Therapeutic NPt Relationship Communication 1 Therapeutic NP Relationship

Therapeutic N-Pt Relationship Communication 1

Therapeutic N-P Relationship • Def: a series of goal-directed interactions • Peplau: nursing as a significant, therapeutic, interpersonal process • Characteristics - goals, stages, specific time and place. It is different from a social relationship 2

N-Pt Relationship • • Communication skills Respect and a desire to help Trust is based on confidentiality Understanding mental mechanisms adaptation styles coping strategies therapeutic intervention skills 3

Communication • • In-born nature Happened at anytime, anyplace, Multi-level Verbal & Nonverbal Proxemics - environmental, social, and personal space Kinesics - body movement • Can be learned 4

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Therapeutic Communication • Def: It is an interpersonal interaction in which the nurse used the self to focus on the client’s emotional issues, establish a therapeutic relationships, identify client’ issues, discern the most important topic at that time, and guide the client toward identifying his/her own solutions to problems 6

Therapeutic Communication Techniques (I) • • Broad opening - start the conversation Offering self - available, concern, interest Active listening - content, emotion Using silence - respect, anxiety Asking questions - what, when, who… General leads - go on, Mm. . . Restating - repeating 7

Thera. Commu. Tech (II) • Making observation - comment on what have been seen • reflecting • Clarification - restate • Focusing - single, important topic • Exploring - getting more information • Interpreting - 8

Thera. Commu. Tech (III) • Giving information - decision making • Presenting reality - but no argument • Voicing doubt - uncertainty about pt’s interpretation/conclusion • Placing an event in time or sequence - R among events • Encouraging comparison - similarity & difference • Summarizing - review the main points 9

Nontherapeutic communication techniques • • Advising vs. information giving Agreeing/approval vs. giving recognition Disagreeing vs. information seeking Challenging/arguing vs. information seeking Defending vs empathy Introducing unrelated topic vs. focusing Judging vs. voicing doubt 10

Nontherapeutic communication techniques (cont’d) • • • Literal response Probing Reassuring - false promising Rejecting - no more sharing Testing - level of insight/knowledge Close-ended question - yes/no 11

Phases of N-Pt Relationship • Preinteraction phase self-awareness, self-exploration • Introductory or orientation phase making a contract, building trust, setting goals • Working phase explore stressors, promoting insight, reality testing, problem-solving, coping, identifying past ineffective behavior • Termination phase goals, evaluation, referrals, separation, loss, emotional responses 12

Orientation Stage • Building trust - honest, consistent, warmth • Basic assessment - coping styles, needs, tentative goals, awareness of the problems • Management of emotions- fear of losing control, anxiety, guilt, confusion, • Providing support - non-judgmental, recognize the healthy actions & feelings • Providing structure - limit setting 13

Assessment • Mental status examination - orientation, memory, calculation, attention, judgment… • Fifth vital signs - Pain • Violence , history of physical/sexual abuse • Substance abuse • Withdrawal symptoms, differential Dx, dual Dx. • Holistic/ interdisciplinary team- realistic goals 14

Working Stage • The process of learning - observation, analysis, interpretation, • In-depth data collection, • Reality testing & cognitive restructuring • Supportive confrontation • Promoting change, • Teaching new skills – social skills, problem solving skills… 15

Termination Stage • • Evaluation; summarize the objectives achieved Referrals Discussion of termination - emotional responses; acceptance, denial, anger, regression. 16

Use of Self - Self is the “Tool” • Want to help • Open to learn about self and others - Process recording • Respect & privacy • Communication - verbal/nonverbal • Insight - defense mechanisms, adaptation, and coping 17

Process Recording • • • The tool with which the nurse assesses pt’s problems, elicits pt’s input, selects interventions evaluates the effectiveness of care learns about self 18

Process Recording (cont’d) • • Verbal interaction & nonverbal behaviors Analysis of content, mood, and interaction Share with colleagues Learning tool / professional growth 19

Nursing Challenges • • • Silence - being quiet, listening, respect, “Doing nothing” - lack of structure Fear of aggression What to say - saying wrong thing Being there vs. being therapeutic - no one is 100% therapeutic • Touch 20

More Nursing Challenges • Self-disclosure - guidelines & cautions • Keep self disclosure effective Not to meet your own needs Monitor your comfort level Respect pt privacy/ comfort level Never agree to secrecy Cultural variations 21

Clinical Wisdom • Remain true to nursing role and avoid the seductions of institutionalization • Nurses must constantly monitor and understand boundary management, transference and countertransference issues 22

Empathy Putting yourself in the other’s shoes • • Being there Listening Assumption - as if Interpretation and validation 23

Barriers in Expressing Empathy • • • Stress Lack of time High acuity, high workload New employee Caring for difficult patients Limited opportunities to spend time with patients 24

English as a Second Language • Diversity trend of the society. • Process information in another language & articulate a culturally sensitive patient response. • Mentor & support the ESL psychiatric worker in linguistic competence & therapeutic communication techniques. 25

Demographics in the U. S. • 1998 - U. S. Bureau of Census • White, 72%; Black, 13% • Hispanic, 11%; Asian and Pacific Islanders 4%. • 2050: Euro-Americans will be the slight majority and the combination of other cultural groups will make up the remaining 48% of the people in the United States 26

Shrink the Earth’s Population to 100 • • • 57 Asians 21 Europeans 14 North, Central and South Americans 8 Africans 70 would be non-white, 30 white 70 would be non-Christian, 30 Christian 27

Cultural Issues • Ethnocentrism – only acknowledging and valuing one’s own culture • Cultural competent nursing – Sensitivity – Awareness – Knowledge – Encounter – Desire 28

Nursing Diagnosis & Nursing Goals Nursing Dx. - be specific and point to a desired outcome Goals 1. adaptive behavior vs. dysfunctional one 2. measurable and achievable in time frame 3. Short- term vs. long-term goals 29

Behavioral Assessment • Context, thought, and feeling associated with the behavior, • Congruence of the behavior to the context • Adapativeness of the behavior 30

Planning • Behavior-oriented problems - suicide, aggression, escape, withdrawal, delusion, compulsive acts, • Update with treatment team • Patient’s strength and weakness • Continuum of care - education, referral, . . . 31

Anxiety, Coping & Crisis Stressor Anxiety Coping behaviors Neurochemical/ physiological reactions Adaptive Maladaptive Dysfunctional 32

Defense Mechanisms • • Compensation Conversion Denial Displacement Dissociation Identification Intellectualization Projection • Rationalization • Reaction formation • Regression • Repression • Sublimation • Suppression • Undoing 33

Defense Mechanisms (II) • Primary gain – relief or expression of anxiety through symptoms of disorder. • Secondary gain – attention and support received from others while ill. 34

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Theory and model • Theory – beliefs about how things happen and work • Theory lead to the expansion of knowledge • Theories & models: – Psychoanalytic theory – Behavior theory – Cognitive-behavior theory – Ecologic-developmental model 37

Family Adaptation Model • Dealing with the catastrophic event – Crisis, chaos, shock – Denial – Hoping against hope • Learning to cope – Anger, gild, resentment – recognition – grief • Moving into the advocacy – Understanding, acceptance, advocacy and action 38

Evidence based practice • Nursing practice based on the scientific method and empirical evidence • Def: Care that integrates the best available evidence from research with clinical expertise • Barrier – – some clients are disenchanted with the outcomes of professionally approved treatments 39 – Pseudoscientific information from internet

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