Mental Health Chapter 5 PDF

Chapter 5 Relationship Development and Therapeutic Communication Copyright ©2019 F.A. Davis Company Introduction § The nurse–patient relationship is the foundation on which psychiatric nursing is established. § The therapeutic interpersonal relationship is the process by which nurses provide care fo...

Chapter 5 Relationship Development and Therapeutic Communication Copyright ©2019 F.A. Davis Company Introduction § The nurse–patient relationship is the foundation on which psychiatric nursing is established. § The therapeutic interpersonal relationship is the process by which nurses provide care for patients in need of psychosocial intervention. Copyright ©2019 F.A. Davis Company Introduction (continued) § Therapeutic use of self is the instrument for delivery of care to patients in need of psychosocial intervention. § Interpersonal communication techniques are the “tools” of psychosocial intervention. Copyright ©2019 F.A. Davis Company The Therapeutic Nurse–Patient Relationship § Therapeutic nurse–patient relationships can occur only when each views the other as a unique human being. When this occurs, both participants have needs met by the relationship. § Therapeutic relationships are goal-oriented and directed at learning and growth promotion. Copyright ©2019 F.A. Davis Company The Therapeutic Nurse–Patient Relationship (continued_1) § Goals are often achieved through use of the problem-solving model. Identify the patient’s problem. Promote discussion of desired changes. Discuss aspects that cannot realistically be changed and ways to cope with them more adaptively. Discuss alternative strategies for creating changes that the patient desires to make. Copyright ©2019 F.A. Davis Company The Therapeutic Nurse–Patient Relationship (continued_2) § Goals and the problem-solving model Weigh benefits and consequences of each alternative. Help patient select an alternative. Encourage patient to implement the change. Provide positive feedback for patient’s attempts to create change. Help patient evaluate outcomes of the change and make modifications as required. Copyright ©2019 F.A. Davis Company Clicker Question 1 1. Which is the primary nursing goal when establishing a therapeutic relationship with a patient? A. To promote patient growth B. To develop the nurse’s personal identity C. To establish a purposeful social interaction D. To develop communication skills Copyright ©2019 F.A. Davis Company Clicker Question Answer 1 Correct Answer: A The goal of a therapeutic nursing interaction is to promote patient insight and behavioral change directed toward patient growth. Copyright ©2019 F.A. Davis Company Therapeutic Use of Self § Ability to use one’s personality consciously and in full awareness in an attempt to establish relatedness and to structure nursing interventions § Nurses must possess self-awareness, selfunderstanding, and a philosophical belief about life, death, and the overall human condition. Copyright ©2019 F.A. Davis Company Conditions Essential to Development of a Therapeutic Relationship § Rapport § Trust § Respect § Genuineness § Empathy Copyright ©2019 F.A. Davis Company Therapeutic Nurse–Patient Relationship Preinteraction phase § Obtain information about the patient from chart, significant others, or other health team members. § Examine one’s own feelings, fears, and anxieties about working with a particular patient. Copyright ©2019 F.A. Davis Company Therapeutic Nurse–Patient Relationship (continued_1) Orientation (introductory) phase § Create an environment for trust and rapport. § Establish contract for intervention. § Gather assessment data. § Identify patient’s strengths and limitations. Copyright ©2019 F.A. Davis Company Therapeutic Nurse–Patient Relationship (continued_2) Orientation phase (continued) § Formulate nursing diagnoses. § Set mutually agreeable goals. § Develop a realistic plan of action. § Explore feelings of both patient and nurse. Copyright ©2019 F.A. Davis Company Therapeutic Nurse–Patient Relationship (continued_3) Working phase § Maintain trust and rapport. § Promote patient’s insight and perception of reality. § Use problem-solving model to work toward achievement of established goals. § Overcome resistance behaviors. § Continuously evaluate progress toward goal attainment. Copyright ©2019 F.A. Davis Company Therapeutic Nurse–Patient Relationship (continued_4) Working phase (continued) § Transference: Occurs when the patient unconsciously displaces (or “transfers”) to the nurse feelings formed toward a person from the past § Countertransference: Refers to the nurse’s behavioral and emotional response to the patient Copyright ©2019 F.A. Davis Company Therapeutic Nurse–Patient Relationship (continued_5) Termination phase § Therapeutic conclusion of relationship occurs when Progress has been made toward attainment of the goals. A plan of action for more adaptive coping with future stressful situations has been established. Feelings about termination of the relationship are recognized and explored. Copyright ©2019 F.A. Davis Company Clicker Question 2 2. A patient threatens to kill himself, his wife, and their children if the wife follows through with divorce proceedings. During the pre-interaction phase of the nurse–patient relationship, which interaction should the nurse employ? A. Acknowledging the patient's actions and encouraging alternative behaviors B. Establishing rapport and developing treatment goals C. Providing community resources on aggression management D. Exploring personal thoughts and feelings that may adversely impact the provision of care Copyright ©2019 F.A. Davis Company Clicker Question Answer 2 Correct Answer: D In the pre-interaction phase, the nurse must clarify personal attitudes, values, and beliefs to become aware of how these might affect the nurse’s