Copy of NCA 2- Finals 1.docx

**THERAPEUTIC NURSE CLIENT RELATIONSHIP** \- A mutual learning experience and a corrective emotional experience for the patient \- The nurse uses personal attributes and clinical techniques to bring about insight and behavioral change **Components of a Therapeutic Relationship** **TRUST** \- Nu...

**THERAPEUTIC NURSE CLIENT RELATIONSHIP** \- A mutual learning experience and a corrective emotional experience for the patient \- The nurse uses personal attributes and clinical techniques to bring about insight and behavioral change **Components of a Therapeutic Relationship** **TRUST** \- Nurse is consistent in his or her words and action- There is congruence \- Can be relied on to do what he or she says (keeping Promises) \- Demonstrated through nursing interventions that convey a sense of warmth and caring **GENUINE INTEREST** \- Nurses response is sincere, that the nurse is not thinking and feeling one thing and saying something different \- The nurse should be honest, sincere and displays congruent behavior **SELF-DISCLOSURE** \- The nurse's willingness to share her own points of view in a Therapeutic manner can be an indication of genuineness \- This encourages the patient to become more open to the nurse in return. **EMPATHY** \- Empathy: the ability to enter into -the life of anoher person, to accurately perceive his or her current feelings and their meanings, and to communicate this understanding to the patient \- The nurse puts aside personal views and values to enter into another\'s world without prejudice. \- Verbal and nonverbal behaviors that Convey high levels of empathy to the patient ➔ Consistent eye contact and response to the patient\'s nonverbal cues ➔ Conveyance of interest, concern, and warmth by the nurse's own facial expressions ➔ A tone of voice consistent with facial expression and verbal response \- Nurse\'s cultural sensitivity \- Not to be confused with sympathy (pity) **ACCEPTANCE/POSITIVE REGARD** \- Unconditional nonjudgmental attitude \- Appreciation of the client as a unique, Worthwhile human being \- Acceptance of the person as worthy - but not accepting inappropriate behaviors - setting boundaries - provides the client with a clear understanding of what is and is not acceptable behavior and what the consequences of their actions will be. \- Shown when the nurse does not become upset or respond negatively to the client's outburst, anger, or acting out. \- Considering client's ideas and preferences when planning care - active participant of care **Pre - Orientation Phase** **Therapeutic Use of Self** \- The nurse uses aspects of his or her personality, experiences, values, feelings and intelligence, needs, coping skills, and perceptions to establish relationships with clients \- Must have "self-awareness" \- Gathering data about the patient: read the background material about the client, medications taken \- Planning for the first interaction: arranges for a quiet, private, comfortable setting **ORIENTATION PHASE** **Task**: to establish a climate of trust. understanding. acceptance and open communication and formulate a contract with the patient **Build Trust** \- The nurse is honest about his or her intentions is consistent, and keeps promises \- Warmth, interest and concern are conveyed with words and congruent body language \- The nurse shares appropriate information about himself or herself (name, reason for being on the unit) **Formulating a contract** \- Begins with the introduction of the Nurse and the client, exchange of Names and explanation of roles \- The contract should state: 1\. Time, place, length of sessions when the sessions will terminate 2\. Who will be involved in the treatment plar (family members, health team members) 3\. Client responsibilities (arrive on time, end on Time, participate in activities) **Confidentiality** - **Providing Structure** \- Unit activities \- Limit setting: the nurse accepts the client as a human being while decreasing self-defeating behaviors 1\. Take temporary control if patient loses control of their thoughts, feelings or behavior 2\. Pointing out behaviors and their negative Effects 3\. Kind but firm strategy \- For withdrawn and nonparticipating clients: spending time with them, even in silence \- explore patients perceptions, thoughts, feelings, actions \- Identify pertinent patient problems \- Define mutual specific goals with the patient **TEACH** T- Trust