INTRODUCTION
The therapeutic interaction
between the nurse and the client will be helpful to develop mutual understanding
between two individuals. Interaction is a learning experience for both
client and for the nurse, and a corrective emotional experience to the client
to modify his behavior. It occurs when the nurse exhibits empathy, utilizes
effective communication skills and responds to the client’s thoughts,
needs and concerns. It establishes trusting relationship, wins the confidentiality
whereby the client can reveal his thoughts and feelings openly. Nurse learns to
implement the careful practice with efficient experience. Relationships between
psychiatric mental health nurses and clients are established through
communication and interaction. Communication between two human beings can be
difficult and challenging. When we communicate, we share significant feelings
with those to whom we are relating. If the interaction facilitates growth,
development, maturity, improved functioning, or improved coping, it is
considered therapeutic (Rogers, 1961
Definitions
The communication of ideas, facts,
feelings and informations is very vital for facilitating human interaction.
Communication
refers to the, ‘imparting, the conveying or the exchanging of ideas, knowledge,
meanings, etc. among individuals through the medium of a sign of some kind’,
e.g. symbol.
‘A process by which two or more
people exchange ideas, facts, feelings ‘common understanding’ of meaning,
intent and use of a message’.
—Paul Leagens
Effective communication
requires knowledge of the symbols, the cues, stimuli to which other persons
will react.
It
consists of 6 small messages:
Ø What
do you mean to say?
Ø What
do you actually say?
Ø What
the other person hears?
Ø What
the person thinks that he hears?
Ø What
the other person says?
Ø What
you think the other person says?
v Awareness
of information.
v Action
information.
v Continuing
information.
v Updating
information.
v It
has to be expressed in terms of human behavior.
v It
should be specific enough able to relate it to actual communication behavior.
v It
should be consistent with the ways in which people do communicate
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 this 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 effective 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.
1. The sender
is the person who sent the message.
2. The message
is the information that is sent from the sender to the receiver.
3. The receiver
is the recipient of the message.
4. The feedback
is the verbal or behavioral response of the receiver to the sender.
5. The context
is the setting in which the communication takes place.
1. Sender.
If
the sender is communicating the same message on both the verbal and nonverbal
levels, it is called congruent communication. However, if the levels are
not in agreement, it is called incongruent communication, which can be a
problem. Incongruent, or double-level, messages produce a dilemma for the
listener, who does not know to which level to respond, the verbal or nonverbal.
Because it is not possible to respond to both levels, the listener is likely to
feel frustrated, angry, or confused. Both patients and nurses can display
incongruent communication if they are not aware of their internal feeling
states and the nature of their communication.
Therapeutic Dialogue:
·
Congruent Communication:
Verbal Level: I’m
pleased to see you.
Nonverbal Level: Warm
tone of voice, continuous eye contact, smile.
·
Incongruent Communication
Verbal Level I’m
pleased to see you.
Nonverbal Level : Cold
and distant tone of voice, little eye contact, neutral facial expression.
2. Message:
The message of the
communication process also can pose problems. Messages can be ineffective,
inappropriate, inadequate, or inefficient. Ineffective messages distract and
prevent the objectives of the nurse-patient relationship from being met.
Inappropriate messages are not relevant to the progress of the relationship.
They may include failures in timing, stereotyping the receiver, or overlooking important
information. Inadequate messages lack sufficient information. In this case,
senders assume that receivers know more than they actually do. Inefficient
messages lack clarity, simplicity, and directness. Using more energy than is
necessary, these messages confuse or complicate the information.
The message is some desired behavior in
physical form; it is the translation of the ideas, the purposes and the
intentions of the nurse (source) into a code, i.e. a systematic set of iconic
or (and) digital signs. A sign is a strong determiner of behavior
Natural sign:
Apart of the larger thing or event, e.g. surgical dressing is a sign of
hemorrhage
a.
Non-natural signs:
Which symbolize something is designated, e.g. body cast signifies some
physical health problem.
b.
Iconic sign: A sign is like
the thing it signifies.
Digital sign:
Independent of their physical parameters for their meaning, e.g. pattern, size
or stimulus, intensity
Message code:
Any group of symbols that can be structured in a way that is meaningful to same
person, e.g. language.
Message content:
The material in the message, i.e. selected by the source to express his purpose
Message treatment:
The source encoder has choices available to him and in coding you can choose
one or another set of elements from within the code. In this,
he demonstrates his style of communicating. We can define treatment of a
message as the decisions which the communication source makes in selecting,
arranging both codes and content. The form of the message will be influenced by
the purpose and the intent of the source and by the type of channel selected to
transmit the message
3. Receiver:
The third
element, the receiver, may experience errors of perception. The receiver may
miss nonverbal cues, respond only to content and ignore messages of emotion, be
selectively inattentive to the speaker’s message because of physical or
psychological discomfort, be preoccupied with other thoughts, or have a
physiological vision or hearing impairment. The receiver also may have problems
in evaluating the message. The meaning of the message may be misinterpreted
because the receiver views it in terms of one’s own value system rather than
that of the speaker.
4. Feedback:
Errors in the feedback element
include all of those that apply to the message. Feedback also can convey to the
sender incorrect information about the message. Another serious error occurs
when the receiver fails to use feedback to validate understanding of the
message. Although feedback is the last step, it has the potential for correcting
previous errors and clarifying the nature of the communication.
