PN1130 Therapeutic Relationships Notes PDF

PN1130 Therapeutic Relationships Learning Objective 3: Explain the communication process and factors that influence communication. 1 Learning Objective 3 Explain the importance of communication in accordance with professional legislation, regulation, standards of practice and guidelines in nursi...

PN1130 Therapeutic Relationships Learning Objective 3: Explain the communication process and factors that influence communication. 1 Learning Objective 3 Explain the importance of communication in accordance with professional legislation, regulation, standards of practice and guidelines in nursing practice. 2. Differentiate between the different types of communication. 1. 3. Differentiate between the models of communication. 4. Describe the communication process and factors that influence communication. 5. Discuss therapeutic communication skills. 6. Discuss the importance of recognizing and assessing nonverbal communication. 7. Discuss strategies to address barriers to therapeutic communication. 2 Definitions What is communication?  The exchange of information, thoughts and feelings among people using speech or other means. What is therapeutic communication?  A complex interactive process used in health care to help clients achieve health-related goals. What is a therapeutic relationship?  An alliance whereby the nurse and client meet for a period to achieve health related treatment goals. (Mallette & Yonge, 2022) All definitions you should be familiar with from the first class….. Therapeutic communication - Different from conversation with social situations with family & friends The importance of good communication cannot be over emphasized Foundational and fundamental building block to client care It is a learned activity which requires knowledge, practice & self-reflection – this is why you’re doing this course Each interaction is unique and individualized. Each interaction : goal focused, client centered, has rules and boundaries, defined health care place 3 Communication with clients should be goal directed, client centered, have rules and boundaries and contain individualized strategies to meet the clients needs. Figure 5.1 –characteristics of TC:CC, rules, individualized strategies &goal directed. 4 The Purpose of Therapeutic Communication?  To establish a Therapeutic Relationship (initiate, maintain, and terminate)  Build rapport and establish trust and respect  Enhance active listening skills  Focus on the client and foster therapeutic relationship  Develop therapeutic listening responses The outcome: to help the patient cope more effectively with their situation. Build rapport with the patient – this leads to trust which will lead to a better interaction and more information will be disclosed. You convey respect maintain confidentiality; stay in the here and now; focus on the patient – don’t be distracted. Purpose; Active engagement of the client as a full partner in the interactive process & inclusion of relevant client’s values and goals. Why do we communicate with the patient?? • to teach, encourage, provide information and to move toward goal achievement. • to allow the client time to answer questions. • to explain routines and treatments • to seek client feedback • identify client’s strengths and resources 5 Professional Communication  A complex interactive process, used in clinical settings to help people achieve health-related goals  Result in patient satisfaction, addressing health issues, safety and quality care As nurses we are guided by standards, policies, ethical codes, regulations and laws. 6 Standards and Guidelines of Nursing Practice  Defined by regulatory bodies  Emphasize the requirement of efficient communication  The Standards for Practice for LPNs  The to the Code of Ethics for LPNs Regulatory bodies-which are different in every province/territory and/or country Standards of practice for LPN's in Newfoundland and labrador--" authoritative statements that define the legal and professional expectations of the LPN's practice. Specifically---Collaborating with clients in the plan of care to address client needs and preferences and to establish client centered goals --establish, maintain and appropriately end the professional therapeutic relationship with the client and their families Collaborate in the analysis, development, implementation, and evaluation of practice and policy to guide evidence informed client-centered care. Provide relevant, timely, and accurate information to clients and healthcare team. Advocate for the protection and promotion of clients’ right to autonomy, confidentiality, dignity, privacy, respect, and access to care and personal health information. Demonstrate effective, respectful, and collaborative interpersonal communication to promote and contribute to a positive practice culture. Go to this website: https://www.clpnnl.ca/sites/default/files/2021- 7 03/Code%20of%20Ethics%202013.pdf Highlight: Principle 2 – Responsibility to clients 2.1.1 – respect choices 2.1.2 – client participation 2.3 – privacy / confidentiality 2.6 – right to choice 2.7 – boundaries 7 Confidentiality  Information is shared in many ways: email, faxes, written BE CAREFUL  Do not take information that can id a client home  Do not ask other health care professionals' details about clients not under your care  Do not access information of clients via electronic records who are not under your care  Do not text or email using client identifying info  Do not speak in public places about clients  Social media!! researchgate.net Very important in nursing practice and in healthcare!!! Legal and ethical standards to protect personal health information and keep it confidential can be found in federal, provincial and territorial legislation, governing personal health information, regulated health professions acts, health facilities, health insurance, occupational health and privacy. --Further, confidentiality is specifically addressed in the Code of Ethics. . Remembering that privacy regulations apply to you in your off-duty time as well as during clinical time. Students can’t at any time reveal private health information. This includes posting any pictures on social media 8 The Importance of Communication With Clients Teach and work towards goal achievement. Allow time to answer questions. Explain routines Identify client’s and treatments strengths and resources Seek client feedback Increases client and family satisfaction Early recognition of health challenges Better understanding Efficient utilization of health services  Remember the communication between health care providers and patients impact the way care is delivered. It is as important as the care itself. 