Therapeutic Relationships Psychiatric Mental Health Nursing Objectives State

Therapeutic Relationships Psychiatric Mental Health Nursing

Objectives State the goals of therapeutic nursepatient relationship Discuss the personal qualities a nurse needs to be an effective helper Describe the nurse’s tasks and possible problems in the four phases of the relationship process Analyze how the nurse can use verbal and non-verbal communication effectively in a therapeutic relationship

Objectives Understand how self-awareness impacts therapeutic relationship Use the Jahari Window and the Values Clarification Process to gain increased selfawareness Demonstrate increasing effectiveness in using therapeutic relationship skills to produce a therapeutic outcome

Defined The therapeutic nurse-patient relationship is a mutual learning experience and a corrective emotional experience for the patient. Based on: mutual respect; acceptance of sociocultural differences; and the humanity of the patient and nurse.

Personal Qualities of the Nurse � SELF ASSESSMENT � Psychological: knowledge of emotions, motivations, self-concept, & personality. � Physical: Knowledge of personal & general physiology (body sensation, body image, & physical potential). � Environmental: components such as sociocultural, relationships to others, knowledge of relationship between humans & nature. � Philosophical component: sense of life having a meaning, including responsibility to the world & the ethics of behavior.

Jahari window Each quadrant describes one aspect of the self. 1 Known to self And Others 2 Known only To others 3 Known only To the self 4 Known neither to Self nor To others

Self disclosing is the revealing to others important aspects of the self. It is considered a sign of personality health & a means of achieving a healthy personality. CAUTIONARY NOTE regarding disclosure with patients - limits, boundaries, professional/therapeutic relationship

Values Clarification What is important to me? Values: concepts that are formed as a result of life experiences with humans, culture, education, work, & leisure. Values have both a positive and negative component (i. e. , honesty vs dishonesty) A nurse’s challenge is to provide care to persons with differing value systems than their own.

Values Clarification Process Steps in the Process Choosing Freely From alternatives After thoughtful consideration of the consequences of each alternative Prizing Cherishing, being happy with the choice Willing to affirm the choice publicly Acting Doing something with the choice Repeatedly, in the same pattern of life

Exploration of Feelings serve as important barometers for feedback about themselves & their relationships to others. Being open to your feelings helps to understand how you are responding to patients and how you appear to patients. Your feelings are valuable clues to the patient’s problems.

Serving as a Role Model � Nurse has an obligation to model adaptive & growth producing behavior. � It is not possible to separate one’s personal life from one’s professional life…a chaotic personal life results in a chaotic professional practice. � Compartmentalization is not possible in psychiatric nursing because this specialty is therapeutic use of the self …the whole self…a self that is fulfilled, satisfied and meaningful.

Altruism Why do I want to help others? Altruism is the concern for others. Maintain a balance between the need to help others and the amount of satisfaction & fulfillment received from work.

Phases of the Relationship: Pre-orientation Self assessment: first contact with patient ◦ What am I feeling? Thinking? What bias or stereotype attitudes do I have about this population? Do I fear closeness, rejection, indifference? How do I feel when a person is rude, hostile or uncooperative? Do I need to feel important and keep patients dependent on me? ØGather Data ØPlanning first interaction with patient.

Stages of the Relationship: Introductory or Orientation Phase Find out why patient sought help (Table 2 -2) p. 20. Establish a partnership Agree on the nature of the problem Set mutual goals Establish a contract

Introductory phase-forming a contract Discuss the issue of confidentiality at this time. Tasks for the nurse are: establish a climate of trust; understanding, acceptance and open communication. Discuss mutually agreed upon specific goals that can be realistically accomplished in the time you have with patient.

Stages of the Relationship: Working Phase Explore stressors Promote the development of insight – link them to perceptions, thoughts, feelings, & actions. Translate the insights into action & change in behavior.