5. Context.
The
fifth element, context, also can contribute to communication problems. The
setting may be physically noisy, cold, or distracting to one or both parties.
The psychosocial context, or past relationship between the communicators, may
be one of mistrust, fear, or resentment. This analysis shows the complexity of
the communication process. It may seem surprising that successful communication
can occur, given all of these potential problems. However, it does occur among
people who understand the process and use appropriate techniques.
Factors Influencing Communication
Communication is a learned
process influenced by a person's attitude, sociocultural or ethnic background,
past experiences, knowledge of subject matter, and ability to relate to others.
Interpersonal perceptions also affect our ability to communicate because they
influence the initiation and response of communication.
Such perception
occurs through the senses of sight, sound, touch, and smell. Environmental
factors that influence communication include time, place, the number of people
present, and the noise level.
1.
Attitude
Attitudes are developed in various
ways. They may be the result of interaction with the environment; assimilation
of others' attitudes; life experiences; intellectual processes; or a traumatic
experience. Attitudes can be described as accepting, caring, prejudiced,
judgmental, and open or closed minded. An individual with a negative or
closed-minded attitude may respond with It won't work or It's no use trying. Conversely,
the individual with a positive or open-minded attitude may state Why not try
it? We have nothing to lose.
2.
Sociocultural or Ethnic Background
Various cultures
and ethnic groups display different communication patterns. For example, people
of French or Italian heritage often are gregarious and talkative, willing to
share thoughts and feelings.
3. Past
Experiences
Previous positive or negative experiences
influence one's ability to communicate. For example, teenagers who have been
criticized by parents whenever attempting to express any feelings may develop a
poor self-image and feel their opinions are not worthwhile. As a result, they
may avoid interacting with others, become indecisive when asked to give an
opinion, or agree with others to avoid what they perceive to be criticism or
confrontation.
4.
Knowledge of Subject Matter
A person who is well educated or
knowledgeable about certain topics may communicate with others at a high level
of understanding. The receiver of the message may be unable to comprehend the
message, or consider the sender to be a know-it-all expert. As a result of this
misperception, the receiver, not wanting to appear ignorant, may neglect to ask
questions and may not receive the correct information.
5.
Ability to Relate to Others
Some people are natural-born talker who
claims to have never met a stranger. Others may possess an intuitive trait that
enables them to say the right thing at the right time and relate well to
people. I feel so comfortable talking with her,
She's so easy to
relate to, and I could talk to him for Hours are just a few comments made about
people who have the ability to relate well with others. Such an ability can
also be a learned process, the result of practicing effective communicative skills
over time.
6.
Interpersonal Perceptions
Interpersonal perceptions are mental
processes by which intellectual, sensory, and emotional data are organized
logically or meaningfully. Satir (1995) warns of looking without seeing,
listening without hearing, touching without feeling, moving without awareness,
and speaking without meaning. In other words, inattentiveness, disinterest, or
lack of use of one's senses during communication can result in distorted
perceptions of others. The following passage reinforces the importance of
perception: I know that you believe you understand what you think I said, but
I'm not sure you realize that what you heard is not what I (Lore, 1981 ).
7.
Environmental Factors
Environmental factors such as time,
place, number of people present, and noise level can influence communication.
Timing is important during a conversation. Consider the child who has
misbehaved and is told by his mother, Just wait until your father gets home. By
the time the father does arrive home, the child may not be able to relate to
him regarding the incident that occurred earlier. Some people prefer to buy
time to handle a situation involving a personal confrontation. They want time
to think things over or cool off. The place in which communication occurs, as
well as the number of people present and noise level, has a definite influence
on interactions. A subway, crowded restaurant, or grocery store would not be a
desirable place to conduct a disclosing, serious, or philosophic
conversation.
1.
One Way Communication
Ø Appears
neat and efficient to an outside observer, faster
Ø Accuracy
is less
Ø Order,
systemization are associated with one way communication
Ø Sender is more psychologically
comfortable
Ø More
accurate than one way communication
Ø More
people in the audience understand better the communication
Ø The
receivers are more sure of themselves and make correct judgements of how right
or wrong they are
Ø Sender
finds himself psychologically under attack because receivers pick-up his
mistakes and oversights and let him know about them.
Ø Relatively
noisy and disorderly with people interrupting the sender and one another
Ø Much
more a trial and error method.
It is a process in which the communicator and the communicate engage in
a face-to-face interaction, eg. Interviews, group meetings.
It
is considered as important for insuring comprehension of a communication, in
identifying barriers to communication and in resolving conflicting motives
related to the adoption of a practice
Person-to-person
the message will be passed like a chain. Sender pass the message to one person,
then that receiver passes information to other and so on.
By using mechanical devices the communication will
be sent, e.g. Internet, website.
If
a stimulus received by the body immediately, the brain receives the information
and transmits to the respective organ through the neurons, where it has to be
passed
Language is the
chief vehicle of communication. Through it, one can interact with other and
exchange of ideas will take place and information can be
passed through. An individual uses verbal communication to convey
content such as ideas, thoughts, or concepts to one or more listeners. Five
levels of inter personal, verbal
communication
Level
5: Conversation: No sharing of oneself occurs during
this interaction. Statements such as how are you doing? And Talk to you later is
superficial. No personal growth can occur at this level.