9 Metacommunication Describes all factors that influence how the message is perceived  Emotional meanings are communicated through body language  Verbal factors: culture, native language, gender, vocal pitch   Nonverbal factors: body language, culture, gender appearance So very important to know that there is more information being shared than the words you can hear. Everyone has their own communication style- specific speech related characteristics, cueing others to how you interpret a message. You can and should learn how to modify your communication style in your clinical practice. It is important to learn your own style (ex. Some of us are more assertive, or dominant, whereas others seek more of an equal partnership, or tend to withdraw. 10 Meaning 2 levels of meaning in language:  Denotation-generalized meaning assigned to a word. Ex. Dog= four-legged creature, domesticated, barks  Connotation-more personalized meaning of a word/phrase. Ex. Working like a dog, “Bark worse than his bite” 11 Types of Communication 1.Verbal 2.Non-verbal 3.Visual greatpeopleinside.com ionos.co Types 1. Verbal - words, sounds, vocal intonation and pace, vocal, sign language Can be written – educational pamphlets; charting; pictures; diagrams; texting; post a picture; use emoji; assignments Methods - face to face, groups (large and small), phone, video, online, intrapersonal (within self) 2. NonVerbal - facial expressions, eye contact, gestures, posture, movements, behaviour, distance, appearance Very important in nsg. Used more often then verbal. Eg. grimace, holding body – pain 3. Visual- 3. Visual – pictures, posters eg children – pain scales photos 12 Verbal Communication  Spoken or written word  Influenced by numerous factors  Can be interpreted differently Words are used by people to think about ideas and communicate with others. Influenced by....your age, sociocultural factors, educational background and gender also by the situation in which the communication is taking place. Interpretation may vary according to the individuals background, cultural context, and experiences. Note: if written, can be considered legal (healthcare), significant (manager wants something, eg complaint in writing before acting on it) Ask for examples Influencing factors: Age, education, socioeconomic groups, gender, situation, culture, language 13 Verbal Style Factors that Influence Communication 1. Moderate pitch and tone 2. Vary vocalizations 3. Encourage involvement 4. Validate worth 5. Advocate 6. Provide needed information 1 Pitch and tone of voice affect how message is received- pitch and tone, loudness, and rate of speaking either support or contradict the content of the verbal message. If the tone of voice does not match the words the message is less likely to be understood and less likely to be believed. 2 Cultural aspects of speech monotone, more emotional highs and lows in vocalization 3 Make pt. part of the discussion – changing in health care pt is now part of the team – ask their opinion, be inclusive in conversation 4 Validate the pt. – make them feel cared for which will sustain the relationship 5 Advocate for the patient- we often have to assume an assertive style of communication with other health care providers or agencies to obtain the best care of services for the people we care for. 6 Give the appropriate information. In a timely manner..but Not too much at once, explainNever assume people understand what you are saying – need to clarify with them that they care getting what you are saying Table 6.1 Styles that influence professional communications in nurse-person relationships. 14 Influencing 14 Most communication between people is non-verbal 15 Non-Verbal Styles of Communication 1. Silence 2. Use non-verbal behaviours that are congruent with what is being said 3. Body language 4. Touch 5. Proxemics 6. Observe non-verbal cues in client 1. Silence- allowing there to be silence sometimes. In our nurse-person communication, we use silence therapeutically, allowing needed time to think about things before responding 2. Congruency between verbal and nonverbal- Nonverbal should be congruent with messages and should reinforce it. When nonverbal cues are incongruent with the verbal information, messages are likely to be misinterpreted. 3. Body language- a communicators conscious or unconscious body positioning or actions. Ex. Tilting your head, posture, facial expression, eye contact, gestures 4. Touch- One of the most powerful ways you can nonverbally communicate. Within a professional relationship, effective touch can convey caring, empathy, comfort and reassurance. Ex. Holding a hand of someone grieving. Care must be taken to respect a persons cultural values and beliefs and their life experiences when using touch. You need to be careful of invading a persons personal space, you must be careful about where or when you touch the person. Be aware your use of touch could elict a misunderstanding if it is perceived as inappropriate or invasive. 5. Proxemics -We can use physical space to improve our interactions. Proxemics refers to the perception or what is a proper distance to be maintained between oneself and others. Knowing that the way we use space communicates messages. In nursing tend to go into the intimate space of pt. very quickly in the relationship; varies by culture 16 6. Attending to nonverbal body cues in others (posture, facial expression, eye contact, gestures) 16 Body Language https://www.youtube.com/watch?v=OvEci5Bjgd4 Posture-Can you think of cues posture may give you? Rapid, diffuse, agitated body movements may indicate anxiety, when someones bows their head and slumps their body at receiving bad news it may convey sadness Facial expression- frowning or smiling add to the verbal message conveyed. Ex. A worried facial expression and lip biting may suggest anxiety. Absence of a smile in greeting or grimacing may convey a message about how ill the person feels. Eye contact- individuals who may direct eye contact while talking or listening create a sense of confidence and credibility, where as downward glances or averted eyes can signal submission, powerlessness or shame. Failure to maintain eye contact may indicate that someone is uncomfortable. Gestures- Movements of the extremities may give cues. Making a fist can convey how angry someone is, just as the use of abrupt hand gestures may suggest distress, where hugging ones arms closely may suggest fear or anxiety. Pictures: https://www.currentconsulting.co.za/importance-body-language-businesscommunication/ https://www.psychologytoday.com/ca/blog/the-athletes-way/201901/35-facialexpressions-convey-emotions-across-cultures 17 https://medium.com/swlh/eye-contact-a-primal-force-in-business-d15f4b86449f https://www.teamtravelsource.com/2022/08/15/5-body-language-cues-that-youshould-know/ Attending behaviors – leaning in; eye contact, facial expressions Need to consider the culture of the patient with regards to eye contact When nonverbal cues are incongruent with the verbal information messages are likely to be misinterpreted. People will go with the nonverbal over the verbal. Eye contact – confidence Communication includes verbal messaging and also implicit messages (intentional or not), which are expressed through non-verbal behaviours. Non-verbal communication include: Body movements (kinesics): hand gestures or nodding or shaking the head Posture: how you stand or sit (i.e.. arms are crossed) Eye contact: the amount of eye contact often determines the level of trust and trustworthiness Facial expressions: smiling, frowning and blinking, which are very hard to control consciously Physiological changes: (i.e. you may sweat or blink more when you are nervous) 17 Factors Regarding Non-verbal Communication  Appearance, demeanor, or behavior of client can help draw attention to areas that might pose a problem for them  Incongruence between verbal communication and non-verbal behavior can highlight client concerns  Face masks!  Non-verbal signals can give clues and additional information and meaning over and above verbal communication. Making Observations Observing that a person looks tired may prompt a client to explain why they haven’t been getting much sleep lately and may lead to the discovery of a health concern/need. Look at the body lang –does it match what the patient is saying - Need to ensure congruency between the verbal and the nonverbal Face mask – can be a barrier to nonverbal communication. Difficult for people hard of hearing or with dementia. People who are hard of hearing often rely on lip reading while people with dementia may loose their ability to understand verbal language but are still able to interpret facial signs such as a smile. When wearing a mask it it important to speak calmly, maintain eye contact, smile, speak clearly, slowly, loud enough. Observe and ask if the client understands 18 Communication Models 2 communication models used most frequently: 1. Linear Communication Model 2. Transactional Communication Models Communication is a complex process and it can be difficult to determine where it begins and ends Models serve a valuable purpose because they help define communication and allow you to see specific steps of the process We will talk about each in the next few slides... 19 Linear Communication Model Components:  Sender  Message  Receiver  Channels of communication  Context  Used in emergency situations  No feedback One way Focused on sending and receiving message Components: Sender: source/sends the message Message: what is being transmitted (both Verbal & non verbal) Receiver- recipient of the message and be open to hear what the sender is sayingonce received the receiver decodes the message and internally interprets its meaning Channel of communication: the medium through which the message is sent Context: the time, space setting, & physical comfort level of sender & receiver impact message Communication is much more complicated than sending a message to other Difficult to determine the effectiveness of communication --Focuses only on the sending and receiving of messages and do not necessarily consider communication as enabling the development of co-created meanings. Useful in emergency situations when time is limited and you need to convey immediate information. 20 Figure 1.4 in textbook 20 Transactional Communication Models Communication is defined as a reciprocal interactive process The transactional model has a number of processes & components: encoding, decoding processes, communicators, message, the channel & noise. both sender and receiver influence each others messages and responses as they converse. Simultaneous feedback and is taken as a new message Figure 1.5 in textbook. 21 Transactional Communication Models  More complex than the linear model  Also called circular model of communication  Exchange of information between sender and receiver (senders and receivers both play an equally important role in communication)  Simultaneous feedback  Perceptions Transactional model of communication is the exchange of messages between the sender & the receiver where each take turns to send/ receive messages. It requires feedback, validation, and is considered a mutual, continuous activity. Provides vital role in communication process. Both the sender & receiver are known as communicators & their role reverses each time in the communication process. Non-verbal feedback (gestures, body language)is considered as feedback in this model. The model is mostly used for interpersonal communication **Perceptions – Individual perceptions influence the transmission, receiving and meaning of the message*** What should you do to help with this – ask students – seek clarification 22 22 Communication Accommodation Theory     Howard Giles theorized that people adapt or adjust their speech, vocal patterns (diction, tone, rate of speaking), language, word choice, and gestures to accommodate others Helps facilitate interactions Convergence May be conscious or unconscious Convergence: adjusting ones speech to our conversational partners to help facilitate our interaction, increase our acceptance, improve trust and rapport. Divergence: Choice of distinctly different style from the person you are speaking to. Ex. Talking to a child vs. talking to someone regarding their health issues 23 Communication Process  Well thought out – what is the purpose of the communication  Be considerate of how client may respond  Not a personal conversation  Client-focused  More formal than non-formal (especially at first) Be competent, sincere and interested Objective 3.4 - Describe the communication process and factors that influence communication. Focused on the client and their needs Formality – definitely can joke around and be yourself however this should occur under the right circumstances – once a relationship is established and you know your client, also the circumstance 24 Factors That Influence Communication       Experiences Culture, bias Language Environmental  Physical setting  Timing  Proxemics Relationship: Age, education Countertransference Experiences Past experiences, education, age ,occupation, experience with med system (good and bad). Culture may have an influence on distancing, maintain eye contact. Language –terms, slang, jargon, clichés; also different languagesdo not use medical terminology when client does not have medical background (BID, prn) Environmental : background noise, setting; Social distance- 3-4 feet; presence of others , economics, privacy Timing- critical Proxemics: Study of individual use of space Relationship: age, job, 19 yr. old LPN with older nurses, clients. e.g.: Student PN caring for retired RN ; How we communicate with strangers Countertransferance – inappropriate emotional response to client due to feelings from similar situation/person, eg that client reminds me of my old BF, whom I hate!! 25 Figure . 