c h a p t e r
Learning Objectives
personal space
proxemics
public space
relationship
silence
social space
task-oriented touch
terminating phase
therapeutic verbal
communication
touch
verbal communication
working phase
A relationship (association between two or more people) is established between the nurse and client when
nursing services are provided. Nurses provide services,
or skills, that assist individuals, called clients or patients,
to promote or restore health, cope with disorders that
will not improve, and die with dignity.
The nurseclient relationship requires the nurse to respond to the clients needs. The National Council of State
Boards of Nursing, which develops the national licensing
examination for practical nurses (NCLEX-PN), designates
four categories of client needs as the structure for the test
plan: (1) safe, effective care environment, (2) health promotion and maintenance, (3) psychosocial integrity, and
(4) physiologic integrity. These four categories apply to all
areas of nursing practice regardless of the stage in the
clients life span or the setting for health care delivery. To
meet these client needs, nurses perform four basic roles:
caregiver, educator, collaborator, and delegator.
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BOX 7-1
Caring Acts
Nursing Acts
Motivated by sympathy
Motivated by altruism
Spontaneous
Planned
Experience-based
Knowledge-based
Legally defined
Laboratory
technician
Pharmacist
Dietitian
LPN
RN
CLIENT
Unlicensed
assistive personnel
MD
Physical
therapist
Respiratory
therapist
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THE THERAPEUTIC
NURSECLIENT RELATIONSHIP
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NURSING RESPONSIBILITIES
Possess current knowledge.
Be aware of unique age-related differences.
Perform technical skills safely.
Be committed to client care.
Be available and courteous.
Facilitate participation of client and family in decisions.
Remain objective.
Advocate on the clients behalf.
Provide explanations in easily understood language.
Promote clients independence.
CLIENT RESPONSIBILITIES
Identify current problem.
Describe desired outcomes.
Answer questions honestly.
Provide accurate historical and subjective data.
Participate to the fullest extent possible.
Be open and flexible to alternatives.
Comply with the plan for care.
Keep appointments for follow-up care.
The nurseclient relationship also can be called a therapeutic relationship because the desired outcome of the
association is almost always moving toward restored
health. A therapeutic relationship differs from a social
relationship. A therapeutic relationship is client-centered
with a focus on goal achievement. It is also time-limited:
the relationship ends when goals are achieved.
The relationship between nurses and clients has
changed. In the past, the role of a sick person was passive;
this allowed others to make decisions and submit to treatments without question or protest. Nurses now encourage
and expect people for whom they care to become actively
involved, to communicate, to question, to assist in planning their care, and to retain as much independence as
possible (Box 7-2).
Underlying Principles
A therapeutic nurseclient relationship is more likely to
develop when the nurse
BOX 7-2
Introductory Phase
The relationship between client and nurse begins with
the introductory phase (period of getting acquainted).
Each person usually brings preconceived ideas about the
other to the initial interaction. These assumptions eventually are confirmed or dismissed.
The client initiates the relationship by identifying one
or more health problems for which he or she is seeking
help. It is important for the nurse to demonstrate courtesy,
active listening, empathy, competency, and appropriate
communication skills to ensure that the relationship
begins positively.
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Working Phase
The working phase (period during which tasks are performed) involves mutually planning the clients care and
enacting the plan. Both nurse and client participate. Each
shares in performing those tasks that lead to the desired
outcomes identified by the client. During the working
phase, the nurse tries not to retard the clients independence: doing too much is as harmful as doing too little.
Terminating Phase
The nurseclient relationship is self-limiting. The terminating phase (period when the relationship comes to an
end) occurs when nurse and client mutually agree that
the clients immediate health problems have improved.
The nurse uses a caring attitude and compassion in facilitating the clients transition of care to other health care
services or independent living.
COMMUNICATION
BOX 7-3
Appearing unkempt: long hair that dangles on or over the client during
care, offensive body or breath odor, wrinkled or soiled uniform, dirty shoes
Failing to identify oneself verbally and with a name tag
Mispronouncing or avoiding the clients name
Using the clients first name without permission
Showing disinterest in the clients personal history and life experiences
Sharing personal or work-related problems with the client or with staff in
the clients presence
Using crude or distasteful language
Revealing confidential information or gossip about other clients, staff, or
people commonly known
Focusing on nursing tasks rather than the clients responses
Being inattentive to the clients requests (e.g., food, pain relief, assistance
with toileting, bathing)
Abandoning the client at stressful or emotional times
Failing to keep promises such as consulting with the physician about a
current need or request
Going on a break or to lunch without keeping the client informed and
identifying who has been delegated for the clients care during the
temporary absence
Verbal Communication
Verbal communication (communication that uses
words) includes speaking, reading, and writing. Both
nurse and client use verbal communication to gather facts.
They also use it to instruct, clarify, and exchange ideas.
