Bridges and Barriers in the Therapeutic Relationship

Barrier: Lack of Respect: In the Williams and Irurita study (2004), clients felt devalued when they perceived that staff were avoiding talking with them or were unfriendly; they felt comforted when a little “chitchat” was exchanged. Lack of respect among members of the team has also been often cited as a cause of adverse client outcomes. Lack of respect for the nurse by the physician has been cited as a factor leading to communication failures resulting in harm to the client (Sutcliffe, Leewton, & Rosenthal, 2004). Safety issues and communication is discussed in Chapter 22.

Barrier: Lack of Caring: Although nursing has had a long-standing commitment to client-focused care, sometimes you may observe a situation in which you feel a nurse is apathetic, trying to meet her own needs rather than the client’s needs. Some nurses develop a detachment that interferes with expressions of caring behaviors. At other times, a nurse can be so rushed to meet multiple demands that she seems unable to focus on the client. Exercise 6-1 will help you focus on the concept of caring.

Barriers: Empowerment is purposeful. It encourages clients to assume responsibility for their own health. This is in direct contrast with the paternalistic attitude formerly found in medicine and characterized by the attitude of “I know what is best for you or I can do it better.” An Australian study showed that lack of information about giving care, managing medicines, or recognizing approaching crises was the major impediment to empowering family members to care for sick relatives (Wilkes, White, & O’Riordan, 2000). Failure to allow our client to assume personal responsibility, or failure to provide him with appropriate resources and support, undermines empowerment.

Barrier: Mistrust: Mistrust has an impact not only on communication but on healing process outcomes. Trust can be replaced with mistrust between nurse and client. Just as some agency managers treat employees as though they are not trustworthy, some nurses treat some clients as though they are misbehaving children. Such would be the case if a client fails to follow the treatment regimen and is labeled with the nursing diagnosis of “noncompliant.” In other examples, the community health nurse who is inconsistent about keeping client appointments or the pediatric nurse who indicates falsely that an injection will not hurt are both jeopardizing client trust. It is hard to maintain trust when one person cannot depend on another. Energy that should be directed toward coping with health problems is rechanneled into assessing the nurse’s commitment and trustworthiness. Having confidence in the nurse’s skills, commitment, and caring allows the client to place full attention on the situation requiring resolution. Clients can also jeopardize the trust a nurse has in them. Sometimes clients “test” a nurse’s trustworthiness by sending the nurse on unnecessary errands or talking endlessly on superficial topics. As long as nurses recognize testing behaviors and set clear limits on their roles and the client’s role, it is possible to develop trust. Exercise 6-2 is designed to help students become more familiar with the concept of trust.

Barrier: Lack of Empathy: Failure to understand the needs of clients may lead you to fail to provide essential client education or to provide needed emotional support. The literature indicates that major barriers to empathy exist in the clinical environment, including lack of time, lack of trust, lack of privacy, or lack of support. Several studies suggest that lack of empathy will affect the quality of care, result in less favorable health outcomes, and lower client satisfaction (Levetown, 2008). However, providers can be taught to express empathy.

Anxiety: Anxiety is a vague, persistent feeling of impending doom. It is a universal feeling; no one fully escapes it. The impact on the self is always uncomfortable. It occurs when a threat (real or imagined) to one’s self-concept is perceived. Lower satisfaction with communication is associated with increased client anxiety. Anxiety is usually observed through the physical and behavioral manifestations of the attempt to relieve the anxious feelings. Although individuals experiencing anxiety may not know they are anxious, specific behaviors provide clues that anxiety is present Exercise 6-5 identifies behaviors associated with anxiety. Table 6-1 shows how an individual’s sensory perceptions, cognitive abilities, coping skills, and behaviors relate to the intensity and level of anxiety experienced.

A mild level of anxiety heightens one’s awareness of the surrounding environment, and fosters learning and decision making. Therefore, it may be desirable to allow a mild degree of anxiety when health teaching is needed or when problem solving is necessary. It is not prudent, however, to prolong even a mild state of anxiety.

