Conceptual Foundations of Nurse-Client Relationships

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N302: Lecture 1

The nurse-patient relationship is active, not passive.

- It is impossible to be therapeutic (way you communicate with patients, not tasks at hand) with patients without communicating.
- Professional nurses not merely carrying out orders.
- Professional nurses establish nurse-client relationship that is foundation of our practice.
- Try to be therapeutic nurse/person.

It doesn't come naturally...

- Developing this relationship does not occur just being friendly, kind, attractive, outgoing.
- Show empathy, be professional and caring even if pushing buttons.
- Establishing therapeutic nurse-client relationship takes practice, skill, knowledge, and caring.
- Want somebody efficient and effective.

People Types Simplified.

- Smart and nice, smart and mean, dumb and nice, or dumb and mean.
- You either know or don't know what you're doing in a certain situation.
- You never have to be mean nurse, but you may be "dumb." If so, have people come in to help.

Nursing Theory

- Set of principles to describe, explain, predict and prescribe nursing practice.
- Guides nurses' practice.
- Represents well-defined view of professional nursing, which differentiates its focus and activities from those of other professions.

Florence Nightengale

- Viewed as first nursing theorist.
- Focused on environment: unclean environment, made observations, changed interventions, and had good outcomes.
- People dying of infectious diseases because of unclean wards.
- Notes on Nursing (published in 1859): Believed that nurses could create environments beneficial to the restoration and preservation of health, within which the client would begin to heal.

Metaparadigm Concepts

- Person
- Environment
- Health
- Nursing

Person

- Metaparadigm concept.
- Viewed as holistic (physical, mental, and social context) being.
- Defined as recipient of nursing care, must be considered as functional whole with unique biopsychosocial and spiritual dimensions.
- Can encompass family, community, or target population such as elderly, adolescents, or ethnic group at risk for particular health care problem.

Environment

- Metaparadigm concept.
- Nothing occurs outside of a context.
- Think of social context.
- Refers to internal and external context of client in health care situation.
- Nurse considers cultural, developmental, physical, and psychosocial conditions that influence client's perception, behaviors, growth, and development.

Health

- Metaparadigm concept.
- Physical, mental, and social well-being; not merely absence of disease.
- Weil (2004): "a dynamic and harmonious equilibrium of all elements and forces making up and surrounding a human being."
- The World Health Organization (1987): "a positive concept emphasizing social and personal resources, as well as physical capacities."

Nursing

- Metaparadigm concept.
- Pullen, Edwards, Lenz et al. (1994): "the provision of essential health services to promote health, prevent illness, and promote cure of/or adaptation to illness."

ICN (International Council of Nursing) Definition of Nursing

"Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups, and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles."

Profession vs. Occupation

- Unique body of knowledge.
- Accountability to the public, license = privilege, reflects your judgment; not a right (i.e. writing bad checks, DUIs, etc.
- Governed by a code of ethics.
- Commitment to promoting public good, altruism (the principle or practice of unselfish concern for or devotion to the welfare of others), most trusted profession.
- Autonomous practice.
- Commitment to common ideal which puts service above personal gain.
-Walking with patient on worst and best day of their life.

Carper's 4 Patterns of Knowing

- Provide a method to individualize and provide quality care.
1. Empirical
2. Personal
3. Aesthetic
4. Ethical

Empirical ways of knowing...

- Grounded in science of nursing and evidenced in scientific principles a nurse consistently incorporates in all phases of the nursing process.
- Example: nurses use scientific rationale as basis for choosing skilled nursing interventions.
- Example: studies have shown that wounds heal faster when patients receive high protein diet.
- Therefore, nurses monitor nutritional intake of post-op patients and encourage protein intake to facilitate healing.

Personal ways of knowing...

- Help nurses understand and acknowledge the humanness of another. Personal knowing occurs when nurse is able to intuitively understand and treat individual clients as unique human beings because nurse's own personal experience and awareness of his or her own humanness. Allows nurse to be authentic with others.
- Knowledge, skill, and a "scar."
- Downfall about this: we can't all feel what patient is feeling because not all of us went through what patient is going through.
- Example: HIV nurse, diabetic nurse

Aesthetic ways of knowing...

- All for creative applications in the relationship designed to connect with clients in different and more meaningful way.
- Example: found in storytelling, in which nurse seeks to understand experience of the client's journey through illness.
- This is very abstract concept.
- When we talk about nursing being both an art and a science, aesthetic knowing reflects the art of nursing.
- Requires personal insight and intuition, maturity on nurse's part.
- Example: patient plays a song about feelings, can respond with (I am sorry, thank you for letting me know how you feel, is there something I can do to make your day better?).

Ethical ways of knowing...

- Refers to moral aspects of nursing. These ways of knowing encompass knowledge of what is right and wrong, attention to standards and codes in making moral choices, and taking responsibility for one's actions, as well as demonstrating professional values in providing health care.
- Based on morals, codes, principles.

Examples of ethical ways of knowing...

- Example: sometimes there is no clear path to take, both directions for care have negative consequences. Nurses can use ethical ways of knowing to decide how to proceed.
- Example: terminal cancer - treat or not (caustic treatment, suffering, pain OR death --> figure out what family and patient wants).
- Examples: addiction therapy (give clean needles means a green light for addicts but would rather give clean needles so patient doesn't contract a disease).

In order to be therapeutic...

