1. WHAT IS HELPING RELATIONSHIP?

The relationships between the nursing professional and the patient are called,
according to the authors, interpersonal relationships, therapeutic relationships or even,
helping relationships. Help is a process that fosters development and that
it pursues two basic objectives (Egan 1998):
1) Help patients solve their problems to live better, and to
enjoy fully the missed opportunities or
underutilized.
2) Help patients take better care of themselves in their daily lives.
A helping relationship can be established over weeks of work with
the patient or in a few minutes. The keys to the helping relationship are:
a) the increase of trust and acceptance between the nursing professional and
the patient and, b) the fundamental belief that the nurse is interested in the
patient and wants to help him.
The helping relationship is influenced by personal characteristics and
professionals of the nurse and the patient. Its development depends on factors
such as age, gender, physical appearance, diagnosis, education, the
values, the ethnic and cultural baggage, personality, expectations, and the scenario.
To create a helping relationship, the nursing professional must have
count all these factors, having good communication skills and
show genuine interest in the patient's well-being. In Box 24-3
they enumerate the characteristics of helping relationships.

2. PHASES OF THE HELPING RELATIONSHIP.

The process of the helping relationship can be described in four successive phases,
each of which is characterized by identifiable tasks and techniques. The
the relationship must go through the four phases sequentially, as each one of
it is based on the previous one. To check the evolution of a relationship, the
nursing professionals need to understand these stages: pre-phase of the
relation, preliminary phase, working phase (maintenance) and termination phase. In
Table 24-4 on page 482 summarizes the tasks and techniques required.

Phase prior to the relationship.

The phase prior to the relationship is similar to the planning phase that precedes a
interview. In most cases, the nursing professional has
information about the patient before their first face-to-face meeting. This
Information usually includes the name, address, age, and background.
medical and social aspects of the patient. Planning for the first visit sometimes
generates a certain anxiety in the nurse. If she acknowledges such feelings and
identify the specific information to comment on, you will achieve positive results.

Preliminary phase.
The importance of the preliminary phase, also known as the orientation phase or
The pre-assistance phase lies in establishing the tone for the rest of the relationship.
During this first meeting, the patient and the nurse observe each other mutually.
meticulously and judge the behavior of the other. The three stages of the preliminary phase
to establish a relationship, clarify the problem, and structure and formulate a
contract (Brammer 1988). Other important tasks of the preliminary phase are
to get to know each other and reach a certain level of trust.

After the introductions, the nurse can start a conversation

of a social type so that the patient can relax. An example would be to talk about the day so
Well, what they do and talk about what they would like to do if they were at home.
It is possible that at the beginning of the preliminary phase the patient may show certain

defensive behaviors. Defensive behaviors are those that inhibit the

participation, collaboration, or change. Its origin may be due to difficulty
to admit that help is needed and, therefore, that one plays a role
dependent; in the fear of exposing and facing feelings; in the anxiety for
the discomfort that comes with changing habits; behavior that causes problems; and
in the fear or anxiety in response to the approach made by the nurse, the
what could be inappropriate in the patient's opinion.
Defensive behaviors are overcome by conveying a loving attitude, a
sincere interest in the patient and a feeling of competence. The nurse who is
behaving this way also facilitates trust in the relationship. Trust is
describe how the undeniable and unquestionable security that someone inspires in us, or
the conviction that that person is capable of helping in difficult times and
that he will probably do it. Trusting someone entails a risk;
patients become vulnerable when they share ideas, feelings, and
attitudes towards the nursing professional. Despite this, trust allows the
The patient expresses their thoughts and feelings frankly.
At the end of the preliminary phase, patients must begin to:
Trust in the nursing professional.
See the nurse as a competent professional able to help them.
To see the nurse as someone sincere, frank, and who cares about her
well-being.
 To believe that the nurse will try to understand and respect your values and
cultural beliefs.
To believe that the nurse will respect the patient's confidentiality.
Feel comfortable talking to the nurse about your feelings and
other sensitive topics.
Understand the purpose of the relationship and the roles to be played.
Feeling actively involved in the preparation of a mutual care plan
agreement.

Work phase.
During the working phase of a helping relationship, the nurse and the patient
they begin to see each other as unique individuals. Both start to
value this uniqueness and to feel a mutual affection. Affection consists of sharing
a deep and genuine interest in the well-being of the other person. Once
Once affection is reached, the possibility of empathy emerging increases.
The work phase consists of two main stages: exploring and understanding the
ideas and feelings, and facilitate action. The nurse helps the patient analyze
the ideas, the feelings, and the actions, as well as to develop a plan of action
to achieve the established objectives.

