Therapeutic Relationships Vidbeck pg144-155

Learning Outcomes Describe necessary components in the nurse-patient relationship. Explain the importance of values, beliefs, and attitudes in the development of the nurse-patient relationship. Describe the importance of self-awareness and therapeutic use of self in the nurse-patient relationship.

Learning Outcomes Describe the differences between social and therapeutic relationships. Describe and implement the phases of the nurse-patient relationship. Explain the negative behaviors that can diminish the nurse-patient relationship.

Therapeutic Relationships The ability to establish therapeutic relationships with patients is one of the most important skills a nurse can develop. Social Relation- (ex: family, friends) info unlimited, more emotionally invested. Can give advice. Therapeutic Relation- (ex: pt/nurse) Info exchange limited, less emotionally invested. Cannot give advice. Nurses carries the whole load.

Therapeutic nurse-patient relationship Purposeful and goal-directed Has defined boundaries Is structured to meet the patient’s needs In Social relationship its give and take, but in an Nurse-Patient relationship its all about the pt. Is safe, confidential, reliable, and consistent Applies Physically and Mentally

Therapeutic Relationships (cont’d) Components include: Trust Genuine interest Empathy (not sympathy) Sympathy implies a feeling of recognition of another's suffering Sympathy makes pt more dependant Empathy is often characterized as the ability to "put oneself into another's shoes". Acceptance of person, not necessarily his or her behavior Unconditional positive regard Self-awareness and therapeutic use of self

Self-Awareness and Therapeutic Use of Self Understanding how we present ourselves and how we are seen by others Self-awareness: process of understanding one’s own values, beliefs, thoughts, feelings, attitudes, motivations, strengths, and limitations and how one’s thoughts and behaviors affect others Self Disclosure- when your’e telling things to a pt that they don’t need to know. Info the pt doesn’t need to know unless its therapeutic Ex: Where you live

Therapeutic Use of Self Use yourself as a tool to help pt grow/heal Therapeutic use of self: the nurse uses aspects of his or her personality, experience, values, feelings, intelligence, needs, coping skills, and perceptions to establish relationships with clients that are beneficial to clients

Establishing the Therapeutic Relationship Therapeutic relationships are focused on the needs, experiences, feelings, and ideas of the patient, not the nurse The therapeutic relationship consists of three phases: Orientation Working Termination

Establishing the Therapeutic Relationship (cont’d) In the orientation phase: Information gathering, to use in interventions and to problem solve The nurse and patient meet Roles are established Purposes and parameters of future meetings are discussed Expectations are clarified Patient’s problems are identified Keep pt involved throughout

Establishing the Therapeutic Relationship (cont’d) The working phase involves: Problem identification The patient identifies the issues or concerns causing problems (Caution: pt may not see what their “real” problem is) Examination of the patient’s feelings and responses Exploitation: Development of better coping skills and a more positive self-image, behavior change, and independence

Establishing the Therapeutic Relationship (cont’d) In the working phase, the nurse must be acutely aware of 2 common elements can arise: Transference: when patients unconsciously transfer feelings they have for significant persons in their life onto the nurse Countertransference: when the nurse responds to the patient based on his or her own unconscious needs and conflicts

Establishing the Therapeutic Relationship (cont’d) The termination aka resolution phase: Begins when the patient’s problems are resolved Ends when the relationship is ended Deals with feelings of anger or abandonment that may occur Anxiety (from readiness to be released) can lead to anger or nervousness Remind then that their time there has been a benefit Happens when problems subside For closure, tell them “goodbye”

Behaviors That Diminish Therapeutic Relationships Inappropriate boundaries (relationship becomes social or intimate) Feelings of sympathy and encouraging dependency (Nurse should show empathy and not sympathy) Nonacceptance of the patient as a person because of his or her behaviors, leading to avoidance of the client Nurse self-awareness is the way to avoid such problems (Keep boundaries and set limits)

Therapeutic Roles of the Nurse in a Relationship Teacher Expressing their feeling Finding social support Coping skills Meds Caregiver Advocate Act on their behave and make sure that they’re not being taken advantage of Make sure they are safe Parent surrogate Not love/hug, but remind them of bathing, hygiene, wash hands, eat vegetables, etc.

