Chapter 2 Therapeutic Nurse-Patient Relationship Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Therapeutic Nurse-Patient Relationship Mutual learning experience Corrective emotional experience Based on the humanity of nurse and patient Includes mutual respect and acceptance of sociocultural differences Nurse uses personal attributes, clinical techniques Promotes insight, behavior change Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Long-Term Patient Goals Self-realization, self-acceptance, self-respect Clear sense of personal identity, integration Form intimate, interdependent, interpersonal relationships with capacity to give and receive love Improved functioning, able to satisfy needs and achieve realistic personal goals Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Elements Affecting Ability to Be Therapeutic Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc. 4

Elements Affecting Ability to Be Therapeutic Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc. 5

Elements Affecting Ability to Be Therapeutic Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc. 6

Qualities of a Competent Psychiatric Nurse Awareness of self Clarification of values Exploration of feelings Ability to serve as role model Altruism Sense of ethics and responsibility Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Achieving Therapeutic Goals Explore various aspects of patient’s life experiences Allow patient to express thoughts, feelings Observe and relate behaviors to thoughts Clarify areas of conflict, anxiety Identify and maximize patient’s ego strengths Encourage socialization, family relatedness Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Awareness of Self Who am I? How do I deal with anxiety, anger, sadness, and joy? Broad range of experiences Recognize health-illness continuum Listen to self Listen and learn from others May self-disclose/reveal aspects of self Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Johari Window Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc. 10

Johari Window Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc. 11

Awareness of Self Acknowledge differences, uniqueness Increase openness, authenticity Interact spontaneously and honestly Identify, discuss, analyze, and resolve problems constructively Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Clarification of Values What is important to me? Values from experiences with family, friends, culture, education, work, relaxation Framework for daily decisions, actions Examples: religious beliefs, family ties, sexual preferences, other ethnic groups, gender role beliefs Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Value Clarification Process Change may occur when certain contradictions perceived in person’s value system To eliminate distress that follows such a realization, person chooses and realigns values Uses new choices with new view of self Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Role Model Nurses have obligation to model adaptive and growth-producing behavior Effective nurses approach life with sense of growing, hopefulness, adapting Chaos, conflict, distress, or denial in nurse’s personal life will decrease effectiveness of care Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Altruism Concern for welfare of others Love for humanity and helping people Nurses need to balance altruism with their needs for satisfaction, compensation, recognition Can be self-destructive if overzealous Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Ethics and Responsibility Assume responsibility for behavior Know limitations, strengths Use resources, knowledge, expertise of others Responsible ethical choices, accountability Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Phases of Nurse-Patient Relationship Each phase builds on preceding one Characterized by specific tasks Preinteraction phase Introductory/orientation phase Working phase Termination phase Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Preinteraction Phase Initial task: self-exploration, self-analysis Challenges of psychiatric setting may cause stress and fear related to: Inadequacy related to inexperience Saying the wrong thing Unpredictable or aggressive behavior Questioning own mental health status Analyze strengths, limitations Gather data about patient Plan for first interaction Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Introductory/Orientation Phase Find out why patient sought help Explore patient’s feelings, identify problems Establish trust, understanding, acceptance, open communication Establish goal consensus, collaboration Formulate contract, explaining roles, confidentiality, responsibilities, expectations of patient and nurse Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Working Phase Nurse and patient explore stressors Promote development of insight by linking perceptions, thoughts, feelings, actions Translate insight into action/behavior change Master anxieties, increase self-responsibility, develop constructive coping mechanisms Standoff, impasse, or plateau may develop if patient resists moving forward Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Termination Phase Learning maximized because of higher levels of trust, intimacy Exchange feelings and memories to evaluate patient progress, goal attainment Establish reality of separation; explore feelings of rejection, loss, sadness, anger Make referrals if needed for continued care or treatment Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Communication Verbal communication Nonverbal communication: includes voice inflection, body movements, facial expression, gestures, posture, physical energy, eye contact, use of space, touch If patient has difficulty speaking English, use fewer words, more gestures, expressive facial behaviors, trained interpreter Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Use of Touch Use touch carefully in psychiatric setting Patients may be sensitive to issues of closeness Could be misinterpreted as an invasion Potential problem if patient interprets touch as sexual invitation to intimacy If procedures require physical contact, explain carefully before and during procedure Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Communication Process Perception: brain receives visual, auditory, or other stimuli for communication Evaluation: cognitive response to information and affective response to relationship aspect of message Transmission: feedback returned to sender after receiver evaluates it Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Components of Communication Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc. 26

