Nursing Self-Awareness and Therapeutic Use

Course Information

• Course title: Care of Clients with Maladaptive Patterns of Acute and Chronic Behaviour
• Course code: NCM 117
• Session: 1, First week
• Duration: 4 hours
• Intended audience: BSN III students

Learning Objectives

• Introduction to Psychiatric Nursing
• Evolution of mental-health-psychiatric nursing practice
• The Mental Health Nurse: Her Role and essential qualities
• Interdisciplinary Mental Health Team
• Mental Health- Illness Continuum

Introduction to Psychiatric Nursing

• Psychiatric Nursing was recognized in the late 1800s, but required in nursing education programs only from 1950 onward.
• Influenced by Hildegard Peplau and June Mellow's work on nurse-client relationships, anxiety, nurse therapy, and interpersonal nursing theory.
• Historically, mental illness was viewed as demonic possession, sin, or weakness, often punished accordingly.
• Today, mental illness is considered a medical problem with symptoms affecting personal growth, characteristics, relationships, and coping skills.

Evolution of Mental-Health-Psychiatric Nursing Practice

• (Images/pictures to be inserted) - details omitted

Mental Disorders: Ancient Times

• Ancient people believed illness to be displeasure from the Gods, punishment for sins or demonic acts.
• Punishments could include ostracism, burning at the stake.
• Aristotle (382-322 BC) believed imbalances of blood, water, yellow, and black bile controlled emotions, contributing to illness.
• Treatment methods included starving, bloodletting, and purging in the 9th century.

Early Christian Times (1-1000 AD)

• Strong superstitions and primitive beliefs that those with mental illness were possessed by evil spirits.
• Treatment involved exorcism, and even brutal measures like incarceration in dungeons, flogging, and starvation if exorcisms failed.

Renaissance (1300-1600) Period in England

• Mental illness was considered a crime.
• People with mental illness were often incarcerated, chained, starved, and treated as less than human.
• Notable example of incarceration: St. Mary of Bethlehem (1547).

1790s: Period of Enlightenment & Creation of Mental Institutions

• Philippe Pinel in France and William Tuke in England advocated for asylums as safe havens. Early treatment involved just beating, whipping and starvation.
• Dorothea Dix (1802-1887) in the United States advocated for reform in treatment of mental illness, promoting better conditions for patients, after visiting a similar institution in England.

Development of Psychopharmacology

• 1950s witnessed the development of psychopharmacology.
• This helped to reduce psychotic thinking and agitation.

1963 Enactment of Community Mental Health Centers Construction Act

• This marked a shift from institutional care to community-based services.
• Services included emergency care, screening, education, partial hospitalization, and outpatient services.

Mental Illness in the 21st Century

• Healthy People 2020 objectives aimed to increase diagnosis, treatment, and support for those with mental illness.
• Goals were to reduce rates of suicide and homelessness and increase employment opportunities.

Psychiatric Nursing Practice Overview

• Hildegard Peplau (1952) and Interpersonal Techniques: The Crux of Psychiatric Nursing
• Peplau described the phases and tasks of the therapeutic nurse-client relationship, particularly focusing on anxiety.
• June Mellow (1968) emphasized focusing on client's psychosocial needs with daily activities.

Summary of Specific Areas of Practice

• Box 1.2, Box 1.3 in Videbeck (Page reference omitted).

Self-Awareness and Therapeutic Use of Self

• Self-awareness is a process of understanding one's values, beliefs, and attitudes.
• Values are abstract standards defining right and wrong conduct, a key element of self-awareness.
• Value Clarification is a process of building self-awareness, identifying beliefs, and considering different perspectives.
• Three-step process of value clarification: Choosing, Prizing, and Acting..
• Beliefs are ideas considered true, but can be irrational without evidence.
• Attitudes are the general feelings around knowledge.

Cultural Awareness

• The purpose is to understand how values, beliefs and attitudes might impact client care

Self-Awareness in Nursing Practice

• Keeping a journal on one's experiences is a method of self-awareness practice.
• Talking about experiences with trusted sources or in clinical supervision is part of self-awareness.
• Learning to take the client's perspective is another aspect of self-awareness and effective practice.
• Avoiding judgments on one's own values, beliefs, and attitudes is also key to be effective.

Therapeutic Use of Self

• Understanding one's own attitudes, experiences, values, and perceptions helps form therapeutic relationships.
• The Johari window is a technique that can help explore one's self-awareness.
• The potential for preconceptions to hinder therapeutic relationships were also addressed
• Countertransference is when the nurse's unconscious needs and conflicts influence the relationship.

