TITLE: COMMUNICATION ( NURSE-CLIENT RELATIONSHIP)

OVERVIEW: Helping relationship, a nurse-client relationships referred as interpersonal relationships,

therapeutic relationships. It is a growth-facilitating process that helps the client manage their problems
in living effectively and develop unused or underused opportunity fully. It also help clients become
better at helping themselves in their everyday life. It may be develop over weeks or working with a
client or within minutes. The keys to the helping relationship are development of trust and acceptance
between the nurse and the client, and an underlying belief that the nurse cares about and wants to help
the client.

OBJECTIVES: 1. To describe the four phases of the helping relationships.

2. To write the various techniques of communication and improving student nurse self-talk.

DISCUSSION: Good day my dear students and future nurses. How are you? I will be talking about
nurse – patient relationship, simply called as NPI. It is the interaction between you and your client and
good to practice at hospital or community setting, yet in times like this, wherein COVID19 Pandemic is
just around the corner, we can enhance this learning through paper and pen method.

Helping relationship is influenced by the personal and professional characteristics of the

nurse and the client. Factors that affect the development of the nurse-client relationship are age, sex,
appearance, diagnosis, education, values, ethnic and cultural background, personality, expectations and
setting. Good communication skills and sincere interest in the client’s welfare will enable the nurse to
create a helping relationship.

Characteristics of a Helping Relationship:

1. It is an intellectual and emotional bond between the nurse and the client and is client-focused.
2. Respects the client as an individual, including: maximizing client’s abilities to participate in
decision making and treatments, considering ethnic and cultural aspects, considering family
relationships and values.
3. Respects client’s confidentiality .
4. Focus on client’s well-being.
5. Is based on mutual trust, respect and acceptance.

There are 4 sequential phases of the helping Relationship, each characterized by identifiable tasks and
skills.

(Preinteraction Phase, Introductory Phase, Working/Maintaining Phase and Termination Phase) The
relationship must progress through the stages in succession, each builds on the one before. Nurses can
identify the progress of a relationship by understanding each phase.

Preinteraction Phase – is similar to the planning stage before an interview. The nurse has information
about the client before the 1st face-to-face meeting. Info includes client’s name, address, medical and
social history. Planning for initial visit may generate some anxious feelings in the nurse. If the nurse
recognizes these feelings and identifies specific information to be discussed, positive outcomes can
evolve.
Introductory Phase – it is also referred as the orientation phase/ prehelping phase. It sets the tone for
the rest of the relationship. During initial relationship, client and the nurse closely observe each other
and form judgments about the other’s behavior. 3 stages of this are opening the relationship, clarifying
the problem and structuring and formulating the contract. Getting to know each other and developing a
degree of trust also included in this phase. The nurse may initially engage in some social interaction so
as to put the client at ease. They can talk about what a nice day it is and what would like to do if at
home.

During initial part of introductory phase, the client may display some resistive behaviors.
Resistive – inhibit involvement, cooperation or change. They may be due to difficulty in acknowledging
the need for help and thus a dependent role, fear of exposing and facing feelings, anxiety in response to
nurse approach. Resistive behavior can be overcome by conveying a caring attitude, genuine interest in
the client, and competence. These behaviors of the nurse also develop trust in the relationship. Trust is
a reliance on someone without doubt or question. They believe that a person can assist in times of
distress and in all likelihood will so. Trusting another person involves risk; clients become vulnerable
when they share thoughts, feelings and attitudes with the nurse. Trust can enable the client to express
thoughts and feelings openly.

At the end of the introductory Phase, clients should begin to:

- Develop trust in the nurse

- View the nurse as a competent professional capable of helping
- View the nurse as honest, open and concerned about their welfare
- Believe the nurse will try to understand and respect their cultural values and beliefs
- Believe the nurse will respect client confidentiality
- Feel comfortable talking with the nurse about feelings and other sensitive issues
- Understand the purpose of the relationship and the roles
- Feel that they are active participants in developing a mutually agreeable plan of care.

Working Phase – during this phase of a helping relationship, the nurse and the client begin to view each
other as unique individuals. They begin to appreciate this uniqueness and care about each other. Caring
is sharing deep and genuine concern about the welfare of another person. Once caring develops, the
potential for empathy increases. Its 2 major stages are exploring and understanding thoughts
and feelings and the other one is facilitating and taking action. The nurse helps the client to explore
thoughts, feelings and actions and help the client plan a program of action to meet preestablished goals.

Exploring and understanding thoughts and feelings: The nurse requires the following skills.