E- Environment A- Assess C- Contract H- Help communicating **WORKING PHASE** \* When the strategies of the Orientation stage are successful and patients are ready to work toward behavioral change \* Problem Identification \- In-depth data collection \- Direct the data collection and focus on manageable and Changeable issues \- Awareness of the problem - ANALYSIS \- The nurse guides the patient to examine feelings and responses and to develop better coping skills and more positive self-image \- Testing-out step involves trying out the new behavior or solution in a safe environment - Role-playing \- Evaluation step assess the success of the New behaviors or solutions to problems **Reality testing and Cognitive restructuring** \* Presenting a point of view so the patient can consider another option \* \"I know the voices seem real to you, but I don\'t hear any.\" \- Goal: help the patient cope with negative thoughts and beliefs and see other viewpoints that will help them come more realistic conclusions. **Testing behaviors** \- Forgetting scheduled sessions or being late \- Expressing anger \- Transference and countertransference become important issues **PROVIDE** \- Promote positive self-concept \- Realistic goal setting \- Organize support system \- Verbalize feelings \- Implement action plan \- Develop positive coping behaviors \- Evaluate results of plan of action **TERMINATION PHASE** \* Begins the first day of the Relationship - when the nurse Explains that the relationship is time limited \* Actual problems are resolved and ends when the relationship is ended \* Usually stressful for the clients **AVOIDING BEHAVIORS THAT DIMINISH THE THERAPEUTIC RELATIONSHIP** \* **Inappropriate Boundaries** \- The nurse must act warmly but must not try
to be friends with the patient \- Giving one\'s phone number and address would be a breach of ethical conduct \* **FEELINGS OF SYMPATHY AND ENCOURAGING CLIENT DEPENDENCY** \- When the nurse sympathizes the patient, she/he can easily be manipulated **COMMUNICATION** \* Exchange of information \* Messages are Simultaneously received on two levels:
1. Verbally - use of words
2. Nonverbally - actions or behaviors that accompany words **Verbal** \* Associated with spoken words **Nonverbal (represents a more accurate message than does verbal content)** \* Accent \* Bodily contact \* Direction of gaze \* Emotive tone in speech \* Facial and gestural movements \* Physical appearance \* Posture **THERAPEUTIC COMMUNICATION** \- Interpersonal interaction between the nurse and the client during which the nurse focuses on the client\'s specific needs to promote an effective exchange of information. **Purposes** \* Establishing a therapeutic nurse-client relationship \* Facilitate expression of emotions \* Identify client\'s concerns and problem. \* Assess client\'s perception of the problem. \* Recognize client\'s needs. \* Implement Interventios \* Guide client towards a satisfying and socially acceptable solution **Attentive Listening** \* Listening actively, using all the senses \* It involves paying attention to the total message, both verbal and non verbal, and noting whether these communications are congruent. **Physical Attending: The manner of being present** **5 specific ways to convey physical attending: SOLER** \* Face the other person SQUARELY \* Adopt an OPEN posture \* LEAN toward the person \* Maintain good EYE contact \* Try to be relatively RELAXED \* **Misconception**: must always be ready with questions \- Superficiality - conversation is vague \- Nurse does not understand - may work from assumptions \* **Active Observation** \- watching the client\'s nonverbal actions as he or she communicates \- First step in the therapeutic interaction \* **Using Concrete messages** \- Words are explicit/clear - Interpretation is not needed \- Concrete questions - direct, clear, and easy to understand \* **Abstract messages** \- Contain figures of speech that are difficult to interpret **Abstract** (unclear) : \"Your clinical performance has to improve\" **Concrete** (clear): \"To administer medications tomorrow, you'll have to be able to calculate dosages correctly by the end of today's class **Therapeutic Communication** \- the nurse focuses on the client\'s specific needs to promote an effective exchange of information  **Therapeutic Communication Techniques** **1. Using silence** \- Absence of verbal communication, which provides time for the client to put thoughts or feelings into words, regain composure and continue talking. \- not a passive technique 2\. **Accepting** \- Indicating that the nurse acknowledges that she has understood and heard what you\'re the client has said. Ex. \"Yes\" or \"I follow what you said\" Nodding.. Then saying \"I hear what they\'re saying.