ability to care for various patients. This occurs before the nurse meets the patient. Copyright ©2019 F.A. Davis Company Boundaries in the Nurse–Patient Relationship Types of boundaries § Material § Social § Personal § Professional: limit and outline expectations for appropriate professional relationships with patients. Copyright ©2019 F.A. Davis Company Boundaries in the Nurse–Patient Relationship (continued_1) § Professional boundary concerns commonly include issues such as Self-disclosure Gift-giving Touch Friendship or romantic association Copyright ©2019 F.A. Davis Company Boundaries in the Nurse–Patient Relationship (continued_2) § Warning signs that indicate that professional boundaries of the nurse–patient relationship may be in jeopardy Favoring one patient’s care over another’s Keeping secrets with a patient Changing dress style when working with a particular patient Copyright ©2019 F.A. Davis Company Boundaries in the Nurse–Patient Relationship (continued_3) § Warning signs (continued) Swapping patient assignments to care for a particular patient Giving special attention or treatment to one patient over others Spending free time with a patient Frequently thinking about the patient when away from work Copyright ©2019 F.A. Davis Company Boundaries in the Nurse–Patient Relationship (continued_4) § Warning signs (continued) Sharing personal information or work concerns with the patient Receiving of gifts or continued contact and communication with the patient after discharge Copyright ©2019 F.A. Davis Company Interpersonal Communication § Interpersonal communication is a transaction between the sender and the receiver. Both persons participate simultaneously. § In the transactional model, both participants perceive each other, listen to each other, and simultaneously engage in the process of creating meaning in a relationship. Copyright ©2019 F.A. Davis Company The Impact of Preexisting Conditions § Values, attitudes, and beliefs Learned ways of thinking § Culture and religion Cultural mores, norms, ideas, and customs provide the basis for our way of thinking Copyright ©2019 F.A. Davis Company The Impact of Preexisting Conditions (continued_1) § Social status High-status persons often convey their highpower position with gestures of hands on hips, power dressing, greater height, and more distance when communicating with individuals considered to be of lower social status. § Gender Masculine and feminine gestures influence messages conveyed in communication with others. Copyright ©2019 F.A. Davis Company The Impact of Preexisting Conditions (continued_2) § Age or developmental level Example: The influence of developmental level on communication is especially evident during adolescence, with words such as dude, cool, awesome, and others. Copyright ©2019 F.A. Davis Company The Impact of Preexisting Conditions (continued_3) § The environment in which the transaction takes place Territoriality, density, and distance are aspects of environment that communicate messages. ‒ Territoriality: The innate tendency to own space ‒ Density: The number of people within a given environmental space ‒ Distance: The means by which various cultures use space to communicate Copyright ©2019 F.A. Davis Company The Impact of Preexisting Conditions (continued_4) § There are four kinds of distance in interpersonal interactions. Intimate distance: The closest distance that individuals allow between themselves and others Personal distance: The distance for interactions that are personal in nature Social distance: The distance for conversation with strangers or acquaintances Public distance: The distance for speaking in public or yelling to someone some distance away Copyright ©2019 F.A. Davis Company Clicker Question 3 3. The unit manager needs to meet with a patient who is exhibiting escalating hostility. Which would be the most appropriate location for the nurse to meet with this patient? A. The patient’s room with the door shut B. A quiet corner of the day room C. The nurse’s station D. The unit’s treatment room Copyright ©2019 F.A. Davis Company Clicker Question Answer 3 Correct Answer: B A quiet corner of the day room provides for some privacy in a neutral space while not limiting access to help if safety issues arise. Copyright ©2019 F.A. Davis Company Nonverbal Communication § Components of nonverbal communication § Physical appearance and dress § Body movement and posture § Touch § Facial expressions § Eye behavior § Vocal cues or paralanguage Copyright ©2019 F.A. Davis Company Therapeutic Communication Techniques § Using silence: Allows patient to take control of the discussion, if he or she so desires § Accepting: Conveys positive regard § Giving recognition: Acknowledging, indicating awareness § Offering self: Making oneself available § Giving broad openings: Allows patient to select the topic Copyright ©2019 F.A. Davis Company Therapeutic Communication Techniques (continued_1) § Offering general leads: Encourages patient to continue § Placing the event in time or sequence: Clarifies the relationship of events in time § Making observations: Verbalizing what is observed or perceived § Encouraging description of perceptions: Asking patient to verbalize what is being perceived Copyright ©2019 F.A. Davis Company Therapeutic Communication Techniques (continued_2) § Encouraging comparison: Asking patient to compare similarities and differences in ideas, experiences, or interpersonal relationships § Restating: Lets patient know whether an expressed statement has been understood § Reflecting: Directs questions or feelings back to patient so that they may be recognized and accepted Copyright ©2019 F.A. Davis Company Therapeutic Communication Techniques (continued_3) § Focusing: Taking notice of a single idea or even a single word § Exploring: Delving further into a