1. Empathetic listening and responding. Attentive listening and communicate (respond) in ways
that indicate they have listened to what was said and understand how the client feels. The nurse
nonverbal behaviors are also important. It indicates empathy (moderate head nodding, steady
gaze, moderate gesturing and a little activity or body movement.
Empathy can be seen as an intellectual process that involves understanding correctly another
person’s emotional state and point of view. Empathetic listening focuses on “being with” clients
to develop an understanding of them and their world. Comfort and caring for the client, a
helping and healing relationship is the end result of empathy.
 2. Respect – the nurse must show respect for the client’s willingness to be available, desire to work
with the client, and a manner that conveys the idea of taking the client’s point of view seriously.

3. Genuineness – personal statements can be helpful in solidifying the rapport between the nurse
and the client. The nurse might offer comments as “ I recall when I was in (a similar situation),
and I felt angry about being put down. Nurses need to exercise caution when making
references about themselves. This should be used with discretion. The extreme of matching
each of the client’s problems with a better story of the nurse’s own is of little value to the client.

Components of genuineness includes: a) The genuine helper does not take refuge in or
overemphasize the role of counselor. b) The genuine person is spontaneous, c) The genuine
person is non-defensive. d) The genuine person displays few discrepancies- that is, the person is
consistent and does not think or feel one thing but say another. e) the genuine person is capable
of deep self- disclosure (self-sharing) when it is appropriate.

4. Concreteness – assist the client to be concrete and specific rather than to speak in generalities.
When the client says,” I am stupid and clumsy,” the nurse narrows the topic to the specific by
pointing out, “ You tripped on the rug”

5. Confrontation – the nurse points out discrepancies between thoughts, feelings, and actions that
inhibit the client’s self-understanding or exploration of specific areas. This is done
empathetically, not judgmentally.

During the first stage of the working phase, the intensity of interaction increases, and feelings of
anger, shame or self-consciousness may be expressed. Skilled nurse in this stage and if the
client is willing to pursue self-exploration, the outcome is a beginning understanding on the part
of the client about behavior and feeling.

Facilitating taking action. Finally, the client must make decisions and take action to become
more effective. The responsibility for action belongs to the client. The nurse, collaborates in
decisions, provides support and may offer options or information.

Termination Phase - this often expected to be difficult and filled with ambivalence ( contradictory of
feeling). If the previous phases have evolved effectively, the client generally has positive outlook and
feels able to handle problems independently. Since caring attitudes have developed, it is natural to
expect feelings of loss, and each person needs to develop a way of saying goodbye

Methods can be used to terminate relationships. Summarizing, reviewing the process can
produce the sense of accomplishment. Sharing reminiscences of how things began and compare them
how they are now. It is helpful for both to express their feelings about termination openly and honestly.
Termination discussions need to start in advance of the termination interview. For this reason it allows
time for the client to adjust to independence. There are some situations wherein referrals are
necessary, it is appropriate to offer an occasional standby meeting to give support as needed. Follow up
phone calls or e-mails are other interventions that ease the client’s transition to independence.

Developing Helping Relationships

Whatever the practice setting, the nurse establishes some type of helping relationship in which mutual
goals (outcome) are set with the client or, if the client is unable to participate with support persons. One
of the ways that does not require special training are:

1. Listening actively
2. Help to identify what the person is feeling. Clients who are troubled are unable to identify or to
label their feelings and have difficulty working with them or talking about them.
3. Put yourself in the other person’s shoes (empathize). Communicate to the client in a way that
shows understanding of the client’s feelings and behavior and experiences underlying these
feelings.
4. Be honest. In effective relationship, nurses honestly recognize any lack of knowledge by saying “I
don’t know the answer to that right now” .
5. Be genuine and credible. Clients will sense whether or not the nurse is truly concerned.
6. Use your ingenuity. (Skill) there are courses of action to consider in handling problems. Be
compatible with the client’s value system, and offer a probability of success.
7. Be aware of cultural differences, that may affect meaning and understanding. Language
recognition and/or dialect that he uses so as to facilitate things. Provide a bilingual interpreter
as needed.
8. Maintain confidentiality. It is a must to client right to privacy. Share information only with other
health care professional as needed for an effective treatment.
9. Know your role and limitations. Every person has unique strengths and problems. If you feel
that you are unable to handle, the client should be informed and referred to appropriate health
professional. Clarify functions and roles, specifically what is expected of the client, nurse and
physician.

