NCM 117 Care Of Clients With Maladaptive Behavior PDF

NCM 117 CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR, ACUTE AND CHRONIC RLE / PROF. PARLAN, PROF. MOLINA...

NCM 117 CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR, ACUTE AND CHRONIC RLE / PROF. PARLAN, PROF. MOLINA Week 1 ______________________________________________________________________________________________________________ PRELIMS WEEK 1 - OUTLINE 2. Mental and substance use disorders are the leading cause of disability worldwide I. Introduction to Psychiatric Nursing About 23% of all years lost because of disability is A. 10 Mental Health Facts caused by mental and substance use disorders. B. 5 barriers to increasing mental health services availability Rugby and solvent have hallucinogenic effects. II. Mental Health and Mental Health Illness A. Elements of Mental Health 3. About 900, 000 people commit suicide every year, 86% of III. Therapeutic Relationships suicides occur in low- and middle-income countries A. Components of building appropriate therapeutic One of the many triggering factors are the culture relationships and low income. B. Values clarification process If you have low income, you cannot sustain basic C. Preconception needs such as education and food leading to D. Carper’s Pattern of Nursing Knowledge family problems. E. Types of relationships However, some less fortunate people strive harder F. Establishing therapeutic relationship to break the pattern of poverty. G. Peplau’s theory of interpersonal relationship H. Confidentiality 4. War and disasters have a large impact on mental health and I. Roles of the nurse in a therapeutic relationship psychosocial well-being. J. Self-awareness issues Can affect on a community level. K. points to consider when building therapeutic relationships No basic needs can cause impact on mental IV. Communication Techniques health A. Therapeutic communication techniques B. Non-therapeutic communication techniques 5. Mental disorders are important risk factors for other DAY 1 diseases, as well as unintentional and intentional injury INTRODUCTION TO PSYCHIATRIC NURSING Anorexia and bulimia are eating disorders. - Think about people in terms of their overall functioning and ○ Bulimia – binge then, purge; because of adaptation rather than by the symptoms of their specific purging (initiating vomiting using their illness index finger onto their throat), there is - “Your illness does not define you” See the patient holistically. scarring of the throat (unintentional - Self - awareness is needed to know if you have hidden injury). emotions that could be triggered before being exposed in the ○ Anorexia - intense fear of gaining weight facility. and distorted body image. - Sometimes it is better to open up on a stranger because they 6. Stigma and discrimination against patients and families have no biases. prevent people from seeking mental health care. Differently able - another term for patients with psychiatric disorders. Thinking of your problem without looking for a solution is a waste of time. Learn how to separate OBJECTIVES your personal problems from work. Define for you the responsibilities as a professional health ○ Disassociation - disconnecting from care provider. yourself and turning into a character. I wish for your curiosity about human nature. (Eg. from Beyonce mom to a performer Openness to new ways of thinking. Beyonce). Delight in the process of learning. 7. Human rights violations of people with mental and LEARNING OBJECTIVES psychological disabilities are routinely reported in most 1. To gain knowledge on the subject matter countries. 2. To understand the concept of psychiatric nursing Advantage of Social Media - easier dissemination 3. To provide an opportunity for self-assessment, and self of information. reflection. 8. Globally, there is huge inequity in the distribution of skilled 10 MENTAL HEALTH FACTS human resources for mental health. 1. Around 20% of the world’s children and adolescents have In LGU, there are no psychiatrists and psychiatric mental disorders or problems. About half of mental disorders nurses. begin at age 14. Similar types of disorders are being Student Nurses or Nurses in general are not reported across cultures. allowed to perform psychiatric evaluation. It is Most low- and middle-income countries have only deeper than studying 117, those who are skilled 1 child psychiatrist for every 1-4 million people and trained are the only ones allowed. Leverage of understanding should be matched with their age. 9. There are 5 barriers to increasing mental health services Children and adolescents were highlighted availability. because this is the age where people develop consciousness. ○ Social media hiatus - those who choose 5 BARRIERS TO INCREASING MENTAL HEALTH SERVICES to take a break from social media. AVAILABILITY ○ Social media detox - those who stray away from toxicity in social media, 1. Absence of mental health from public health agenda and the ○ Lurking - those who use social media implications of funding. but do not share their things online. BSN-3C 1  ○ Senseless or irrational 2. The current organization of mental health services PSYCHOSIS/PSYCHOTIC 3. Lack of integration in primary care ○ Greek origin 4. Inadequate human resources for mental health ○ Condition or disease of the mind and soul 5. Lack of public mental health leadership PARANOID ○ Greek origin 10. Financial resources to increase services are relatively ○ Denote a lack of mental soundness modest. LUNATIC ○ Luna, the Roman moon goddess MENTAL HEALTH AND MENTAL ILLNESS ○ Cyclical insanity caused by exposure to the moon PSYCHIATRY ELEMENTS OF MENTAL HEALTH ○ Branch of medicine dealing with the study, 1. Self- treatment and prevention of mental disorders. ○ More of prioritizing yourself before thinking of what PSYCHODYNAMICS you can give to others. ○ Understanding the reasons behind human ○ “Fill your cup until your cup runneth over” behavior ○ You cannot give what you do not have. If you are research not happy, you cannot be happy for others. PSYCHOPATHOLOGY ○ Analogy of sponge and a person who always ○ Part of psychodynamics dealing with receives toxicity - you absorb toxicity until you understanding abnormal human behavior cannot absorb anymore. ○ → disease process 2. Personal growth ○ This includes your hobbies to divert your attention PSYCHIATRIC NURSING from surrounding toxicities. Interpersonal process - that provide and maintains 3. Sense of purpose and meaning behavior that contributes to integrated functioning ○ Finding what you want to do without bias and ○ Human-to-human relationship – the core of pressure from others. psychiatric nursing 4. Positive relations with others A specialized area of nursing ○ How are you with your friends” Both science and an art ○ One way or another, you will need the help of your ○ Science: use of different theories in the practice of friends so build a positive relationship with them. nursing ○ You should know how to carry yourself in different ○ Art: therapeutic use of self environments. Munchausen syndrome - those who say they feel pain when 5. Environmental mastery in reality they are not truly in pain. ○ Environment can affect your mental health. Know how to divert your attention. QUALITIES OF A PSYCHIATRIC NURSE 6. Autonomy ○ Self-government and independence. ○ An activity where we unearth our true selves. ○ You can handle yourself and be on your own. Self ○ If you are too dependent, if you depend your ○ This includes accepting your family. happiness on other people, you will have problems Accepting the Patient once they cannot cater to you anymore. ○ Most common hindrance to patient relationship: biases and prejudice; so as a psychiatric nurse, MENTAL ILLNESS you should accept your patient as a whole Mental disorder or condition Being Sincerely Interested in Patient Care Manifested by disorganization and impairment of function ○ Although they are differently abled, they are more Arises from various causes such as psychological, conscious of their surroundings. neurobiological and genetic factors Being Available A mental health condition that has a negative effect on the ○ Therapeutic use of self - knowledge and skills. way an individual… Empathizing with the Patient thinks Reliability feels ○ Mastery of being a psychiatric nurse and behaves Professionalism ○ Creating boundaries between patients and within MENTAL HEALTH AND MENTAL ILLNESS CONTINUUM you Accountability The Ability to Think Critically THERAPEUTIC USE OF SELF ADAPTIVE MALADAPTIVE HILDEGARD PEPLAU (1952) Healthy Psychosis who described this therapeutic use of self in the nurse-client Adaptive coping Maladaptive coping relationship, believed that nurses must have a clear understanding Interacts with real Hallucination/ of themselves to promote their client’s growth and to avoid limiting environment delusion client’s choices to those valued by the nurse. Socially acceptable Bizarre behavior behavior THERAPEUTIC USE OF SELF It is the main tool used by the nurse in the practice of Psychiatric Nursing Coping mechanism is a band-aid solution. You cannot always be in It is the positive use of one’s self in the process of therapy denial. Somehow, you need to face reality. Therapeutic use of self requires SELF-AWARENESS!! MENTAL HEALTH AND MENTAL ILLNESS CONTINUUM SELF-AWARENESS CRAZY Do you know who you are? ○ Scandinavian origin, 16th century → Who are you when no one is watching? ○ Restrained and confused INSANE DEBBIE FORD ○ Latin “Insarus” BSN-3C 2  “Self-awareness is the ability to take an honest look at your life 4 PERSPECTIVES without any attachment to it being right or wrong, good or bad.” SELF-AWARENESS Self-awareness means the ability to monitor our inner world our thoughts and feelings Key component of the psychiatric experience Goal: To achieve authentic, open, and personal communication ○ Some schizophrenic people change topics from time to time, one thing to do is bring them back to reality. The nurse must be able to examine personal feelings, actions, and reactions as a provider of care A firm understanding and of self allows the nurse to acknowledge a patient's differences and uniqueness. ○ You should learn how to adjust depending on the patient’s condition. COMPONENTS OF SELF-AWARENESS 1. Open/free area - traits that you can freely show to everyone (CAMPBELL) (you are aware that you are showing these characteristics). 1. Psychological Component 2. Blind area - traits that you don’t know or are aware of (e.g. Knowledge of emotions, motivations, self concept when you are idling). and personality 3. Hidden area - traits that you know but you don't want to …being sensitive to feelings show it to others because you are conscious and not proud of it. (e.g. being violent) 2. Physical Component 4. Unknown area - traits that you and other people do not know. Knowledge of personal and general physiology, as PRINCIPLES well as of bodily sensations, body image, and A change in any one quadrant affects all the other quadrants physical potential The smaller the first quadrant, the poorer the communication ○ The goal of Johari window is to enlarge the 1st 3. Environmental Component quadrant and to lessen the 2nd, 3rd, and 4th Socio-cultural environment, relationships with quadrants others and knowledge of the relationships between Interpersonal learning means that a change has taken place, humans and nature so quadrant 1 is larger and one or more of the other quadrants are smaller 4. Philosophical Component → Goal of Johari Window: make the first quadrant (open/ Sense of life having meaning free area) larger JOHARI WINDOW A model of different degree of openness between two people It is based on the degree of self-disclosure and solicitation of feedback when sharing information with another person 1. Listen to self A simple and useful tool for illustrating and improving Allow genuine emotions to be experienced self-awareness, and mutual understanding between ○ Hard when you are in a group you are individuals within a group unfamiliar with. Can also be used to assess and improve a group’s Identify and accept personal needs relationship with other groups Move the body in free, joyful and spontaneous Actually represents information – feelings, experience, ways views, attitudes, skills, intentions, motivation, etc. within or ○ Non-verbal communication is more about a person – in relation to their group, from four reliable than verbal communication. perspectives 2. Listen to and learn from others As we relate to others, we broaden our perceptions of self, but such learning requires active listening and openness to the feedback others provide ○ Active listening - giving undivided attention. → avoid giving unsolicited advice BSN-3C 3  understanding, and consistent; keeping promises and listening to and being honest with the client. Sample scenario: “I have to leave now to go to a clinical conference, but I will be back at 2pm” and indeed returns at 2pm to see the client. When working with a client with psychiatric problem some of the symptoms of the disorder may make trust difficult to establish: CLIENT WITH DEPRESSION - Has little psychic energy to listen to or to comprehend what the nurse is saying. (resentful, decreased mood, apathetic) CLIENT WITH PANIC DISORDER - Maybe too anxious to focus on the nurse’s communication. CLIENT WITH PARANOIA 3. Reduce the size of quadrant 3 by self-disclosing. - Has the most problem building trust with an unknown/ Revealing to others important aspects of the stranger person. personality. CLIENT WITH MANIC DISORDER Self-disclosure - a symptom of personality health - Distorted thoughts and cannot focus on a one-on-one and a means of