subject, idea, experience, or relationship § Seeking clarification and validation: Striving to explain what is vague and searching for mutual understanding § Presenting reality: Clarifying misconceptions that the patient may be expressing Copyright ©2019 F.A. Davis Company Therapeutic Communication Techniques (continued_4) § Voicing doubt: Expressing uncertainty as to the reality of patient’s perception § Verbalizing the implied: Putting into words what patient has only implied § Attempting to translate words into feelings: Putting into words the feelings the patient has expressed only indirectly § Formulating plan of action: Striving to prevent anger or anxiety escalating to unmanageable level when stressor recurs Copyright ©2019 F.A. Davis Company Clicker Question 4 4. As the move-out date to leave the shelter gets closer, a battered wife states, “I'm afraid to leave here. I'm afraid for my safety and the safety of my children.” Which nursing statement is most supportive? A. “This is a difficult transition. Let's formulate a plan to keep you all safe in the community.” B. “It’s the policy that patients can only live here for 30 days. Maybe we can ask for more time.” C. “You've had a month to come up with a plan for keeping you and your family safe.” D. “Hopefully, your husband has been in counseling. I’m sure this will work out fine.” Copyright ©2019 F.A. Davis Company Clicker Question Answer 4 Correct Answer: A The nurse is using the therapeutic techniques of “reflection” and “formulating a plan of action.” The use of these communication facilitators indicates that the nurse is supportive of the patient’s feelings and appreciates the need for a safety plan. Copyright ©2019 F.A. Davis Company Nontherapeutic Communication Techniques § Giving reassurance: May discourage the patient from a further expression of feelings if the patient believes the feelings will only be downplayed or ridiculed § Rejecting: Refusing to consider the patient’s ideas or behavior § Approving or disapproving: Implies that the nurse has the right to pass judgment on the “goodness” or “badness” of the patient’s behavior Copyright ©2019 F.A. Davis Company Nontherapeutic Communication Techniques (continued_1) § Agreeing or disagreeing: Implies that the nurse has the right to pass judgment on whether the patient’s ideas or opinions are “right” or “wrong” § Giving advice: Implies that the nurse knows what is best for the patient and that the patient is incapable of any self-direction Copyright ©2019 F.A. Davis Company Nontherapeutic Communication Techniques (continued_2) § Probing: Pushing for answers to issues that the patient does not wish to discuss causes the patient to feel used and valued only for what is shared with the nurse § Defending: To defend what the patient has criticized implies that the patient has no right to express ideas, opinions, or feelings § Requesting an explanation: Asking “why” implies that the patient must defend his or her behavior or feelings Copyright ©2019 F.A. Davis Company Nontherapeutic Communication Techniques (continued_3) § Indicating the existence of an external source of power: Encourages the patient to project blame for his or her thoughts or behaviors on others § Belittling feelings expressed: Causes patient to feel insignificant or unimportant § Making stereotyped comments, clichés, and trite expressions: These are meaningless in a nurse–patient relationship Copyright ©2019 F.A. Davis Company Nontherapeutic Communication Techniques (continued_4) § Using denial: Blocks discussion with the patient and avoids helping the patient identify and explore areas of difficulty § Interpreting: Results in the therapist telling the patient the meaning of his or her experience § Introducing an unrelated topic: Causes the nurse to take over the direction of the discussion Copyright ©2019 F.A. Davis Company Clicker Question 5 5. The nurse is performing an initial assessment on a newly admitted patient who is oriented times four. Which of the following communication techniques would best facilitate obtaining accurate and complete patient data? A. Closed-ended questions B. Requesting an explanation C. Open-ended questions D. Interpreting Copyright ©2019 F.A. Davis Company Clicker Question Answer 5 Correct Answer: C Open-ended questions are phrased in a way that gathers as much information as possible. By the use of phrases such as “Tell me about…” or “Describe to me…” a varied and rich body of information can be assessed. Copyright ©2019 F.A. Davis Company Active Listening § To listen actively is to be attentive to what patient is saying, both verbally and nonverbally. § Several nonverbal behaviors have been designed to facilitate attentive listening. Copyright ©2019 F.A. Davis Company Active Listening (continued) § S: Sit squarely facing the patient § O: Observe an open posture § L: Lean forward toward the patient § E: Establish eye contact § R: Relax Copyright ©2019 F.A. Davis Company Motivational Interviewing § Evidence-based, patient-centered style of communication that promotes behavior change by guiding patients to explore their own motivation for change and the advantages and disadvantages of their decisions § Incorporates active listening and therapeutic communication techniques but focuses on what the patient wants to do Copyright ©2019 F.A. Davis Company Process Recordings § Process recordings are written reports of verbal interactions with patients. § They are written by the nurse or student as a tool for improving communication techniques. Copyright ©2019 F.A. Davis Company Feedback § Feedback is useful when it: Is descriptive rather than evaluative Is specific rather than general Is directed toward behavior that the patient has the capacity to modify Imparts information rather than offers advice Is well-timed Copyright ©2019 F.A. Davis Company