delaune ch14 253-268

UNIT IV

Promoting Client Health

14 Nursing, Healing, and Caring

15 Communication

16 Health and Wellness Promotion

17 Family and Community Health

18 The Life Cycle

19 The Older Client

20 Cultural Diversity

21 Client Education

“ ”Competencies

1 Describe the influence of caring and compassion on the practice of profes-sional nursing.

2 Explore the value of nursing care in today’s technologically advanced healthcare system.

3 Compare selected perspectives on the relationship between caring and nursing.

4 Explain the primary nursing functions in each phase of the nurse-client relationship.

5 Discuss the impact of communication on the delivery of compassionate care.

6 Describe the characteristics of a therapeutic relationship.

7 Explain nursing roles that are important in demonstrating care and compassion.

CHAPTER 14

Nursing, Healing, and Caring

Above all, nursing is caring.

—Diers (1986)

Chapter 14 Nursing, Healing, and Caring 255

This chapter presents information about caring—the fun-damental value in nursing. The relationship betweencaring and nursing is explored and nursing’s impact onhealing is examined. The nurse-client relationship is dis-cussed, and the stages of this relationship are describedwith attendant nursing goals and behaviors usuallyexhibited by clients in each stage.

Nursing’s TherapeuticValueNursing is both an art and a science that leads to thera-peutic outcomes in clients. The term therapeutic refersto activities that are beneficial to the client. When ther-apeutic interventions are performed in a caring compas-sionate manner, an environment that promotes healingis established.

Definition of Nursing

According to the American Nurses Association (ANA)(2004), nursing is defined as “the protection, promotion,and optimization of health and abilities, prevention of ill-ness and injury, alleviation of suffering through the diag-nosis and treatment of human response, and advocacy inthe care of individuals, families, communities, and popu-lations” (p. 7). This definition places nursing’s focus on

the individual experiencing a health problem rather thanon the problem (or disease) itself—that is, on caring forclients as they deal with health issues fundamental to thepractice of professional nursing.

The Canadian Nurses Association (CNA, 1986),similarly, describes nursing as a caring relationshipthat helps the client achieve and maintain an optimallevel of health.

Nursing: A Blend of Art and Science

Nursing creates therapeutic change through the applica-tion of scientific principles. As the science of nursing hasrapidly progressed over the past decade, nurse theoristshave formulated various frameworks by which to organizenursing’s unique body of knowledge. While continuing toexpand its theoretical base, nursing must remain firmlyrooted in its essence—caring. In other words, nursingdoes not rely on science alone.

Caring is a universal value that directs nursing prac-tice. Leininger (2002, p. 21) defines caring in the nurse-client relationship as “the direct (or indirect) nurturantand skillful activities, processes, and decisions related toassisting people to achieve or maintain health.” Eventhough clients cannot always be cured, caring is ongoingwithin the nurse-client relationship.

A prerequisite for the nursing art is the nurse’s com-mittment to helping the client; this trait is also referred toas intentionality. Intention occurs when we consciouslyfocus on someone in order to learn something about andto help that person (Dossey et al., 2000). As Isenalumhe(2000, p. 25) states:

Therapeutic use of self marks the art of nursingas different from the science of nursing. . . . Thetheories, concepts, and standard proceduraltechniques for clinical performance or practicein any profession constitute its scientific base. . . .The art of nursing can be learned, throughshared, as well as hands-on, experience.

Caring is more that an intuitive process; it can be learnedboth intellectually and interpersonally. One learns caringby interacting with others who demonstrate caring. Whennurses exhibit caring behaviors, they are serving as rolemodels—to students, colleagues, clients, and families.

Purposes of Nursing

A therapeutic relationship is one that benefits theclient’s health status. The therapeutic relationship isbased on the belief that a person has a natural drive

KEY TERMS

active listening

attending behaviors

catharsis

client advocate

depersonalization

empathy

empowerment

healing

nurse-client relationship

orientation phase

paraverbal communication

presence

rapport

role

termination phase

therapeutic

therapeutic relationship

therapeutic use of self

transcultural nursing

working phase

toward optimal health. Caring—being willing and able tonurture others—is an attribute of the effective nurse.Curing rids the client of the disease or disability; caringnurtures the person even if the disorder is incurable.Ebersole (2002, p. 237) relates the following story:

A chaplain I once knew devised a word game:put a bridge over the U in cure and it becomescare, the essence of . . . nursing. We are thebridge from the curing emphasis of medicine tothe caring needs of humanity. The excellence ofnursing care can be measured by this ability.

When it is understood that complete, or perhaps evenpartial, recovery is not possible, nursing goals focus onfacilitating comfort by alleviating pain and promoting asmuch client autonomy as possible.

As Higgins (2001, p. 116) asserts, “Caring makes adifference to the patient’s sense of well-being.” Nursingpromotes healthy lifestyle behaviors, prevents the devel-opment of illness and injury, and restores individuals totheir optimal level of functioning.

Another purpose of nursing is to improve client satis-faction with the delivery of health care services. Consumersatisfaction greatly influences where services are provided.Nurses who demonstrate caring behaviors enhance thequality of care provided; thus, clients are more satisfiedwith the care delivered in a caring, compassionate manner.Specific nursing actions that demonstrate caring are pre-serving dignity, being truly present, teaching (Yonge &Molzahn, 2002), anticipating client needs, responding toclient requests, and communicating effectively.