achieving a healthy personality. conversation. UNKNOWN FACTORS GENUINE INTEREST An ability that is underestimated or untried through lack of A client with mental illness can detect when someone is opportunity, encouragement, confidence or training exhibiting dishonest or artificial behavior such as asking a A natural ability or aptitude that a person doesn't realize they question and then not waiting for the answer, talking over possess him or her, or assuring him or her everything will be alright. A fear or aversion that a person does not know they have ○ Be sensitive with their needs and wants An unknown illness Self-disclosure, revealing personal information (e.g. Repressed or subconscious feelings biographical data, ideas, thoughts, feelings), can enhance Conditioned behavior or attitudes from childhood openness and honesty. The nurse MUST not shift emphasis to his or her own problems rather than the client’s. PRE-JOHARI WINDOW STATE: EMPATHY Is the ability of the nurse to perceive the meanings and feelings of the client and to communicate that understanding to the client. Considered as one of the essential skills a nurse must develop. Being able to put himself/herself in the client’s shoes does not mean that the nurse had the same exact experiences as the client. EMPATHY VS. SYMPATHY DAY 2 By expressing sympathy, the nurse may project his/her THERAPEUTIC RELATIONSHIPS personal concerns onto the client, thus inhibiting the client’s BUILDING NURSE-CLIENT RELATIONSHIPS (NCR) expression of feelings Sympathy often shifts the emphasis to the nurse’s feelings, LEARNING OBJECTIVES hindering the nurse’s ability to view the client’s needs objectively. Explain the importance of values, beliefs, and attitudes in the development of the nurse-client relationship. Sample of Sympathy: Describe the importance of self-awareness and therapeutic “I know how confusing sons can be. My son confuses me, too and I use of self in the nurse-client relationship. know how bad that makes you feel” Identify self-awareness issues that can enhance or hinder the nurse-client relationship. Describe the difference between social, intimate and therapeutic relationships. The nurse who does not become upset or respond Explain the negative behaviors that can hinder or diminish negatively to a client’s outburst, anger, or acting out conveys the nurse-client relationship. to the client. Explain the various possible roles of the nurse (teacher, Avoiding judgements of the person, no matter what the caregiver, advocate, and parent surrogate) in the nurse-client behavior, is. relationship. The nurse must set boundaries for behavior in the nurse-client relationship, by being clear and firm without COMPONENTS INVOLVED IN ESTABLISHING APPROPRIATE anger or judgment. THERAPEUTIC NURSE-CLIENT RELATIONSHIPS TRUST SAMPLE SCENARIO: Unnecessary Touching Builds when the client is confident in the nurse and when the APPROPRIATE RESPONSE: nurse’s presence conveys integrity and reliability. “John, do not place your hand on me. We are working on your Develops when the client believes that the nurse will be relationship with your girlfriend and that does not require you to touch consistent in his or her words and actions and can be relied me. Now, let’s continue.” on to do what he/she says. Some behaviors the nurse can exhibit to help build the INAPPROPRIATE RESPONSE: client’s trust include being friendly, caring, interested, “John, stop that! What’s gotten into you? I am leaving and maybe I’ll return tomorrow.” BSN-3C 4  → Let them know the reality POSITIVE REGARD Unconditional non judgemental attitude ○ An effective way of proving to them that you are trustworthy The nurse who appreciates the client as a unique worthwhile human being can respect the client regardless of his/her behavior, background or lifestyle. Non-verbal techniques that create an atmosphere of presence include leaning toward the client, maintaining eye contact, being relaxed, having arms resting at the sides, and having an interested but neutral attitude ○ Positive regard through your nonverbal cues. SELF-AWARENESS AND THERAPEUTIC USE OF SELF ❖ - the process of developing an understanding of one’s own values, beliefs, thoughts, feeling, attitudes, motivations, INTERPRETATION: prejudices, strengths and limitations and how these qualities If quadrant 1 is the longest list, this indicates that the nurse is affect others open to others; a smaller quadrant 1 means that the nurse shares little about himself/herself with others. ❖ VALUES - are abstract standards that give a person a sense If quadrant 1 and 3 are both small, the person demonstrates of right and wrong, and establish a code of conduct for living little insight. Who are you when no one is watching? The goal is to work toward moving qualities from quadrant 2, Examples: 3 and 4 into quadrant 1 (qualities known to self and others) Hard work YT link:: The Johari Window Honesty Sincerity PRECONCEPTION Cleanliness Ways one person expects another to behave or speak, as a roadblock to the formation of an authentic relationship. It often prevents people VALUES CLARIFICATION PROCESS from getting to know one another. CHOOSING - considers a range of possibilities and SAMPLE SCENARIO freely chooses the value that Mr. Lopez, a client, has the preconceived stereotypical idea that all feels right male nurses are homosexual and refuses to have Samuel, a male PRIZING - considers the value nurse, take care of him. While Samuel has a preconceived embrace it and publicly stereotypical notion that all Hispanic use switchblades, he is relieved attaches to it that Mr. Lopez has refused to work with him. ACTING - putting into action BELIEFS - ideas that one NURSE MARY IS ASSIGNED TO CARE FOR A SUICIDAL CLIENT. holds to be true. But other INITIALLY, WHICH IS THE NURSE’S HIGHEST CARE PRIORITY? beliefs are irrational and may persist, despite these beliefs A. Assessing the client’s home environment and having no supportive evidence relationships outside the hospital. (support outside the or the existence of hospital is important. Know the cause) contradictory empirical evidence. B. Exploring the nurse’s own feelings about suicide. C. Discussing the future with the client. ATTITUDES - are general feelings or a frame of reference D. Referring the client to a clergyperson to discuss the moral around which a person organizes knowledge about the world. implications of suicide. ○ How you perceive or react THERAPEUTIC USE OF SELF - by developing self-awareness CARPERS’S PATTERN OF NURSING KNOWLEDGE and beginning to understand his/her attitudes, the nurse can begin to use aspects of his/her personality, experiences, values, feeling, intelligence, needs, coping skills and perceptions to establish relationship with client ○ Nurses use themselves as a therapeutic tool to establish therapeutic relationships with clients and