Therapeutic RelationshipsVidbeck 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 SelfUse 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:

1) Orientation

2) Working

3) 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.

• 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

CommunicationCommunication

• 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

Communication (cont’d)Communication (cont’d)

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 AssessmentHelps 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 thinksThought 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 behaviorCont. 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