The effective nurse-client relationship is a helping relationship that facilitates growth of the individual.
Each four phases has a specific purpose or goal and requires specific skills of the nurse.

Example of a nurse-client interaction:

what I said: magandang umaga po, ako po si …

why I said: to introduce myself

what the client/SO said?

Why they said?

Therapeutic communication used: read those techniques, description and examples used

Evaluation: SO/client answer completely and immediately, understand hospital protocols,

approachable, listen attentively and understood
 Now let us talk about communication where we all know that it is a process which people affect
one another through exchange of information, ideas and feelings. As one of the member of the health
care team, nurses need to communicate information about clients accurately, timely, in an effective
manner. Documentation/recording is a vital aspect of nursing practice. Health personnel communicate
through discussion, reports and records. At the end of the shift in the hospital nurses give both verbal
and written reports to the next shift.

It is the ability to communicate with one another. Client information is required so health
providers can plan an organized, comprehensive care plan.

We have the modes of communication such as verbal (spoken or written) and nonverbal
(gestures, facial expression, posture/gait, body movements, physical appearance, eye contact, voice
tone)

Characteristics of Communication:

1. Simplicity – use of commonly understood words, brevity and completeness

2. Clarity- saying exactly what is meant. The nurse needs to speak slowly and pronounce words
well. Repeat the message when needed, reduce distractions.
3. Timing and relevance – requires choice of appropriate time and consideration of the client’s
interests and concerns. Ask one question at a time. Wait for an answer before making another
comment.
4. Adaptability – it involves adjustment on what the nurse says and how it is said depending on
moods and behavior of a client.
5. Credibility – worthiness of belief. The nurse requires adequate knowledge about the topic being
discussed. The nurse should be able to provide accurate information, to convey confidence and
certainty in what she says. She should be a good role model for what he teaches.

Components of Communication are the sender (encoder) , message, receiver (decoder) ,

response (feedback)

We can say that communication is a basic component of human relationships and nurse-client
relationship. Non-verbal is more accurate expression of a person’s thoughts and feelings. Variety of
feelings can be expressed by a single non-verbal expression. Effective communication is reciprocal
interaction (2-way process) based on trust and aimed at identifying client needs and developing mutual
goals. Trust is the foundation of a positive nurse-client relationship. It develops gradually as the client
perceives an attitude of acceptance, understanding and empathy from the nurse. The client initially may
test the nurse’ confidence (sharing that he expects remain confidential)

Covert represents the inner feelings that a person may be uncomfortable talking about it. Such
can be revealed through non verbal modes. Validation is required for overt communication. It is an
attempt to confirm the observer’s perception through feedback, interpretation and classification.

Therapeutic communication is a fundamental component in all phases of nursing process and it

is used for establishing NPI. Effective nurse-client relationship is a helping relationship which is growth
facilitating and provides support, comfort and hope.
 Now we proceed to documentation and reporting, we all know that documents is a permanent
record of client information and care. Reporting takes place when two or more people share
information about client care, either face to face or by telephone.

So what are the purposes of Client’s Record/Chart:

1. Communication – provides efficient and effective method of sharing information. It conveys

meaningful data about the client.
2. Legal documentation – it is an evidence in a court of law
3. Research – provides valuable health-related data for research
4. Statistics – as an information that can be utilized for planning people’s future needs
5. Education – serves as educational tool for students in health discipline
6. Audit and quality assurance – monitors the quality of care received by the client and the
competence of health care givers
7. Planning client care – provides data which the entire health team uses to plan care for the client
8. Reimbursement – provides the basis for decisions regarding care to be provided and subsequent
reimbursement to the agency, to cover health related expenses.

A. Source oriented medical record (traditional client record) wherein each person or
department makes notations in a separate section/s of the client’s chart.
5 basic components are the 1. Admission sheet 2. Physician order sheet 3.
Medical history 4. Nurses’ notes and 5. Special records and reports such as referrals,
x-ray reports, laboratory findings, report of surgery, anesthesia record, flow sheets, vital signs,
I&O and medications.
B. Problem-Oriented Medical Record (POMR or POR) – it includes 1. Data about the client are
recorded and arranged according to the source of information. 2. The record integrates
all data about the problem, gathered by the members of the health team
4 basic components are: 1. Database- initial information about the client 2.
Problem list – contains all the aspects of the person’s life requiring health care 3. Initial
list of orders or care plans 4. Progress notes: a) nurse’s narrative notes (SOAPIE)
subjective, objective, assessment, planning, intervention, evaluation, b)flow sheets (data
are monitored), c)discharge notes or referral summaries