\' 3\. **Giving Recognition** \- Acknowledging, indicating awareness of change, or noting efforts the client has made all show that the nurse recognizes the client as a person. Ex. "I noticed you combed your hair." 4\. **Offering self** \- Making oneself available \- To offer his /her presence,interest and desire to understand Ex. \"I\'II sit with you awhile.\" "Let\'s walk to the cafeteria together.\" 5\. **Using Broad Openings** \- Allowing the patient to. take the Initiative in introducing a topic Ex. \"What would you like to talk about?\" \"Tell me what\'s bothering you.\" \"Tell me where you\'d like to begin?\" **6. Using General Leads** \- This indicates that the nurse is listening and following what the client is saying and letting the client know that he or she is on the right track and should continue Ex. \"Go on." "Hmmm.. I am listening\" \"Tell me about it\" \"Please go on.\" 7\. **Placing the event in time or sequence** \- Putting events in proper sequence helps both the nurse and the client to see them in perspective - client may gain insight into cause and effect behavior and consequences Ex. \"What seemed to lead up to\...?\" \"Were you frightened before or after the movie?" 8\. **Making Observations** \- Verbalizing what the nurse perceives. Ex. \"You appear tense\" \"I notice you are biting your lips. 9\. **Encouraging Description of Perceptions** \- Asking the client to verbalize what he or she perceives - to relieve the tension he/she is feeling thus he/she is likely to. take action on ideas that are harmful or frightening. Ex. \"What do you think is happening to you right now..?\" \"What are these voices telling you to do?\" 10\. **Restating** \- Repeating the main idea expressed- this lets the client know that he/she communicated the idea effectively and to let him/her know that he/she is heard Ex. Client: \"I can\'t sleep. I stay awake all night.\" Nurse: \"You have difficulty sleeping\" Client: \"I\'m down.\" Nurse: \"You feel depressed?\" 11\. **Reflecting**\* \- Directing client\'s actions, thoughts and feelings back to the client - encourages the client to recognize and accept his or her own feelings Ex. Patient: \"Do you think I should tell the doctor?\" Nurse: \"Do you think you should tell the doctor?\" 12\. **Focusing** \- Concentrating on a single paint - prevents a multitude of factors or problems from overwhelming the client. Ex. \"This point seems worth looking at more closely.\" \"You said something earlier that I want you to go back to." 13\. **Exploring** \- Delving further into a subject or idea - to understand better the problem Ex. \"Would you describe that more fully.\" \"These dreams you mentioned, what are they like?\" 14\. **Giving Information** \- Making available what the client needs. Ex. \"My name is\...I am a student nurse..\"\"My purpose in being here is\..." 15\. **Seeking Clarification** \- Asking patients to elaborate, or give examples of ideas or feelings to seek clarification of what is unclear. \- restating, reflecting, exploring Ex. \"I am not familiar with your work, can you describe it further for me\" \"When you say your brother is crazy, does the word crazy mean \"kind of wild?\" \"Tell me if we both understand that word in the same way.\" 16\. **Presenting Reality** \- Offering for consideration that which is real.- to indicate an alternative line of thought for the client and not belittling his her experience. - do not argue Ex. \"I know you hear voices, but I do not hear them.\" \"This is a hospital, not a hotel.\" 17\. **Voicing Doubt** \- Expressing uncertainty about the reality of the client\'s perception - to encourage the client to reconsider or reevaluate what has happened. Ex. \"I find it hard to believe.. " 18\. **Seeking Consensual Validation** \- Searching for consensual understanding. Ex. \"Tell me whether my understanding of it agrees with yours.\" 19\. **Verbalizing the Implied\*** \- An attempt to detect the true meaning of verbal messages Ex. Client: \'I won\'t be bothering you anymore soon.\" Nurse: \"Are you thinking of killing yourself?