Pattern of Knowing: Preconception

• Preconceptions, including personal biases and beliefs, can hinder therapeutic relationships.
• An example: a client refusing an assignment to a male nurse, due to preconceived stereotypes.

Casper's Pattern of Nursing Knowledge (Table 5.1 pg 85)

• Four patterns in nursing are outlined:
  • Empirical Knowledge (science of nursing)
  • Ethical Knowledge (moral knowledge of nursing)
  • Personal Knowledge (life experiences)
  • Aesthetic Knowledge (Art of Nursing)

Johari Window (pg. 85)

• Four quadrants showcasing self-awareness:
  • Open/Public quadrant
  • Blind/Unaware quadrant
  • Hidden/Private quadrant
  • Unknown quadrant

Types of Relationships

• Social relationship: initiated for tasks, such as weather and news.
• Intimate relationship: involving emotional connection, has no place in a nurse-client relationship.

Therapeutic Relationship

• Focuses on client's needs, experiences, and feelings.
• Nurse uses communication skills, personal strengths, and understanding of human behavior to interact with the client.
• Client preferences and likes are irrelevant.

Phases of Establishing Therapeutic Relationships

• Orientation phase: introduction, gathering information, assessing preconceptions

During Orientation Phase

• Building trust and understanding with the client and conveying sympathy/empathy.
• Listening attentively to the client's history, perceptions, and misconceptions.

Nurse-Client Contracts

• Agreements about time, place, duration, and termination of sessions.
• Defining roles and responsibilities of both nurse and client.
• Agreement on treatment plan and if family/support team should be involved.
• Maintaining confidentiality.

Working Phase

• Identifying client issues and concerns
• Guiding client to examine feelings and responses.
• Developing coping skills
• Improving self-image
• Avoiding value judgments, focusing on exploring and elaborating on patient concerns; refraining from offering advise.

Specific Tasks of the Working Phase

• Maintaining relationships
• Gathering data (client history & current state)
• Exploring client perceptions of reality
• Developing coping mechanisms
• Promoting positive self-concept
• Encouraging verbalizations of feelings
• Facilitating behavior change
• Using therapeutic skills

Working Through Resistance

• Evaluating progress and readjusting goals as needed
• Providing opportunities to apply learned coping skills
• Fostering independence

Transference and Countertransference

• Transference: client unconsciously transferring feelings from significant others to the nurse
• Countertransference: nurse projecting his/her own unconscious needs and conflicts to clients

Termination or Resolution Phase

• Client issues are resolved
• Ending the relationship appropriately.
• Acknowledging and valuing the time spent in therapy

Psychiatric Mental Health Nurses

• The second-largest group of behavioral health professionals.
• They have autonomy but also work within a larger healthcare team.

Mental Health Interdisciplinary Team

• Professionals in the team include, but are not limited to, Pharmacist, Psychiatrist, Psychologist, Psychiatric Nurse, Psychiatric Social Worker, Occupational Therapist, Recreation Therapist, and Vocational Rehabilitation Specialist

Core Skills of the Team

• Interpersonal skills (tolerance, patience, acceptance, empathy, genuineness),
• Understanding mental disorders, behavior, and symptoms are also important.
• Communication skills and team cooperation
• Risk assessment and management skills
• Personal qualities like consistency, assertiveness, and problem-solving ability

Student Concerns and Questions to consider as a student nurse

• The purpose of the session is to prepare students to start a psychiatric clinical rotation and reflect on self-awareness.

• Common concerns:

• What if I say the wrong thing?

• What will I be doing?

• What if no one will talk to me?

• Am I prying when I ask personal questions?

• How will I handle bizarre or inappropriate behaviors?

• What happens if a client asks me for a date or displays inappropriate sexual behavior?

• Questions:

• Safety of the student, considerations of patient safety, professionalism and boundaries.

• Confidentiality consideration.

• Potential problems and concerns regarding client interaction and professionalism in mental health, including the importance of handling inappropriate behaviour.

Next steps

• Mental Health- Illness Continuum (Part 2 - to be covered in the next slide show)

Explore the essential concepts of self-awareness in nursing through this quiz. Questions cover the Johari Window, ethical knowing, and the historical perspectives of mental illness. Enhance your understanding of therapeutic relationships and the significance of self-reflection in nursing practice.