Therapeutic Relationships

1. Therapeutic Relationships

2. Learning Outcomes • Describe necessary components in the nurse-patient relationship. • Explain the importance of values, beliefs, and attitudes in the development of the nurse-patient relationship. • Describe the importance of self-awareness and therapeutic use of self in the nurse-patient relationship. • Describe the differences between social and therapeutic relationships. • Describe and implement the phases of the nurse-patient relationship. • Explain the negative behaviors that can diminish the nurse-patient relationship.

3. Therapeutic Relationships • The ability to establish therapeutic relationships with patients is one of the most important skills a nurse can develop • The therapeutic relationship is especially crucial to the success of interventions with clients requiring psychiatric care because the therapeutic relationship and the communication within it serve as the underpinning for treatment and success • Therapeutic nurse-client relationships: • Trust • Genuine interest • Acceptance • Positive regard • Self awareness • Therapeutic use of self

4. Therapeutic nurse-patient relationship • Purposeful and goal-directed • Directed towards the clients needs • Has defined boundaries • Clients know what they can do and the nurse defines these boundaries • Is structured to meet the patient’s needs • Is safe, confidential, reliable, and consistent • A social relationship between friends is subject matter, in a therapeutic relationship there is no social relationship, its all about the patient • Nurse is responsible for initiating the nurse-patient relationship

5. Therapeutic Relationships (cont’d) • Components include: • Trust • Builds when the client is confident in the nurse and when the nurse’s presence convey integrity and reliability • Develops when the client believes that the nurse will be consistent in her words and actions, can be relied on • Congruence (when words and actions match) • Ex. Nurse has to leave for a meeting and says she will be back at 2 pm, and she is back by 2 pm • Genuine interest • When the nurse is comfortable with herself, aware of her strengths and limitation, and is clearly focused • Dishonest or artificial behavior: asking a question and not waiting for the answer, talking over the client • Revealing personal information (biographical data, ideas, thoughts, feeling) can enhance openness and honesty and allow for the client to share more information about themselves • Empathy (not sympathy) • The ability of the nurse to perceive the meaning and feelings of the client and to communicate that understanding to the client • Being able to put myself in the clients shoes (not poor you = sympathy) • “gift of self”: client – by feeling safe enough to share feelings; nurse – by listening closely enough to understand

6. Therapeutic Relationships (cont’d) • Acceptance of person, not necessarily his or her behavior • Nurse does not become upset or respond negatively to a client’s outburst, anger or acting out • Avoiding judgment of the person no matter what the behavior but be clear and firm • Unconditional positive regard • Appreciates the client as a unique worthwhile human being can respect the client regardless of his or her behavior, background, or lifestyle • Unconditional nonjudgmental attitude (don’t have to accept behavior) • Calling the client by name, spending time with the client, listening and responding openly • Consider the client’s ideas and preferences • Attending – uses nonverbal and verbal communication techniques to make the client aware that he is receiving full attention • Nonverbal: leaning toward the client, maintaining eye contact, being relaxed, arms at side, interested but neutral attitude • Verbal: avoids communicating value judgments or negative opinions about the client’s behavior • Self-awareness and therapeutic use of self • Before the nurse can understand clients, the nurse must first know herself • (Next slide  )

7. Self-Awareness and Therapeutic Use of Self • Self-awareness:process of understanding one’s own values, beliefs, thoughts, feelings, attitudes, motivations, strengths, and limitations and how one’s thoughts and behaviors affect others • Allows the nurse to observe, pay attention to and understand the subtle responses and reactions of clients interacting with them • Values: abstract standards that give a person a sense of right and wrong and establish a code of conduct for living • Hard work, honesty, sincerity, cleanliness, orderliness • Choosing – when the person considers a range of possibilities and freely chooses the value that feels right • Prizing – when the person considers the value, cherishes it, and publicly attaches it to herself • Acting – when the person puts the value into action • Beliefs: ideas that one holds to be true • Ex. All old people are hard of hearing • Attitudes: are general feelings or a frame of reference around which a person organized knowledge about the world