Knowledge of Context Context: setting where communication takes place Knowledge of context necessary to understand full meaning of message Also includes psychosocial setting Relationships Past experiences with each other Experiences with similar situations Cultural values, norms Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Key Terms Congruent communication: sender communicating same message on verbal and nonverbal levels Incongruent communication: messages on verbal and nonverbal levels differ Causes dilemma, confusion, frustration for listener, who does not know to which level to respond Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Therapeutic Communication Techniques Listening is the foundation Use broad openings to encourage patient to communicate what is important to him/her Restate part of patient’s statement Clarify vague ideas, thoughts Reflect on/validate patient’s behavior, feelings Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Communication Techniques Use appropriate depth of feeling Use focusing to help patient expand on topic of importance Share perceptions by asking patient to verify nurse’s perception of patient’s thoughts Identify themes by noting underlying issues or problems Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Communication Techniques Use silence appropriately Use humor as a constructive coping behavior Consistent with social, cultural values To promote insight and decrease tension or anxiety Don’t use to mask feelings, increase social distance, allow avoidance, or ridicule others Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Communication Techniques Limit repetitive direct questions (especially “why” or yes/no questions) Inform: share simple facts or information Suggest: can be therapeutic or nontherapeutic Communicate understanding before giving suggestions or advice Communication must preserve self-respect of both individuals Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Motivational Interviewing Help people: Talk about their ambivalence toward change Use their own motivation, energy, and commitment to learn new skills and make needed changes in their lives Guided rather than directive approach Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc. 33

Principles of Motivational Interviewing Express empathy through reflective listening Understand patient’s motivations Identify discrepancies between patient’s goals or values and current behavior Avoid trying to make things right Support patient’s self-efficacy Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Responsive Dimensions of Therapeutic Relationship Convey genuineness or “real” caring Respect or unconditional positive regard Empathic understanding: perceive and convey understanding of patient’s current feelings and meanings Concreteness: use specific terminology rather than abstractions to avoid vagueness, generalizations, ambiguity Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Levels of Concreteness in Therapeutic Relationship Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc. 36

Action Dimensions Confrontation: discuss patient’s behavior with empathy and respect Immediacy: current nurse-patient interaction Nurse self-disclosure: only for therapeutic goal Emotional catharsis: encourage patient to talk about troublesome fears, feelings Role playing: dialogue to develop insight and practice more adaptive behaviors Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Levels of Confrontation in Therapeutic Relationship Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc. 38

Therapeutic Impasses Resistance: patient reluctant/avoids verbalizing or exploring troubling aspects of himself or herself Transference: unconscious patient response of feelings toward nurse originally associated with significant others Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Therapeutic Impasses Countertransference: nurse’s specific emotional response to qualities of patient Inappropriate to content and context of relationship Inappropriate intensity of emotion Intense love or caring Disgust or hostility Intense anxiety, often in response to resistance by patient Can be group phenomenon Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Therapeutic Impasses Boundary violations of nurse Behavior intrusive with patients or families Difficulty setting limits Relates to patient like friend or family Has sexual feelings toward patient Feels he/she is only one who understands patient Too involved with patient or family Feels other staff too critical of patient Believes other staff members are jealous of his/her relationship with patient Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Types of Boundary Violations Intimacy and sexual boundaries Role boundaries Time boundaries Place and space boundaries Money boundaries Gifts and services boundaries Clothing boundaries Language boundaries Postdischarge social boundaries Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Therapeutic Outcome Effectiveness of nurse-patient relationship related to: Knowledge base Clinical skills Capacity for introspection and self-evaluation Pattern of reciprocal emotions Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.

Emotional Response of Nurse May bring up painful feelings Emotionally draining if patient expresses prolonged, intense sadness, despair, or anger Working with suicidal patients can cause feelings of helplessness, intense anxiety Therapeutic use of self is challenging and stressful Use available guidance and support Mosby items and derived items © 2013, 2009 by Mosby, an imprint of Elsevier Inc.