to help clients grow, change and heal. JOHARI WINDOW EMPIRICAL KNOWING - derived from the science of nursing (evidenced based, backed up by research) PERSONAL KNOWING - from life experiences ETHICAL KNOWING - from moral knowledge of nursing (values) AESTHETIC KNOWING - from art of nursing BSN-3C 5  ❖ Clarifies preconceptions and expectations of nurse TYPES OF RELATIONSHIPS DEFINITION: SOCIAL RELATIONSHIP Begins when the nurse and client meets and ends when the Primarily initiated for the purpose of friendship, socialization, client begins to identify problems to examine. companionship or accomplishment of a task. The purpose of meeting, and the parameters of subsequent Communication usually focuses on sharing ideas, feelings meetings; identifies the client’s problems and clarifies and experiences and meets the basic needs for people to ○ Before meeting the nurse should know the interact. background or chart of the patient. SAMPLE SCENARIO: greeting of client, chat about the ➔ Before meeting the client the nurse must: weather, small talks. ❖ Read background materials available on the client INTIMATE RELATIONSHIP ❖ Becomes familiar with the medication the client is taking Involves 2 people who are emotionally committed to each ❖ Gathers necessary paperwork other.(Husband and wife) ❖ Arranges a quite private comfortable Both parties are concerned about having their individual settings needs met and helping each other to meet needs as well. ❖ The nurse should consider his/her The intimate relationship has no place in the nurse-client personal strengths and limitations in interaction. working with this client. (e.g. if this client is a spouse abuser and the nurse’s THERAPEUTIC RELATIONSHIP father was also, the nurse needs to Differs from the social or intimate relationships in many ways consider the situation. because it focuses on the needs, experiences, feelings and Before the orientation phase, the patient must take their ideas of the client only. medication. Do a drug analysis/study to know more about ○ Be neutral. Avoid agreeing/disagreeing with your the patient’s medications. client. If you have any experiences with abuse, tell your clinical The nurse and client agree about the areas to work on and instructor. evaluate the outcomes. In order to become a trustworthy nurse, practice consistency. The nurse uses communication skills, personal strengths, and understanding of human behavior to interact with clients. SAMPLE CONVERSATION A The nurse should not be concerned about whether or not the NURSE: “Hello, Mr. Santos, I am Cecilia Cruz, a nursing student from client likes him/her. FEU-NRMF. I will be coming to the hospital for the next 6 Mondays. I would like to meet with you each time I am here to help support you as ESTABLISHING THERAPEUTIC RELATIONSHIP you work on your treatment goals.” ❖ The nurse who has self-confidence rooted in self-awareness is ready to establish appropriate therapeutic relationships SAMPLE CONVERSATION B with clients. NURSE: “Mr. Santos, we will meet every Monday from June 1 to July Peplau’s Phases of the nurse-client relationship: 15 at 11am in conference room 2. We can use that time to work on A. Orientation Phase your feelings of loss since the death of your twin sister.” B. Identification Phase (Working) C. Exploitation Phase (Working) ➔ At the first meeting, the client may be distrustful if previous D. Termination Phase relationships with nurses have been unsatisfactory. The client may use rambling speech, act out, or exaggerate PEPLAU’S THEORY OF INTERPERSONAL RELATIONSHIPS episodes as plays to avoid discussing the real problems. ➔ It may take several sessions until the client believes he/ she can trust the nurse. ➔ The nurse should consider his or her personal strengths and limitations in working with this client. Are there any areas that might signal difficulty because of past experiences? CONFIDENTIALITY Means respecting the client’s right to keep private any information about his/her mental and physical health and related care. Adult clients (PH setting: consenting age: 21 years old and above) can decide which family member, if any, may be involved in treatment and may have access to clinical information. For a child (pediatric: 18 years old and below), the parent or ORIENTATION PHASE appointed guardian is allowed access to information and can CLIENT make treatment decisions as outlined by the health care ❖ Seeks assistance team. ❖ Conveys needs The nurse must avoid any promises to keep secrets. ❖ Ask questions ○ priority: patient’s safety ❖ Shares preconceptions and expectations of nurse based on past experiences SAMPLE SCENARIO: Avoid asking the same question. Try to practice Client: “I am going to jump off the 14th floor of my apartment building active listening. You set the expectation. tonight, but please don’t tell anyone.” NURSE Nurse: “I cannot keep such a promise, especially if it involves your ❖ Responds to client safety. I sense you are feeling frightened. The staff and I will help you ❖ Gives parameters of meeting stay safe. ❖ Explains role ❖ Gathers data In this circumstance, the nurse must report the homicidal ❖ Helps client identify problem threat to the nursing supervisor and attending physician so ❖ Helps client plan use of community resources and services that both the police and intended victim can be modified. ❖ Reduces anxiety and tension ❖ Practices active listening BSN-3C 6  This is called DUTY TO WARN. (should be reported and c. Confronting the client about discrepancies in verbal or documented) nonverbal behavior Self-Disclosure - means revealing personal information d. The client feels angry towards the nurse who resembles his such as biographical information and personal ideas, mother thoughts, feelings about oneself to clients. The nurse can use self-disclosure to convey support, educate clients, and PROVIDE demonstrate a client’s anxiety is normal and that many ❖ P → Promote positive self - concept people deal with stress and problems in their lives. ❖ R → Realistic goal setting ○ When using self-disclosure, the nurse must also ❖ O → Organizing support system consider cultural factors. (also the educational ❖ V → Verbalizes feelings attainment) ❖ I → Implement action plan ○ Self-disclosure may help the client feel more ❖ D → Develop positive coping behavior (help and guide comfortable and more willing to share thoughts patient) and feelings or help the client gain insight into his ❖ E → Evaluate the result of plan of action or her situation. TERMINATION PHASE A male client admitted to the psychiatric unit for treatment of substance abuse says to the nurse. “It felt so wonderful to get high.” Which of the It begins when the problems are resolved and it ends when following is the most appropriate response? the relationship is ended. a. “If you continue to talk like that, I’m going to stop