8. Therapeutic Use of Self • Therapeutic use ofself:the nurse uses aspects of his or her personality, experience, values, feelings, intelligence, needs, coping skills, and perceptions to establish relationships with clients that are beneficial to clients • Nurses use themselves as a therapeutic tool to establish therapeutic relationships with clients and to help clients grow, change, and heal • Nurse’s personal actions arise from conscious and unconscious responses that are formed by life experiences and educational, spiritual and cultural values • Johari window • Quadrant 1: open/public self – qualities one knows about self and others also know • Quadrant 2: blind/unaware self – qualities know only to others • Quadrant 3: hidden/private self – qualities know only on oneself • Quadrant 4: unknown – an empty quadrant to symbolize qualities as yet undiscovered by oneself or others

9. Establishing the Therapeutic Relationship • Therapeutic relationships are focused on the needs, experiences, feelings, and ideas of the patient, not the nurse • The therapeutic relationship consists of three phases: • Orientation – begins when the nurse and client meet and ends when the client begins to identify problems to examine • Working – divided into 2 sub-phases: • Problem identification: client identifies the issues or concerns causing problems • Exploitation: the nurse guides the client to examine feelings and responses and to develop better coping skills and a more positive self image, this encourages behavior change and develops independence • Termination – final stage in nurse-client relationship, begins when the problems are resolved, and it ends when the relationship is ended • Client may feel the termination as an impending loss, often try to avoid termination by acting angry or as if the problem has not been resolved

10. Establishing the Therapeutic Relationship (cont’d) • In the orientation phase: • The nurse and patient meet • Roles are established • Purposes and parameters of future meetings are discussed • Expectations are clarified • Patient’s problems are identified • Nurse builds trust with client • Client shares preconceptions and expectations of nurse based on past experience • Nurse helps client plan use of community resources and services

11. Establishing the Therapeutic Relationship (cont’d) • The working phaseinvolves: • Problem identification • The patient identifies the issues or concerns causing problems • Examination of the patient’s feelings and responses • Client fluctuates dependence, independence and interdependence in relationship with nurse • Exploitation: • Development of better coping skills and a more positive self-image, behavior change, and independence • Client develops skill in interpersonal relationships and problem solving • Client displays changes in manner of communication (more open, flexible)

12. Establishing the Therapeutic Relationship (cont’d) • In the working phase, the nurse must be acutely aware of 2 common elements that can arise: • Transference: when patients unconsciously transfer feelings they have for significant persons in their life onto the nurse • Countertransference: when the nurse responds to the patient based on his or her own unconscious needs and conflicts

13. Establishing the Therapeutic Relationship (cont’d) • The termination or resolution phase: • Begins when the patient’s problems are resolved • Ends when the relationship is ended • Deals with feelings of anger or abandonment that may occur • Client maintains changes in style of communication and interaction • Client shows positive changes in view of self

14. Behaviors That Diminish Therapeutic Relationships • Inappropriate boundaries (relationship becomes social or intimate) • Feelings of sympathy and encouraging dependency • Want them to be as independent as they can be • You want to be empathetic and not sympathic • Nonacceptance of the patient as a person because of his or her behaviors, leading to avoidance of the client, negative verbal responses or facial expressions of annoyance or turning away from the client • Nurse self-awareness is the way to avoid such problems (obtain professional boundaries)

15. Therapeutic Roles of the Nurse in a Relationship • Teacher • During the working phase the nurse my teach the client new methods of coping and solving problems, instruct about med regimen and availability of community resources • To be a good teacher the nurse must feel confident about the knowledge he or se has and must know the limitations of that knowledge base • Caregiver • Help them explore feelings, build trust, assist the client in problem solving and help the client meet psychosocial needs • Help them to be able to talk with others • Help them with physical complaints • If the client requires physical care, the nurse needs to explain to the client the need for touch so they don’t perceive it as intimacy or sexual • Advocate • Act on client’s behalf, informs the client and then supports him in whatever decision he makes • Make sure needs are met, not being taken advantage of, physically and psychologically safe, ensure privacy and dignity, promoting informed consent, preventing unnecessary exams and procedures, accessing needed services and benefits, ensuring safety from abuse and exploitation by a health professional or authority figure • Parent surrogate • Many have very child like behaviors • May have to remind them to eat, bathe or actually feed or bathe them • Be very careful that it is a therapeutic type of reminder (be open, easy going, nonjudgmental) • Be clear and firm and set limits or reiterate the previously set limits