The following factors affect ability to communicate
orally or in writing:
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TABLE 7.1
TECHNIQUE
USE
EXAMPLE
Broad opening
Giving information
Direct questioning
Open-ended
questioning
Reflecting
Paraphrasing
Summarizing
Silence
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Listening
Listening is as important during communication as speaking. Giving attention to what clients say provides a stim-
TABLE 7.2
EXAMPLE
IMPROVEMENT
Agreeing
Does not allow the client flexibility to
change his or her mind
Disagreeing
Intimidates the client; makes him or her
feel foolish or inadequate
Demanding an Explanation
Puts the client on the defensive; he or
she may be tempted to make up an
excuse rather than risk disapproval
for an honest answer
Giving Advice
Discourages independent problem
solving and decision making; provides
a biased view that may prejudice the
clients choice
Using Clichs
Provides worthless advice and curtails
exploring alternatives
Defending
Indicates such a strong allegiance that
any disagreement is unacceptable
Belittling
Disregards how the client is responding
as an individual
Patronizing
Treats the client condescendingly
(less than capable of making an
independent decision)
Changing the Subject
Alters the direction of the discussion to
a safer or more comfortable topic
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People communicate nonverbally through the techniques described next: kinesics, paralanguage, proxemics,
and touch.
Kinesics
Kinesics (body language) includes nonverbal techniques
such as facial expressions, posture, gestures, and body
movements. Some add that clothing style and accessories
such as jewelry also affect the context of communication.
Paralanguage
Silence
Silence (intentionally withholding verbal commentary)
plays an important role in communication. It may seem
contradictory to include silence as a form of verbal communication. Nevertheless, one of its uses is to encourage
the client to participate in verbal discussions. Other therapeutic uses for silence include relieving a clients anxiety just by providing a personal presence and offering a
brief period during which clients can process information
or respond to questions.
Clients may use silence to camouflage fears or to
express contentment. They also use silence for introspection when they need to explore feelings or pray. Interrupting someone deep in concentration disturbs his or her
thought process. A common obstacle to effective communication is ignoring the importance of silence and talking
excessively.
Proxemics
Proxemics (use and relationship of space to communication) varies among people from different cultural backgrounds. Generally four zones are observed in interactions
between Americans (Hall, 1959, 1963, 1966): intimate
space (within 6 inches), personal space (6 inches to
4 feet), social space (4 to 12 feet), and public space
(more than 12 feet; Table 7-3).
Most people in the United States comfortably tolerate
strangers in a 2- to 3-foot area. Venturing closer may cause
TABLE 7.3
COMMUNICATION ZONES
ZONE
DISTANCE
PURPOSE
Intimate space
Within 6 inches
Personal space
6 inches to
4 feet
Social space
4 to 12 feet
Public space
12 or more feet
Nonverbal Communication
Nonverbal communication (exchange of information
without using words) involves what is not said. The
manner in which a person conveys verbal information
affects its meaning. A person has less control over nonverbal than verbal communication. Words can be chosen
with care, but a facial expression is harder to control. As
a result, people often communicate messages more accurately through nonverbal communication.
Lovemaking
Confiding secrets
Sharing confidential
information
Interviewing
Physical assessment
Therapeutic
interventions
involving touch
Private conversations
Teaching one-on-one
Group interactions
Lecturing
Conversations that
are not intended to
be private
Giving speeches
Gatherings of
strangers
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Touch
Touch (tactile stimulus produced by making personal contact with another person or object) occurs frequently in
nurseclient relationships. While caring for clients, touch
can be task-oriented, affective, or both. Task-oriented
touch involves the personal contact required when performing nursing procedures (Fig. 7-4). Affective touch
is used to demonstrate concern or affection (Fig. 7-5).
Affective touch has different meanings to different
people depending on their upbringing and cultural background. Because nursing care involves a high degree of
touching, the nurse is sensitive as to how clients may perceive it. Most people respond positively to touch, but there
are variations among individuals. Therefore, nurses use
affective touching cautiously even though its intention is
to communicate caring and support. In general, affective
touch is therapeutic when a client is
FIGURE 7.5 This nurse uses affective touch as she talks with her client.
(Copyright B. Proud.)
Lonely
Uncomfortable
Near death
Anxious, insecure, or frightened
Disoriented
Disfigured
Semiconscious or comatose
Visually impaired
Sensory deprived
GENERAL GERONTOLOGIC
CONSIDERATIONS
Begin an initial contact with an exchange of names and a handshake if
appropriate. Before calling a person by his or her first name, obtain
permission or wait to be invited to use a more familiar form of address,
which some cultures reserve for family and close friends.
Never treat older adults as if they are children; avoid using any terms that
are demeaning or connote childlike or infantile behavior or actions
(e.g., remarks such as He acts just like a baby and references to
incontinence products as diapers).
Use touch purposefully as a primary method of nonverbal communication
and to reinforce verbal messages; recognize that touch as a form of
communication is usually more important to older adults than to
younger adults.
Sit in a face-to-face position, provide good lighting while avoiding background glare, and eliminate as much background noise as possible.
Promote as much control over decisions and choices as possible. Dependence is often difficult to accept; independence maintains self-esteem
and dignity.
Allow older adults to pace their own care and maintain as much independence as possible even when this requires more time.
Encourage reminiscing. Ask about past events and relationships associated with positive experiences and feelings. Giving older adults an
opportunity to talk about earlier times in their lives reinforces their
value and unique identity.
CHAPTER 7
Be aware of subtle verbal messages that convey bias or inequality; for example, calling white men Mister but men of color by their first names.
Avoid addressing older adults in familiar terms such as Dear, Grandma,
or Pop, unless the older adult suggests it.
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