Greater levels of anxiety decrease perceptual ability. The anxious state is accompanied by verbal and nonverbal behaviors that inhibit effective individual functioning. For example, anxiety causes you to hold your breath, which can lead to even greater levels of anxiety (Puetz, 2005). Moderate-to-severe anxiety on the part of either nurse or client hinders the development of the therapeutic relationship. To accomplish goals and attain mutuality, greater levels of anxiety must be reduced. Once the presence of anxiety has been identified, the nurse needs to take appropriate action. Strategies to reduce anxiety are listed in Box 6-2.

Severe anxiety requires medical and psychiatric intervention to alleviate the stress. A prolonged panic state is incompatible with life. It is such an extreme level of anxiety that, without immediate medical and psychiatric assistance, suicide or homicide may ensue. Some of these interpersonal strategies used to reduce moderate anxiety also are used during severe anxiety and panic attacks as part of a team approach to client care.

Choosing from various strategies to reduce client anxiety can be difficult. Not all methods are appropriate or work equally well with all clients. If a nurse attempting to build trust pushes a client too fast into revealing what he is not yet ready to discuss, this can increase anxiety. You need to accurately identify your client’s level of anxiety. You should also identify and reduce your own anxiety. Anxiety can cloud your perceptions and interfere with relationships.

Stereotyping and Bias: Stereotyping is the process of attributing characteristics to a group of people as though all persons in the identified group possessed them. People may be stereotyped according to ethnic origin, culture, religion, social class, occupation, age, and other factors. Even health issues can be the stimulus for stereotyping individuals. For example, alcoholism, mental illness, and sexually transmitted diseases are fertile grounds for the development of stereotypes. Stereotypes have been shown to be consistent across cultures and somewhat across generations, although the value placed on a stereotype changes.

Stereotypes are learned during childhood and reinforced by life experiences. They may carry positive or negative connotations. For example, Harding, North, and Perkins (2008) suggest that our culture has stereotyped an image of men as less feeling than women. We all have personal biases, usually based on unconscious past learning. As nurses, we may act on these unknowingly. Stereotypes negate empathy and erode the nurse-client relationship. As nurses, we must work to develop insight into our own expectations and prejudgments about people. Telenurses in Hoglund and Holmstrom’s (2008) study revealed distrust in fathers’ competence to provide care for ill children, an example of stereotyping by nurses. Stewart and Payne’s (2008) study showed that mentally making an intentional resolution to avoid a stereotype enables one to change.

Stereotypes are never completely accurate. No attribute applies to every member of a group. All of us like to think that our way is the correct way, and that everyone else thinks about life experiences just as we do. The reality is that there are many roads in life, and one road is not necessarily any better than another.

Emotions play a role in the value we place on negative stereotypes. Stereotypes based on strong emotions are called prejudices. Highly emotionally charged stereotypes are less amenable to change. In the extreme, this can result in discrimination. Discrimination as a legal statute refers to actions in which a person is denied a legitimate opportunity offered to others because of prejudice. In the United States, federal laws prohibit workplace discrimination based on age, creed, gender, sexual preference, disability, race, religion, or genetics.

Everyone has biases. If nurses bring their biases with them to the clinical situation, they will distort their perception, prevent client change, and disrupt the provider-client relationship. Nurses need to make it a goal to reduce bias. We do this by recognizing a client as a unique individual, both different from and similar to self. Acceptance of the other person needs to be total. This unconditional acceptance, as described by Carl Rogers (1961), is an essential element in the helping relationship. It does not imply agreement or approval; acceptance occurs without judgment. Mr. Fred Rogers, the children’s television show host, ended his programs by telling his audience, “I like you just the way you are.” How wonderful if we, as nurses, could convey this type of acceptance to our clients through our words and actions. Exercise 6-6 examines ways of reducing clinical bias.

Overinvolvement as a Barrier: Objectivity is important if you are to provide competent, professional care. This may be more likely to occur in a long-term relationship. Sharing too much information about yourself, your job problems, or about your other clients can become a barrier if your client becomes unclear about his role in your relationship. Many of us enjoy warm relationships with our clients, but if we are to remain effective, we need to be alert to the disadvantages of overinvolvement.

Violation of Personal Space: Personal space is an invisible boundary around an individual. The emotional personal space boundary provides a sense of comfort and protection. It is defined by past experiences, current circumstances, and our culture.