25 Therapeutic Communication Skills  Listening skills (active listening)  Interacting skills (active listening responses)  Therapeutic communication skills  Communication techniques (verbal and non-verbal responses) Therapeutic communication skills involve… Note this content is important for Labs 5/6 26 Active listening is an intentional form of listening-“a dynamically focused, interpersonal process in which a nurse hears a person’s message, decodes its meaning, asks questions for clarification, and provides feedback to the person” (Mallette & Yonge, 2022, p. 74) Being aware of what is being communicated Pay attention to nonverbal! Client may be leaving information out, but you can tell with nonverbal Goal: understand what the client is trying to communicate Essential component in client-centered care Allows the nurse to partner with the client and carry out the nursing process 27 Active Listening An “intentional” form of listening The nurse listen for themes, makes observations and explores feelings Designed to encourage respect and understanding A component  in client-centered care Requires great effort and practice Active listening: technique for developing the ability to listen. AL entails the nurse using all senses to focus on what the C is communicating. It conveys an attitude of caring and genuine interest to the client. (Undivided attention communicates that Clt is not alone) Understand & reflect on c’s message - It is a learned skill.. Awareness of the client’s verbal and non verbal communications and monitoring of one’s own verbal and non verbal communications -Involves more than simply just hearing words 28 Components of Active Listening 1. Give the speaker your undivided attention 2. Demonstrate that you are listening 3. Provide feedback 4. Remain nonjudgemental 5. Respond appropriately 1. Give the Speaker your Undivided Attention and acknowledge the message (Undivided attention communicates that the is not alone) • Maintain eye contact, relaxed demeanor. • Avoid being distracted by environmental factors (e.g. noise, other clients) • Note to the speaker's non-verbal cues (body language)- recognizing that non-verbal communication also “speaks” loudly 2. Demonstrate That You're Listening • Use body language & gestures appropriately to promote engaging. • Sit facing the client, open posture, lean toward the client, eye contact, relax • Smile. Encourage conversation using uh hum, nodding, yes. • Ensure posture is open and interested 3. Provide Feedback • Reflect on what is being said and seek clarification if needed. "What did you mean when you said... ." • Use paraphrasing. "What I'm hearing is... ," Just to clarify, it sounds like you are saying… these are great ways to reflect back • Summarize occasionally. 4. Defer Judgment • Do not interrupt the client when they are speaking---this can be frustrating • Allow the client to finish each point before asking questions. • Be respectful to others thoughts and opinions 5. Respond Appropriately 29 • Be honest & genuine , respectful. 29 Improve your listening skills with active listening. https://www.youtube.com/watch?v=3 _dAkDsBQyk 30 SOLER S: Sit O: Open Posture L: Lean E: Eye Contact R: Relax Non-verbal skills that can enhance your active listening ability can be applied using the acronym SOLER S= Sitting facing the person- indicating you want to listen and are interested in what they have to say O= Ensure your posture is open. Arms and legs must be uncrossed indicating you are open to what the other person is saying- sometimes crossed arms can indicate that you are uncomfortable and not open to what the other person is saying L= Leaning towards the person- letting them know you are interested and engaged in the conversation E= Initiate and maintain eye contact- this shows you are listening to what the person is telling you- not maintaining eye contact or shifting your eyes away can indicate you are distracted or not listening. R= As you communicate to the person try to relax. Being restless can portray you are uncomfortable or show the person a lack of interest 31 Asking Questions  Assessing  Reflection  Explanation  Listen for themes Another way you can show the person you are listening to them is by asking questions… Is a fundamental component of any nursing assessment Its necessary in the Assessment Phase of the Nursing Process (as well as used in all other phases) Reflect on the purpose and need to obtain the information Explain to the client the reason you are asking specific questions and the relevance of the question and how it may impact their health and well-being When listening to client responses, the nurse listens for themes Be direct and seek precise information- asking irrelevant information may make you seem unfocused or like you are prying Have you been tested for COVID? Do you smoke? Probing –allows nurse to get more subjective data based on clt’s answer. How did that affect/impact you? Themes – message; not necessarily obvious, eg I’m not sure I should do the therapy; talks of pressure at home, maybe wants it but can’t do to family reasons 32 Types of Questions 1. Close ended 2. Open ended 3. Focused We will talk in more detail about each of these… 33  Narrow  “yes” or “no”  Can limit a client’s response conversationstartersworld.com Narrowly focused questions Yes no or a simple phrase Ask students when these should be used: emergency, person agitated use to help calm them down, child, not always the need for elaboration- when there is a need to get an answer quickly and the context or person’s emotional reactions are not important because of the seriousness of the immediate situation. Ask for examples Have you been tested for COVID? Do you smoke? “Are you having pain?” “Is the medication working?” How useful in therapeutic communication? Narrow focus Can be answered with “yes” or “no” Can limit a client’s response and thought expression & require several questions to obtain information 34 Prompt a client to share more information Requires the client to think, reflect and express self in own words Cannot be answered by “yes” or “no”, or a one word response For example: “You look uncomfortable. Tell me how you are feeling right now?” OEQ are used in each phase of the TNC interaction. It is recommended in the orientation phase of the relationship, (e.g., “What brought you to the clinic today?”) CEQ-may take several questions to obtain information OEQ-questions that invite the client to describe, open up about experience/issue, .Client typically speaks in sentences. What was going on in our life when you became anxious/stressed? How have you been feeling since hospitalization? Good to end interaction with open ended question, eg me in PAU 35 These are just some examples… They focus in on a particular area to gain more specific information Require more than a “yes” or “no” response Limits the topic to be addressed Provides the client an opportunity 36 to expand on information Can be also be useful in emergency situations Example: “What would you say is worrying you the most?” This type of question is asked to help the client expand on a particular topic. Probing –allows nurse to get more subjective data based on clt’s answer. Ask: Do you know the difference between subjective and objective data? Objective – vitals; subjective – description of pain How did that affect/impact you? When did the symptoms begin? Describe your hallucinations 36 WHY Questions  Avoid questions that start with WHY?  