Professional & Therapeutic Communication NUSC 1P10 Fall 2023 Lecture Notes PDF

NUSC 1P10 | Fall 2023 Lecture 2 Class Objectives • Discuss the relationship between communication and the developing self • Describe the structure and phases in therapeutic relationships • Discuss key aspects of each phase including: • • • • • professional introductions, person-centred care (PCC...

NUSC 1P10 | Fall 2023 Lecture 2 Class Objectives • Discuss the relationship between communication and the developing self • Describe the structure and phases in therapeutic relationships • Discuss key aspects of each phase including: • • • • • professional introductions, person-centred care (PCC), therapeutic use of self, shared decision making, and warm referrals • Describe the importance of understanding and communicating the nursing role • Describe professional boundaries and how to recognize crossings and violations NUSC 1P10 | Fall 2023 Therapeutic Nurse-client Relationships Social vs. Professional Relationships Social Relationships • Unlimited length of time • Shared focus on both self and other person • Unlimited expression of emotion • Personal feelings are expressed and shared Professional Relationships • Time-limited • Focused on client • Limited expression of emotion • Personal feelings are used as a means of reflecting how to help (Stien-Parbury, 2018) What is the Nurse-Client relationship? • The core of nursing • Knowledge and skill • Caring attitudes and behavior • Trust, empathy, respect, professional intimacy and appropriate use of power • May be individuals, families, groups or communities (CNO, 2006) Clinical vs. Therapeutic Relationships Clinical Relationships • Routine or standard • ↓ vulnerability and/or dependence • Follows clinical protocols • Little negotiation • Feelings not typically explored Therapeutic Relationships • Focus on both content and emotions • Empathetic communication • Shared understanding of health experience Therapeutic Nurse-Client Relationship “a professional, interpersonal alliance in which the nurse and client join together for a defined period to achieve health-related treatment goals” (Arnold & Boggs, 2016, p. 180) Standards & Therapeutic Nurse-Client Relationships Standards (CNO, 2006) 1. Therapeutic communication - Nurses use a wide range of effective communication strategies and interpersonal skills to appropriately establish, maintain, re-establish and terminate the nurse-client relationship. 2. Client-centred care - Nurses work with the client to ensure that all professional behaviours and actions meet the therapeutic needs of the client. 3. Maintaining boundaries - Nurses are responsible for effectively establishing and maintaining the limits or boundaries in the therapeutic nurse-client relationship. 4. Protecting the client from abuse - Nurses protect the client from harm by ensuring that abuse is prevented or stopped and reported. Nurses’ Requirements for Effective TNCRs • Knowledge • background knowledge that informs practice • knowledge necessary to the specifics of the client • Reflective Practice/Self-awareness • self-reflection à self-knowledge à differentiate between nurse and client experience and values, empathy, and awareness of boundaries à person-centred care • Phases of therapeutic relationships • recognize phase and appropriate actions (RNAO, 2006) Termination Working Orientation Pre-Interaction Phases of the Nurse-Patient Relationship Pre-Interaction Phases of the Nurse-Patient Relationship • During this phase, the nurse: • Patient/client not directly involved • Reflect on goals • Address gaps in knowledge • Examine personal bias and past experiences • develops the appropriate physical and interpersonal environment for an optimal relationship in collaboration with other health care professionals and significant others in the client’s life • anticipates potential client issues • prepares for the client interaction • determines how they will initially approach the client (Peplau, 1988) What is Relational Nursing Practice? • Personal and contextual (nurse & patient) factors can make therapeutic relationships difficult • An understanding of patients’ health care needs within complicated or complex contexts is needed • Relational Practice focuses on how intrapersonal, interpersonal, and social structural (contextual) factors shape patients’ lived experiences How do we practice relationally? Intrapersonal What is going on within the people involved? Contextual What is going on around the people and situation? Interpersonal What is going on among and between people? Relational capacities The 5 Cs of relational inquiry • Compassionate • Curious • Committed • Competent • Corresponding (Doane & Varcoe, 2021) Relational Capacities Compassionate – to be with people in uncertainty, anguish and suffering, recognize shared humanity, and practice self-compassion Curious – the ability to work in-between knowing and not knowing. Not knowing à knowledgeable, compassionate care Committed – paying attention to the choices we are making and ensuring they are in alignment with our values Competent – not just the knowledge and skills you possess, but what transpires in relational