Self-Awareness Issues Self-awareness on the nurse’s part is crucial to developing therapeutic relationships As a nurse, know your role. Keep treatment non-biased. Values clarification, journaling, group discussions, and reading will assist with this process Developing self-awareness is a continual, ongoing process; the nurse needs to plan for self-growth

Therapeutic Communication

Learning Outcomes Describe the goals of therapeutic communication. Identify therapeutic and nontherapeutic verbal communication skills. Discuss boundaries in therapeutic communication.

Communication The process people use to exchange information: Verbal Speech Context the set of facts or circumstances that surround a situation or event Nonverbal Eyes, Facial expression, Tone of voice Congruency The quality of agreeing; being suitable and appropriate Incongruency out of place, absurd behavior

Communication (cont’d) Interpersonal interactions between the nurse and the patient It focuses on the patient’s specific needs and is used to: Establish the therapeutic relationship Identify the patient’s most important concerns Assess the patient’s perceptions Facilitate the patient’s expression of emotions Teach the patient and family necessary self-care skills Recognize the patient’s needs Implement interventions designed to address the patient’s needs Guide the patient toward satisfactory and acceptable solutions

Essential Components of Therapeutic Communication Privacy and respect for boundaries – Therapeutic communication is most comfortable at 3 to 6 feet; should not be less than 18 inches Touching – Touch may be comforting and supportive – Touch also is an invasion of intimate and personal space (Telegraph when you’re about to touch the pt) – Nurse must evaluate whether the patient perceives touch as positive or threatening and unwanted; never assume that touching a patient is acceptable

Essential Components of Therapeutic Communication (cont’d) Active listening- means refraining from other internal mental activities and concentrating exclusively on what the patient says Active observation- means watching the speaker’s nonverbal actions as he or she communicates

Verbal Communication Skills Use concrete messages Use words that are clear and concise Concrete messages are specific and clear Concrete messages elicit more accurate responses

Verbal Communication Skills (cont’d) Therapeutic communication techniques facilitate interaction and enhance communication between patient and nurse Techniques that encourage the patient to discuss his or her feelings or concerns in more depth include: Exploring- delving further into the subject Focusing- concentrate ?’s on a certain point Restating- clarification, repeating Reflecting- good to help pt “open up” Ask broad open-ended ?’s, make observations (NOTE: Refer to p. 107-111,table 6.1)

Verbal Communication Skills (cont’d) Nontherapeutic communication includes: Advising- Don’t give advice Agreeing- Don’t agree w/ delusions or hallucinations- things that pt sees, hears, smells (but, don’t argue either) “I know you see that giant Penguin, but I don’t.” Reassuring- Don’t give them false reassurances. Can lead to pt no longer trusting you

Nonverbal Communication Skills Facial expression Body language Gestures, posture Vocal cues Tone of voice Eye contact Some pts will not make eye contact Can be a tale to their emotions Don’t look in eyes all the time, b/c they think u can see what they are thinking Silence They may be processing info Are they gathering their thoughts?

Understanding the Meaning of Communication Messages often contain more meaning than just the spoken words The nurse must try to discover all the meaning in the patient’s communication, not only the literal meaning of the words

Understanding Context Understanding the context of a situation gives the nurse more information and reduces the risk of assumptions To clarify context, the nurse must gather information from verbal and nonverbal sources and validate findings with the patient

Understanding Spirituality Spirituality is a patient’s belief about life, illness, death, and one’s relationship to the health, universe The nurse must first assess his or her own spiritual beliefs (self-awareness, remain unbiased) The nurse must remain objective and nonjudgmental The nurse must assess the patient’s spiritual needs

Cultural Considerations The nurse must be aware of cultural differences in: Speech patterns and habits Styles of speech and expression Eye contact Touch Concept of time Health and health care Be sensitive to their culture