ANALYZE AND UNDERSTAND IDEAS AND FEELINGS. In this phase of the

In a helping relationship, the nurse needs the following skills:
Listen and respond with empathy. The nursing professional must
listen attentively and communicate (respond) in a way that indicates
that he has heard what has been said and understands how he feels
patient. The nurse responds to the content, to the feelings, or to both
things as needed. Non-verbal behaviors of
the nurse. Among the non-verbal behaviors that indicate empathy are
nod moderately with your head, maintain eye contact, gesture with
moderation and moving the body little. According to Egan (1998), empathy 'can
to be regarded as an intellectual process during which it is interpreted as
correctly the emotional situation and the point of view of another person
besides as an emotional response experienced by the one who helps
(page 73). Empathetic listening aims to achieve a kind of
"meeting" with the patients that allows understanding them and their
world. In addition, this understanding must be conveyed to the patient (response
 empathetic). The final result of empathy is to comfort and care for the patient, thus
how to establish a useful and healthy relationship.

Respect. The nurse must show respect in order to have availability.

of the patient, desire to work with him, and a behavior that conveys the idea of
that takes the other person's point of view seriously.
Authenticity or sincerity. Personal statements help a lot to
consolidate the relationship between the nurse and the patient. The nurse can
make comments like, 'I remember when I was in (a situation
similar), and it upset me terribly that they criticized me." Egan (1998) highlights five

behaviors that comprise sincerity (see Box 24-4). The

Nursing professionals must be careful when making comments about themselves.
same. These statements must be used with caution. The patient must
it is of little use that, for each of your problems, the nurse has a
better own story.
Concretion. The nurse must help the patient to speak concretely.
and specific, not generalities. If the patient says, 'I am an idiot and a'
clumsy," the nurse will specify the topic by stating, "He has stumbled upon the
carpet.
Confrontation. The nurse points out the discrepancies between the ideas, the
feelings and actions that make it difficult for the patient to understand themselves
same or analyze certain themes. This must be done in an empathetic manner,
not from a critical point of view.
During this first stage of the working phase, the intensity of the relationship
increases and feelings such as anger, shame or can be expressed
shyness. If the nurse is well acquainted with this stage and the patient is willing to
continue your self-exploration, the result will be the understanding of behavior
and the feelings on the part of the patient.

FACILITATE ACTION. Finally, the patient must make decisions and enter
in action to be more effective. The responsibility for the action lies with the
patient. Despite this, the nurse collaborates in such decisions, provides
support, and can provide opinions or information.

Termination phase.
The ending phase of the relationship is often anticipated to be difficult and filled with

ambivalences. Despite this, when the previous phases progress in a

effective, the patient generally has a positive outlook and feels capable
to face problems independently. However, the affection that
it has been reached, it is natural to expect feelings of loss, and each
a person has to find a way to say goodbye.
There are various methods to end a relationship. To make a
A summary or a review of the process brings a sense of accomplishment. One way to
doing it consists of remembering together how things were at the beginning of the relationship,
and compare them with how they are now. It is also useful for the nurse
For the patient, to express their feelings openly and sincerely
about the end of the relationship. Thus, we must start talking about the
termination of the relationship before the final interview. This gives the patient time.
to adapt to independence. In some cases, it is necessary to refer to the
patient to other professionals, or it is advisable to offer them an occasional meeting to
help you with whatever you need. Other interventions that facilitate the transition of
Calls and emails are what help the patient towards their independence.
tracking electronics.

Development of helping relationships.

Whatever the work environment, the nursing professional establishes a relationship
of help in which mutual objectives (results) are set with the patient or, if
he cannot participate with the support people. Although it is useful to have
special training in counseling techniques, there are many ways to
help patients for whom no special preparation is needed.
Active listening.
Help identify the person's feelings. Often, people
who are worried are unable to identify or classify their
feelings, which makes it difficult for them to formulate or talk about them. Responses
such as, "It seems that it bothers him that his boss gives him orders," or "It seems

as if you had been alone since your wife died," they help the
patients to recognize their feelings and to express them.
Put yourself in the other person's shoes (this is empathy). Communicate.
with the patient in such a way that they demonstrate understanding of their feelings,
and the behavior and the experience that originates them.