16. Self-Awareness Issues • Self-awareness on the nurse’s part is crucial to developing therapeutic relationships • Values clarification, journaling, group discussions, and reading will assist with this process • Developing self-awareness is a continual, ongoing process; the nurse needs to plan for self-growth • Nurses need to learn to “care for themselves” • Balancing work with leisure time, building satisfying personal relationships with friends, taking time to relax and pamper oneself • Overly committed to work become burned out • Nurses who fail to take good care of themselves also cannot take good care of clients and families

17. Therapeutic Communication

18. Learning Outcomes • Describe the goals of therapeutic communication. • Identify therapeutic and non-therapeutic verbal communication skills. • Discuss boundaries in therapeutic communication.

19. Communication • The process people use to exchange information: • Verbal • Words a person uses to speak • Context • Environment in which communication occurs and can include the time and the physical, social, emotional and cultural environment • Nonverbal • Behavior that accompanies verbal content such as body language, eye contact, facial expression, tone of voice, speed and hesitations in speech • Congruency • Is what you are saying and your actions congruent • When verbal and nonverbal communications agree • Incongruency • When verbal and nonverbal communications don’t agree • When what the speaker says and what he or se doesn’t agree

20. Communication (cont’d) • Interpersonal interactions between the nurse and the patient during which the nurse focuses on the client’s specific needs to promote and effective exchange of information • It focuses on the patient’s specific needs and is used to: • Establish the therapeutic relationship • Identify the patient’s most important concerns • Assess the patient’s perceptions • Facilitate the patient’s expression of emotions • Teach the patient and family necessary self-care skills • Recognize the patient’s needs • Implement interventions designed to address the patient’s needs • Guide the patient toward satisfactory and acceptable solutions

21. Essential Components of Therapeutic Communication • Privacy and respect for boundaries • Therapeutic communication is most comfortable at 3 to 6 feet; should not be less than 18 inches • Privacy is desirable but not always possible in therapeutic communication • An interview or conference room is optimal if the nurse believes this setting is not too isolative for the interaction • Intimate zone – 0-18 inches, this space is comfortable with parents with young children, intimate couples, whispering, invasion is threatening and produces anxiety • Personal zone – 18-36 inches, comfortable between friends and family • Social zone – 4-12 feet, communication in social, work and business settings • Public zone – 12-25 feet, between speaker and audience, small groups, other informal functions • Touching • Touch may be comforting and supportive • Touch also is an invasion of intimate and personal space • Nurse must evaluate whether the patient perceives touch as positive or threatening and unwanted; never assume that touching a patient is acceptable • Need to let them know when you are going to touch them: “I am going to take your dressing off now”, “I am going to touch you” • Professional-functional – used when doing procedures • Social-polite – greeting, hand shake • Friendship-warmth – hug, arm around shoulder • Love-intimacy – tight hugs and kisses b/w lovers or close family • Sexual-arousal – touch used by lovers

22. Essential Components of Therapeutic Communication (cont’d) • Active listening means refraining from other internal mental activities and concentrating exclusively on what the patient says • Active observation means watching the speaker’s nonverbal actions as he or she communicates • These are used to help the nurse to: • Recognize the issue that is most important to the client at this time • Know what further questions to ask the client • Use additional therapeutic communication techniques to guide the client to describe his perceptions fully • Understand the client’s perceptions of the issue instead of jumping to conclusions • Interpret and respond to the message objectively