Why questions are more difficult for people to answer and can be interpreted as blaming  A person may become defensive  Ex. What brought you to the ER today vs. WHY did you come to the ER? 37 Review Which of the following is an example of an openended question? A. How many times have you walked in the hall today? B. What are your concerns about taking care of your new colostomy? C. Do you feel rested this morning? D. Are you experiencing pain at this time? B The other questions are close-ended questions that can be answered with a yes or no answer. Ask students to reformulate the incorrect responses into open-ended questions. 38 Active Listening Responses 1. 2. 3. 4. 5. 6. 7. 8. Minimal cues and leads Clarification Restatement Paraphrasing Reflection Summarizing Silence Touch Table 5.1, p. 83 Many of these techniques (2-6) are very similar. Subtle differences We will be discussing each one in depth along with other methods of communication These next several slides will be very important and form the basis of you understanding therapeutic communication. 39 Minimal Cues and Leads  Transmitted through body language and gestures which encourage the client to continue speaking  Non-verbal cues and short phrases that are brief verbal prompts to encourage clients to continue the conversation  Lets the client know you are paying attention  Examples: “Go on”; “Um-humm”; “And then what?”  Non-verbal examples: Leaning forward, nodding Brief, one to three-word statement, or non-verbal gestures. These responses demonstrate to the speaker that you are following the conversation. Examples • “Um-humm” • “Go on.” • “Yes.” • “Oh really.” • I see. True… • Smiling • Nodding 40 Clarification  Brief question or statement seeking understanding  Use a neutral tone of voice  Provides the client/nurse the opportunity to confirm understanding  “Failure to ask for clarification when part of the communication is poorly understood means that you might act on incomplete or inaccurate information” (Mallette & Yonge, 2022, p.83-84)  Example: “When you said your mother is getting a bit more forgetful, what exactly did you mean?” Can you tell me a little more about...?” “I am not sure I understand….” “Can you give me an example of...so I can be sure I understand?” “Can you tell me what you mean when you said........” “Can you say more about . . .” Avoid questions that start with WHY? As it can be interpreted as blaming and may cause the person to become defensive. Why questions are perceived as challenging by clients – unless you are in a relationship where you feel comfortable enough to challenge. This likely not going to happen in a regular acute care setting. 41 Restatement  Used to obtain further information on a client statement  Repeat what the client said  Allows the client to elaborate  Example: Client states: “I am so sad”. Nurse states: “You’re sad?” Used to broaden a persons perspective or when the nurse needs to validate or clarify the person’s statement. Restating what the other person has said to you, indicating that you understand. Let’s the client know that their message got across and you understand or are asking for confirmation if you are unsure. So, what you are saying is… OR Are you saying that.. (repeat the persons words) Indicates nurse is listening & calls attention to something important. 42 Paraphrasing Listening responses that check whether you have interpreted the information correctly Taking the original message and transforming it into your own words- be sure not to lose the original meaning Shorter and more specific Objective is to understand what issues are important to the client Allows you to summarize and streamline a message The nurse’s statement can be shorter and more specific in order to focus on the important content Several purposes: ensure the nurse understands what the client means provides a summary focuses on the important elements Example: Client: I can't focus, my mind keeps wandering. I can’t stop asking myself why I’m having such trouble sitting down and doing my work. It’s so hard to deal with. It’s so hard to get things done.”. 43 Nurse: “You’re having difficulty concentrating and focusing?” Paraphrasing helps the speaker feel they are being listened to and understood and it helps the listener confirm their understanding is accurate. When you paraphrase what a person has told you, you give a re-worded statement of the message content (which is usually shorter then the original message). “What I’m hearing is…” “ “It sounds like what’s most important to you is . . . “ 43 Reflection      Focuses on the emotional part of the message “Should be a simple observational comment, expressed tentatively, not an exhaustive comment about the person’s emotional reaction.” (Mallette & Yonge, 2022, p.85) Mirror the emotion the client is expressing Use statement such as “It sounds like you feel ________because ___________” Example: Client spoke in detail about a prior negative experience while hospitalized, what happened and all the negative results. Nurse: “You’re upset and anxious now because of your last time in hospital.” Reflection- a way that a nurse can empathetically mirror their sense of how a person may be emotionally experiencing their health situation. . A technique used to direct ideas and feelings back to the client. The goal is to help them explore their feelings about a situation. Redirecting the client’s ideas, feelings and content Example: “You’re feeling anxious, and it’s related to a phone call you got from a family member last night.” • “It seems like you felt confused and worried when that happened.” • “So, you’re saying that you were feeling more frightened than angry?” 44 Summarization  Brief review of the content of the communication to ensure the nurse understands what the client means  Brings it all together in a few sentences  “Let me just check if I’m understanding what you just told me. Please let me know if there’s anything wrong.”  