Goals of a Therapeutic Communication Session Establishing rapport (get along) Identifying issues of concern Being empathetic, genuine, caring, and unconditionally accepting of the person Understanding the patient’s perception Exploring the patient’s thoughts and feelings Developing problem-solving skills Promoting the patient’s evaluation of solutions Make sure it is all pt oriented

Beginning Therapeutic Communication Introduce and establish a contract “I’m the nurse. I will… And I expect you to…” Find patient-centered goals Everyone is different. Depends on what the pt’s needs are. -Use directive or nondirective role appropriately, based on patient behaviors

Beginning Therapeutic Communication (cont’d) Phrase questions appropriately Ask for clarification Manage patient’s avoidance of the anxiety-producing topic Change subject for a minute Avoid asking why Guide the patient in problem-solving and empower the patient to change Help them realize they can solve problems Alert for inappropriate responses by nurse Ex: Judging, arguing

Community-Based Care Nurses are increasingly caring for patients in the family unit and in communities Nurses need increased self-awareness and knowledge about cultural differences Nurses need self-awareness and sensitivity to the beliefs, behaviors, and feelings of others Nurses must collaborate with the patient and family as well as other healthcare providers

Self-Awareness Issues Nonverbal communication is as important as verbal Ask colleagues for feedback “Am I getting the info that I need?” Examine your communication skills

Patient’s Response to Illness

Learning Outcomes Discuss individual characteristics and factors that influence a patient’s response to illness. Explain the nurse’s role working with patients of different cultural backgrounds. Describe cultural factors important in assessing and working with patients of different cultures.

Individual Factors Age, stage of growth and development Genetics and biologic factors Just because your mom is psycho, doesn’t mean you’re going to be… Physical health and health practices Response to drugs Not everyone reacts to meds the same Elderly: slower metabolism, med stays in their system longer.

Individual Factors (cont’d) Pts have different coping skills: Self-efficacy His/her perception of illness Hardiness- ability to survive, resist illness Resilience and resourcefulness- how u bounce back Spirituality- being punished Ask to self: how quick can pt bounce back? Or how do they respond to illness. How we respond has to do w/ how hardy and resilient we are.

Interpersonal Factors Sense of belonging If pt feels valued or that they fit in, they will do much better in recovery/treatment Social networks and social support Fitting in family, job, friends Family support

Cultural Factors Beliefs about causes of illness Factors in cultural assessment: Communication Physical space or distance Social organization Time orientation Environmental control Biologic variations Socioeconomic status and social class

Cultural Patterns and Differences Knowledge of expected cultural patterns provides a starting place for the nurse to begin to relate to persons from different ethnic backgrounds. May see a mix of cultures Look at the person/Indv.

Cultural Patterns and Differences (cont’d) No Q’s specifically about diff cultures; but understand that they exist. African Americans Usually family-oriented, but client makes own decisions Conversation animated Handshakes and direct eye contact convey interest and respect View mental illness as a spiritual imbalance or punishment for sin

Cultural Patterns and Differences (cont’d) Filipinos Greet others with smiles rather than handshakes Facial expressions animated Direct eye contact impolite, especially with authority figures Mental illness viewed as having religious and mystical causes

Cultural Patterns and Differences (cont’d) Mexican Americans Touching prevalent among family, but not necessarily welcome from strangers Direct eye contact with authority figures avoided Silence denotes disagreement Illness comes from imbalance between person and environment

Nurse’s Role in Working With Clients From Various Cultures Nurse must learn about the client’s cultural values, beliefs, and health practices Best source of information is the client: “How would you like to be cared for?” “What do you expect (or want) me to do for you?”

Self-Awareness Issues Maintain a genuine, caring attitude Ask how you can promote or assist with spiritual, religious, and health practices Recognize your own feelings and possible prejudices Remember that the patient’s response to illness is complex and unique

Assessment

Learning Outcomes Identify the factors that influence the assessing of a mental health patient. Describe how to conduct a interview with a patient on a mental health unit. Explain the components used to gather information in the psychosocial assessment of a mental health patient. Identify other sources of data used in patient assessment.