Proxemics is the study of an individual’s use of space. Optimal territorial space needed by most individuals living in Western culture: 86 to 108 square feet of personal space. Other research has found that 60 square feet is the minimum needed for each client in multiple-occupancy rooms, and 80 square feet is the minimum for private rooms in hospitals and institutions. Critical care units offer even less square footage.

Among the many factors that affect the individual’s need for personal distance are cultural dictates. In some cultures, people approach each other closely, whereas in others, more personal space is required. In most cultures, men need more space than women do. People generally need less space in the morning. The elderly need more control over their space, whereas small children generally like to touch and be touched by others. Although the elderly appreciate human touch, they generally do not like it to be applied indiscriminately. Situational anxiety causes a need for more space. Persons with low self-esteem prefer more space, as well as some control over who enters their space and in what manner. Usually people will tolerate a person standing close to them at their side more readily than directly in front of them. Direct eye contact causes a need for more space. Placing oneself at the same level (e.g., sitting while the client is sitting, or standing at eye level when the client is standing) allows the nurse more access to the client’s personal space because such a stance is perceived as less threatening.

Hospitals are not home. Many nursing care procedures are a direct intrusion into your client’s personal space. Commonly, procedures that require tubes (e.g., nasal gastric intubation, administration of oxygen, catheterization, and intravenous initiation) restrict the mobility of the client and the client’s sense of control over personal territory. When more than one health professional is involved, the impact of the intrusion on the client may be even stronger. In many instances, personal space requirements are an integral part of a person’s self-image. When clients lose control over personal space, they may experience a loss of identity and self-esteem. It’s recommended you maintain a social physical body distance of 4 feet when not actually giving care. Consider the issue of respect for personal space in the clinical examples presented in Box 6-3.

When institutionalized clients are able to incorporate parts of their rooms into their personal space, it increases their self-esteem and helps them to maintain a sense of identity. This feeling of security is evidenced when a client asks, “Close my door, please.” Freedom from worry about personal space allows the client to trust the nurse and fosters a therapeutic relationship. When invasions of personal space are necessary while performing a procedure, you can minimize impact by explaining why a procedure is needed. Conversation with clients at such times reinforces their feelings that they are human beings worthy of respect and not just objects being worked on. Advocating for the client’s personal space needs is an aspect of the nursing role. This is done by communicating your clients preferences to the members of the health team and including them in their care plan.

Home is not quite home when the home health nurse, infusion nurse, or other aides invade the client’s personal space. Some modification of “take-charge” behavior is required when giving care in a client’s home.

Cultural Barriers: Cross-cultural communication is discussed extensively in Chapter 11. Every interaction encounters a basic challenge of communicating between the culture of a client and the medical culture of the health professional (Teal & Street, 2009). Cultural background and level of health literacy may have a powerful influence on communication practices. For example, Gordon and associates (2006) found lower levels of participation in cancer communication by ethnic minority clients. It is important to identify any cultural issues that will influence how your client or their family responds to your type of health communication. In some cultures, the sick role is no longer valid after symptoms disappear, so when your client’s diabetes is under control, he and his family may no longer see the need for special diet or medication (Chang & Kelly, 2007). As we move into a more multicultural society, all health care providers need to work to become culturally competent communicators.

Cultural competence requires us to become aware of the arbitrary nature of our own cultural beliefs. Culturally competent communication is characterized by a willingness to try to understand and respond to your client’s beliefs. Knowledge of the client’s cultural preferences helps you avoid stereotyping and allows you to adapt your communication (Ngo-Metzger, August, Srinivasan, Liao, & Meyskens, 2008; Teal & Street, 2008).

Gender Differences: Gender is defined as the culture’s attributions of masculine or feminine. Recently, more attention has been given to gender role, communication barriers, and health inequalities. In Hoglund and Holmstrom’s (2008) study, phone calls by male clients to female telenurses revealed expressions of disrespect related to the nurse’s gender, as well as her professional advice. Earlier studies seemed to show little communication or outcome difference relevant to the gender of the care provider. But Harding and coauthors’ (2008) more recent study indicated that male nurses’ touching of clients is problematic. This is because although our culture equates female touch with caring, being touched by a male individual is perceived as sexual. Women traditionally were considered to be better communicators, but some studies found no differences. Although results are mixed, it appears that gender need not be a factor in developing therapeutic communication with clients.