Usually towards the end of the conversation  Can act as a bridge to change the subject  Example: Nurse: “I want to make sure I’ve understood you. You are concerned about the amount of pain you still feel after undergoing surgery last month. Is that right?” I use this a lot; 3rd statement is what I say This techniques is useful for nurses to capture what a client has said. This technique demonstrates to a client that the nurse was listening and allows the nurse to document conversations. Ending a summary with a phrase like “Does that sound correct?” can be beneficial. Using this communication technique gives clients permission to make corrections if necessary. This communication technique is useful at the end of a teaching session or a nurse-client interaction. Summarizing condenses all of what a person has said into two or three sentences. • “Let me summarize what I have heard so far. . . . “ • “It sounds like there are two things that really matter most to you . . . “ 45 Silence     https://unsplash.com/s/photos/silence  Lack of verbal communication for a therapeutic reason Time to gather thoughts, process what was said, and formulate a response Time to deal with an emotional response (for example, sadness, anger) Gives client a time to gain insight about what has been said Can feel comfortable or uncomfortable A brief pause, it can be a very powerful listening response. Silence can give both the nurse and client an opportunity to consider what to say next in a conversation. It may enable the client to gain insights into their views 46 Touch social-engineering.org     Must be used carefully Not all clients appreciate being touched due to a variety of reasons (cultural, trauma history) Can be powerful if used appropriately Example: Nurse places their hand on the client’s hand while the client in tearful. **Assess the client and decide if touch would be an appropriate and effective intervention. Every client is different** It can convey empathy and compassion. Touch must be used carefully as it can be perceived in an offensive threatening manner. Person experiencing DV, PTSD, abuse –seek permission to touch. 47 Negative Listening Responses      False reassurance Giving advice False inferences Moralizing Value judgement Table 5.2 p.86 There are also negative listening responses If you know about them you can recognize if and when you use them and then try to avoid them False reassurance- using phrases that are meant to be comforting however can be misinterpreted---Everything will be okay (pseudo comforting phrases) Giving advice-Making a decision for a person- If I were you, I’d False inferences –making unsubstantiated assumptions "so what you really mean is you do not like..” Moralizing- expressing your own views , ex. using drugs is so wrong Value judgement – conveying approval or disapproval about the persons behaviour- “ that really wasn’t a nice way to behave” 48 Communication Techniques  Make eye contact  Introduce yourself!! (name, title, reason for being there)  Full attention  Use plain, clear language  Set time limit  Accept the client’s communication style  Listen The next three slides speak to tech that can and should be used in the clinical settings. Ask students there experiences when someone did not introduce themselves and starting speaking to them or another example can be asked here Attention – no yawning, looking around, at clock Client may use certain words that have other meanings - clarify Time limit – busy elsewhere Client’s level of understanding – education; med condition; cognition; sleepy; sedated; developmental needs See Box 5.3 49 Communication Techniques  Encourage participation  Speak  Use  Be to client’s level of understanding appropriate non-verbal cues open  Start with general questions, move to more specific  Provide feedback Ask students there experiences when someone did not introduce themselves Attention – no yawning, looking around, at clock Client may use certain words that have other meanings - clarify Time limit – busy elsewhere Client’s level of understanding – education; med condition; cognition; sleepy; sedated; developmental needs See Box 5.3 50 Communication Techniques  Repeat  Focus  Find  Not key points on one topic at a time common ground too much information  Observe non-verbal cues (does client understand)  Broad openings  Focusing Examples of nonverbal cues (nodding, verbals like ok, uh huh Not too much info – over whelming Allows clients to direct the flow of conversation and decide what to talk about; discuss what’s on their mind; Example: Nurse “What’s on your mind today?” or “What would you like to talk about?” Broad openings - Focusing - Opportunity to focus on a specific comment made by a client.; allows nurse to provide direction 51 Use of Humour  Can help establish rapport and can be a powerful communication technique  Coping strategy  Part during a difficult situation of caring  Needs to be suitable to the situation  Don’t focus on personal characteristics  Know the client and decide if it is appropriate Lot of factors need to be understood before bringing in humour, especially if things are tense Hospitals are stressful places for patients, sharing hope that they can perservere through their current situation and lightening the mood with humor can help nurses establish rapport quickly. Lighten the mood- this technique can put patients in a positive state of mind Appropriate language 52 Challenging a Client The nurse can disagree with the client  Trust must be established  Can promote insight, by encouraging reflection on unhealthy behaviours  Present reality  Challenge the client’s views  Promotion of open communication  Can lead to positive change • Can also lead to being competitive and dares to make client explain. 53 Review What listening technique is being used by the LPN in the following situation? Client "No one cares about me anyway" LPN "No one cares?" A) Focusing B) Restatement C) Summarizing D) Paraphrasing B) Restatement 54 Review  The nurse has been listening carefully to the patient explain how the cost of managing her diabetes has caused her family to file for bankruptcy. The nurse responds, "I would not worry. With the Affordable Care Act, all your medical bills will be paid." A. Giving advice B. Over generalizing C. Paraphrasing D. False reassurances 55 “Words direct the content of the message whereas emotions accentuate and clarify the message of the words” (Mallette & Yonge, 2022) Objective 3.6 - Discuss the importance of recognizing and assessing nonverbal communication. Non-verbal communication is made up of 38% verbal cues and 55% non-verbal body cues 90% of messages are made up, no of words, but of verbal pitch and nonverbal cues 56 Non-verbal Communication   Facial expression, body posture, movement, and agitation are all signs that offer suggestions as to how the client is feeling about what is being said Is there a congruence between verbal and non-verbal?  