy: Level 5: Full therapeutic acknowledgment of the client’s hidden message and meaning (nurse has clearer, more objective view than client, thus the nurse is able to sate deep hidden feelings unknown to the client) 21

Barrier: Lack of Empathy:

Barrier: Lack of Empathy Failure to understand the need of clients may lead nurse to fail to provide essential client education or needed emotional support Lack of empathy leads to less than favorable health outcomes Major barriers to empathy exist in the clinical environment, such as: lack of privacy, lack of time, lack of support from colleagues Exercise 6-3 22

5. Mutuality:

5. Mutuality Mutuality occurs when: nurse and client agree on client’s health problems, and means for resolving them, & both parties are committed to enhancing client’s well-being Decisions then have meaning to client who buys into the agreed upon plan to achieve success Upon termination of mutual relationship, both parties experience a sense of accomplishment 23

Additional Bridges :

Additional Bridges Veracity ( truthfulness): because client knows he can expect truth from nurse, this promotes trust and helps build relationship 24

Additional Bridges (cont.):

Additional Bridges (cont.) Confidentiality: client can feel reassured that nurse will not divulge private information Information obtained thru interviewing and history taking is used by nurse and health care workers to arrive at individualized client care plan Only pertinent information should be obtained Any confidential information that does not contribute to management of client care should not be included in record Data about client or client’s condition are not shared with client’s family or health professionals who are not involved in the client’s care without client’s consent 25

Barrier: Violations of Confidentiality:

Barrier: Violations of Confidentiality Confidentiality is breached if conversations are heard by other clients, visitors, or anyone not involved in direct care of client The advent of computerized client information constitutes a new problem in confidentiality, because once info is entered into the computer, nurse may not know who will access it Instances when confidentiality is waived: cases of suspicion of abuse of minors or elders, commission of a crime, or threat of harm to oneself or others, courts may subpoena client records without the client’s permission Examples p. 125 26

Additional barriers to therapeutic relationship:

Additional barriers to therapeutic relationship Anxiety Stereotyping & Bias Over involvement as boundary violation Violation of personal space Gender differences Lack of consistent assignment of nurse to client Lack of time (low staff-client ratios, early discharge or same-day surgery) 27


Anxiety A vague, persistent feeling of impending danger Occurs when a threat (real or imagined) to one’s self-concept is perceived Specific behaviors provide clues about anxiety (Table 6-2) A mild level of anxiety heightens one’s awareness of surrounding and fosters learning and decision making A high level of anxiety decreases perceptual ability Moderate to severe anxiety on part of nurse or client hinders development of therapeutic relationship Once presence of anxiety has been identified, nurse needs to take appropriate action to reduce it 28

Anxiety (cont.):

Anxiety (cont.) Severe anxiety requires medical and psychological intervention to alleviate the stress, otherwise, suicide or homicide may follow A prolonged panic state is incompatible with life 29

Strategies to reduce anxiety:

Strategies to reduce anxiety Active listening Honesty Explanations Acting in calm, unhurried manner Speaking clearly, firmly Setting reasonable limits Encourage clients to explore reasons for anxiety Using play therapy with dolls, puppets, games Drawing for young clients Using therapeutic touch, warm baths, back rub Recreational activities like music, card games, reading Teaching breathing and relaxation techniques Using guided imagery 30

Stereotyping & Bias:

Stereotyping & Bias Stereotyping is attributing characteristics to a group of people as though all persons in identified group possess them Stereotyping can be according to ethnic origin, culture, religion, social class, occupation, age, health issues, etc. Stereotypes are learned during childhood and reinforced by life experiences 31

Stereotyping & Bias (cont.):

Stereotyping & Bias (cont.) Stereotyping may carry positive or negative connotations Stereotypes negate empathy and erode nurse-client relationship Stereotypes based on strong emotions are called predjudices, less amenable to change; in the extreme these predjuces can lead to discrimination in which a person is denied legitimate opportunity offered to others Acceptance of the other person needs to be total: unconditional acceptance, i.e.; without judgement Exercise 6-7 32

Over involvement as boundary violation :

Over involvement as boundary violation Sharing too much info about yourself or about your other clients can make your client unclear about his/her role in your relationship A client might feel that if you are talking about other clients, you might also be talking about him or her Boundary violations more common in long-term relationship 33

Violation of personal space (cont.):

Violation of personal space (cont.) Personal space is defined by culture, past experiences and current circumstances Proxemics is study of an individual’s use of space In most cultures, men need more space than women People need less space in morning Elderly need more control over their space Situational anxiety causes need for more space People with low self-esteem need more space 34

Violation of personal space:

Violation of personal space Direct eye contact causes need for more space Placing oneself at same level allows nurse more access to person’s personal space (less threatening) When more than one health professional is involved in implementing procedures, impact on client may be stronger Person who loses control over personal space, may experience loss of individuality, self-identity and self-esteem 35

Violation of personal space (cont.):

Violation of personal space (cont.) When institutionalized clients are able to incorporate parts of their rooms into their personal space, it increases their self-esteem and self-identity When invasions of personal space are necessary, explanation of procedure is in order Advocate for client’s personal space and communicate client’s preferences to members of health team 36

Gender Differences:

Gender Differences No conclusive research evidence exists showing that gender differences obstruct therapeutic relationship Until further evidence, gender need not be a factor in development of therapeutic relationship 37

Steps in caring Process:

Steps in caring Process To help communicate caring to your client: C=Connect with your client. Offer your attention. Introduce purpose of encounter, use client’s formal name, and avoid “sweetie” A=Appreciate client’s situation R=Respond to what your client needs D=Empower the client to problem solve with you 38

Steps in caring Process (cont.):

Steps in caring Process (cont.) Ability to become a caring professional is influenced by previous experiences Caring is not caretaking 39

Strategies for Empowerment:

Strategies for Empowerment Accept your client without judgments Explore client’s feelings about his condition Mutually decide about his care Reinforce client’s autonomy Offer information Clarify that patient has major responsibility for health decisions he makes and consequences 40

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