Purposes of Psychosocial Assessment To construct picture of patient’s current emotional state, mental capacity, and behavioral function To form basis for plan of care To establish clinical baseline to evaluate effectiveness of treatment and interventions

Factors Influencing Assessment More of a nursing observation on a psych floor. Patient’s participation/feedback Answers may show signs of impaired thinking Patient’s health status Pain may hamper response/feedback Patient’s previous experiences/misconceptions about health care Consider possible previous abuse or forced admission Patient’s ability to understand Patient may be unable to read or have language barrier Nurse’s attitude and approach Safety 1st, for pt and for yourself

How to Conduct the Interview Provide a comfortable, private, safe environment Obtain input from family and friends (with patient’s permission) Ask questions that are open-ended or closed-ended as needed (avoid “Yes or No” type Q’s) “How can we help?” Very important to obtain “accurate” input

Content of the Assessment History- very important General appearance and motor behavior (Slide 62) Observe: Grooming habits, style Mood and affect* (Next slide) Thought process and content* (Slide 55) Does he know the time and place? Is pt oriented or in touch w/ reality? Sensorium and intellectual processes Ability to problem solve Judgment and insight Self-concept Many clients don’t think they need to be there Roles and relationships Have they severed relationships? Physiologic and self-care concerns Are they misinterpreting pain or physical problems?

Mood and Affect Assessment Helps w/ diagnosis Mood- is pervasive and sustained quality of person’s emotional tone: described as euphoric, dysphoric, euthymic, or labile (rapidly changing) Affect- outward expression of emotion: described as blunted, flat, inappropriate/incongruent to verbal, appropriate, hyper-reactive, or restricted/constricted

Thought Processes and Content Thought process- how patient thinks Thought content- what patient actually says Common terms in assessing : Delusions- false fixed ideas. Ex: someone is out to get them (persecutory, paranoid, grandiose, somatic) Hallucinations- something heard (#1), smelled, or seen (#2) Ideas of reference- interpretation of external events having reference to one's self (thoughts directed towards him) Loose associations- jump from one subject to another (random thoughts/ideas) Tangential thinking- talking to them and their mind just wanders off Abstract thinking- understand the glass house thing

Thought Process and Content (cont’d) when talking to them, make sure to give them time to answer Thought blocking- stopping abruptly when thinking (for some reason pt can’t think right now) Thought broadcasting- others can hear your thoughts Thought insertion- others are putting thoughts in head, controlling them Thought withdrawal- others are taking thoughts from head Word salad- putting words together that have no meaning/ connection/ relation Concrete thinking- form logical thought Phobic- fearful of item/ situation/ environment Reality oriented-

Data Analysis After completing the assessment the nurse analyzes all the data to help in forming the patient’s plan of care Other data may be gathered from the following Psychosocial assessment Psychological tests Psychiatric diagnoses Mental status exam

Psychological Tests Psychological tests are another source of data to use in planning care Intelligence tests assess cognitive abilities and intellectual functioning Personality tests evaluate self-concept, impulse control, reality testing, and major defense mechanisms

Psychiatric Diagnoses Based on the DSM-IV-TR multiaxial system: Axis I: clinical disorders Axis II: personality disorders, mental retardation Axis III: general medical conditions Axis IV: psychosocial and environmental problems Axis V: global assessment of functioning (GAF)

Mental Status Exam Focuses on the patient’s cognitive abilities: Orientation to person, time, place, date, season, day of the week Ability to interpret proverbs Ability to perform math calculations Memorization and short-term recall Naming common objects in the environment Ability to follow multi-step commands Ability to write or copy a simple drawing

Self-Awareness Issues Judgments are not part of the assessment process Be open, clear, and direct when asking about personal or uncomfortable topics Examining one’s own beliefs and gaining self-awareness is a growth-producing experience The nurse must not allow personal beliefs to interfere with the nurse–patient relationship and the assessment process

Appearance/Motor behavior Cont. from slide 53 Neologism- invented words; a word coined by a psychotic or delirious patient that is meaningful only to the patient. Psychomotor retardation- overall slowed movements Waxy flexibility- maintain of posture even if uncomfortable or awkward Automatism- repeated purposeful behavior Tapping/clicking related to anxiety