Level
4: Reporting
of Facts: Communicating at this level reveals very little about oneself and
minimal or no interaction is expected from others. No personal interaction
occurs at this level.
Level
3: Revelation
of Ideas and Judgments: Such communication occurs under strict censorship by
the speaker, who is watching the listener's response for an indication of acceptance
or approval. If the speaker is unable to read the reactions of the listener,
the speaker may revert to safer topics rather than face disapproval or
rejection.
Level
2: Spontaneous
Here-and-Now Emotions: Revealing one's feelings or emotions takes courage
because one faces the possibility of rejection by the listener. Powell (1969)
states that if one reveals the contents of the mind and heart, one may fear that
such emotional honesty will not be tolerated by another. As a result, the
speaker may resort to dishonesty and superficial conversation.
Level
1: Open,
Honest Communication: When this type of communication occurs, two people share
emotions. Open communication may not occur until people relate to each other over
a period of time, getting to know and trust each other.
Through gestures, body movements,
posture, facial expressions, etc. the ideas or the processes will be
communicated.
There are five
types of non-verbal behavior.
• Vocal
• Action
• Object
• Space
•
Touch
Vocal
Cues
are also known as paralinguistic cues. They include all the noises and extra speech
sounds. Some examples include pitch, tone of voice, sounds - SU9I1 as laughing,
nervous coughing and sound of hesitation (urn, uh). These are particularly
vital cues of emotion, and can be powerful conveyors of information. You can
recall from your clinical experience the types of vocal cues to communicate
pain usually given by women in progressive labour or by the post-operative patient
while you are dressing his wound.
Action
Cues
are body movements. They include posture, facial expression, gestures,
mannerisms and actions of any kind. Facial movements and postures can be particularly
significant in interpreting the speaker’s mood.
Object
Cues
are dress, furnishings and possessions. They communicate something to the observer
about the speaker’s feelings. To make it more clear to you, that in the
hospital set-up, the operation theatre nurses wear a different type and colour
of uniform to distinguish them from the ward nurses.
Space
provides another cue to the nature of the relationship between two people.Seating
arrangements in the health education situation communicate the type of teaching
method of the day. Chairs placed in a circle decrease the space between the
patients, and between the nurse and the patients. It increases interaction
between the nurse and the patients, and that enhances their relationship.
Further our observation of the use of space by the patients can provide valuable
information to us. For instance, the interested / learner patient occupies more
space in the chair while interacting with the group. It communicates that he is
more relaxed. Usually, the uninterested patient sits at the edge of the chair,
and communicates that he is just waiting for the time to get out from that
place.
Touch
is the most personal of the non-verbal messages. It involves both personal
space and action. Most often in nursing, we use touch with a therapeutic goal.
We lay hands on the body of an ill person for the purpose of comforting
him/her. Touch is a universal and basic aspect of all nurse-patient
relationships. It is often described as the first and the most fundamental means
of communication.
All types of non-verbal messages of the
patients are important, and interpreting them correctly is also equally
important. Because the meaning attached to nonverbal behavior is so subjective,
it is essential that we check its meaning through feedback. Remember that the
nurse’s non-verbal cues are also communicating our interest, respect, genuineness
or disinterest, lack of respect and/or an impersonal attitude to the patients. The
nurse’s smile, positive head nods, gestures, eye contact, communicate
acceptance to them. The nurse’s attitude, appearance and behavior motivate the
patients to come closer to him/ her to seek help. That results in effective
nurse-patient relationship. Thus, we agree that communication skills in receiving
and interpreting correctly the verbal and non-verbal messages of the patients
build up the therapeutic relationship, and that loving contact is essential for
helping Relationships.
·
Officially organized channels of communication
·
Delayed communication.
Friends, interest groups, like-minded people,
clique-gossip groups, casual groups. Communication is very faster here.
Principles
of communication
v Communication
should have conviction
v Communication
should be appropriate to situation
v Communication
should have objectives and purpose
v Communication
should promote total achievement of purpose
v Communication
should represent the personality and individuality of the communicator,
v Communication
involves special preparation
v Communication
through personal contact
v Communication
should be oriented to the interest and needs of the receiver
v Communication
should be familiar
v Communication
should seek attention
v Credibility
is very important in communication
v Communication
programme should make use of existing facilities to the great extent possible
and should avoid challenging them unnecessarily.
The therapeutic interaction between
the nurse and the patient helps to develop mutual growth of two individuals and
the world of each is enlarged and enriched by the other. The two communicate
through a dialogue or discussion, not a monologue. Therefore the therapeutic
nurse-patient interaction is a mutual learning experience and a corrective
emotional experience for the patient. In this relationship, the nurse uses
personal attributes and clinical techniques in working with the patient to
bring about insight and behavioral change. The general goal of nurse-patient interaction
is to help the patient to grow.
DEFINITION
“The nurse directs the communication
towards the patient to identify his current health problems, plans, implements
and evaluates the action taken”.
—Bimla Kapoor, 2002
“Promotes
mutual understanding, establishes a
constructive relationship between the nurse and the client”.
—Kozier, 2004
“It is a process, in which the
nurse utilizes a planned
approach to learn about the client”.
Therapeutic
Goals of Nurse-Patient Communication
1.
Self-realization, self-acceptance and an increased genuine self-respect.