Be sincere. In effective relationships, the nursing professional recognizes

with frankness his lack of knowledge when he states "At this moment
I don't know the answer"; he openly comments on his own discomfort saying,
for example, "I feel uncomfortable with this conversation"; admits with
 prudence the existence of problems, such as when a patient
He/She says, 'I'm a mess, right?'
Be frank and credible. Patients immediately notice if a nurse is
really worried or not.
Use your ingenuity. There are many ways to confront problems.
Whichever direction chosen, one must try to achieve the objectives of the
patient (results), to be compatible with this system of values and
offer a probability of success.
To be aware of the cultural differences that may influence meaning.
and understanding (see Chapter 13). To facilitate the relationship between the patient
And the nursing professional needs to identify what language or dialect they use.
patient. Get a bilingual interpreter if the patient has problems with the
language.
Maintain patient confidentiality. To defend the right of
patient to their privacy, share the information exclusively with others
health professionals, and only when deemed necessary to improve the
care and treatment.
Know your own functions and limitations. Each person has their
qualities and their unique problems. When you feel unable to handle
certain problems, you must inform the patient and refer them to the professional
appropriate sanitary. Clarify the functions and roles, especially what
waiting of the patient, the nurse and the doctor.

3. WHAT IS THERAPEUTIC COMMUNICATION?

Therapeutic communication promotes understanding and helps to establish a
constructive relationship between the nurse and the patient. Unlike the relationship
social, in which there may not be a specific purpose or direction, the
The therapeutic helping relationship is focused on the patient and the objectives.
Nursing professionals must respond not only to the content of
verbal message from the patient, but also the feelings expressed. Before
It is essential to understand how the patient sees and feels about the situation.
The content of the patient's communication is the words or the ideas, for
contradiction to feelings. There are times when the person conveys
an idea with words while your emotions contradict what is expressed; that is
words and feelings are incongruent. For example, a patient says:
I am glad that he left me; he was very cruel. However, the
The nurse observes that the patient’s eyes fill with tears as she says it.
To respond to the woman's words, it may be enough to simply repeat them.
phrase, for example: 'She is happy that I have left her.' To respond to the
feelings, the nursing professional should be made aware of the
tears saying, for example: "It seems that all of this makes him sad." One
This response helps the patient to focus on their feelings. In some
In cases, the nurse needs to know more about the patient and their resources to
to confront these feelings.
There are times when patients need time to cope with their
feelings. Strong emotions tend to be exhausting. Generally, before
taking care of other matters, such as learning new skills or making plans for
future, people have to face their feelings. This is especially
evident in hospitals, when patients are informed that they suffer from a
terminal illness. Some require hours, days, or even weeks before
be prepared to start other tasks. There are those who only ask for time for themselves
same, who needs someone to listen, who requires help to
identify and express their feelings, who needs support to make
decisions about how to proceed in the future.

Active listening.
Unlike passive listening, in which only the ear participates, the
Active listening involves hearing actively, using all the senses for that purpose.
It is probably the most important technique in nursing, and it is essential for the
the rest of the techniques. Active listening is a dynamic process that requires energy
and concentration. It involves paying attention to the entirety of the message, both verbal
as non-verbal, and observe if the communication is congruent. Active listening
it means to absorb the content and the feeling that the person conveys, without doing
selections. The receiver does not choose or only listen to what they want to hear; the
The nurse focuses not on her own needs but on those of the patient.
Active listening conveys an attitude of affection and interest, which encourages the
patient to express themselves.

Active listening also involves listening to the key topics of communication.

The nursing professional must be careful not to react quickly.
to the message. The speaker should not be interrupted, and the nurse (who responds)
You need to take some time to meditate on the message before responding. Like
the receptor must also ask questions to obtain more information or to
clarify the message you have received.
Nursing professionals need to be aware of their own
prejudices. One should not discredit a message that reflects values or convictions
different. According to Rondeau (1992), the sender of the message (that is, the patient) has
to decide when the conversation ends. If it is the nurse who closes the
conversation, the patient may interpret that they have not given importance to
message.
In summary, active listening is a very complex technique, but
Fortunately, it can be learned through practice. There are several ways to
convey an attitude of attention when listening to patients. The most responses
Common are nodding the head, saying 'uh huh' or 'mmm', repeating words
what the patient has used, or say 'I understand what you want to express'. Each
the nurse has a characteristic way of responding, and must be careful not to
seem insincere or false.

Physical attention.
Egan (1998) highlighted five specific ways to provide physical attention, something that he
define as the way of being present for another person, or of being with her. In
in your frame of reference, what a person does when they are present is
listen.
Therapeutic communication techniques facilitate communication and focus on
the patient's problems.

Obstacles to communication.
The nursing professional must identify the barriers or the responses not
therapeutic practices for effective communication. The inability to listen, the
incorrect decoding of the message that the patient intends to transmit and the
the fact of prioritizing the needs of the nurse over those of the patient is the
main obstacles to communication.