Kardex – provides a concise method of organizing and recording data about a client, making
information readily accessible to all members of the health team. It is a series of flip cards
usually kept in portable file. It is a way to ensure continuity of care from one shift to
another and from one day to the next. It is a tool for change of shift report. Endorsement is
not simply reciting Kardex content. The health care needs of the client is still primary basis
for endorsement. Inclusions are personal data (demographic), basic needs, allergies,
diagnostic tests, daily nursing procedures, medications and IVT, BT, change of dressings,
mechanical ventilation. Entries are usually in pencil so they can change as client condition
changes. Kardex is for planning and communication purposes only.
Let us take a look on the characteristics of good Recording:
1. Brevity- concise entries, complete sentences not required. Start each entry with capital
letter and end the entry with period even if the entry is a single word or phrase.
 2. Use of ink/permanence – avoid felt pen or pencil for permanence of data, the client’s
char can be used as an evidence in a legal court
3. Accuracy – chart objective facts, not your interpretations and opinions ( correct: ate
50% of food served, incorrect: ate with poor appetite) (correct: refused medications,
incorrect: uncooperative) (correct: seen crying, incorrect: depressed) place complaint
of the client in quotation marks to indicate that it is his statement. (chest pain radiating
down the left arm) objective data are also to be charted. Skin cold and clammy,
diaphoretic, prefers to sit up. Vs taken as follows: describe behaviors rather than
feelings to allow other health team members to determine the actual problems of the
client. Refusal of medications and treatments must be documented.

4. Appropriateness – only information that pertain to the client’s health problems and care
are recorded. Any other personal information that is conveyed to the nurse is
inappropriate for the record.

5. Completeness and chronology/organization/sequencing/timing

a) It should appear on the succeeding line, b) continuous charting is done for each
entry unless a time change occurs. No need for a new line for each new idea or
entry. C) Date is entered in the date column on the first line of every page of
nurses’ notes and whenever the date changes. d) time is entered in the time
column whenever a new time entry occurs e) avoid time changes in the text of the
nurse’s notes. f) avoid double chart. If something appears on a particular sheet, it
does not need to appear on the nurse’s notes, unless there is an alteration from the
normal, (BP, temp) g) avoid squeezing information into a space because you forgot
to chart it earlier. Add the information on the first available line. Write the time the
event occurred, not the time you entered the information.

The following information must be charted:

A) Physician’s visits B) times the patient leaves and returns to the unit, mode of transportation and
destination C) medications should be charted immediately after given D) treatments should be
charted immediately after given.
6. Use of standard terminology – use only those abbreviation and symbols approved by the
institution, spell correctly, use proper grammar.
7. Signed – affix signature, place at the end of the charting, at the right hand margin of the
nurse’s notes; sign each entry with your full name and status, (SN for student nurse,
RN for registered nurse) script, not printing is used for the signature.
8. In case of ERROR – correct errors by drawing a single horizontal line through the error,
write the word error above the line, then sign your signature. No ink eradication,
erasures or use of occlusive materials.
9. Confidentiality – only the health personnel who participate in the care of the client are
allowed to read the chart.
 10. Legal awareness – chart only what you personally have done, observed, heard, smelled
or felt. Do not discard any part of the client record.
11. Legible – writing must be clear and easily read by the others. If not so, then print.
12. Do not use the word patient or pt in the chart – the chart belongs to the patient. All
information in the chart pertain to the patient.
13. A horizontal line drawn to fill up a partial line, this is to prevent other persons from
adding information in the nurses’ notes. -------------Rodela Cristina L. Baslan RN

Reporting : Types
1. Change of shift reports or endorsement – for continuity of care, it is based on health
care needs of the client
2. Telephone reports – provide a clear, accurate, and concise information, the nurse
documents telephone report by including: a) when the call was made b) who made
the call/report c) who was called d) to whom information was given e) what
information was given f) what information was received
3. Telephone orders – only RNs may receive telephone orders, the order needs to be
verified by reporting it clearly and precisely. The order should be countersigned
by the physician who made the order within prescribed period of time (within 24
hours)
4. Transfer reports – this is done when transferring a client from one unit to another.

Take extra time for readings especially the most commonly used abbreviations. Ok?

TEACHING AND LEARNING (CLIENT EDUCATION/PATIENT TEACHING)

Learning- change in human disposition or capability that persists over a period of time, reflected by a
change of behavior.