Knowing the client  Ask client to clarify non-verbal activity, especially when there is non-congruence  Also exhibited by the nurse 3.6=Discuss the importance of recognizing and assessing nonverbal communication. -Clients habits, beliefs, culture, attitude all affect non-verbal -if you have developed a therapeutic relationship with a client, you will be more familiar with their reactions -Clients and families are also watching nurses, so be aware 57 Physical Behavioural Cues  Emblems  Illustrators  Affect displays  Regulators  Adaptors  Physical characteristics Box 5.1 Emblems – gestures with common interpretation, eg wave, handshake Illustrators – emphasizes a verbal message eg smile, pounding fist Affect display – Regulators – means to reinforce, eg hand up, look of surprise Adaptors – person specific, repetitive – eg. hair twirling, blushing Physical characteristics – body odour, clothing, appearance 58 Nonverbal Cues  Facial expression  Vocal tones (uhuh, oh , okay , no,  Body yeah) positioning  Gestures  Posture  Touch  Eye contact  Personal space  Nodding  Body movements Body Languages Are your arms crossed Do you have an open position>? Maintain eye contact appearance, clothing body language, space Nurses: The greater the level of self aware nonverbally, the more effective nursing interventions 59 Bridges to Effective Communication       Listen before you speak Know what you are speaking about Use words wisely Be open to different views and ideas Work within the system Do not promise what you cannot deliver!! Next we will discuss Objective 3.7 - Discuss strategies to address barriers to therapeutic communication. Page 504-506 Work within the system – do not promise a patient something they will not get, eg you won’t be admitted (PAU); long wait lists Be upfront and honest 60 Barriers to Communication Coming from the client  Pain  Don’t understand language used  Emotional  Feeling insecure  Message  No topic too complex privacy  Sensory or cognitive deficits 61 Barriers to Communication Coming from the nurse  Preoccupied with own problems  In a hurry  Making assumptions about client  Stereotypes  Feeling inadequate  Thinking ahead, not in the moment  Intense emotional reaction to client  Random comments Lab 4 will explore communication deficits Further discussion in Objective 4 62 What are Professional Boundaries? “Invisible structures imposed by legal, ethical, and professional standards of nursing that respect the rights and privacy of the person and protect the functional integrity of the relationship between the nurse and person.” Mallette & Yonge, 2022, p. 204 Conflict of interest The responsibility lies with the nurse not the client 63 64 Standards of Code of Ethics for Practice for LPNs LPNs in Canada. 2013. in Canada. 2020 2.7 Develop trusting, therapeutic relationships, while maintaining professional boundaries. 4.4 Maintain professional boundaries in the nurse / client therapeutic relationship. Needed for practice in any setting—remember these 65 Imbalance in client/nurse care The opposite is disengagement-withdrawal from patient for some reason- doesn’t like the patients behavior etc., patient left to struggle alone. -Disengagement is just as wrong as over involvement 66 Professional Boundaries Must be Defined by the Following: Setting Time Purpose Focus of conversation Length of contact 67 Level of Involvement The nurse-client relationship is an interdependent relationship whereby the nurse must remain emotionally objective and ensure there is a balance between compassion and professionalism. What does involvement mean – the degree of the nurse’s attachment and active participation in the client's care. Degree of involvement may change throughout the therapeutic interaction but the professional boundaries should not be crossed. Can be very difficult, gets blurred by the length of time looking after patient. Nurses have to maintain emotional objectivity while remaining present to the patient. Over involvement result in the nurse losing the necessary objectivity needed to help the client reach health goals Some clients are so nice, some are manipulative, some are deserving of extra care – however you must always remain objective – hard sometimes because you know that the client may deserve or need more. It is not up to you to provide anything outside of nursing care How can you do this: May need to step away from the patient- be reassigned Discuss with co-workers Move units Some strategies include:  understanding the limits of the therapeutic relationship  establishing, maintaining and communicating professional boundaries with the client  avoiding dual relationships (therapeutic and social) to the extent possible  adhering to the plan of care  communicating the expectations for and limits of confidentiality  being sensitive to the context in which care is provided  implementing reflective practice and terminating the therapeutic relationship. ARNNL. (2014). The therapeutic nurse-client relationship: expectations for registered nurses. https://www.crnnl.ca/sites/default/files/documents/ID_Therapeutic_Nurse_Client_Relationship_ Expectations_for_Registered_Nurses.pdf 68 WARNING SIGNS OF OVER-INVOLVEMENT  Extra time and attention to certain clients  Visiting outside of regular work hours  Discounting the actions/care of other professionals  Feeling resentment about how others care for the client  Belief that you are the only care giver who understands the client’s needs  Gift giving -Establish boundaries within the relationship AND recognize when boundaries are being crossed. -Abstain from disclosing personal information (in most cases) -Over involvement results in the nurse's loss of an essential objectivity needed to support the patient in meeting health goals; it can also compromise the nurse’s obligation to the service agency, to collegial relationships and responsivities to other patients -Debriefing after emotional experiences can help nurses maintain their professional involvement. 69 WARNING SIGNS OF OVER-INVOLVEMENT  Accepting a client as friend on Facebook  Providing health care advice on social media  Keeping secrets with clients  Breaching confidentiality  Using the client’s confidential information to benefit the needs of the LPN.  