2. A clear sense
o f personal identity and an improved level of personal integration.
3. An ability to
form intimate, inter dependent, inter personal relationships with a capacity to
give and receive love.
4. Improved
functioning and increased ability to satisfy needs and achieve realistic
personal goals.
Function
of a Nurse in Therapeutic Nurse-Patient Interaction:
1. Allows the
patient to express his thoughts and feelings and relates these to observed and reported
actions.
2. Clarifies the
areas of conflict and anxiety.
3. Identifies
and maximizes the patient’s ego strengths and encourages socialization and
family relatedness.
4. Corrects the
communication problems.
5. Modifies
maladaptive behavior patterns.
6. Encourages
patient to test new patterns of behavior and new coping mechanisms.
Purposes
of Nurse-Patient Communication:
Determining the
patients’ reason for seeking help from psychiatric nurses influences the establishment
of mutuality between the nurse and the patient and also helps the nurse to id appropriate
nursing approaches.
1. Environmental change from home to hospital:
They desire protection, comfort, rest freedom from demands of their usual home
and work environments.
2. Nurturance: They wish someone to care
for them, cure their illnesses and make them better.
3. Control: They are aware of their
destructive impulses to themselves or others but lack' t nal-control.
4. Psychiatric symptoms: They describe
symptoms of depression, nervousness, or crying
They know they
need psychiatric help and actively want to help themselves.
5. Problem solving: They identity a
specific problem or area of conflict and express desi reason it out and change.
6. Advice to
come to hospital: Family member, friend, or health professional has come with them
to come to hospital. They may feel angry, ambivalent, or indifferent about
being
Therapeutic
Communication Characteristics:
The nurse must
achieve certain skills or qualities to initiate and continue a therapeutic
relationship. These skills or qualities incorporate verbal and nonverbal
behavior and the attitudes and feelings, behind communication. Truax, Carkhoff
and Berenson have identified specific core conditions for facilitative interpersonal
relationships. They broadly divided these conditions into:
A.
Responsive Dimensions - Genuineness, respect, empathic
understanding, and concreteness.
B.
Action Dimensions - confrontation, immediacy, therapist
self-disclosure, catharsis and role playing.
A.l
Genuineness:
It implies that the
nurse is an open, honest, sincere person who is actively involved in the
relationship. Genuineness is the opposite of self-alienation, which occurs when
many of one’s real, spontaneous reactions to life are repressed or suppressed. Genuineness
means that the nurse’s response is sincere rather than phony, that the nurse is
not thinking and feeling one thing and saying something different. It is an
essential quality, because the nurse cannot expect openness, self-acceptance,
and personal freedom in the patient, if he or she lacks these qualities in the
relationship.
A.2
Respect:
‘Non possessive warmth’
or ‘unconditional positive regard’ is known as respect.’ Positive regard
is unconditional in that it does not depend on the patients’ behavior Caring,
liking and valuing are other terms for respect. The patient is regarded as a person ‘worth; he is accepted.
The nurse’s attitude is non-judgmental; it is without criticism, clue,
depreciation, or reservation. Imperfections are accepted along with mistakes
and weaknesses as a part of the his condition.
Respect to
Patient is communicated in Many Ways:
• By sitting
silently with a patient who is crying
• Laughing with
a patient over a particular event
• Maintaining
confidentiality
• By apologizing
for the hurt unintentionally made
• Being genuine
with the patient
• Listening
A.3
Empathic Understanding
Empathy is an
ability to enter into the life of another person, to accurately perceive current
feelings and their meanings. It is an essential element of the interpersonal
process. Communicated, it forms the
basis for a helping relationship between the nurse and the patient.-
Empathy understands
the patient’s world as if it were your own, but without losing ‘As if’ quality.
. '
• Accurate
empathy involves more than knowing what the patient means. It also involves,
nurse’s sensitivity to the patient’s current feelings and the verbal ability to
communicate understanding in a language attuned to the patient.
• Accurate
empathy also means that the nurse frequently confirms with the patient the accuracy
of one’s perceptions and being guided by the patient’s responses.
Mansfield
identified specific verbal and non-verbal behaviors that conveyed high levels empathy
to the patient:
i) Having the
nurse introduce himself or herself to the patient.
ii) Head and
body positions turned towards the patient and occasionally leaning forward.
iii) Verbal
responses to the patients’ previous comments, responses that focus on his
strength and resources.
iv) Consistent
eye contact and response to the patients’ non-verbal cues such has signs, tone voice,
restlessness, and facial expressions.
v) Conveyance of
interest, concern and warmth by the nurse’s own facial expressions.
vi) A tone of
voice consistent with facial expression and verbal response.
vii) Mirror imaging of
body position and gestures between the nurse and patient.
A4.
Concreteness
Concreteness
involves using specific terminology rather than abstractions when discussing the
patient’s feelings, experience and behavior. It avoids vagueness and ambiguity
and is the opposite of generalizing, categorizing, classifying and labeling the
patient’s experiences. It has three functions:
i) To keep the
nurse’s responses close to the patient’s feeling and experiences
ii) To foster
accuracy of understanding by the nurse, and
iii) To
encourage the patient to attend to specific problem areas.
By focusing the
patient in specific and concrete terms to his vague responses, the nurse helps
the patient identify significant aspects of his problem.
