The Traditional Nurse-Patient Relationship

The nursing process can begin only after the nurse and patient establish their initial therapeutic nurse-patient relationship.

There are three phases - orientation, working, and termination- is sequential and builds on previous phases

The orientation phase

The orientation phase, or introductory phase, is the period often described as "getting to know you" in social settings.

There must be trust between the two parties for the relationship to develop.

During the orientation phase, nurse and patient assess one another.

Developing Trust

The orientation phase includes the beginning development of trust.

Nurses must orient patients and help them feel comfortable and as trusting as possible.

• A straightforward, nondefensive manner is important. Answering all questions as fully as possible and admitting to the limits of your knowledge also facilitate trust.
• Meet with patients at the designated times, or make arrangements to let them know of a change in plans.
• Use active listening, and accept the patient's thoughts and feelings without judgement.  
• Congruence between verbal and nonverbal communication is as key factor in the development of trust

Tasks of the orientation phase

First, the patient will have developed enough trust in the nurse to continue to participate in the relationship.

Second, the patient and nurse will see each other as individuals, unique from all others and worthy of one another's respect.

Third, the patient's perception of major problems and needs will have been identified. 

And Fourth, the approximate length of the relationship will have been estimated, and the nurse and patient will have agreed to work together on some aspect of the identified problems.  This agreement, whether formalized in writing or informally agreed on, is sometimes called a "contract."

The working phase

It is during this time that the nurse an patient tackle tasks outlined in the previous phase.

Nurses should recognize that in the working phase patients may exhibit alternation periods of intense effort and of resistance to change.

Nurses who become frustrated when a patient's progress toward self-care is not smooth and sustained must realize that regression is an ego defense mechanism that occurs as a reaction to stress and that regression often precedes periods of positive behavioral change.

Patience, self-awareness, and maturity are required of nurses during the working phase

The termination phase

Includes those activities that enable the patient and the nurse to end the relationship in a therapeutic manner.

People tend to respond to the end of relationships in much the same way they have responded to other losses in life.  Feelings of anger and fear may surface, in addition to sadness.

Summarizing the gains the patient has made is an important activity during this phase.

Because termination is often painful, participants are sometimes tempted to continue the relationship on a social basis.  

The nurse must realize that professional relationships are different from social relationships.  It is nothelpful to stay in touch with patients after termination of a professional nurse-patient relationship.

Developing Self-Awareness

Awareness of oneself, called self-awareness, is basic to effective interpersonal relationships, especially the nurse-patient relationship.

An important guideline in professional nursing is this: nurses should get their own emotional needs met outside of the nurse-patient relationship, otherwise professionalism is lost, and relationships become social in nature.

When the nurse-patient relationship strays from the therapeutic, it can go beyond professional boundaries and result in role confusion that can be damaging to both the patient and nurse.

Professional boundaries

They were first addressed by Florence Nightingale in the Nightingale Pledge (Box 3-1, p.68).

The National Council of State Boards of Nursing (NCSBN) defined professional boundaries as "the spaces between the nurse's power and the client's vulnerability.  The power of the nurse comes from the professional position and the access to private knowledge about the client." Patient vulnerability arises from dependency on caregiving provided by the nurse.  Boundary violations occur when "there is confusion between the needs of the nurse and those of the client."

Underinvolvement (such as distancing, disinterest, neglect) and overinvolvement (such as excessive personal disclosure from the nurse, secrecy, role reversal, touching, gestures, money or gifts, special attention, social contact, getting involved in a patient's personal affairs, or sexual misconduct) can be detrimental to patient and nurse.

Reflective Practice

Nurses who have emotional reactions to patients, positive or negative, sometimes feel disturbed or guilty about these feelings.  

Part of self-awareness is recognizing one's feelings and understanding that, although feelings cannot be controlled, behaviors can.

Developing self-awareness requires individuals to engage in personal reflection.  Reflection can produce discomfort as nurses become aware of tensions and anxieties within themselves about their everyday activities.

Self-awareness empowers nurses and frees them to behave assertively on their own behalf and on behalf of their patients and is well worth the time required to develop and sustain it.

Avoiding Stereotypes

Stereotypes are prejudices and attitudes developed through interactions with family, friends, and others in each individuals' social and cultural system

They are irrational, or illogical beliefs. 

Professional nurses deliver high-quality care to all patients regardless of ethnicity, age, gender, religion, lifestyle, or diagnosis.

Every professional nurse's goal is to accept all patients as individuals of dignity and worth who deserve the best nursing care possible.

Elderspeak

Professionals call it elderspeak, the sweetly belittling form of address that has always rankled older people.