speaking to Often the clients try to avoid the termination phase by acting you.” angry. b. “You told me you got fired from your last job for missing too It is inappropriate for the nurse to agree to meet with the many days after taking drugs all night.” client outside the therapeutic relationship. c. “Tell me more about how it felt to get high.” Accepting gifts or giving a client’s one’s home address or d. “Don’t you know it’s illegal to use drugs?” phone number would be considered a breach of ethical conduct. TEACH If the client tries to reopen and discuss old resolved issues ❖ T → Trust and rapport (manipulative behavior), the nurse must avoid feeling as if ❖ E → Environment (quiet and accommodating) the sessions were unsuccessful; instead, he or she should ❖ A → Assess client’s strengths and weakness identify the client's stalling maneuvers and refocus the client ❖ C → Contract (tell your patient when it will begin and end, on newly learned behaviors and skills to handle the problem. setting their expectation) It is appropriate to tell the client that the nurse enjoyed the ❖ H → Help communicate (create a leading questions) time spent with the client and will remember him or her, but it is inappropriate for the nurse to agree to see the client YT link: Psychiatric interviews for teaching depression outside the therapeutic relationship. ○ Hallucinations are perceived by senses WORKING PHASE ○ Delusions are perceived by beliefs. (IDENTIFICATION AND EXPLOITATION) PRIDE Divided into 2 subphase: ❖ P → Promote self-care 1. Problem Identification - the client identifies the issues or ❖ R → Recognize increasing anxiety (WOF manipulative concerns causing problem behavior) You direct your client ❖ I → Increase independence 2. Exploitation - the nurse guides the client to examine ❖ D → Demonstrate emotional stability (hardest to achieve) feelings and responses and to develop better coping skills ❖ E → Environmental support and more positive self - image; develops independence Sometimes the client will use outrageous stories or acting-out behaviors to test the nurse. This is the most difficult phase, SAMPLE SITUATION: Mrs. Cruz suffers from depression. She continues to complain to the nurse about the lack of concern her children show her. With the nurse Joan’s assistance, Mrs. Cruz explores how she communicates with her children and discovers that her approach is usually highly critical and needy. Mrs. Cruz realizes that her behavior contributes to driving her children away. The nurse must remember that it is the client who examines and explores problems, situations and relationships. ○ promote independency The nurse must be non judgemental and refrain from giving advice; the nurse should allow the client to analyze situations. TRANSFERENCE - the client unconsciously transfers to the nurse feelings he or she has for significant others. AVOIDING BEHAVIORS THAT DIMINISH THE THERAPEUTIC (COUNTERTRANSFERENCE) RELATIONSHIP Solution is SELF-AWARENESS Inappropriate Boundaries Feelings of Sympathy and Encouraging Client Dependency SAMPLE SITUATION: Non and Avoidance John had negative experience with MMDA personnel and he might display similar reactions of negativity and resistance to the nurse, who ROLES OF THE NURSE IN A THERAPEUTIC RELATIONSHIP also is viewed as an authority. TEACHER Nurse Myrna develops a counter-transference reaction. This is The nurse may teach the client a new method of coping and evidenced by: solving problems. a. Revealing personal information to the client He/ she may interact about the medication regimen b. Focusing on the feelings of the client available. BSN-3C 7 CAREGIVER Rationale: Greeting the client by name, indicating awareness of Implementation of the therapeutic relationship to build trust, change, or noting efforts the client has made all show that the nurse explore feelings, assist the client in problem solving. recognizes the client as a person, as an individual. Such recognition does not carry the notion of value, that is of being "good" or "bad". PARENT SURROGATE SILENCE When the client exhibits child-like behavior or when a nurse ABSENCE OF VERBAL COMMUNICATION, WHICH PROVIDES is required to provide personal care such as feeding or TIME FOR THE CLIENT TO PUT THOUGHTS OR FEELINGS INTO bathing. WORDS, TO REGAIN COMPOSURE OR TO CONTINUE TALKING. In such situations, the nurse must be clear and firm and set limits or reiterate the previously set limits. Example: Nurse says nothing but continues to maintain eye contact and convey interest ADVOCATE The nurse informs the client and then supports him/her Rationale: Silence often encourages the client to verbalize, provided whatever decision he/she makes he or she is interested and expectant. Silence gives the client time to Advocacy - is the process of acting on the client’s behalf organize thoughts, direct the topic of interaction, or focus on when he/she cannot do so issues that are most important. Much nonverbal behavior takes place There are times when the nurse does not advocate for the during silence. client’s autonomy or right to self-determination, such as by supporting involuntary hospitalization for suicidal client ACCEPTING INDICATING RECEPTION SELF-AWARENESS ISSUES ❖ If the nurse has certain beliefs and attitudes that he/she will Example: “Yes” not change, it may be best for another nurse to care for the “I follow that you said” client. Nodding ❖ Nurses also need to learn to “care for themselves”. This means balancing work leisure time, building satisfying Rationale: An accepting response indicates the nurse has heard and personal relationships with friends. followed the train of thought. It does not indicate agreement but is non-judgemental. Facial expressions, tone of voice and so fourth also POINTS TO CONSIDER WHEN BUILDING THERAPEUTIC must convey or the words lose their meaning. RELATIONSHIPS 1. Attend workshops about values clarification, beliefs, and GENERAL LEADS attitudes to help you assess and learn about yourself. 2. Keep a journal of thoughts, feelings, and lessons learned to GIVING ENCOURAGEMENT TO CONTINUE provide self-insight 3. Listen to feedback from colleagues about your relationship Example: “Go on…” with the client. “And then?” 4. Participate in group discussions on self-growth at the local “Tell me about it.” library or health center to aid self-understanding. 