The level of
concreteness varies in different phases of nurse patient relationship. To
increase empathy high level of concreteness in the orientation phase, to
facilitate a thorough self exploration, low level of empathy in the working
phase, and at the terminal phase again high levels of concreteness are desired.
B.
Action Dimension
B.l.
Confrontation
B.2. Immediacy
B.3. Self
disclosure
B.4. Emotional
Catharsis
B.5.Role Playing.
The action
dimensions must have a context of warmth and understanding. With the action dimensions,
the nurse moves the therapeutic relationship upward and outward by identifying obstacles
to the patient’s progress and the need for both internal understanding and
external action.
B.l
Confrontation:
Confrontation
usually implies venting anger and aggressive behavior. This has the effect of belittling,
blaming, and embarrassing the receiver- all of which are harmful and
destructive in both social and therapeutic relationships. But confrontation in
action dimension is an assertive rather than aggressive action. Confrontation
is an expression by nurse of perceived discrepancies in the patient’s behavior.
Carkhoff identifies three categories of confrontation:
i) Discrepancy
between the patient’s expressions of what he is (self-concept) and what he wants
to be (self-ideal).
ii)
Discrepancies between the patient’s verbal expressions about himself and his
behavior.
iii)
Discrepancies between the patients’ expressed experience of himself and the
nurse’s experience of him Confrontation is an attempt by the nurse to make the
patient aware of incongruence in feelings, attitudes, beliefs, and behaviors.
It also points out the discrepancies involving his I sources and the strengths
that are unrecognized and unused. The nurse who uses confrontation I modeling
an active role to the patient; the nurse is using insight and understanding to
ambiguity and inconsistency and thus seek deeper understanding.
B.2.
Immediacy:
Immediacy
involves focusing on the current interaction of the nurse and the patient in 1 relationship.
Immediacy may be viewed as empathy, genuineness or confrontation that involves
particular content-the relationship between the nurse and the patient. Immediacy
connotes sensitivity by the nurse to the patient’s feelings and willingness to
with these feelings rather than ignore them. Patient is actively involved in
describing what! Feels is helping or hindering the relationship. It is not
possible or appropriate for the nurse ' focus continually on the immediacy o f
the relationship. It is most appropriate to do so when I relationship seems to
be stalled or is not progressing.
B.3.
Nurse Self-Disclosure:
Self-disclosure
has three characteristics. They are:
i) Subjectively
true.
ii) Personal
statements about the self and
iii)
Intentionally revealed to another person.
In self-disclosure, the nurse
reveals information about himself or herself such as ideas, values, feelings
and attitudes. The nurse may share that he/she has had experiences or feelings
similar to those of the patient and may emphasize both the similarities and
differences. This kind of self-disclosure
is an index of the closeness of the relationship and involves a particular kind
of respect for the
patient. It is an expression of genuineness and honesty by the nurse and is an
aspect of empathy. Nurse’s self-disclosure increases the likelihood of patient
self-disclosure. Patient self-disclosure is necessary for a successful
therapeutic outcome. The number of disclosures and the, appropriateness or the
relevance of the nurse’s self disclosure are based on the clinical experience, and
that determines the optimum therapeutic level. Usefulness o f self disclosures
are cooperation, learning to deal with life problems more effectively,
catharsis of the suppressed feelings and support to accomplish his life goals.
The nurse should
take into account the type and goal of treatment, the context of the nurse patient
relationship, the patient’s ego strength, the patient’s feelings about the
nurse and the nurse’s feelings about the patient. These guidelines govern the
“dosage and timing” of self-disclosures and help the nurses assess the
appropriateness, effectiveness and anticipated response of the patient to the
self-disclosure.
B.4.
Emotional Catharsis:
Emotional catharsis
occurs when the patient is encouraged to talk about things that bother him
most. Catharsis brings fears, feelings and experiences out into the open so
that they can be examined and discussed with the nurse. The expression of
feelings can be very therapeutic in itself, even if behavioral change does not
ensue. The patient’s catharsis depends on the confidence and trust he has in
the nurse.
The nurse must
be able to recognize cues from the patient that he is ready to discuss his problems.
It is important that the nurse proceeds with the patient at the rate he chooses
and support him as he discusses difficult areas. If the patient is having
difficulty expressing feelings, the nurse may help by suggesting how he or she
might feel in the patient’s place or how others Might feel in that situation.
The nurse might validate with the patient the feeling he seems to be describing
in a general way. For this, the dimensions of empathy and immediacy are
required for the nurse to notice and express emotions.
B.5.
Role Playing:
Role-playing
involves acting out a particular situation. It increases the patient’s insight
into human relations and can deepen his ability to see the situation from
another person’s point of view. The intent of role playing is to represent closely
real life behaviors that involve the individual holistically, to focus
attention on a problem and to permit the individual to see himself in action in
a neutral situation. It provides a bridge between thought and action in a
“safe” environment in which the patient can feel free to experiment with new
behavior. It is a method of learning that makes actual behavior the focus of
study; it is action oriented and provides immediately available information.
Role
Playing Consists of the Following Steps:
a.
Defining the problem.
b.
Creating a readiness for role-playing.
c.
Establishing the situation.
d.
Casting the characters.
e.
Briefing and warming up.
f.
Considering the training design.
g.
Acting.
h.