They found that when nurses used phrases like "good girl" or "How are we feeling?" patients were more aggressive and less cooperative or receptive to care.

If addressed as infants, some showed their irritation by grimacing, screaming, or refusing to do what staff members asked of them.

Elderspeak sent a message that the patient was incompetent and "begins a negative downward spiral for older persons, who react with decreased self-esteem, depression, withdrawal and the assumption of dependent behaviors . . . it's also giving messages to older adults that they're incompetent."

Nonjudgmental Acceptance

Nonjudgmental acceptance means that nurses acknowledge all patient's rights to be different an do express their uniqueness

Theory of Human Relatedness

Hagerty and Patusky (2003) proposed reconceptualizing the nurse-patient relationship using the theory of human relatedness as a framework.

They recommended approaching each nurse-patient contact as an opportunity for connection and goal achievement rather than as one step in a lengthy relationship-building process.

Communication

Is the exchange of thoughts, ideas, or information and is at the heart of all relationships.  

Communication is a dynamic process that is the primary instrument through which change occurs in nursing situations.

Communication begins the moment two people become aware of each other's presence.

Levels of Communication

Communication exists simultaneously on at least two levels: verbal and nonverbal.

Verbal Communication consists of all speech and represents the most obvious aspect of communication.

Nonverbal Communication includes grooming, clothing, gestures, posture, facial expressions, eye contact, tone and volume of voice and actions.

As much as 65% of a message, consists of nonverbal communication.

When congruent communication occurs, the verbal and nonverbal aspects match and reinforce each other. In incongruent communication, the words and nonverbal communication do not match.

Elements of the Communication Process

• Sender
• Message
• Receiver
• Feedback
• Context

The sender is the person sending the message

The message, is what is actually said plus accompanying nonverbal communication

The receiver is the person receiving the message.

Feedback is the response to a message

Context is the setting in which an interaction occurs - including the mood, relationship between sender and receiver, and other factors.

Operations in the Communication Process

• Perception
• Evaluation
• Transmission

Perception

Is the selection, organization, and interpretation of incoming signals into meaningful messages.

Individual's perceptual screen

Each person perceives the information differently, on the basis of factors such as personal experience, previous knowledge, alertness, sensitivity to subtleties of meaning, and sociocultural background.

Evaluation

Is the analysis of information received

Transmission

Refers to the expression of information, verbal or nonveral.

Factors influencing perception,

evaluation, and transmission

• The gender, and culture of the sender and receiver
• the interest and mood of both parties
• the value, clarity and legth of the message
• the presence or absence of feedback
• the atmosphere of the context

How communication develops

• Somatic Language
• Action Language
• Verbal Language

Somatic Language

Consists of crying; reddening of the skin; fast, shallow breathing; facial expressions, and jerking of the limbs.

(infants use somatic language to signal their needs to caretakers)

Action Language

Consists of reaching out, pointing, crawling toward a desired object, or closing the lips and turning the head when an undesired food is offered.

Verbal Language

Beginning with repetitive noises and sounds and progressing to words, phrases, and complete sentences

Successful communication

• Feedback
• Appropriateness
• Efficiency 
• Flexibility

Feedback

When a receiver relays to a sender the effect of the sender's message.

Effective nurses do not assume that they fully understand what their patients are telling them until they feed the statement back to the patient and receive cofirmation

Appropriateness

When a reply fits the circumstances and matches the message, and the amount is neither too great nor too little, appropriateness has been achieved.

Example:  "How are you?" is not a genuine question.  The individual who launches into a lenghty, detailed description of how his morning has gone has communicated inappropriately.

Efficiency

Means using simple, clear words that are timed at a pace suitable to participants.

Messages must be adapted to each patient's age, verbal level, and level of understanding

For efficient communication to occur, nurses must recognize patients' needs and adjust messages accordingly.

Fexibility

The flexible communicator bases messages on the immediate situation rather than preconceived expectations.

Active Listening

Involves focusing solely on a person and acknowledging feelings in a nonjudgmental manner.

It is a method of communicating interest and attention and is best accomplished without distractions playing in the background

Open Posture

leaning forward; relaxed; arms uncrossed, also communicate interest.

Venting

Is the term used to describe the verbal "letting off steam" that occurs when talking about concerns or frustrations

Listening Mistakes

Three common listening faults include interrupting, finishing sentences for others, and lack of interest

Empathy

Consists of awareness of, sensitivity to, and identification with the feelings of another person.

Empathy is different from sympathy in that the sympathetic nurse enters into the feeling with the patient, whereas the empathic nurse appreciates the patient's feelings but is not swept along with the feelings