Nursing and Healing

Nursing is a humanistic discipline that provides carefrom a holistic framework. Seeing and responding to theclient as a whole person instead of a disease, disorder, orcase leads to complete care of the total person. Healingis the process of recovery from illness, accident, or dis-ability. This return to an optimum level of functioningmay occur rapidly or gradually. Healing encompassesthe physical, emotional, and spiritual domains of indi-viduals. Nursing and caring are essential components inthe healing process. See Chapter 31 for further discus-sion of nurses as healers.

Theoretical Perspectivesof CaringThere are numerous theoretical concepts relative tocaring in nursing. Some major ideas related to caringhave been postulated in Watson’s theory of human caring,

Leininger’s theory of transcultural caring, and Benner’snovice to expert model. Table 14-1 provides an overviewof these concepts.

The Theory of Human Caring evolved from Watson’sbeliefs, values, and assumptions about caring. In Watson’sview (1985), care and love comprise the primal universalpsychic energy and are the basis for our humanity.

Watson’s theory is composed of 10 carative factors,which are classified as nursing actions or caringprocesses. Watson’s carative factors are:

1. Formation of a humanistic-altruistic system of values2. Nurturing of faith-hope3. Cultivation of sensitivity to one’s self and to others4. Developing a helping-trusting, human caring rela-

tionship5. Promotion and acceptance of the expression of

positive and negative feelings6. Use of creative problem solving method processes7. Promotion of transpersonal teaching and learning8. Provision for a supportive, protective, or corrective

mental, physical, sociocultural, and spiritual envi-ronment

9. Assistance with gratification of human needs10. Allowance for existential-phenomenological forces

(Watson, 1999a)

The first three carative factors serve as the philosophicalfoundation for the science of caring. The remaining sevenprovide more specific direction for nursing actions.

Transcultural nursing focuses on the study andanalysis of different cultures and subcultures withrespect to cultural care, health beliefs, and health prac-tices, with the goal of providing health care within thecontext of the client’s culture (Leininger, 2002). A basicassumption of transcultural nursing is that when healthcare providers see problems from the client’s culturalviewpoint, they are more open to understanding, appre-ciating, and working effectively with those clients. Otherassumptions of transcultural nursing theory are:

Every culture has some kind of system for healthcare that is based on values and behaviors.Cultures have certain methods for providing healthcare. These methods of care are often unknown bynurses from other cultures (Leininger, 2002).

Leininger identifies several behaviors as caring andstates that these behaviors occur in various cultures; seethe accompanying display on caring behaviors.

Benner (2001, p. 49) describes the caring nurse asone who has “courage to be with the patient, offeringwhatever comfort the situation allows.” Caring occurs

256 Unit IV Promoting Client Health

within the context of a relationship that consists of sev-eral steps. First, hope is mobilized for both the client andnurse. Secondly, the relationship focuses on discoveringthe meaning of the illness, pain, or emotion. Finally, theclient is aided in using social and spiritual support(Benner, 2001).

Caring—being willing and able to nurture others—is a hallmark of the effective nurse. It occurs when anurse acts in a genuine, authentic manner with theclient. Caring is a process and an art that requires com-mitment and knowledge; it is a combination of behaviorsand attitudes. The way in which nursing actions are

implemented expresses caring. Specific behaviors thatindicate caring are provision of information, relief ofpain, spending time with clients and families, and pro-moting client autonomy. Treating each client in a digni-fied, courteous manner is the true expression of caring.

Touch is an effective method for communicating asense of caring (Figure 14-1). Touch is a powerful non-verbal medium for communication that can be used tosoothe, comfort, and establish rapport. It can communi-cate a sense of caring—as it does when a nurse holds aperson’s hand during a painful procedure—or it can beperceived as intrusive or hostile. Touch, no matter howwell intended, may sometimes be misinterpreted by aclient. Therefore, it is wise to avoid touching clientswho are suspicious, hostile, or very confused. “Nursesfrequently use touch to provide comfort . . . often, this


TABLE 14-1Perspectives of Caring in Nursing

Theorist Theory Major Concepts

Watson Theory of human caring • Caring is central to nursing practice.

• Emphasis is on the dignity and worth of individuals.

• Each person’s response to illness is unique.

• Caring is demonstrated interpersonally.

• Caring involves a commitment to care and is basedon knowledge.

Leininger Transcultural care theory • Caring is the essence of nursing.

• Caring is universal, occurring in all cultures.

• Caring behaviors are determined by and occurwithin a cultural context.

Benner Novice to expert • Caring is central to all helping professions.

• Caring is the foundation of being.

• People and interpersonal concerns are important.

• Caring is communicated through actions.

• Problem solving is a major component of caring.

• Advocacy is caring.

Source: Data from Benner, P. (2001). From novice to expert: Excellence and power in clinical nursing practice (Comm. ed.). Upper Saddle River, NJ:Prentice-Hall; Leininger, M. (2002). Transcultural nursing (3rd ed.). New York: McGraw-Hill; Watson, J. (1999). Nursing. Human science and human care.Boston: Jones & Bartlett; Watson, J. (1999). The philosophy and science of caring. Denver, CO: University Press of Colorado.

CARING BEHAVIORS THAT OCCUR INDIFFERENT CULTURES

Source: Data modified from Leininger, M. (2002). Transculturalnursing (3rd ed.). New York: McGraw-Hill.