situations Corresponding – relating to and with people in a way that is meaningful to them Orientation Phases of the Nurse-Patient Relationship • During this phase, the nurse: • Introductions • Establishing rapport • Orientation to setting • Expectations • Purpose of the relationship • Defining goals • introduces themselves to the client by using first and last name and designation • identifies the purpose and timing of the relationship • builds a sense of trust with the client • identifies the client’s strengths • assesses the client’s needs • collects data that form the basis for developing relevant nursing diagnosis/goals • ends this phase with a therapeutic contract mutually defined with the client (Peplau, 1988) Orientation Phase – Developing the Relationship Trust Focus Anticipate Know Evaluate • Genuine interactions • Compassion & respect • Sharing information • Aware of context • Physically & mentally present • Notice & acknowledge • Active listening • Responsive • Ask about past experiences of care • Inform about potential changes • Pre-empt conflicting needs • Scope of practice & recognize limitation • PCC • Equal weight to technical and caring aspects • Talk to and observe patients • Get to know cues • Determine if expectation are met • Iterative cycle From: Feo, et al. 2017 – Table 2 Orientation Phase – Therapeutic Use of Self More than what the nurse does à connection between nurse and patient/client • Requires authenticity • Seeks understanding • Demonstrates presence Working Phases of the Nurse-Patient Relationship • During this phase, the nurse: • Problem-solving • Supporting selfmanagement and self-monitoring • Shared-decision making • Giving feedback • works with the client to address health care needs • actively problem solves with the client • uses a variety of interpersonal strategies to assist the client to develop new insights and methods of coping • focuses on self-direction and self-management to whatever extent is possible in promoting the client’s health and well-being (Peplau, 1988) Patient-centered Care (PCC) Relationships • Personal experience > biomedical processes • Requires a holistic understanding of patient preferences and life goals Working Phase – Shared Decision Making Shared decision making (SDM) – the interactive process between clinician and patient which promotes defining problems, presenting options, and providing high-quality information so patients can participate more actively in care (Arnold & Boggs, 2020). Opportunities for SDM include: • Bedside shift report • Reviewing care plans with patients • Asking directly about patient/family priorities Working Phase – Shared Decision Making • Choice talk – finding out what information the patient has, how much information they want and who should be involved in the decisionmaking process • Option talk – sufficient and relevant information about potential treatment options, risks involved, and pros/cons of one option vs. another • Decision talk – “are you ready to make a decision, or do you need more time to think about it?” Termination Phases of the Nurse-Patient Relationship • During this phase, the nurse: • Evaluation • Planning/referrals • Anticipatory guidance • Finality • evaluates the client’s responses to treatment in collaboration with the client • explores the meaning of the relationship and what goals have been achieved • discusses client achievements and plans • initiates referrals when necessary (Peplau, 1988) Termination Phase – Warm Referrals • Address clients’ feelings of anxiety, apprehension, or fear • Minimize client risk of becoming overwhelmed by complex system demands • Increase likelihood of successful engagement and follow-through • Minimize the potential for traumatic stress by being aware of and navigating potential triggers https://phnprep.ca/resources/tvic-warm-referrals/ Evaluation of the Therapeutic NurseClient Relationship • Was the problem definition adequate and appropriate for the patient? • Were the interventions chosen adequate, consistent with patient preferences, and appropriate to resolve the patient's problem? • Were the interventions implemented effectively and efficiently to both the patient's and the nurse's satisfaction within the allotted time frame? • Is the patient progressing toward maximum health and well-being? • Is the patient satisfied with their progress and care received? • What type of follow-up care or self-monitoring is needed? • If follow-up care is indicated, is the patient satisfied with the recommendation and able to the carry forward their treatment plan in the community? (Arnold & Boggs, 2020) NUSC 1P10 | Fall 2023 Role Communication & Boundaries Standards & Therapeutic Nurse-Client Relationships Standards (CNO, 2006) 1. Therapeutic communication - Nurses use a wide range of effective communication strategies and interpersonal skills to appropriately establish, maintain, re-establish and terminate the nurse-client relationship. 2. Client-centred care - Nurses work with the client to ensure that all professional behaviours and actions meet the therapeutic needs of the client. 