Establishing a Nurse—Client Relationship

Nursing Procedure 2.1

Establishing a Nurse—Client Relationship

Facilitates client's sense of well-being and control
Promotes beneficial interaction between the nurse and the client/family
Anticipates barriers to communication

Calendars
Clocks
Picture or word boards
Any items needed to add clarity to message
Pen

Assessment should focus on the following:

Client's age, developmental level, cultural or ethnic background, educational level
Physical and mental barriers to communication (e.g., poor sight or hearing, speech impediment, pain level)
Client's use of nonverbal gesturing
Client's perceptions of people and situations
Sources of stress for client
Client's use of defense and coping mechanisms
Immediate environment (e.g., noise, lighting, visitors)
Support systems (e.g., family, friends, community agencies; See Nursing Procedure 13.4)

Nursing diagnoses may include the following:

Anxiety related to perceived threat of inability to communicate needs during the postoperative period
Noncompliance related to feeling of lack of control in personal choices for minimizing complications of diabetes
Ineffective coping related to multiple stressors

Outcome Identification and Planning

Desired Outcomes

Sample desired outcomes include the following:

Client shows no signs of anxiety and identifies ways to communicate needs effectively after surgery.
Client shows personal actions that indicate active participation in agreed-upon dietary, activity, or home health regimen.
Client discusses current major stressors in life.

Special Considerations in Planning and Implementation

General

Anticipate questions and concerns when explaining factual information to clients. Plan interaction times to ensure privacy and avoid interruptions. When planning interactions, consider the phase of the nurse–client relationship:

Orientation phase: initial meeting of client and nurse; verbal contract is made
Working phase: basic nurse–client trust established and relationship solidified through meeting of objectives
Termination phase: preparation for discharge and ending of relationship

Avoid statements or behaviors that might result in barriers to communication (Display 2.1). When interacting with clients, consider their stage of coping or possible grief: denial, anger, bargaining, depression, and acceptance (Display 2.2). Special considerations are needed in communicating with potentially violent clients (Display 2.3).

Pediatric

Consider the child's developmental stage. Approach the child slowly after informing him or her of your intentions, as children may perceive sudden body movements by an adult as threatening.

Geriatric

Elderly clients may have one or more communication barriers that may readily be removed once discovered; dentures, hearing aids, and glasses should be acquired, if possible. With increasing age, a client's speech and comprehension may be slowed, requiring more time for communication.

End-of-Life Care

Communication with the dying client is vital, as it is believed that hearing is the last sense to leave the body. When in the room with the client, speak in a normal tone of voice, as whispering causes unnecessary strain. Do not speak as if the client is not in the room. During the final hours of life, the client may become restless, as agitation is common; however, unresolved physiological (including pharmacological), emotional, or spiritual issues should also be considered. Those who have come to terms and are at peace with death tend to become less communicative; therefore, explanations should be provided to family members that this process is common and does not indicate that their loved one is rejecting them. Client and family wishes should be granted as much as possible. Family members should be allowed to remain with the client as much as possible, and explanations should be provided to allay anxiety and avoid miscommunication.

Home Health

Encourage the client and family to prepare a list of questions or concerns during the time between the nurse's visits. Use of a diary or journal may promote communication of the content as well as the context of the client's concerns.

Transcultural

Use of an interpreter for clients whose native language is not English may reduce the chance of miscommunication by client and nurse. Sociocultural differences should be considered when interpreting a client's nonverbal behavior. For example, clients from some cultures may view direct eye contact as offensive and intrusive. It is best to follow the cues of the client in developing rapport.

Delegation

All levels of personnel interacting with clients and families should receive training and education about appropriate client communication, including clients with special needs. When clients have special communication needs, appropriate personnel should be assigned to work with those clients, and the staff should be informed of the communication needs to facilitate appropriate communication. Communication specifically addressing the progress or status of the client should not be delegated, but rather should be performed by the nurse or other appropriate and trained personnel as designated by the agency policies. All levels of staff should be informed about potential dangers in communicating with agitated, angry, or potentially violent clients.

[Outline]

Desired Outcomes
Special Considerations in Planning and Implementation

Action		Rationale
1	Approach the client in a purposeful but unhurried manner.	Promotes a controlled and nonthreatening interaction
2	Identify self and relationship to client.	Initiates orientation phase of nurse–client relationship
3	Arrange environment so that it is conducive to type of interaction needed. (Ask client or family for permission and assistance if in the home setting.)	Eliminates environmental distractions
4	Use the following physical attending skills throughout the interaction process:
	Face directly and lean toward client.
	Maintain eye contact and an open posture (do not cross legs or arms).	Exhibits nonverbal body language consistent with verbalizations; conveys interest, attentiveness, sincerity, and lack of defensiveness
5	Begin interactions using the following therapeutic techniques when eliciting or sharing information or responses:	Promotes purposeful and mutually beneficial interactions between nurse and client
	Use open-ended statements and questions.	Allows client to express feelings and concerns most important to him or her at the time
	Restate or paraphrase client’s statements when indicated.	Confirms significance of client’s comments
	Clarify unclear comments.	Ensures that intended message was received
	Focus the statement when client tends to ramble or is vague.	Promotes concreteness of message
	Explore further when additional information is needed.	Promotes gathering of complete information
	Provide rationale why more information is needed, when appropriate.	Maintains professional integrity of interaction
	Use touch and silence, when appropriate.	Conveys compassion and allows time for client to gain composure
6	Use the following active listening techniques:	Conveys interest, attentiveness, sincerity, and lack of defensiveness
	Do not interrupt client in the middle of comments.	Prevents distraction
	Use verbal indicators of acceptance and understanding (e.g., “um-hmm,” “yes”).	Expresses interest
7	When client is speaking, note his or her gestures, facial expressions, and elements of speech (e.g., tone, pitch, emphasis of words).	Facilitates receipt of complete message
8	When you are speaking, note client’s nonverbal gestures (e.g., grimacing, smiling, crossing arms or legs).	Helps detect cues indicating acceptance or nonacceptance of message
9	Toward the end of the interaction, summarize important aspects of the conversation.	Avoids abrupt and incomplete close to interaction

Were desired outcomes achieved? Examples of evaluation include:

Desired outcome met: Client showed signs of anxiety and identified ways to communicate needs effectively after surgery.
Desired outcome met: Client complied with dietary, activity, or home health regimen.
Desired outcome met: Client discussed current major stressors in life.

The following should be noted on the client's record:

Date, time, and place of interaction
Client's reaction to initial meeting and interaction
Any adaptations made to the environment
Nature and significant highlights of the discussion
Communication barriers (if any) and interventions used
Client's gestures, facial expressions, and elements of speech while talking
Client's significant nonverbal gestures while listening

section name header

Purpose ⬇

Equipment ⬆ ⬇

Assessment ⬆ ⬇

Nursing Diagnoses ⬆ ⬇

Outcome Id ⬆ ⬇

Implementation ⬆ ⬇

Evaluation ⬆ ⬇

Documentation ⬆