ComfortEmpathyTendernessAttentionSupportCompassionLoveTouch

ProtectionPersonalized helpSurveillancePresenceTrustNurturanceRestorationInstruction

REFLECTIVE THINKINGImportance of Caring

A television commercial for a real estate agencystated, “People don’t care how much you know tillthey know how much you care.” How does thisstatement apply to nursing?

human and warm contact is the only avenue of comfortand communication available” (Benner, 2001, p. 63).

Care in the High-Technology EnvironmentCaring is the soul of nursing. Nurses demonstrate caringin various ways, such as anticipating client requests andproviding information. Clients feel supported and morecomfortable in the presence of a nurse who, throughcaring, helps alleviate clients’ fears and anxieties. Caringis what clients want and need most from nurses.Although technological advances have resulted in manypossibilities in health care, the major risk of reliance ontechnology is that clients may be perceived as objects.The focus of attention becomes the disease, instead of theindividual experiencing the illness. The compassionatenurse treats each client with respect and dignity.

Depersonalization is the process in which individ-uals are treated as objects instead of people. Some exam-ples of dehumanizing actions are checking on theequipment and not the person, failing to respond to the client, and communicating a lack of interest in whatthe client says. Caring is a tool to be used in providingnursing care. When the machinery becomes the focus ofthe nurse’s activities, depersonalization of the client islikely to occur. Spending time with the client is one wayto counteract depersonalization; see Figure 14-2.

Nursing care counteracts depersonalization byemphasizing a client’s individuality. It is through caringthat the nurse humanizes the client. The reason peopleare admitted to acute-care facilities is to receive nursing

care. Most diagnostic testing, treatment procedures, andsome surgical interventions can be performed in outpa-tient settings such as clinics. While receiving care,people want to be treated with compassion. The nontech-nical element of care makes clients feel cared for as indi-viduals; the use of high-touch activities communicatescaring. As society continues to place a high value ontechnology, caring is often undervalued. Nurses make acrucial contribution by valuing both care and technology.

Although the concept of caring is being deempha-sized in today’s health care environment because ofexploding technology and cost-containment strategies,nursing must persevere in delivering care to clients. Thechallenge of nursing is to create moments of caringthrough human-to-human interaction in the face of thefast-paced world of health care.

Nurse-Client RelationshipCaring is communicated interpersonally; thus, the vehi-cle for communicating a caring intent is the nurse-clientrelationship. The nurse-client relationship is the one-to-one interactive process between client and nurse thatis directed at improving the client’s health status orassisting in problem solving. The primary goal of therelationship is the client’s achievement of therapeuticoutcomes. Caring is “patient-centered and action-oriented” (Baldursdottir & Jonsdottir, 2002, p. 68). Thenurse-client relationship is a planned process that focuseson meeting the needs of the client. There are many dif-ferences between the therapeutic nurse-client relation-ship and a social relationship as shown in Table 14-2.

The interactive process between client and nursegreatly influences the client’s progress in healing.Peplau (1952), the first nurse theorist to define nursing as


FIGURE 14-1 Clasping the client’s hand is one way tocommunicate through touch.

FIGURE 14-2 Nursing is caring. It is showing concern forand interest in the client. Identify behaviors of the nursethat demonstrate caring.

an interpersonal process, viewed the nurse-client rela-tionship as the basis of nursing. Interpersonal skills arethe foundation for establishing the therapeutic relation-ship. Only through interacting does the nurse have theability to adequately assess the client’s needs, teachmethods for best meeting those needs, empower theclient to achieve goals, and evaluate the outcome of nurs-ing interventions.

Phases of TherapeuticRelationship

The three phases of the nurse-client relationship are ori-entation, working, and termination. These phases overlapand influence each other. Each phase is characterized byspecific client behaviors and nursing goals. Figure 14-3illustrates the phases of the interactive relationship.

Orientation Phase

The orientation (or introductory) phase is the first stageof the therapeutic relationship, in which the nurse andclient become acquainted with each other, establishtrust, and determine the expectations of the other.Usually, the only knowledge the client and nurse have of


TABLE 14-2Comparison of Social and Therapeutic Relationships

Social Therapeutic

• Is spontaneous, just happens.

• Is mutually beneficial.

• Often has no planned agenda.

• Is based on mutual interests.

• Each participant expects to be liked by the other.

• Problems are shared.

• Communication is spontaneous.

• Is planned and goal-directed.

• Seeks to meet clients’ needs.

• Is based on theory.

• Privileged information is available to health care provider.

• Clients are emotionally vulnerable.

• Clients must be accepted as they are.

• Communication is planned.

• Has clear-cut boundaries.

RESEARCH FOCUS

Title of Study “The Importance of Nurse CaringBehaviors as Perceived by Patients Receiving Care at anEmergency Department.”

Authors G. Baldursdottir and H. Jonsdottir

Purpose To identify which nursing behaviors are per-ceived as caring by clients in an emergency department.

Methods Cronin and Harrison’s Caring BehaviorsAssessment (CBA) tool was used to design a 61-item ques-tionnaire. This tool was mailed to 300 emergency depart-ment clients. There was a 60.7% response rate.

Findings Clinical competence was identified as themost important caring behavior demonstrated by nurses.Participants used the following phrases to describe caringnurses: “Know what they are doing,” “Know when it is nec-essary to call the doctor,” and “Know how to handle equip-ment.” Participants also stated that the nurse’s ability totreat clients as individuals demonstrates caring.