23. Verbal Communication Skills • Use concrete messages • Concrete messages are specific and clear (explicit and need no interpretation, use nouns instead of pronouns) • What health symptoms caused you to come to the hospital today? • Concrete messages elicit more accurate responses • Many patients can’t understand if you do not use concrete words or messages

24. Verbal Communication Skills (cont’d)(NOTE: Refer to p. 107-111,table 6.1) • Therapeutic communication – techniques facilitate interaction and enhance communication between patient and nurse • Techniques that encourage the patient to discuss his or her feelings or concerns in more depth include: • Exploring – delving further into a subject • “Tell me more about that” • Focusing – concentrating on a single point • “This point seem worth looking at more closely” • Restating – clarification, repeating the main idea the client has stated to you • Pt says “I can’t take this med” nurse says “you can’t take this med?” • Reflecting – directing client actions, thoughts and feelings back to the client • Pt “do you think I should tell the dr….”, nurse “do you think you should?” • Make observations – verbalizing what the nurse perceives • Have a client who is just sitting there and not interacting with anyone, ask them what is wrong with them • “you appear tense”, “are you uncomfortable when…?”,

25. Verbal Communication Skills (cont’d) • Non-therapeutic communication includes: • Advising – telling the client what to do • “I think you should…”, “why don’t you…” • Agreeing – false fix ideal, indicating accord with the client, you don’t argue with them cause they do have that belief and you will not win, don’t agree with her delusions – voice doubt about the delusions • Once you believe you are superman its hard to believe you can fly • Reassuring – indicating there is no reason for anxiety or other feelings of discomfort, don’t tell them “everything will be ok”, cause you don’t know if it will be and if its not you don’t want them asking you why and blaming you • “I wouldn’t worry about that”, “keep your chin up”

26. Nonverbal Communication Skills • Facial expression – connect with words to illustrate meaning • Expressive – portrays person’s thoughts, feelings, needs • Impassive – face is frozen, emotionless • Confusing – opposite of what the person wants to convey • Body language – gestures, posture, movements, body positions • Closed – legs crossed, arms folded • Accepting – face client, feet on floor, knees parallel, hands at side of body, you can cross legs at ankle • Vocal cues – voice volume, tone, pitch, intensity, emphasis, speed, pauses augment the sender’s message • Eye contact – looking into the other person’s eyes during communications, mirror of the soul, reflects our emotions • Silence – can mean different things • Client may be depressed and struggling to find the energy to talk • Client is thoughtfully considering the question before responding • Not paying attention • Rude for the nurse to jump in, be patient and give them time

27. Understanding the Meaning of Communication • Messages often contain more meaning than just the spoken words • The nurse must try to discover all the meaning in the patient’s communication, not only the literal meaning of the words • Ex. A pt with depression says “I’m so tired that I just can’t go on” • It could mean fatigue associated with depression or that they want to die

28. Understanding Context • Understanding the context of a situation gives the nurse more information and reduces the risk of assumptions • To clarify context, the nurse must gather information from verbal and nonverbal sources and validate findings with the patient • Ex. Pt says “I collapsed” • Could mean she fainted or felt weak and had to sit down OR she could mean she was tired and went to bed

29. Understanding Spirituality • Spirituality is a patient’s belief about life, illness, death, and one’s relationship to the health, universe • The nurse must first assess his or her own spiritual beliefs • Nurse must remain objective and nonjudgmental regarding the client’s beliefs and must not allow them to alter nursing care • The nurse must remain objective and nonjudgmental • The nurse must assess the patient’s spiritual needs • Also must guard against imposing her own on the client • Must ensure that the client is not ignored or ridiculed because his beliefs and values differ from those of the staff

30. Cultural Considerations • Culture – all the socially learned behaviors, values, beliefs and customs transmitted down to each generation • The nurse must be aware of cultural differences in: • Speech patterns and habits • Styles of speech and expression • Eye contact • Touch • Concept of time • Health and health care