Theories of Learning:

1. Behaviorism- the transfer of knowledge could occur if the new situation closely resembled the
old situation (Thorndike)
2. Cognitive – intellectual activity (Lewin). It is an individualized process. People do the best they
can for themselves relative to their unique perceptions.
3. Humanism – there is a natural tendency for people to learn and it flourishes in an encouraging
environment. It involves respect for human dignity.

PRINCIPLES OF TEACHING AND LEARNING

1. Meet priority needs first. Basic needs must be met first before an individual can be
expected to engage in learning new skills and behavior. Relieve chest pain first before health
teaching
2. Make learning relevant. As they consider it useful to their needs. Teach people in the
community that herbal plants for illness treatment.
3. Keep learning goals realistic. – teach the daughter of an elderly client on how to monitor
blood sugar level of the client
4. Relate new information to previous learning – teach clients on different food groups before
planning well-balanced diet.
 5. Include significant others- teach the wife of the client with hypertension on how to prepare
low sodium, low fat, low cholesterol diet.
6. Consider individual learning strengths and weaknesses – data regarding client’s intellectual
and physical capabilities should guide the choice of appropriate teaching materials. Use of
audio-visual aids, models, articles, equipment to facilitate learning.
7. Choose appropriate instructional strategies – patient learning style preferences should guide
the choice of teaching strategies. Some are visual, audio kinesthetic learners. Use lecture,
demonstration, discussion, role playing
8. Provide for practice and feedback. – practice to master the task. Allow the client to
manipulate equipment and articles.

DOMAIN OF LEARNING (BLOOM)

1. Cognitive domain – intellectual skills, diabetic client after attendance of diabetes
education comprehends diabetes process, its signs , symptoms and complications
2. Affective domain – include feelings, emotions, interests, attitudes and appreciation.
Diabetic client values the importance of daily foot care to prevent development of
diabetic ulcer.
3. Psychomotor domain – motor skills, diabetic client is able to perform self-monitoring of
blood glucose correctly and accurately.

FACTORS FACILITATING LEARNING

1. Motivation – desire to learn. It is greatest when recognizes the need. (hypertensive client
need to know the effects of alcohol before he recognizes the need to stop drinking alcohol)
2. Readiness – willingness and ability to learn at specific time. Client may search out
information by asking questions, reading books or articles, talking to others, show interests.
3. Active involvement – if the client participates, learning is faster and retention is better. He
gains self-confidence in his ability to learn.
4. Feedback – evaluation of person’s performance in meeting goal. Positive such as praise,
positive worded corrections and suggestions .
5. Simple to complex – materials should be logically organized
6. Repetition – facilitates retention of newly learned material. Provide adequate time for
practice of psychomotor skills. Summarize content, rephrase and approach the material
from another point of view to reinforce learning.
7. Timing – the shorter the length of time from learning to application, the greater the amount
of material retained
8. Environment – should be physically and psychologically comfortable- free from distractions
(noise, with adequate lights, good ventilation and room temperature, with privacy, free
from anxiety-provoking situation)

There are factors that inhibit learning such as emotions (depression, anxiety), physiologic (pain, acute
illness, impaired mobility, decreased level of energy) and cultural barriers. (language, health belief
differences, customs and practices)
Teaching – it is a system of activities aimed to produce learning. It involves dynamic interaction between
teacher and a learner. Trust and respect is a must between them teacher (nurse) and learner (patient).

GUIDELINES IN LEARNING/TEACHING

1. Teaching activity should help the client meet individual learning objectives. Demonstrate to a
diabetic client on how to hold the syringe when teaching on self injection of insulin.
2. Rapport between teacher and learner is essential. Relationship between them must be
constructive and accepting.
3. Teacher should use previous learning in the present situation to encourage learning of new skills
4. Nurse-teacher must able to communicate clearly and accurately. Provide current or updated
materials
5. Nurses often need to communicate effectively with small/large group of individuals.
6. Client’s knowledge and factors that affect learning should be determined before planning or
teaching.
7. When a client is involved in planning, learning is enhanced.
8. Teaching that involves a number of client’s senses often enhances learning
9. Anticipated behavioral changes that indicate learning has taken place must always be adapted
to clients lifestyle and resources.

As expected, I want you to be a wide reader, knowledgeable and skillful, good in talking, caring,
comforting and communicating to your clients and to other people as well. Book is a must, good
attitude is well appreciated. Good luck my dear students, enjoy the second semester. God bless you.

Finally, present your own nurse-client interaction to your designated clinical instructors.
Various cases available provided you apply well and good therapeutic communication.