Implications It is important for nurses in criticalcare areas to continue to communicate caring throughtheir behavior to clients. Further studies are needed todetermine clients’ perceptions of caring behaviors demon-strated by nurses in noncritical practice areas.

Source: Baldursdottir, G., & Jonsdottir, H. (2002). The importance of nurse caringbehaviors as perceived by patients receiving care at an emergency department.Heart & Lung, 31(1), 67–75.

Orientation

Phase I

Working

Phase II

Termination

Phase III

FIGURE 14-3 Phases of the Nurse-Client Relationship

each other is preconceived ideas. The nurse gets to knowthe client as an individual by giving up biases and judg-mental thoughts. The orientation stage is especiallyimportant because it is the time in which the foundationfor the relationship is established.

Client Behaviors. The usual response of the client inthe orientation stage is anxiety, which can result fromseveral factors including:

Fear of the unknownPain or distressUnfamiliar environmentUndergoing unfamiliar, often painful, proceduresLoss of freedom and control

As a result of the client’s insecurity, anxiety escalates.Because anxiety is communicated interpersonally, thenurse should project a calm, relaxed attitude duringevery interaction with the client to decrease anxiety.

Another behavior frequently exhibited by the clientduring the orientation stage is testing. The clientattempts to determine the degree of the nurse’s trustwor-thiness. Through behavior, the client is asking:

Is the nurse truly willing to help?Is the nurse competent to help? Is the nurse reliable and trustworthy?

The nurse answers such questions through consistent,reliable behavior that promotes the development of trust.

Nurse Behaviors. The most important nursing actionsduring the orientation phase are assessment and creatinga climate conducive to rapport. The nurse must determine

the client’s needs, knowledge base, strengths and limita-tions, coping mechanisms, and support system. Oftenclients do not express their needs directly; behavior is theonly clue to their needs. The nurse’s goal is to determinethe real meaning of the behavior and to assess the client’sperception of the most crucial needs and problems.

To reduce a client’s anxiety and promote trust, thenurse provides some specific information. Information theclient should receive during the orientation phase includes:

Nurse’s nameNurse’s roleReasons the nurse must ask questionsConfidentiality and its parameters

Working Phase

The working phase is the second stage of the therapeu-tic relationship in which problems are identified, goalsare established, and problem solving methods areselected. Actions are chosen after carefully consideringboth the consequences of actions and the client’s values.It is necessary to consider the client’s value system whendetermining problem solving methods. Client participa-tion increases when consideration of values is incorpo-rated into care planning.

Client Behaviors. The client engages with the nurse inactive problem solving to achieve mutually developedoutcomes. Behaviors that indicate the client is in theworking phase are:

Asking questions about own problemsSeeking clarification from the nurseBeing attentive to instructionsAsking for more information about own role in recovery

Nurse Behaviors. The nurse seeks to maximize theclient’s success in problem solving. Nursing goals to beachieved during the working phase are to:

Reevaluate goals and related activities as new infor-mation arisesSupport realistic problem solving activities of the client

Termination Phase

The termination phase, the third and final stage of theof the therapeutic relationship, focuses on the evaluationof goal achievement and effectiveness of treatment. It is important that the client has been prepared for thefinal stage of the relationship by encouraging discussionof feelings.


REFLECTIVE THINKINGConfidentiality in the Therapeutic RelationshipNurses have an ethical and legal responsibility toprotect client confidentiality. Consider what youwould do in each of the following situations:

You are assisting Ms. Adams with her AM carewhen she says, “Isn’t it just terrible about Mr. Denton across the hall? I heard his testscame back negative. What are his chances ofmaking it?”Your neighbor asks you if a mutual friend isbeing treated for AIDS.In a crowded elevator at work, you overhear twocoworkers discussing a client’s condition.

Client Behaviors. Some clients welcome this finalphase, whereas other clients who have become overlydependent on their nurse will be more resistant to sayinggood-bye. Planning for termination is actually initiatedduring the beginning of the relationship. A relationshipthat ends abruptly is likely to place the client at risk fordifficulties such as increased:

Anxiety levelsFrustrationSuspiciousnessUnwillingness to engage in future relationships withhealth care providers

Nurse Behaviors. Evaluation is the primary goal forthe client and nurse in the third stage of the nurse-clientrelationship. Questions to be answered include:

Were the goals meaningful?Were the goals realistic?Were the client and family actively involved?

See the Nursing Checklist, which can be used to eval-uate skill in establishing a therapeutic nurse-clientrelationship.

Therapeutic Use of SelfThe interpersonal process between nurse and client is atherapeutic process because interventions are plannedand implemented to benefit the client. The nurse’s mosteffective tool for helping the client is the therapeuticuse of self, a process in which nurses deliberately plantheir actions and approach the relationship with a spe-cific goal in mind before interacting with the client.The nurse’s most effective tool for demonstrating caringis not some technologically sophisticated machine withlights and alarms but rather one’s self. Figure 14-4

illustrates therapuetic use of self. Therapeutic use ofself provides an opportunity for nurse and client tomake a person-to-person connection. The term pres-ence refers to the process of “just being with” another.Presence requires the nurse to demonstrate patiencein a caring manner. “For some clients, the hurryingbehavior of the nurse . . . is distressing; it conveys alack of concern and a lack of time to give care” (Murray& Zentner, 2000, p. 56).