31. Goals of a Therapeutic Communication Session • Establishing rapport by being empathetic, genuine, caring, and unconditionally accepting of the client • Identifying issues of concern by actively listening, formulate a client-centered goal for the interaction • Being empathetic, genuine, caring, and unconditionally accepting of the person • Understanding the patient’s perception, in depth, foster empathy in the nurse-client relationship • Exploring the patient’s thoughts and feelings • Developing problem-solving skills • Promoting the patient’s evaluation of solutions

32. Beginning Therapeutic Communication • Introduce and establish a contract • Find patient-centered goals • Use directive or nondirective role appropriately, based on patient behaviors • Directive – asking direct yes/no questions and using problem solving to help the client develop new coping mechanisms to deal with present issues • Used when the client is suicidal, experiencing crisis, or out of touch with reality • Nondirective – using broad openings and open ended question to collect information and help the client to identify and discuss the topic of concern • Client does most of the talking

33. Beginning Therapeutic Communication (cont’d) • Phrase questions appropriately: • Ask for clarification • Manage patient’s avoidance of the anxiety-producing topic • Avoid asking why • Guide the patient in problem-solving and empower the patient to change • Identify the problem, brainstorm all possible solutions, select the best alternative, implement the selected alternative, evaluate the situation, if dissatisfied with results select another alternative and continue the process • Alert for inappropriate responses by nurse

34. Community-Based Care • Nurses are increasingly caring for patients in the family unit and in communities • Nurses need increased self-awareness and knowledge about cultural differences • Nurses need self-awareness and sensitivity to the beliefs, behaviors, and feelings of others • Nurses must collaborate with the patient and family as well as other healthcare providers • Assess relationships of the family

35. Self-Awareness Issues • Nonverbal communication is as important as verbal • Ask colleagues for feedback • Examine your communication skills

36. Patient’s Response to Illness

37. Learning Outcomes • Discuss individual characteristics and factors that influence a patient’s response to illness. • Explain the nurse’s role working with patients of different cultural backgrounds. • Describe cultural factors important in assessing and working with patients of different cultures.

38. Individual Factors • Age, stage of growth and development • Diagnosed at a younger age has poorer outcomes than diagnosed at an older age because younger people have not had experiences of successful independent living or the opportunity to work and be self sufficient and have a less well developed sense of personal identity than older clients • Lack understanding and ability to describe feelings • Genetics and biologic factors • Some disorder have been linked genetically • Others that research has not proven are genetic, tend to appear more frequently in families • Family history and background are important assessments • Physical health and health practices • The healthier a person is the better they cope • Walking and stretching decrease negative effects to depression and anxiety • Response to drugs • Be alert to side effects and serum drug levels in clients from different ethnic backgrounds

39. Individual Factors (cont’d) • Self-efficacy (confidence) • A belief that personal abilities and efforts affect the events in our lives • Experience of success in overcoming obstacles • Social modeling (observing successful people) • Social persuasion (persuading to believe in themselves) • Reduce stress, build physical strength, learn how to interpret physical sensation positively • Hardiness • Ability to resist illness when under stress • Commitment: active involvement in life activities • Control: ability to make appropriate decisions in life • Challenge: ability to perceive change as beneficial rather than stressful • Moderating or buffering effect on people experiencing stress • Resilience and resourcefulness • Resilience: having healthy responses to stressful or risky circumstances • Resourcefulness: using problem solving abilities and believing that one can cope with adverse situations • Spirituality • Involves the essence of a person’s being and his beliefs about the meaning of life and the purpose for living • Includes belief in God or a higher power, practice of religion, cultural beliefs and practices, relationship with the environment • Serves as a primary coping device and a source of meaning, helps develop a social network

40. Interpersonal Factors • Sense of belonging • Feeling of connectedness with or involvement in a social system or environment of which a person feels an integral part • Maslow described a sense of belonging as a basic human psychosocial need that involves both feelings of value and fit • Support systems: family, friends, coworkers, clubs, social groups, health care providers • Social networks and social support • Social networks: groups of people whom one knows and with one feels connected (can help reduce stress, diminish illness, positively influence ability to cope and adapt – emotional support) • Social support: emotional sustenance that comes from friends, family members, health care providers who help a person when a problem arises (does not always provide emotional support) • Client must feel connected to these in order for it to be positive (boost confidence, self esteem, assistance in problem solving • Family support • Key factor in recovery, most important part of recovery even if not the most positive • Nurse encourages family to support client while in hospital and should identify family strengths such as love and caring