...we need to incorporate all 4 patterns of knowing (bring all concepts together).
- Not just a science.
- "Everything that can be counted does not necessarily count; everything that counts cannot necessarily be counted," - Albert Einstein.

Hildegard Peplau 1

- First nurse theorist to describe the nurse-client relationship as the foundation of nursing practice.
- Theory of interpersonal relationships is example of mid-range theory that builds upon Harry Stack Sullivan's psychodynamic interpersonal theory.
- Shifts focus from what nurses do to clients to what nurses do with clients.
- Nurses are the therapeutic agents.

Hildegard Peplau 2

- Nursing is a "developmental educational instrument" designed to help individuals, families, and communities achieve changes in health care status and well-being, and illness as an opportunity for improved functioning.
- Nurses observes and listens to a client, he or she develops impressions and general ideas about meaning of client's situation.
- Nurses actively engage with their clients, simultaneously observing clients' behaviors and their own responses, and providing assistance, information, and encouragement as needed.

Peplau's Six Nursing Roles

1. Stranger
2. Resource
3. Teaching
4. Counseling
5. Surrogate
6. Active Leadership

Stranger (Peplau)

- Nursing role.
- Receives the client the same way one meets a stranger in other life situations; provides an accepting climate that builds trust.

Resource (Peplau)

- Nursing role.
- Answers questions, interprets clinical treatment data, gives information.

Teaching (Peplau)

- Nursing role.
- Gives instructions and provides training; involves analysis and synthesis of the learner experience.

Counseling (Peplau)

- Nursing role.
- Helps client understand and integrate meaning of current life circumstances; provides guidance and encouragement to make changes.

Surrogate (Peplau)

- Nursing role.
- Helps client clarify domains of dependence, interdependence, and independence, and acts on client's behalf as advocate.

Active Leadership (Peplau)

- Nursing role.
- Helps client assume maximum responsibility for meeting treatment goals in a mutually satisfying way.

4 phases in nurse-client relationship

1. Orientation phase
2. Working phase
3. Termination phase

Orientation Phase

- Sets the stage for the rest of the relationship by offering a systematic means for gathering assessment data from the client and establishing rapport with client.

Working Phase

- Identification: focuses on mutual clarification of ideas and expectations, setting of goals, and treatment planning to achieve identified goals.
- Exploitation phase: helps client work toward treatment goals, resolve health care issues and learn new coping strategies.

Termination (Resolution) Phase

- Nurse assists client to review progress towards goals, makes referrals, and brings closure to therapeutic relationship.

Carl Rogers

- Identifies 3 helper characteristics essential to development of client-centered relationships:
1. Unconditional positive regard (even if you dislike the patient for abusing a child).
2. Empathetic understanding (try to understand what patient is going through).
3. Genuineness
- Later added 4th characteristic (spiritual or transcendental presence): intuitive way of being with a client.
- Necessary to a successful therapeutic relationship.

Abraham Maslow

- Physiological needs (lowest level): hunger, thirst, and sexual and sensory stimulation.
- Safety and security: physical and emotional.
- Love and belonging: need to be part of a family or community.
- Self-esteem: dignity, respect, and approval by others.
- Self-actualization: humanity at its best, may feel insecure and vulnerable but accept this humanness and strive to share with others.

Communication

Interpersonal activity involving transmission of messages from a source to a receiver for the purpose of influencing the receiver's behavior.

Basic Assumptions of Communication Theory

1. It is impossible not to communicate because can be verbal and nonverbal.
2. We only know about ourselves and others through communication.
3. Faulty communication results in flawed feeling and acting.
4. Feedback is the only way we know that our perceptions are valid.
5. Silence is form of communication.
6. All parts of communication system are interrelated and affect one another.
7. People communicate through words and through nonverbal behaviors, both of which are necessary to interpret appropriately for complete understanding.

Linear Theory of Communication

- Sender - message - receiver.
- Sender encodes message, transmits message (verbal or nonverbal), and receiver decodes message.
- Over simplistic theory that doesn't account for frequency of miscommunications that go on.

Example of miscommunication with linear theory

- In western culture, thumbs up is interpreted as "okay" or "good to go."
- In some Latin American and Middle Eastern culture, means "up yours" or "sit on it."

Transactional Model

- Circular model is transactional model that expands on linear models to include context of communication, feedback loops, and validation.
- Communication is conceptualized as continuous, mutually interconnected activity in which sender and receiver influence each other in transmission and receiving of message.
- Take into account the role relationships between communicators (symmetrical or complementary roles).

Other vocabulary for transactional models

- Symmetric role: relationships are equal.
- Complementary role: typically operate with one person holding higher position than the other in communication process.
- Metacommunication: nonverbal message about how receiver should interpret message.
- Feedback: verbal or nonverbal response the receiver gives to sender about the message.
- Validation: provides verbal and nonverbal confirmation that both participants have same basic understanding of message and feedback.

Other Information

- Breakdown in communication was leading cause of sentinel events (something happened that wasn't supposed to happen) reported by JCAH between 1995-2006.
- One of culprits involves hand off procedures or giving report.
- During one hospital stay patients will be cared for by multiple providers.
- Misunderstandings lead to dangerous errors and patient injury.

Therapeutic Communication

- Purposeful form of communication used in the helping relationship.
- Not a method but a specialized application of basic communication principles designed to promote client's health and well-being.
- Nurses use to provide new information, correct misinformation, promote understanding of client responses to health problems, explore options for care, assist in decision making, and facilitate client well-being.

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