Therapeutic use of self involves verbal and nonver-bal communication. Just as important as what one says ishow one says it. With a deliberate, planned approach, thenurse communicates a sense of caring and willingness tohelp: The nurse is committed to helping clients find waysto help themselves. The nurse’s true expression ofhumanistic concern for a client is shown by taking thetime to simply “be with” the client.

Caring andCommunicationCommunication is the mechanism for demonstratingcompassion and caring. Therapeutic communication isdeliberately planned by the nurse to result in positiveclient outcomes. See the accompanying display for the


Nursing ChecklistEstablishing Therapeutic Relationships

✔ Introduce self on initial contact✔ Explain own role✔ Develop groundwork for trust✔ Establish therapeutic boundaries✔ Determine client’s perception of problem(s)✔ Understand client’s expectations of care✔ Communicate at client’s level of compre-

hension✔ Involve client in evaluating treatment FIGURE 14-4 In this situation, what factors indicate that

rapport has been established between nurse and client?

characteristics of therapeutic communication. There arenumerous techniques that are helpful in promoting ther-apeutic communication; see Chapter 15 for an explana-tion of these techniques.

Characteristics ofTherapeutic RelationshipsIn order to establish therapeutic relationships, the nursemust possess certain interpersonal skills; see the accom-panying display on characteristics of therapeutic nurses.

The term catharsis, which refers to the relief expe-rienced from verbalizing one’s problems, is illustrated inFigure 14-5. This “getting things off one’s chest” is auniversal experience that is therapeutic for individualsexperiencing anxiety.

Nurses use interpersonal skills to help clients meettheir needs. A discussion of each characteristic follows.

Warmth

Warmth is the demonstration of positive behaviorstoward the client. Respect, genuine interest, caring—all are expressions of warmth. The nurse who demon-strates warmth is approachable and available ratherthan aloof. Warmth means projecting an interested atti-tude without overwhelming the client. The nursedemonstrating warmth responds to the client as onehuman being to another. The therapeutic nurse is

approachable and available yet maintains objectiveboundaries. “Warmth reflects respect and acceptanceand is communicated extensively by nonverbal behav-iors” (Rafael, 2000, p. 38).

Hope

Hope means anticipating the future by helping clientslook realistically at their potential. Hope is strength-ened by relationships with others; social isolation rein-forces a sense of despair. Many clients, especiallythose with great losses, experience distress, despair,and hopelessness. The reemergence of hope may be a gradual process. Hope is not to be confused withfalse reassurance.

Westburg (2003) reports that hopeful individualsexperience numerous benefits, including recuperatingmore quickly from physical injury, adjusting better tochronic illness, experiencing less pain, and demonstrat-ing effective coping skills. Providing opportunities forclients to socialize and making resources available aretwo ways in which nurses can help instill hope in clients.The instillation of hope helps clients meet their spiritualneeds. Hope is necessary for coping with server stres-sors, such as illness. Nurses must determine the client’ssource of hope, which may include the following:

Relationships with othersPositive emotionsAnticipating the futureAvailability of resources


Comfort

Anxiety Relief

Fear

Anxiety

Catharsis

FIGURE 14-5 Cycle of Catharsis

CHARACTERISTICS OF THERAPEUTIC NURSESWarmthHopeRapportTrustEmpathyAcceptanceHumor

CompassionSelf-awarenessFlexibilityRisk-takingActive listeningNonjudgmental approach

CHARACTERISTICS OF THERAPEUTIC COMMUNICATIONTherapeutic communication:

Is purposeful and goal-directedHas well-defined boundariesIs client-focusedIs nonjudgmentalUses well-planned, selected techniques

Since spirituality is closely related to hope, nurses canalso assess clients’ spiritual needs to determine whichinterventions are most appropriate; see Chapter 17.

Rapport

Rapport is a bond between two people that is based onmutual trust. This connection does not just happen spon-taneously; it is planned by the nurse who purposefullyimplements behaviors that promote trust. When seekingto establish trust, the nurse recognizes the client as aunique individual and reinforces that individuality. Inother words, actions that humanize the client are thera-peutic. To establish rapport, the nurse’s actions showthat the client is considered important. Actions areimplemented to boost the level of the client’s self-esteem.Nonverbal interventions are of utmost importance inhelping establish rapport.

Interacting with family and significant others is alsohelpful in establishing rapport with the client (Figure 14-6). Recognizing the importance of the family’s influenceon the healing process allows the nurse to bond with thosewho will encourage and support the client. “The nursemust know when to move aside and allow family membersa greater role in the care of the patient and when torelieve the family member” (Benner, 2001, p. 66).

Trust

Trust must be present for help to be given andreceived. A therapeutic relationship is firmly rooted intrust. The nurse sets the tone of the relationship bycreating an atmosphere in which the client feels free to

express feelings. How does the nurse promote a trust-ing relationship? Three major activities will facilitatethe development of trust: consistency, respect, and hon-esty. Table 14-3 lists actions that facilitate the devel-opment of trust. Being consistently trustworthy is anexpression of the nurse’s personal integrity and buildsthe foundation for a therapeutic relationship.

Empathy

Empathy—understanding another person’s perceptionof the situation—is a key element in the therapeuticrelationship. The phrase “Walk a mile in my shoes”describes empathy well. “Empathy is a complex multi-dimensional concept that has moral, cognitive, emotive,and behavioural components” (Mercer & Reynolds,2002, p. S-10). The empathic nurse understands that theclient’s perception of the situation is real to the client.By perceiving clients’ understanding of their own needs,the nurse is better able to assist clients in determiningwhich interventions are most appropriate. Empathyenables the nurse to assist the client to become a fullyparticipating partner in treatment rather than a passiverecipient of care.