5. Develop a continually changing care plan for self-growth. Rationale: General leads indicate that the nurse is listening and 6. Read books on topics that support the strengths you have following what the client is saying without taking away the initiative for identified and help to develop your areas of weakness. the interaction. They also encourage the client to continue if he or she is hesitant or uncomfortable about the topic. COMMUNICATION TECHNIQUES THERAPEUTIC COMMUNICATION TECHNIQUES BROAD OPENINGS ALLOWING THE CLIENT TO TAKE INITIATIVE IN INTRODUCING OFFERING SELF THE TOPIC MAKING ONESELF AVAILABLE Example: “Is there something you’d like to talk about?” Example: “I’ll stay here with you.” “Where would you like to begin” “I’m interested in what you think.” Rationale: Broad openings make it explicit that the client has the lead Rationale: The nurse can offer his or her presence, interest, and in interaction. For the client who is hesitant about talking, broad desire to understand. It is important that this offer is unconditional, openings may stimulate him or her to take initiative. that is, the client does not have to respond verbally to get the nurse’s attention. MAKING OBSERVATIONS VERBALIZING WHAT THE NURSE PERCEIVES GIVING INFORMATION MAKING AVAILABLE THE FACTS THAT THE CLIENT NEEDS. Example: “You appear tense.” “Are you uncomfortable when…?” Examples: “My name is…” “I notice that you’re biting your lip.” “My purpose in being here is…” “Visiting hours are…” Rationale: Sometimes clients cannot verbalize or make themselves understood, or the client may not be ready to talk. Rationale: Informing the client of facts increases his or her knowledge about a topic or lets the client know what to expect. The nurse is ENCOURAGING EXPRESSION functioning as a resource person. Giving information also builds trust ASKING THE CLIENT TO APPRAISE THE QUALITY OF HIS OR with the client. HER EXPERIENCES GIVING RECOGNITION Example: “What are your feelings in response to….?” ACKNOWLEDGING, INDICATING AWARENESS. “Does this contribute to distress?” Examples: "Good morning, Mr. S…” Rationale: The nurse asks the client to consider people and events in "You've finished your list of things to do.” light of his or her values. Doing so encourages the client to make his or “I notice that you've combed your hair.” her appraisal rather than accept the opinion of others. BSN-3C 8  “When did this happen?” EXPLORING DELVING FURTHER INTO SUBJECT OR AN IDEA Rationale: Putting events in proper sequence helps both the nurse and the client to see them in perspective. The client may gain Example: “Tell me more about that?” insight into cause and effect behavior and consequences or the client “Would you describe it more fully?” may be able to see that perhaps some things are not related. The “What kind of work?” nurse may gain information about recurrent patterns or themes in the client’s behavior or relationship. Rationale: When clients deal with topics superficially. exploring can help them examine the issue more fully. ENCOURAGING DESCRIPTIONS OF PERCEPTIONS Any problem or concern can be better understood if explored in depth. ASKING THE CLIENT TO VERBALIZE WHAT HE OR SHE If the client expresses an unwillingness to explore a subject, however, PERCEIVE the nurse must respect his or her wishes. Example: "Tell me when you feel anxious." FOCUSING “What is happening?” CONCENTRATING ON A SINGLE POINT. IT IS A USEFUL "What does the voice seem to be saying?” TECHNIQUE WHEN A CLIENT JUMPS FROM ONE TOPIC TO ANOTHER. Rationale: To understand the client, the nurse must see things from his or her perspective. Encouraging the client to fully describe ideas Example: “This point seems worth looking at more closely.” may relieve the tension the client is feeling, and he or she might be “ Of all the concerns you’ve mentioned, which is the less likely to take actions on ideas that are harmful or frightening. most troublesome?” PRESENTING REALITY Rationale: The nurse encourages the client to concentrate his or her OFFERING FOR CONSIDERATION THAT WHICH IS REAL energies on a single point, which may prevent a multitude of factors or problems from overwhelming the client. Example: “I see no one else in the room.” “That sound was a car backfiring” RESTATING “Your mother is not here. I am a nurse.” REPEATING THE MAIN IDEA EXPRESSED Rationale: When it is obvious that the client is misinterpreting reality, Example: the nurse can indicate what is real. The nurse does this by calmly Client - “I can’t sleep. I stay all night” and quietly expressing his or her perceptions or the facts, not by Nurse - “You have difficulty sleeping” way of arguing with the client or belittling his or her experience. The Client - “I’m really mad, I’m really upset” intent is to indicate an alternative line of thought for the client to Nurse - “You’re really mad and upset” consider, not to “convince” the client that he or she is wrong. Rationale: The nurse repeats what the client has said in SEEKING INFORMATION approximately or nearly the same words the client has used. This SEEKING TO MAKE CLEAR THAT WHICH IS NOT MEANINGFUL restatement lets the client know that he or she communicated the idea OR THAT WHICH IS VAGUE effectively. This encourages the client to continue. Or if the client has been misunderstood, he or she can clarify his or her thoughts. Example: “I’m not sure that I follow.” “Have I heard you correctly?” REFLECTING DIRECTING CLIENT’S ACTIONS, THOUGHTS, AND FEELINGS Rationale: The nurse should seek clarification throughout interactions BACK TO CLIENT with the client. Doing so can help the nurse to avoid making assumptions that understanding has occurred when it has not. It Example: helps the client articulate thoughts, feelings and ideas more clearly. Client - “Do you think I should tell the doctor?” Nurse - “Do you think you should?” CONSENSUAL VALIDATION Client - “My brother spends all my money and then SEARCHING FOR MUTUAL UNDERSTANDING FOR ACCORD IN has the nerve to ask for more.” THE MEANING OF THE WORDS Nurse - “This causes you to feel angry?” Example: “Tell me whether my understanding of it agrees with Rationale: Reflection encourages the client to recognize and accept yours.” his or her own feelings. The nurse indicates that the client’s point of “Are you using this word to convey that…?” view has value and that the client has the right to have opinions, make decisions and think independently. Rationale: For verbal communication to be meaningful, it is essential that the words being used have the same meaning for both or all ENCOURAGING COMPASSION participants. Sometimes words, phrases or slang terms have different ASKING THAT SIMILARITIES AND DIFFERENCES BE NOTED meanings to different people and can be easily misunderstood. Example: “Was it something like…..” TRANSLATING INTO FEELINGS “Have you had a similar experience?” SEEKING TO VERBALIZE CLIENT’S FEELINGS THAT HE OR SHE EXPRESS ONLY INDIRECTLY Rationale: Comparing ideas, experiences, relationships brings out many recurring themes. The client benefits from making these Example: Client - “I’m dead.” comparisons because he or she might recall past coping strategies Nurse - “Are you suggesting that you feel lifeless?” that were effective or remember that he or she has survived a similar Client - “I’m way out in the ocean.” situation. Nurse - “You seem