Stages of the Relationship: Termination Phase Difficult but most important phase of relationship- whether meeting is one time or many. Exchange feelings and memories Work through feelings of separation. Evaluate patient’s progress & goal attainment. Make referrals if appropriate. Review criteria for determining patient’s readiness for termination (Stuart, p. 21, Box 2 -5)

Facilitative communication All communication takes place on two levels (verbal & non-verbal) which can serve to develop a relationship or block it. ◦ Communication is the vehicle psychiatric nurses use to establish relationships with patients. ◦ Communication is the means by which a psychiatric nurse influences the behavior of another.

Exchange of messages

Verbal communication Occurs through words, either spoken or written. Not as effective in communicating feelings or subtle meanings between individuals. A limitation is that words change meaning in different social and cultural groups and words change meaning over time. ◦ Example: bread (the food); bread (can mean money). ◦ Nurses need to be prepared to communicate effectively with a wide diverse population of individuals.

Non-verbal communication Includes all relayed information not involving spoken or written words…including cures from the 5 senses. 55% of meaning is transmitted by body cues. Non-verbal communication is often unconsciously motivated & is, therefore, more accurate in meaning.

Types of non-verbal (NV) communication All these behaviors are influenced by one’s sociocultural background. There are 5 catagories of NV: ◦ ◦ ◦ vocal cues action cues object cures space touch

Action cues

Space There are four zones of space in Western society:

TOUCH Response to touch is influences by many factors: setting, cultural background, type of relationship, gender of persons, ages, & expectations. Touch can be nurturing or threatening depending on the person’s experience with it. TT & Reiki as means of therapy.

Interpretation of nv cues Context Sociocultural background Check out the nv cue with the patient…by referring to the specific behavior observed & try to confirm its meaning with the person.

Therapeutic communication techniques Preserve self-respect of both individuals Communicate acceptance & understanding before giving advice or suggestions. (first listen to their story). Techniques: listening, broad openings, restating, clarification, reflection, focusing, sharing perceptions, theme identification, silence, humor, informing, & suggesting.

Some suggestions & comments Listening- practice keeping your mouth shut until the person stops talking. Don’t formulate a response until you hear the whole story. Listening itself is therapeutic. You do not have to have all the answers. Listening is a sign of deep respect. While listening, you should not be thinking about yourself. Broad openings- allows the person to pick the topic most urgent in their minds. Restating – is a repeating (in your words) of the main theme you are hearing in the person’s statements.

Clarification – given the verbal and nonverbal communication you observed in the exchange with the person…try to pull it together and make a statement that reflects what you have heard them say…and then ask, “Is this what you mean? ” Reflection – ◦ refection of content is also called validation…it is the nurse letting the person know they are understood, using fewer words that express the essential ideas the person stated. ◦ Reflection of feeling is a nurse’s response to the person’s feelings…intent is to increase awareness of feelings.

Focusing – helps the person expand on a topic, be specific, & clarify its meaning. Sharing perceptions – involves asking the person to verify the nursing’s understanding of what the person is thinking or feeling. Theme identification – underlying issues or problems experienced by the person that emerge repeatedly during a conversation. Silence – “the pregnant pause” silence allows the person time to think & gain insights. Allow the person to break the silence. Maintain nv cues of interest when you use this.

Humor – it is a constructive coping behavior. It can provide insight by making conscious repressed issues. Humor’s use in a relationship depends on the nature of the relationship. See positive uses of humor (Stuart, p. 29, Box 2 -6). Be mindful of its negative effects: It can be inappropriate to the person’s values, or when it ridicules people or belittles others. If used inappropriately, it can be destructive and anxiety producing.

Informing – information giving is an essential role of nurses for health teaching or patient education. It is not the same as giving suggestions or advice. Suggesting – presents alternative ideas to cope or solve problems. It can be negative if it reinforces a person’s dependency needs. Avoid the trap of being responsible for the person’s outcome…shift the responsibility to the person by allowing them to make their own choice of the options presented.

Take home concepts Therapeutic relationship ◦ Mutual learning ◦ Corrective emotional experience for the patient ◦ Occurs in stages Nurses use of self ◦ Self-awareness of personal attributes Verbal and non-verbal communication