Dressing differently when assigned to certain clients -Establish boundaries within the relationship AND recognize when boundaries are being crossed. -Abstain from disclosing personal information (in most cases) -Over involvement results in the nurse's loss of an essential objectivity needed to support the patient in meeting health goals; it can also compromise the nurse’s obligation to the service agency, to collegial relationships and responsivities to other patients -Debriefing after emotional experiences can help nurses maintain their professional involvement. 70 Examples GIVING A CLIENT YOUR CELL NUMBER ACCEPTING A CLIENT’S FACEBOOK REQUEST HAVING A PICTURE TAKEN WITH A CLIENT IN HOSPITAL ACCEPTING GIFTS FROM CLIENTS BUYING A COFFEE FOR A SPECIFIC CLIENT ON YOUR WAY TO WORK VISITING OUTSIDE WORK HOURS Can you think of any examples? Personal examples; client wanted to bend visitation rules, other pt with CP; charming and manipulative Bringing pt in coffee/drinks Hc professional in relationship with former client; when did it start? Client agreeable 71 What do you do if you know a client?? Tell supervisor; do you inform client?; do you remove self from their care? Reassignment possibly 72 Objective 4 Objective 4.6: Discuss strategies which promote respectful, professional interpersonal e-communication and social media use We will go into objective 4 more next class, however we need to go over Objective 4.6 to ensure that we discuss professional interpersonal e-communication and social media use for your case study assignment 73 Professional Written Communication Skills Communicating professionally in email is important in health care and in learning environments  Netiquette refers to rules and guidelines for etiquette on the Internet  Method of contact for important matters  Means to provide effective, clear and professional communication  Reflects professionalism  Contributes to a respectful workplace In professional settings, strong written communication skills are necessary. It is important that you communicate professionally, both in your interactions with clients in the clinical setting and with your faculty/instructors in the education setting. Netiquette is important in online classes/emails because it causes communication to be more professional, clear and polite, enabling students to exchange ideas freely and offer input on assignments, online forums & emails. Etiquette is expected of students /faculty in online discussion/emails ; the same as what’s expected in class. There is a problem, though: the absence of visual & auditory clues. In face-to-face discussions, these clues contribute a lot of nonverbal nuances of meaning. It's impossible to replicate these NV cues online. This is why it’s important to be careful when writing emails 74 Guidelines – Do’s  Use a professional email address  Subject line should contain purpose of email (ex. Exam Question)  Use a professional greeting ("Good morning Ms. White", not "hey there")  Address the recipient using professional title  Introduce yourself  Use short concise sentences- get to the point  Acceptable grammar, spelling and sentence structure For work/school purposes, not personal email Not (I need help!!) Professional greeting – eg Dear ….; To whom it may concern Dr or Ms or Instructor or Professor Short sentence – no irrelevant info. Recipient may receive lots of emails, doesn’t want to read ++ of unnecessary info Introduce yourself – eg student in N103; LPN on unit XX. Recipient may not know who you are, but if you put in context it will help. Also helpful for subject line, eg N103 Missed Lab 75 Guidelines – Do’s  Keep it formal  Use professional font (eg Times New Roman, not Comic Sans MS)  Be polite and honest and sensible  Check your email for content and typos before sending  Double-check who you are sending email to  Include contact info (full name, email, phone if applicable)  Respond in timely fashion when you receive an email Sensible – be careful what you say Be careful to hit reply and not reply all 76 Guidelines – Don’ts  Do not use all CAPS- be cognizant of the tone  Do not use emojis  Do not use excessive exclamation points !!!!!  Do not use abbreviations, shorthand or slang (eg FYI, IDK, LOL, OMG)  Do not add irrelevant information, so that it is long and rambling  Do not use humour  Avoid overuse of Urgent or High Priority 77 Important Points About Emails  Remember email is not private! And it can be archived forever  Do not send confidential information  If in doubt, keep it formal  Once they are sent, there’s not taking them back  If you are emotional or stressed, wait before you hit send – give yourself time to center and focus  There is a human at the other end to the email – be kind 78  “I WANT TO SEE YOU ASAP!!!!!!!!!!!!!!!!!!!”  Response: right now. I feel a little threatened  Remember there is a person on the other end of this email. 79 Email Etiquette Assignment  Posted on D2L  Due September 28th, 2023  There is a Part 1 & a Part 2: Note different scenarios for each  Answers should be written in Microsoft Word Hammond, L., & Moseley, K. (2018). Reeling in proper “netiquette”. Nursing Made Incredibly Easy! 16(2), pp. 50-53. https://journals.lww.com/nursingmadeincrediblyeasy/fulltext/2018/03000/reeling_in_proper__netiquette_.11.aspx Smith, J. (2016). 15 Email etiquette rules every professional should follow. https://www.inc.com/business-insider/emailetiquette-rules.html The Scholarship System. (2021). How to write a professional email- A guide for learners. https://thescholarshipsystem.com/blog-for-students-families/how-to-write-a-professional- email-a-guide-forstudents/ 80 Summary The therapeutic nurse-client relationship is based on trust, respect, and professional integrity  The therapeutic relationship is essential in providing safe and competent, compassionate and ethical nursing care   There are multiple ways to communicate with clients  Multiple different skills can be learned in order to improve communication  Communicating professionally in email is important in healthcare and in learning environments 81 References  College of Licensed Practical Nurses of Alberta. (2018). Relational Practice. https://www.clpna.com/2018/01/study-clpna-relational-practice-self-studycourse/#:~:text=Relational%20practice%20is%20the%20current,%2C%20families%2C%20colleagues %20and%20others  Mallette, C. & Yonge, O. (2022). Arnold & Boggs’s Interpersonal relationships: Professional communication skills for Canadian nurses. Elsevier.  MindTools. (2015). Improve your listening skills with active listening. https://www.youtube.com/watch?v=t2z9mdX1j4A&feature=youtu.be  Smith, J. (2016). 15 Email etiquette rules every professional should follow. https://www.inc.com/business-insider/email-etiquette-rules.html  Standards of practice for licensed practical nurses in Canada (2020).  The Scholarship System. (2021). How to write a professional email- A guide for learners. https://thescholarshipsystem.com/blog-for-students-families/how-to-write-a-professionalemail-a-guide-for-students/ 82