Stopping.
i.
Involving the audience.
j.
Analyzing and discussing.
k.
Evaluation.
When
role-playing is -used for attitude change; it relies heavily on role reversal.
The patient may be asked to play the role of a certain person in a specific
situation or to play the role of someone with opposing beliefs. This helps the
patient to re evaluate the other person’s intentions and become more
understanding of the other person’s positions. After role reversal, patients
may be more receptive in modifying their own attitudes.
Role playing
helps in promoting self awareness, ‘experience a situation rather than just
‘talk about it,’ elicits feelings, provides opportunity to develop insight and
for the expression of affect. It also allows the patient to experiment with new
behavior in a safe environment..
Therapeutic
Communication Techniques:
These techniques
in psychiatric nursing aim at preserving the self respect of the patient and
nurses. Secondly, they help in the formation of the nurse-patient relationship
and, the implementation of the nursing process. They are keys to the successful
psychiatric nursing skills. Now let us discuss the therapeutic communication
techniques.
1. Listening: It is an active process of
receiving information. The complete attention of nurse is required and there
should be no occupation with oneself. Listening is a sign respect for the
person who is talking and is a powerful reinforce of relationships. It also the
patients have to talk more, without which the relationship cannot progress.
2. Broad Openings: These encourage the
patient to select topics for discussion, and indications that the nurse is
there, listening to him and following him. For example, questions such what
shall we discuss today? “Can you tell me more about that”? “And then what happened?”
from the part of the nurse encourages the patient to talk.
4.
Restating: The nurse repeats to the patient the
main thought he has expressed. It indicates that the nurse is listening. It
also brings attention to something important.
5.
Clarification: The patient’s verbalization,
especially when he is disturbed or feeling deeply, is not always clear. The
patient’s remarks may be confused, incomplete or disordered due to their
illness. So, the nurses need to clarify the feelings and ideas expressed by the
patients. The nurses need to provide correlation between the patient’s feelings
and actions. For example, “I am not sure what you mean”? “Could you tell me
once again?” clarifies the unintelligible ideas of the patients.
v) Reflection:
This means directing back to the patient his ideas, feelings, questions and
content. Reflection of content is also called validation. Reflection of
feelings consists of responses to the patient’s feelings about the
content.Reflection of the content is for the patient to know that we have heard
and that we have understood the content. Reflection of feeling is also for
telling the patient that we are aware of what he is feeling. It signifies
understanding, empathy, interest and respect for the patient. It also increases
our level of involvement with the patient.
vi)
Focusing: It
means expanding the discussion on a topic of importance. It helps the patient
to become more specific, move from vagueness to clarity and focus on reality.
Encouraging a description of the patient’s perceptions, encouraging
comparisons, and placing events in a time sequence, are focusing techniques that
promote specificity and problem analysis.
vii)
Sharing Perceptions: These are the techniques of asking the
patient to verify the nurse understands of what he is thinking or feeling. For
example, the nurse could ask the patient, as “you are smiling, but I sense that
you are really very angry with me”. It helps to confirm the nurse understands
and allows the patient to correct their perception, if necessary. It further
clarifies confusing communication.
viii)
Theme Identification: This involves identifying the
underlying issues or problems experienced by the patient that emerge repeatedly
during the course of the nurse-patient interaction. Once we identify the basic
themes, it becomes easy to decide which of the patient’s feelings and thoughts
to respond to and pursue.
Theme can relate
to feelings like depression or anxiety, behavior (rebelling against authority or
withdrawal) and experiences (being loved, hurt, or raped); or combinations of
all three. So you need to identify the theme to understand the patient better.
ix)
Silence: This is lack of verbal .communication for a
therapeutic reason. Then the nurse’s silence prompts patient to talk. For
example, just sitting with a patient without talking, nonverbally communicates
our interest in the patient. Silence gives time for the patient to think and
gain insight. It encourages the patient to initiate conversation. It is also
helpful to the nurse when she is unsure how to respond to a patient’s comments;
a safe approach is to maintain silence.
X)
Humor: This is the discharge of energy through the comic
enjoyment of the imperfect a socially acceptable form
of sublimation. It is a part of nurse patient relationship. It is a constructive
coping behavior, and by learning to express humor, a patient learns to how
others feel. Humor resolves paradoxes, tempers, aggression, and reveals
new options to the patients, example, joking allows the nurse and the
patient to retain their uneasy security in unchanging individual
existences.
POSITIVE
FUNCTIONS OF HUMOR
o
Reduces stress and tension
o
Promotes social closeness
o
Provides social control
o
Permits cognitive reframing
o
Reflects social change
o
Provides perspective
o
Expresses emotion
o
Facilitates learning
o
Reinforces self-concept
o
Voices social conflict
o
Avoids conflict
o
Facilitates enculturation
o
Instills hope
xi)
Informing: This is the skill of giving information.
The nurse shares simple facts with patient. For example, the
nurse saying to the patient ‘I think you need to know more about how medication
works’, is helpful in health teaching or patient education. This is considered
as one of the essential nursing techniques in communication.
xii)
Suggesting: This is the presentation of alternative
ideas related to problem solving. It is a most useful communication
technique when the patient has analyzed his problem area, is ready to
explore alternative coping mechanisms. At that time suggesting techniques increase the patient’s choices.