\" 20\. **Encouraging decisions** \- Asking the patient to make a choice among options Ex. \"Given all these choices, what would you prefer to do?\" 21\. **Attempting to Translate Into Feelings** \- Seeking to verbalize client\'s feelings that helshe expresses indirectly. Ex. Client: \"I\'m dead.\" Nurse: \"Are you suggesting that you feel lifeless.\" 22\. **Suggesting Collaboration** \- Offering to share, to strive, to work with the client for his /her benefit - the nurse offers to do things with, rather than for the client. Ex. "Let\'s talk and see if we can work together to understand this.\" \"Perhaps we can discuss this and see what offended you.\" 23\. **Summarizing** \- Organizing and summing up what has gone before. - ta bring out the important points of the discussion, to provide sense of closure Ex. \"Let\'s see, so far you have said.." \"During this meeting, we discussed what you will do when you feel the urge to hurt yourself again and this includes." **NON THERAPEUTIC COMMUNICATION** \- may hinder nurse client relationship 1\. **Overloading** \- talking rapidly, changing subjects too often, and asking for more information than can be absorbed at one time. \- \"What\'s your name? I see you like sports. Where do you live?\" 2\. **Value Judgments** \- giving one\'s own opinion, evaluating, moralizing or implying one\'s values by using words such as \"nice\", \"bad\", \"right\",
\"wrong\", \"should\" and \"ought\'\'.
\"You shouldn\'t do that, its wrong\". 3\. **Incongruence** \- sending verbal and non-verbal messages that contradict one another. \- The nurse tells the patient \"I\'d like to spend time with you\" and then walks away. 4\. **Underloading** \- remaining silent and unresponsive, not picking up cues, and failing to give feedback. \- The patient asks the nurse, the nurse simply walks away. 5\. **False reassurance** \- Using cliché to reassure clients. \- \"It\'s going to be alright\". 6\. **Focusing on self** \- responding in a way that focuses attention on the nurse instead of the client. \- \"This sunshine is good for my roses. I have beautiful rose garden\" 7\. **Changing the subject** \- introducing new topic inappropriately, a pattern that may indicate anxiety. \- The client is crying, when the nurse asks \"How many children do you have?\" 8\. **Giving advice** \- telling the client what to do, giving opinions or making decisions for the client, implies the client cannot handle his or her own life decisions and that the nurse is accepting responsibility. \- \"If I were you\... Or it would be better if you do it this way.. 9\. **Internal validation** \- making an assumption about the meaning of someone else\'s behavior that is not validated by the other person (jumping into conclusion). \- The nurse sees a suicidal client smiling and tells another nurse the patient is in good mood. 10\. **Rejecting** \- Refusing to discuss certain topics with the client. These responses often make clients feel that the nurse is rejecting not only their communication but also the client themselves. \- \" I don\'t want to discuss that. Let\'s talk about.." "Let\'s discuss other areas of interest to you rather than the two problems you keep mentioning.\" \" I can\'t talk now. I\'m on my way for a coffee break.\" 11\. **Defending** \- attempting to protect someone or something from verbal attack. (may imply that the client has no right to express opinions, impressions and feelings.) \- \"This hospital has a fine reputation.\"\"I\'m sure your doctor has your best interest in mind." 12\. **Interpreting** \- telling the client the meaning of his or her experience. (The client\'s thoughts and feelings are his or her own, not to be interpreted by the nurse for hidden meaning.) \- \"Whât you really mean\...\" \"Unconsciously you\'re saying\...\" 13\. **Requesting an explanation** \- asking the client to provide reasons for thoughts, feelings, behaviors, events. \- \"Why do you think that?\" \"Why do you feel that way?\" ***Other ineffective behaviors and responses:*** \* Literal responses - \"If you feel empty then you should eat more\". \* Looking too busy. \* Appearing uncomfortable in silence. \* Being opinionated. \* Avoiding sensitive topics \* Arguing and telling the client is wrong \* Making false promises - \"I\'lI make sure to call you when you get home\" \* Making sarcastic remarks \* Laughing nervously \* Showing disapproval - \"You should not do those things.\'