3. Maintaining boundaries - Nurses are responsible for effectively establishing and maintaining the limits or boundaries in the therapeutic nurse-client relationship. 4. Protecting the client from abuse - Nurses protect the client from harm by ensuring that abuse is prevented or stopped and reported. Ethical basis of relationships Ethics – a branch of philosophy that deals with questions of right and wrong and of ought and ought not in our interactions with others Ethical values – guide care provision within the therapeutic nurse-client relationship (CNA, 2017; CNO, 2019) CNO CNA Client well-being Providing safe, compassionate, competent and ethical care Client choice Promoting health and well-being Privacy and confidentiality Promoting and respecting informed decision-making Respect for life Honouring dignity Maintaining commitments Maintaining privacy and confidentiality Truthfulness Promoting justice Fairness Being accountable Legal considerations • Nurses are legally responsible for all aspects of nursing care provided • Relevant to communication and the nurse-client relationship are issues of • Confidentiality (PHIPA) • Informed consent • Professional liability (e.g., professional conduct of the relationship, boundaries) Protecting the Person’s Privacy • Provinces and territories’ personal health information legislation and nursing standards related to privacy and confidentiality guide nursing practice • Ontario à Personal Health Information Protection Act (PHIPA) • Disclosure can only be released with express of implied consent Confidentiality • Providing only the information needed to provide care for the person to other health care providers on a need-to-know basis. • Breaches of confidentiality occur when there is: • Release of information to unauthorized people. • Public discussion of people receiving care. • Photos without consent. • Procedures without consent. • Sharing of identifiable data. Professional Sharing of Confidential Information • Acceptable discussion forums • • • • • Nursing reports Interdisciplinary team case conferences Change-of-shift reports One-on-one health care provider conversations Person-approved family consultations • Discussions in private room, door closed • Relevant information specific to assessment or treatment • Continues after the person is discharged Mandatory Reporting • Varies among provinces and territories • Centres around child abuse or neglect, public health and communicable disease legislation and disclosure of information to protect public health and safety Informed Consent Process • A person must be: • Informed by a health care practitioner of the nature and purpose of the treatment and alternatives, and risks and benefits of having or not having the treatment. • Given the opportunity to ask questions prior to signing the consent. • Competent to provide consent. (CNPS, 2018; Keatings & Adams, 2020) Professional Boundaries “Professional boundaries represent invisible structures imposed by legal, ethical, and professional standards of nursing that respect nurse and client rights, and protect the functional integrity of the alliance between nurse and client” (Arnold & Boggs, 2020, p. 183) Boundary Violations and Crossings • Take advantage of client vulnerability • Represent a conflict of interest • Harmful to the goals of the therapeutic relationship Involvement & Therapeutic Nurse-Client Relationships • Overinvolvement can result in the loss of objectivity • Disengagement can lead to client feelings of isolation or abandonment • Both lead to the inability to achieve patient-centered care Source: Arnold, E., & Boggs, K. U. (2016). Interpersonal relationships : professional communication skills for nurses (6 ed.). St. Louis. MO: Elsevier. Page 185. . Overinvolvement – Warning Signs • Extra time and attention • Visiting during off-hours • Discounting the actions of other professionals • Keeping secrets with patients • Believing they are the only ones who understand patient’s needs Understanding & Communicating Nursing Role(s) Role – a multidimensional psychosocial concept defined as a traditional pattern of behaviour and self-expression performed by or expected of an individual within a given society Nursing Roles (CNO, 2019) 1. 2. 3. 4. 5. 6. 7. 8. 9. Clinician Professional Communicator Collaborator Coordinator Leader Advocate Educator Scholar Registered Nurse Scope of Practice Roles, functions, and accountabilities that registered nurses are legislated, educated, and authorized to perform, are defined by the Nursing Act, 1991 The practice of nursing is the promotion of health and the assessment of, the provision of care for and the treatment of health conditions by supportive, preventive, therapeutic, palliative and rehabilitative means in order to attain or maintain optimal function See - An Introduction to the Nursing Act, 1991 - posted on Brightspace Advocating for Nursing • Nurses readily embrace the advocacy role as it applies to patients • Advocacy on behalf of colleagues, the profession and even oneself is not consistently noted in nursing • Advocating for nursing may include: • • • • Safe work conditions Violence against healthcare workers Bullying Clarifying or amplifying nursing image or role NUSC 1P10 | Fall 2023