NONTHERAPEUTIC
COMMUNICATION TECHNIQUES OR BARRIERS OF COMMUNICATION
Several
approaches are considered to be barriers to open communication between the
nurse and the client. Hays and Larson (1963) identified a number of these Techniques.
The nurse should recognize and eliminate the use of these patterns in his or
her relationships with clients. Avoiding these communication barriers will
maximize the effectiveness of communication and enhance the nurse client
relationship.
1. Giving reassurance
Indicating to
the client that there is no cause for anxiety, thereby devaluing the client’s
feelings; may discourage the client from further expression of feelings if
client believes he or she will only be downplayed or ridiculed.
“I wouldn’t
worry about that if I were you”
“Everything will
be all right.”
Better to say: “We
will work on that together.”
2. Rejecting
Refusing to
consider or showing contempt for the client’s ideas or behavior. This may cause
the client to discontinue interaction with the nurse for fear of further
rejection.
“Let’s not
discuss…”
“I don’t want to
hear about…”
Better to say: “Let’s
look at that a little closer.”
3.
Approving
or disapproving
Sanctioning or
denouncing the client’s ideas or behavior; implies that the nurse has the right
to pass judgment on whether the client’s ideas or behaviors are “good” or
“bad,” and that the client is expected to please the nurse. The nurse’s
acceptance of the client is then seen as conditional depending on the client’s
behavior.
“That’s good.
I’m glad that you…”
“That’s bad. I’d
rather you wouldn’t…”
Better
to say: “Let’s talk about how your behavior invoked anger in
the other clients at dinner.”
4.
Agreeing
or Disagreeing
Indicating
accord with or opposition to the client’s ideas or opinions; implies that the
nurse has the right to pass judgment on whether the client’s ideas or opinions
are “right” or “wrong.” Agreement prevents the client from later modifying his
or her point of view without admitting error. Disagreement implies inaccuracy,
provoking the need for defensiveness on the part of the client.
“That’s right. I
agree.”
“That’s wrong. I
disagree.”
“I don’t believe
that.”
Better
to say: “Let’s discuss what you feel is unfair about the new
community rules.”
5. Giving advice
Telling the
client what to do or how to behave implies that the nurse knows what is best
and that the client is incapable of any self-direction. It nurtures the client
in the dependent role by discouraging independent thinking.
“I think you
should…”
“Why don’t you…”
Better
to say: “What do you think you should do?”
6. Probing
Persistent
questioning of the client; pushing for answers to issues the client does not
wish to discuss. This causes the client to feel used and valued only for what
is shared with the nurse and places the client on the defensive.
“Tell me how
your mother abused you when you were a child.”
“Tell me how you
feel toward your mother now that she is dead.”
“Now tell me
about…”
Better
technique: The nurse should be aware of the
client’s response and discontinue the interaction at the first sign of
discomfort.
7. Defending
Attempting to protect someone or something
from verbal attack. To defend what the client has criticized is to imply that
he or she has no right to express ideas, opinions, or feelings. Defending does
not change the client’s feelings and may cause the client to think the nurse is
taking sides with those being criticized and against the client.
“No one here
would lie to you.”
“You have a very
capable physician. I’m sure he only has your best interests in mind.”
Better
to say: “I will try to answer your questions and clarify
some issues regarding your treatment
8.
Requesting
an explanation
Asking the
client to provide the reasons for thoughts, feelings, behavior, and events.
Asking “why” a client did something or feels a certain way can be very intimidating,
and implies that the client must defend his or her behavior or feelings.
“Why do you
think that?”
“Why do you feel
this way?”
“Why did you do
that?”
Better
to say: “Describe what you were feeling just before that
happened.”
9.
Indicating
the existence of an external source of power
Attributing the source of thoughts, feelings,
and behavior to others
or to outside influences. This encourages
the client to project blame for his or
her thoughts or behaviors on others rather than the responsibility personally.
What makes you say that?”
“What made you
do that?”
“What made you
so angry last night?”
Better
to say: “You became angry when your brother insulted your
wife
10. Belittling feelings expressed
When the nurse misjudges the degree of the client’s discomfort, a lack of
empathy and understanding may
be conveyed. The nurse may tell
the client to “perk up” or “snap out of it.” This causes the client to feel insignificant or unimportant. When one is
experiencing discomfort, it
is no relief to hear that others are or have been in similar situations.
Cl: “I have
nothing to live for. I wish I were dead.”
Ns: “Everybody
gets down in the dumps at times.
I feel that way
myself sometimes.”
Better
to say: “You must be very upset. Tell me what you are
feeling right now.”
11. Making stereotyped comments
Clichés and trite expressions are meaningless
in a nurse–client
relationship. When the nurse makes
empty conversation, it encourages a like response from the client.
“I’m fine, and
how are you?”
“Hang in there.
It’s for your own good.”
“Keep your chin
up.”
Better
to say: “The therapy must be difficult for you at times. How
do you feel about your progress at this point?”
12. Using denial
Denying that a
problem exists blocks discussion with the client and avoids helping the client identify
and explore areas of difficulty.
Cl: “I’m
nothing.”
Ns: “Of course
you’re something. Everybody is somebody.
Better
to say: “You’re feeling like no one cares about you right
now.”
13. Interpreting
With this
technique the therapist seeks to make conscious that which is unconscious, to
tell the client the meaning of his or her experience.