Through empathy, the nurse validates the experi-ences of the client. The challenge for the nurse is tosee the world from the client’s perspective with asmuch understanding as possible. Empathy is not thesame as sympathy. Sympathy is rarely therapeutic; infact, a barrier occurs when the nurse sympathizes andbecomes paralyzed by the expression of pity. For exam-ple, empathic listening allows the nurse to encourageclients to find meaning in their experiences and moveon to problem solving. According to Mercer andReynolds (2002, p. S-11), empathy rests on the nurse’sskill in:


REFLECTIVE THINKINGHope Versus False Reassurance

Consider the following example of false reassur-ance. Mrs. Ngyuen is awaiting results of diagnostictesting that will confirm or deny the suspecteddiagnosis of cancer. She says to her nurse, “I thinkit’s taking a long time to get the results. Somethingmust be wrong.” The nurse replies,“Oh, don’t worry,everything’s going to be just fine!”

What do you suppose motivated the nurse’sresponse?What will be the impact of the nurse’s behavioron Mrs. Ngyuen?

FIGURE 14-6 Through interaction with the client’s family,how can the nurse help the client obtain optimal health?

Understanding the patient’s feelings and perspectiveCommunicating that understandingValidating the understanding with the clientActing in a therapeutic manner

Acceptance

Accepting the client as a person worthy of dignity andrespect is basic to providing nursing care. Acceptancemeans compassionately working with clients, even thosewho demonstrate negative behaviors. It is extremelyimportant for the nurse to show acceptance of the clientwhile setting limits on unhealthy or undesirable behav-ior. The accepting nurse conveys the message that theclient does not have to put on a front. The client knows itis safe to be genuine because of the nurse’s acceptance.

Active Listening

Active listening (listening that focuses on the speaker) isthe basic skill for interpersonal effectiveness. Active lis-tening is facilitated by attending behaviors, a set of non-verbal listening skills that conveys interest in what theother person is saying. These behaviors allow the nurse toshow caring, concern, and acceptance. Behaviors suchas sitting down, facing the client, maintaining eye contact,and head nodding facilitate the development of trust.Active listening requires the nurse to turn down innerdialogue. Total attention must be focused on what theclient is saying.

Also, it is important for the nurse to avoid lookingrushed or distracted. The primary message that is com-municated through active listening is the nurse’s con-cern and intent to assist in problem solving. Activelistening is required in every nurse-client relationship.

The active listener is cognizant of all three elementsof communication: the verbal, paraverbal, and nonver-bal. The verbal message is what is said. Paraverbalcommunication is the way in which a person speaks,including voice tone, pitch, and inflection; and the non-verbal message is body language. The active listenerpays attention to all three aspects to hear the true intentof the communicator.

Active listening means that the nurse focuses onthe feelings behind the words, not just the words them-selves. It is important for the nurse to note any incon-gruities between the client’s verbal and nonverbalmessages. For example, if the client says, “Oh, I’m justfine!” and is slumped over with head hanging down,there is an incongruity—the behavior and the wordsdo not match.

The client’s expression of feelings demonstrates trustin the nurse. This expression of trust must be recognizedand respected. By listening carefully to the client, thenurse is able to learn what the client perceives as themost crucial problem. Listening is the first step in person-alizing care for each client. Listening can improve clientoutcomes. The accompanying display lists outcomes ofactive listening.

Humor

Humor is another characteristic of therapeutic nurses.The use of humor as a therapeutic intervention is not anew concept for nurses. Nightingale (1969) recognizedthe influence of the mind on the body and acknowledgedhumor as an important nursing intervention.

As shown in Figure 14-7, humor can assist in estab-lishing a relationship because it helps break the ice,decreases fear, and promotes trust. Humor is a mediumfor sharing; thus, it can be used to strengthen the thera-peutic relationship. Humor also stimulates creative


TABLE 14-3Trust: Essential Behaviors

Consistency Respect Honesty

• Follow through on plans.

• Adhere to schedule.

• Seek out client for extra time to interact.

• Be straightfor-ward; no hid-den motives.

• Call client byname.

• Provide clearexplanations.

• Recognizeown strengthsand limitations.

• Listen to client.

• Ask clientabout personalpreferences.

• Keep anypromises.

• Maintain confi-dentiality.

• Be flexible inresponding torequests.

REFLECTIVE THINKINGAcceptance of Clients

Think of some client behaviors that you may notapprove of, such as smoking, using alcohol, refus-ing to comply with treatment, or aborting a fetus.Even when clients engage in behavior that nursesthink is wrong, bad, or immoral, those clients stillhave a legal and ethical right to quality nursingcare. How will you respond when caring for some-one whose behavior opposes your basic values?

thinking, which is helpful for both clients and nurses inproblem solving.

Humor is influenced by one’s cultural background,so it is imperative that the nurse be sensitive to theclient’s interpretation and use of humor. A humor assess-ment can be conducted by noting:

What makes the client smile or laughThe use of jokes by clientsType of humor expressed by the client

Humor is a powerful tool for coping. Humor helpsindividuals to relieve stress and to express anger in asocially acceptable manner.

Nurses use humor to defuse the negative effects ofstress. Although humor can relieve tension and stabilizehigh-stress situations, it must be used with caution. Itcan be dangerous and destructive if used carelessly. Forexample, when using humor as a therapeutic interven-tion, the nurse must differentiate between laughing atand laughing with another.