to feel lonely or deserted.” PLACING EVENT IN TIME OR SEQUENCE Rationale: Often what the client says, when taken literally, seems CLARIFYING THE RELATIONSHIP OF EVENTS IN TIME meaningless or far removed from reality. To understand, the nurse must concentrate on what the client might be feeling to express Example: “What seemed to lead up to…?” him or herself this way. “Was this before or after…?” BSN-3C 9 FORMULATING A PLAN OF ACTION NON-THERAPEUTIC COMMUNICATION TECHNIQUES ASKING THE CLIENT TO CONSIDER KINDS OF BEHAVIOR ADVISING LIKELY TORGANIZING AND SUMMING UP THAT WHICH HAS TELLING CLIENT WHAT TO DO GONE BEFORE Example: “I think you should…” Example: “Have I got this straight?” “Why don’t you…” “You’ve said that…” “During the past hour, you and I have discussed…” Rationale: Giving advice implies that only the nurse knows what is best for the client. Rationale: Summarization seeks to bring out the important points of the discussion and seeks to increase the awareness and - advising promotes dependency understanding of both participants. It omits the irrelevant and organizes - can be leading to client the pertinent aspects of the interaction. It allows both client and nurse to depart with the same ideas and provides a sense of closure at the DISAGREEING completion of each discussion. O BE APPROPRIATE IN FUTURE SITUATIONS OPPOSING THE CLIENT’S IDEAS Example: "What could you do to let your anger out Example: “That's wrong.” harmlessly?” “I definitely disagree with…." “Next time this comes up, what might you do handle it?” Rationale: Disagreeing implies the client is “wrong.” Consequently, the client feels defensive about his or her point of view or ideas. Rationale: It may be helpful for the client to plan in advance what he or she might do in future similar situations. Making definite plans DISAPPROVING increases the likelihood that the client will cope more effectively DENOUNCING THE CLIENT’S BEHAVIOR or IDEAS in similar situations. Example: “That's bad.” SUGGESTING COLLABORATION “I’d rather you wouldn't…” OFFERING TO SHARE, TO STRIVE, AND TO WORK WITH THE CLIENT FOR HIS OR HER BENEFIT Rationale: Disapproving implies that the nurse has the right to pass judgment on the client's thoughts or actions. It further implies that the Example: “Perhaps you and I can discuss and discover the triggers for client is expected to please the nurse. your anxiety.” “Let’s go to your room, and I’ll help you find what you’re DEFENDING looking for.” ATTEMPTING TO PROTECT SOMEONE OR SOMETHING FROM VERBAL ATTACK Rationale: The nurse seeks to offer a relationship in which the client can identify problems in living with others, grow emotionally, and Example: “This hospital has a fine reputation.” improve the ability to form satisfactory relationships. The nurse offers “I’m sure your doctor has your best interest in mind.” to do things with, rather than for, the client. Rationale: Defending what the client has criticized implies that he or SUMMARIZING she has no right to express impressions, opinions or feelings. Telling the client that his or her criticism is unjust or unfounded does VERBALIZING THE IMPLIED not change the client’s feelings but only serves to block further communication. VOICING WHAT THE CLIENT HAS HINTED AT OR SUGGESTED CHALLENGING Example: Client: “I can’t talk to you or anyone. It’s a waste of time.” Nurse: “Do you feel that no one understands?” DEMANDING PROOF FROM THE CLIENT Rationale: Putting into words what the client has implied or said Example: in-directly tends to make the discussion less obscure. The nurse “But how can you be president of the United States?” should be as direct as possible without being unfeelingly blunt or “If you’re dead, why is your heart beating” obtuse. The client may have difficulty communicating directly. The nurse should take care to express only what is fairly obvious; Rationale: Often the nurse believes that if he or she can challenge the otherwise, the nurse may be jumping to conclusions or interpreting the client to prove unrealistic ideas, the client will realize there is no “proof” client’s communication. and then will recognize reality. Actually, challenging causes the client to defend the delusions or misperceptions more strongly than VOICING DOUBT before. EXPRESSING UNCERTAINTY ABOUT THE REALITY OF THE INTERPRETING CLIENT’S PERCEPTIONS ASKING TO MAKE CONSCIOUS THAT WHICH IS UNCONSCIOUS, Example: “Isn’t that unusual?” TELLING THE CLIENT THE MEANING OF HIS OR HER “Really?” EXPERIENCE “That’s hard to believe.” Example: “What you really mean is…” Rationale: Another means of responding to distortions of reality is to “Unconsciously you’re saying…” express doubt. Such expression permits the client to become aware that others do not necessarily perceive events in the same way or draw Rationale: The client’s thoughts and feelings are his or her own , not the same conclusions. to be interpreted by the nurse for hidden meaning. Only the client can This does not mean the client will alter his or her point of view, but at identify or confirm the presence of feelings. least the nurse will encourage the client to reconsider or reevaluate what has happened. The nurse neither agreed nor disagreed; however, - making a conscious effort to change or interpret client’s he or she has not let the misperceptions and distortions pass without thoughts and feelings comment. PROBING BSN-3C 10 PERSISTENT QUESTIONING OF THE CLIENT INDICATING THE EXISTENCE OF AN EXTERNAL SOURCE ATTRIBUTING THE SOURCE OF THOUGHTS, FEELINGS, Example: BEHAVIORS TO OTHERS OR TO OUTSIDE INFLUENCES “Now, tell me about the problem. You know I have to find out.” Example: “What makes you say that?” “Tell me your psychiatric history” “What made you do that?” “Who told you that you were a prophet?” Rationale: Probing tends to make the client used or invaded. Clients have the right not to talk about issues or concerns if they Rationale: The nurse can ask, “What happened?” or “What events choose. Pushing and probing by the nurse will not encourage the client led you to draw such a conclusion?”, however to question “What to talk. made you think that?” implies that the client was made or compelled to think in a certain way. Usually, the nurse does not intend to suggest - when you feel client is resentful or guarded, change topic for that the source is external, but that is often what the client thinks. a while - you continuously and persistently question the client when INTRODUCING AN UNRELATED TOPIC he or she rejects the topic it becomes non therapeutic CHANGING THE SUBJECT REASSURING Example: Client - “I’d like to die.” Nurse - “Did you have visitors last evening?” INDICATING THERE IS NO REASON FOR ANXIETY OR OTHER FEELINGS OF DISCOMFORT Rationale: The nurse takes the initiative for the interaction away from the client. This usually happens because the nurse is Example: “I