“What you really
mean is…”
“Unconsciously
you’re saying…”
Better
technique: The nurse must leave interpretation of
the client’s behavior to the psychiatrist. The nurse has not been prepared to
perform this technique, and in attempting to do so, may endanger other nursing
roles with the client.”
14. Introducing an unrelated topic
Changing the
subject causes the nurse to take over the direction of the discussion. This may
occur to get to something that the nurse wants to discuss with the client or to
get away from a topic that he or she would prefer not to discuss.
Cl: “I don’t
have anything to live for.”
Ns: “Did you
have visitors this weekend?”
Better
technique: The nurse must remain open and free to
hear the client and to take in all that is being conveyed, both verbally and
nonverbally.
Process
Recordings:
Process recordings are written reports
of verbal interactions with clients. They are verbatim (to the extent that this
is possible) accounts, written by the nurse or student as a tool for improving
interpersonal communication techniques. The process recording can take many
forms, but usually includes the verbal and nonverbal communication of both
nurse and client. The interaction provides a means for the nurse to analyze both
the content and pattern of the interaction. The process recording is not
documentation in and of itself, but should be used as a learning tool for
professional development.
Active
Listening:
To listen
actively is to be attentive to what the client is saying, both verbally and
nonverbally. Attentive listening creates a climate in which the client can
communicate. With active listening the nurse communicates acceptance and
respect for the client, and trust is enhanced. A climate is established within
the relationship that promotes openness and honest expression .Several
nonverbal behaviors have been designated as facilitative skills for attentive
listening. Those listed here can be identified by the acronym SOLER:
S—Sit
squarely facing the client.
This gives the message that the nurse is there
to listen and is interested in what the client has to say.
O—Observe
an open posture.
Posture is considered “open” when arms and
legs remain uncrossed. This suggests that the nurse is “open” to what the
client has to say. With a “closed” position, the nurse can convey a somewhat
defensive stance, possibly invoking a similar response in the client.
L—Lean
forward toward the client.
This conveys to the client that you are
involved in the interaction, interested in what is being said, and making a
sincere effort to be attentive.
E—Establish
eye contact.
Direct eye contact is another behavior that
conveys the nurse’s involvement and willingness to listen to what the client
has to say. The absence of eye contact, or the constant shifting of eye contact,
gives the message that the nurse is not really interested in what is being
said.
R—Relax.
Whether sitting or
standing during the interaction, the nurse should communicate a sense of being
relaxed and comfortable with the client. Restlessness and fidgetiness
communicate a lack of interest and a feeling of discomfort that are likely to be
transferred to the client.
Feedback:
Feedback is a
method of communication that helps the client considers a modification
of behavior. Feedback gives information to clients about how they are
being perceived by others. It should be presented in a manner that
discourages defensiveness on the part of the client. Feedback can be
useful to the client if presented with objectivity by a trusted
individual. Some criteria about useful feedback include:
● Feedback
should be descriptive rather than evaluative and focused on the behavior rather
than on the client. Avoiding evaluative language reduces the need for the
client to react defensively. An objective description allows the client to take
the information and use it in whatever way he or she chooses. When the focus is
on the client, the nurse makes judgments about the client.
Skill is the ability or
efficiency of the nurse to utilize their knowledge systematically and
effectively in proficiency manner
General ability, e.g.
ability to listen, interprets, speak and express through writing
Special abilities
For example,
observation and its interpretation
-
Process the therapeutic interaction to
attain the goals
-
Ability to ascertain
-
Ability to differentiate and follow when
to be silent, speak, smile, interact
-
Ability to wait, proceed, speed
-
Participates actively and maintains
Therapeutic Nurse-Patient Relationship
CONCLUSION
Interpersonal
communication is a transaction between the sender and the receiver. In all
interpersonal transactions, both the sender and receiver bring certain
preexisting conditions to the exchange that influence both the intended message
and the way in which it is interpreted .The nurse must be aware of the
therapeutic or non therapeutic value of the communication techniques used with
the patient, as they are the "tools" of psychosocial intervention.
REFERENCES
1.
Mary C Townsend; Psychiatric Mental
Health Nursing; 5thedition;Jaypee Brothers Medical
Publishers;(2007);Pp:123-128
2. Gail
W Stuart,Michele T Laraia;Principles and practices of psychiatric nursing,7thedition,Harcourt
(India)Pvt Ltd; (2001) ;Pp:33-37
3. Norman
L Keltner,LeeHilyardSchwecke,Carol E Bostrom;Psychiatric nursing;5thedition,Mosby
publishers; (2007);Pp:93-94
4. Mary
Ann Boyd,Psychiatric nursing ,Contemporary practice,4thedition,Lippincott
Williams and Wilkins Publishers, (2008);Pp:139-141
5. Elizabeth
M Varcarolis,Foundations of psychiatric mental health nursing,3rd
edition ,W B Saunders company , (1998)
6. Katherine
M Fortinash, Patricia A HolodayWorret, Psychiatric mental health nursing, 3rd
edition, Mosby publishers(2004),Pp: 131-132
7. K.Lalitha, Mental Health and
Psychiatric Nursing, an Indian perspective,VMG publications
8. Niraj ,Ahuja, A Short text book
of Psychiarty,5th
edition,Jaypee Brothers publisher
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