Compassion

Compassion is truly caring about what happens toanother person. Kindness and genuine concern aredemonstrated through compassionate acts. Some behav-iors that communicate the nurse’s compassion include:

Acting on the belief that everyone is equally deserv-ing of careTreating individuals with dignityRespecting a client’s privacy—which includes simpleacts such as keeping the client covered and knockingon the door before entering the room, as these actsshow compassion

Other examples of compassion are a nurse caring for thehomeless in a shelter or holding the hand of a personwith acquired immunodeficiency syndrome (AIDS).

Self-Awareness

Self-awareness is necessary for the nurse to be therapeu-tic. Being aware of one’s feelings is the first step in devel-oping therapeutic behavior. Knowledge of one’s assets isnecessary in that effective nurses are able to identify theirown skills and abilities. Conversely, only after identifyingdeficits in knowledge and skills can the nurse initiatenecessary improvements. This process of analyzing one’sstrengths and limitations is an ongoing part of learning.The therapeutic nurse knows learning is a lifelongprocess that contributes to growth—personally and pro-fessionally. Self-awareness allows the nurse to remainobjective, that is, separate enough to distinguish one’sown feelings and needs from those of the client. Self-awareness is based on “one’s own thoughts, feelings, andexperiences in the clinical setting . . . and allows thenurse to be fully present to the client, not hidden behindprofessional detachment” (Rafael, 2000, p. 37).


OUTCOMES OF ACTIVE LISTENINGEstablishment of rapportExpression of genuine concernCommunication of intent to assist in problem solvingPromotion of comfort levelDecreased level of anxietyClient empowerment for self-careLearning is facilitated

FIGURE 14-7 Note the exchange of laughter betweenclient and nurse.What are some therapeutic outcomesfacilitated by the nurse’s deliberate use of humor?

Nonjudgmental Approach

Nonjudgmental behavior must be used if nursing inter-ventions are to be therapeutic. Nonjudgmental meansacting without biases, preconceptions, or stereotypes.Nonjudgmental nurses do not evaluate the client’s moralvalues nor tell the client what to do; these nurses acceptpeople as they are. Nonjudgmental nurses do not stereo-type people, nor expect others to behave in certain waysbecause they belong to a certain group.

Judgment influences perceptions because peopletend to see what they expect to see. Judgmental behaviorinterferes with the therapeutic value of nursing interven-tions. It is nontherapeutic for nurses to allow biasedviews that stem from personal values to influence theiractions. The initial assessment of clients is often influ-enced by preconceived ideas.

Becoming nonjudgmental is an ongoing process con-sisting of the following steps:

The first step is the most difficult—recognizing thatone’s thought are biased and prejudicial. Second, in order to change, nurses must accept theirown feelings. The third step consists of identifying the source ofthe negative feelings—not to blame but to gain anunderstanding of the origins.

To counter such negative feelings, learn about differentcultures. Getting to know people with diverse culturalbackgrounds expands the knowledge base and helps onebecome more tolerant and open-minded.

Flexibility

Flexibility is another trait necessary for creating a ther-apeutic relationship. A flexible nurse is one who is readyfor the unexpected—knowing that every day is filled withunplanned events and situations. The flexible nurse isable to adapt by “taking things in stride” and makingnecessary adjustments. Some of the unexpected eventsrequire immediate actions. The flexible nurse is able toestablish priorities by determining which needs areurgent and which can be tended to later. Staying calmduring a crisis is characteristic of the flexible nurse.

Risk Taker

A risk taker is a person who takes steps to find innovativesolutions in problem solving. To become effective risktakers, nurses must give themselves permission to trysomething new, to step outside the ordinary, and to not bebound by tradition or fear. The result is creative solutions

to problems. Successful risk takers give themselvescredit for trying something new regardless of the out-come. Smart risk takers learn from those risk taking ven-tures that are less than successful. They do not allowthemselves to become complacent, content to stay at acomfortable plateau.

Therapeutic Valueof the Nursing ProcessThe nursing process provides a framework for the deliv-ery of compassionate care. It gives direction by organiz-ing the nurse’s actions: assessing, diagnosing, planning,implementing, and evaluating.

The nursing process itself is therapeutic because itfocuses on the client’s response to illness, disease, or dis-ability rather than just on the problem. By focusing on thecaring aspects, the nursing process helps nursing defineits practice. Professional accountability is reinforced bythe use of this process, which is client-centered. Whenfunctioning within the parameters of the nursing process,the nurse assumes a variety of roles.

Nursing Roles

A role is a set of expected behaviors associated with anindividual’s status or position. Role includes behaviors,rights, and responsibilities. Nurses function in a varietyof roles every day (see the accompanying display onnursing roles). Often roles overlap, which may lead to aconflict in expectations or responsibilities. A discussionof some predominant nursing roles follows.

Caregiver

The caregiver is the role most commonly associatedwith nursing by the general public. In the role of care-giver, the nurse provides direct care when clients areunable to meet their own needs. Specific activitiescharacteristic of the caregiver role include feeding,bathing, and administering medications. When indi-viduals are ill, they are more likely to be dependentupon others for assistance in meeting their basicneeds. Such dependency may result in the person


NURSING ROLESCaregiverCounselorTeacherClient advocate

Change agentTeam memberResource person

experiencing a perceived loss of control and feelings ofhelplessness. Effective nurses understand the impor-tance of helping clients maintain control as much aspossible. To promote healing, nurses must help clientsregain or maintain a sense of control. “Many patientsfeel alienated from their recovery and treatment; frequently it is the nurse who assists the patient inregaining a sense of participation and control”(Benner, 2001, p. 61).