wouldn’t worry about that.” uncomfortable, doesn’t know how to respond, or has a topic he or “Everything will be all right.” she would rather discuss. “You’re coming along just fine." MAKING STEREOTYPED COMMENTS Rationale: Attempts to dispel the client’s anxiety by implying that there is not sufficient reason for concern completely devalue the client’s OFFERING CLICHES OR TRITE COMMENTS feelings. Vague reassurances without accompanying facts are meaningless to the client. Example: “It’s for your own good” “Keep your chin up.” TESTING “Just have a positive attitude and you’ll be better in no time.” APPRAISING THE CLIENT’S DEGREE OF INSIGHT Rationale: Social conversations contain many cliches and much Example: “Do you know what kind of hospital this is?” meaningless chit-chat. Such comments are of no value in the “Do you still have the idea that…?” nurse-client relationship. Any automatic responses will lack the nurse’s consideration or thoughtfulness. Rationale: These types of questions force the client to try to recognize his or her problems. The client’s acknowledgement that REQUESTING AN EXPLANATION he or she doesn't know these things may meet the nurse’s needs but is not helpful for the client. ASKING THE CLIENT TO PROVIDE REASONS FOR THOUGHTS, FEELINGS, BEHAVIORS, AND EVENTS BELITTLING FEELINGS EXPRESSED Example: “Why do you think that?” MISJUDGING THE DEGREE OF THE CLIENT’S DISCOMFORT “Why do you feel that way?” Example: Rationale: There is difference between asking the client to describe Client - “I have nothing to live for… I wish I was dead.” what is occurring or has taken place and asking him to explain why. Nurse - “Everybody gets down in the dumps” or Usually, a why question is intimidating. In addition, the client is “I’ve felt that way myself.” unlikely to know “why” and may become defensive trying to explain himself or herself. Rationale: When the nurse tries to equate the intense and overwhelming feeling the client has expressed to “everybody” or to the - you can be viewed as challenging your client nurse’s own feelings, the nurse implies that the discomfort is temporary, mild, self-limiting or not that important. The client is USING DENIAL focused on his or her own worries and feelings; hearing the problems or feelings of others is not helpful. REFUSING TO ADMIT THAT A PROBLEM EXIST - Gaslighting - when a person exploits the other party and Example: Client - “I’m nothing.” makes a minor issue to a bigger one. Nurse - “Of course you’re something.” - invalidating feelings of others Client - “I’m dead” Nurse - “Don’t be silly.” GIVING LITERAL RESPONSES Rationale: The nurse denies the client’s feelings or the RESPONDING TO A FIGURATIVE COMMENT AS THOUGH IT seriousness of the situation by dismissing his or her comments WERE A STATEMENT OF FACT without attempting to discover the feelings or meaning behind them. Example: Quiz #1 - Day 2 discussions (10 items) → after foundation week Client - “They’re looking in my head with a television camera” Prelim coverage Nurse - “Try not to watch television.” or - self-awareness “What channel?” - Johari window - Therapeutic relationships Rationale: Often, the client is at a loss to describe his or her - communication techniques feelings, so such comments are the best he or she can do. Usually, it is helpful for the nurse to focus on the client’s feelings in response to such statements. BSN-3C 11  QUIZ #1 13/15 c. The nurse must be able to examine personal feelings, actions, and reactions as a provider 1. Which of the following scenario displays of care acceptance: d. Self-awareness means the ability to monitor a. The client is shouting foul words while the our inner world nurse went out of the room to talk to other 11. TRUE or FALSE: Johari window is a model of nurses. different degree of openness between 2 people, it b. The resident was seen flashing genitals to is based solely on the degree of self-disclosure. nursing students while the nurse laughed but a. FALSE explains the reason why he is like that. b. TRUE c. The resident is shouting derogatory remarks 12. In therapeutic use of self, the most important tool towards the hospital while the nurse shouts that the nurse must have is; back to the client. a. Chair and quite room d. While the client is showing tantrums, the b. Quiet place and good lighting nurse is only observing. c. Self 2. What are the components involved in establishing d. Pen and paper to list attitude, belief and an appropriate therapeutic nurse-client values during self-awareness relationship? 13. TRUE or FALSE beliefs are ideas that one holds to a. Trust, open interest, sympathy be true but sometimes irrational and may persist b. Self-awareness, sympathy, natural regard despite their beliefs having no supportive c. Empathy, open communication, sincerity evidence. d. Acceptance, trust, positive regard a. FALSE 3. All but on is part f values clarification process b. TRUE a. Prizing 14. Nurse Mary is assigned to care for a suicidal b. Choosing client. Initially which is the nurse’s highest care c. Accepting priority? d. Acting a. Exploring the nurse’s own feelings about 4. TRUE or FALSE: therapeutic use of self requires suicide self-awareness b. Assess the client’s home environment a. TRUE and relationship outside the hospital b. FALSE c. Referring the client to a clergy person to 5. Which statement is true of positive regard? discuss the moral implications of suicide a. It is an unconditional non-judgmental d. Discussing the future with the client attitude 15. Nurse theorist who described the therapeutic use b. It depends to verbal techniques that create of self in the nurse-client relationship believed an atmosphere of presence that nurses must have a clear understanding of 6. Which is true of Johari window? themselves to promote their client’s growth and to a. Hidden area – unknown by you but known to avoid limiting client’s choices to those valued by others the nurse. b. Blind area – known to you unknown to others a. Dorothy Johnson c. Unknown area – known by you and unknown b. Hildegard Peplau to others c. Virginia Henderson d. Open area – known by you and seen by d. Dorothea Orem others 7. All are components of self-awareness according to Campbell except: a. Environmental b. Physical c. Psychological d. Emotional 8. These are abstract standards that give a person a sense of right or wrong and establish a code of conduct for living a. Values b. Beliefs c. Attitude 9. The goal of Johari window is to: a. Enlarge hidden area, shrink open area b. Enlarge open are, shrink hidden area c. Enlarge all quadrant d. No goal as long as you know yourself 10. All the true about self-awareness EXCEPT: a. The goal is to achieve only personal communication b. Self-awareness is the ability to take an honest look at your life without any attachment to it being right or wrong, good or bad BSN-3C 12