1. Therapeutic Relationships Vidbeck pg144-155

2. 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.

3. 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.

4. 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.

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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”

14. 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)

15. 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.

16. 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

17. Therapeutic Communication

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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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 ,table 6.1)

25. 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

26. 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?

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. Patient’s Response to Illness

37. 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.

38. 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.

39. 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.

40. 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

41. 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

42. 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.

43. 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

44. 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

45. 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

46. 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?”

47. 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

48. Assessment

49. 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.

50. 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

51. 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

52. 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

53. 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?

54. 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

55. 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

56. 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-

57. 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

58. 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

59. 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)

60. 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

61. 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

62. 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