Counselor

When acting as a counselor, the nurse assists clientswith problem identification and resolution. The coun-selor facilitates client action by helping clients to maketheir own decisions. Counseling is done to help clientsincrease their coping skills. Effective counseling is holis-tic, in that it addresses the individual’s emotional, psy-chological, spiritual, and cognitive dimensions. Thecounselor role is most often fulfilled by the nurse whointervenes with clients experiencing chronic conditionsand those who are grieving.

Teacher

Teaching is an intrinsic part of nursing. The nurse viewseach interaction as an opportunity for education; bothclient and nurse can learn something from everyencounter with each other (Figure 14-8). Client educa-tion focuses on client empowerment, that is, empower-ing clients to do as much as possible for themselves.“Caring is the unique capacity to make choices thatbring about good for another” (Schaefer, 2002, p. 290).Thus, compassionate nurses provide information that iseasily understood by clients and that will assist them in

problem solving. Schaefer (2002, p. 290) views educationas one avenue for “improving the patient’s living condi-tions as much as possible.”

Client Advocate

A client advocate is a person who speaks up for or actson behalf of the client. Advocacy empowers clients to bepartners in the therapeutic process rather than passiverecipients of care. The relationship that encouragesclient empowerment is one of mutual participation byclient and nurse. Clients and families are activelyinvolved in establishing goals.

Frequently, clients and families do not communicatetheir concerns to physicians but will do so to the nursewith whom a bond has been established. Nurses functionas client advocates by listening and communicating theexpressed concerns to other health care providers andincluding those concerns in care planning.

Change Agent

Nurses who function in the role of change agent recog-nize that change is a complex process. The changeagent is proactive (takes the initiative to make thingshappen) rather than reactive (responding to things afterthey have happened). Change should not be done in arandom manner. It should be planned carefully andimplemented in a deliberate way to facilitate theclient’s progress.

The compassionate nurse understands that the deci-sion to change rests with the client. For example, con-sider the client who is instructed to lose weight in orderto lower cholesterol levels. The nurse provides the nec-essary information but knows that the client has ultimatecontrol in determining whether to make the necessarylifestyle modifications recommended by the health careproviders. In other words, caring nurses do not attempt toforce people to change. “This requires that the nursecreate an opportunity for active participation of the clientin the caring process to the extent that the client isable/willing” (Rafael, 2000, p. 38).

Team Member

A vital role of the nurse is that of team member. Thenurse does not function in isolation but rather works withother members of the health care team. Collaborationrequires the nurse to use effective interpersonal skillsand promotes continuity of care. See Chapter 15 for adiscussion on promoting healthy relationships withclients and colleagues.


FIGURE 14-8 In this situation, the nurse is providingprenatal instructions to the clients.

Resource Person

The nurse functions as a resource person by provid-ing skilled intervention and information. Identifyingresources and making referrals as needed also fall underthe auspices of this role. Nurses must consider the clientstrengths as well as availability of resources, includingphysical, intellectual, economic, social, and environ-mental factors.

KEY CONCEPTS

• Caring is the fundamental value in nursing.• Today’s high-tech environment requires that nurses

provide humanistic caring.• The therapeutic nurse-client relationship is the one-

to-one interactive process between client and nursethat is directed at improving the client’s health statusor assisting in problem solving.

• Therapeutic relationships differ from social rela-tionships in that they are deliberately planned, focuson client problems, and communicate acceptance ofthe client.

• Nursing is an interpersonal process between some-one who needs help in meeting needs and someonewho is competent to assist in meeting those needs.

• The three interwoven phases of the nurse-client rela-tionship are orientation, working, and termination.

• Therapeutic use of self is a process in which nursesdeliberately plan their actions and approach therelationship with a specific goal in mind before inter-acting with the client.

• Several interpersonal characteristics and skills canbe developed to increase the therapeutic value of anurse’s interventions. These include warmth, hope,rapport, trust, empathy, acceptance, active listening,humor, compassion, awareness, nonjudgmental atti-tude, flexibility, and risk taking.

• The nursing process is the framework for providingcompassionate care.

• Nurses function in a variety of roles when workingwith clients. The roles overlap and have specificresponsibilities.

CRITICAL THINKING ACTIVITIES

1. Interview professional nurses. Ask them to identifyspecific ways they demonstrate caring.

2. Briefly write your philosophy of health, includingyour beliefs about healing and caring.

3. Analyze your next interaction with a client anddetermine:

a. Which attending behaviors you usedb. Other actions that let the client know you were

actively listeningc. How you actualized the concept of therapeutic

use of self4. Some nurses believe it is “unprofessional” to laugh

with clients, even when laughter is a naturalresponse. What do you think of nurses usinghumor? Answer the following to help you decide:

a. What are the risks of using humor with clients?b. Name two benefits of implementing humor

with a client.5. Identify a situation in which humor has helped you

cope with an anxiety-provoking situation.


Visit the DeLaune and Ladner online companion resourceat www.delmarhealthcare.com for additional contentand study aids. Click on Online Companions then selectthe Nursing discipline.

delaune ch14 253-268

Documents