41. Cultural Factors • Beliefs about causes of illness • Culturally competent nursing care means being sensitive to issues related to culture, race, gender, sexual orientation, social class, economic situation • Factors in cultural assessment: • Communication (language, translator, nonverbal) • Physical space or distance (what distance is comfortable for the client) • Social organization (family structure and organization, religious values and beliefs, ethnicity, culture) • Time orientation (whether one views time as precise or approximate – urgency, taking meds on time) • Environmental control (client’s ability to control surroundings or direct factors in the environment) • Biologic variations (ethnicity – cause variations in response to drugs, race – biologic variations based on physical makeup) • Socioeconomic status and social class (status – income, education, occupation, influences a persons health, access to care, can afford meds; class – can be influence on social relationships, how people relate to each other, better than someone else)

42. Cultural Patterns and Differences • Knowledge of expected cultural patterns provides a starting place for the nurse to begin to relate to persons from different ethnic backgrounds. • Individual assessment of each person and family is necessary to provide culturally competent care that meets the client’s needs

43. Cultural Patterns and Differences (cont’d) • African Americans • Usually family-oriented, but client makes own decisions • Conversation animated and loud • Comfortable with public affection • Handshakes and direct eye contact convey interest and respect • Silence may indicate lack of trust • Church is important and a valued support system • Prayers are an important part of healing • View mental illness as a spiritual imbalance or punishment for sin • Use folk remedies in conjunction with western meds

44. Cultural Patterns and Differences (cont’d) • Filipinos • Greet others with smiles rather than handshakes • Facial expressions animated • Direct eye contact impolite, especially with authority figures • Soft spoken, avoid expressing disagreement • Mental illness viewed as having religious and mystical causes • Result of a disruption of the harmonious function of the whole person and the spiritual world • Can include: contact with a stronger life force, ghosts, souls of the dead, disharmony among wind, vapors, diet and shifted body organd • Most are catholic, may want priest and dr • Ill assume passive role, eldest male in household will make decisions after conferring with family members

45. Cultural Patterns and Differences (cont’d) • Mexican Americans • Touching prevalent among family, but not necessarily welcome from strangers • Handshake is ok • Direct eye contact with authority figures avoided • Silence denotes disagreement • Illness comes from imbalance between person and environment • Includes: emotional, spiritual, social and physical factors • Catholic, observe the rites and sacraments of that religion

46. Nurse’s Role in Working With Clients From Various Cultures • Nurse must learn about the client’s cultural values, beliefs, and health practices • Best source of information is the client: • “How would you like to be cared for?” • “What do you expect (or want) me to do for you?” • Religious beliefs and health practices • Do you follow any dietary preferences or restrictions? • How can I assist you in practicing your religious or spiritual beliefs? • What kinds of remedies have you tried at home? • Client is more likely to share personal and cultural information if the nurse is genuinely interested in knowing and does not appear skeptical or judgment

47. Self-Awareness Issues • Maintain a genuine, caring attitude • Ask how you can promote or assist with spiritual, religious, and health practices • Recognize your own feelings and possible prejudices • Remember that the patient’s response to illness is complex and unique

48. Assessment

49. Learning Outcomes • Identify the factors that influence the assessing of a mental health patient. • Describe how to conduct a interview with a patient on a mental health unit. • Explain the components used to gather information in the psychosocial assessment of a mental health patient. • Identify other sources of data used in patient assessment.

50. Purposes of Psychosocial Assessment • To construct picture of patient’s current emotional state, mental capacity, and behavioral function • To form basis for plan of care • To establish clinical baseline to evaluate effectiveness of treatment and interventions