Professional Interaction

1. Professional Interaction Sources: Psychiatric Nursing Skills, A patient-centred approach, Graham Dexter & Michael Wash, 2nd ed., Nelson Thomas Ltd., 2001 Mental Health Nursing, The Nurse-Patient Journey, Verna Benner Carson, 2nd ed., W.B. Saunders Co., 2000 Instructor: Doris O. Aghazarian, M.A., B.Sc.N., R.N.

2. Introduction • The mental health nurse must: • Have sound judgement • Identify the needs of clients / consumers / patients • Assist the clients in functioning as independently as possible. This means knowing when to withdraw in order not to create a new dependence.

3. Introduction (cont´d) • The client must be seen as an individual with whom dialogue is of prime importance • Counselling skills are very important, but the nurse is not a full-time counsellor: she/he is more of a coordinator of care • Knowledge about the ”abnormal mind” combined to interaction skills is the starting point

4. Professional interactionPersonal skills • The ability to adapt to different settings, roles and patients • Using self as a therapeutic tool: focusing on client´s own needs, dealing with own issues and being a role model • Sound core values and attitudes: having realistic expectations, not readily frustrated and ethical • Being ”a specialist in people”.

5. Professional interactionPersonal skills • SELF-AWARENESS Complete the following sentences: • I see myself as ... • My friends see me as ... • My family see me as ... • What I like about myself is ... • What I dislike about myself is ... • One thing other people like about me is ... • One thing other people dislike about me is ... • One asepct within me I would like to change is ... • The aspects about me other people would like to change are ...

6. Professional interactionPersonal skills • It is not necessary to see yourself as others see you, but you have to be aware of both perceptions and accept that they might be very different and conflicting • Have the courage to look at yourself honestly and to admit and accept your own negative qualities and attituteds. Otherwise, they will be get in the way of your helping relationship

7. Professional InteractionDeveloping self-awareness • Complete the following sentences: • The things in my life that are going right are ... • The things in my life that are going wrong are ... • The occasion when I am most likely to blame other things or people for my behaviour or circumstances is ... • The situations when I tend to lose control are ... • My main ”strengths” are ... • My main ”weaknesses” are ... • The situations I am uncomfortable in are ... • The reason I wish to be a nurse is ... • In one word I would describe myself as ... • In one word others would describe me as ...

8. Professional interactionSelf-esteem • To which extent do you agree with the following statements on a scale of 1-5: • My opinion is as important as that of my elders • I am confident enough to express my opinion in most situations • I am attractive/handsome and likeable • I am competent in what I do • I am fairly intelligent • It is important to make myself a priority at times • I can say no to requests for favours when I am busy • I take care of my body and self

9. Professional InteractionSelf-esteem (cont´d) • Levels of self-esteem fluctuate • Regularly or continually holding oneself in low esteem subjects a person to stress and suffering • Burnout can occur on the job because of low self-esteem • It is important to take care of oneself and we all have different ways of listening to our own needs and fulfilling them on a regular basis • Seek support from a personal tutor or cousellor if you suffer from low self-esteem

10. Professional interactionHandling feelings • Identification: if you are going through a similar period in life as the client (e.g. separation) it is important not to ”contaminate” the listening by assuming that you know what it is like for the client. • Interpersonal issues: if a nurse has strong feelings or emotions such as extreme attraction, extreme revulsion or fear, these must be acknowledged, voiced and support must be received to overcome them.

11. Professional interactionHandling feelings (cont´d) • Before entering into the world of another, the right to do so must be earned by looking scrupulously into one´s own world first. Awareness of own prejudices, feelings, situation and the areas one needs to develop must be realized.

12. Professional interactionClient-centred counselling skills • A councellor has to shed the preconceived idea of being the ”expert” • The counsellor does not advise, suggest, persuade or in any interfere with the client´s view of himself or his condition. He or she has a DIALOGUE. • The counsellor does not impose his or her own value system on the client – just clarifies if something is generally considered beneficial or unhealthy, but makes room for the individual´s choices about abortion, sexual orientation, beliefs and other values. A DIALOGUE IS ESTABLISHED. • Client-centred therapy requires a turst in human beings: that all people have inner resources and above all are motivated to improve, given the correct climate. THIS IS A TOPIC FOR DIALOGUE. • The client is encouraged to diagnose, prescribe and treat him/herself and is only given the necessary means and environment to do so.

13. Professional interactionConfidentiality • Inform your patient that you have to disclose the information you get to other members of your team and get permission to do so • The client must understand the full implications of confidentiality vs. disclosure • Tell the client that you must protect others as well as the client

14. Professional interactionSelf-disclosure • Be yourself – a real person with feelings and experiences. Regulate the distance between you and the client keeping in mind that you are a role model. • There is acceptable and unacceptable self-disclosure. Purposeful self-disclosure is acceptable. Self-disclosure of an emotional nature is unacceptable. • Self-disclosure is a highly effective and even informative communication tool, when used appropriately. It must always be goal-oriented and therapeutic, never an outlet for the nurse!

15. Professional interactionNon-verbal communication BE SENSITIVE, ATTENTIVE AND PERCEPTIVE! LOOK AT: - The face (especially the eyes) - Posture - Body space - Gestures - Touch - Tone of voice # First and foremest: BE AWARE OF THE SIGNALS YOU YOURSELF ARE SENDING!!! (¤ see handout of feeling vocabulary)

16. Professional interactionCommunication strategies • Use the following exploratory responding techniques while maintaining neutrality: • Paraphrasing (You are saying that ...) • Reflecting (It sounds that you are saying/feeling that ...[your interpretation]) • Clarifying (I am not sure what you are saying. Is it that ...?) • Summarizing (Your main concern/s seem to be ... Am I correct?) • As well as SILENCE, pauses are communicative

17. Professional interactionChallenging the client • Challenging is a very powerful way of helping people, but because of its power it can be either helpful or harmful. • Attempts at trying to shock clients into changing their attitudes may have very negative results and should be avoided. • Good challenging helps the client realize contradictions and new approaches and supports the careful and positive thinking of the client.

18. Professional interactionChallenging the client (cont´d) • Challenging usually means bringing the evasive client back to the subject being discussed • Challenging is a matter of giving honest feedback in a sensitive way, with the intention of introducing new ideas or ways of looking at a situation • An effective nurse tries to enable the client to begin challenging him/herself • When in doubt about the outcome, do not challenge!

19. Type of challenge Very good challenge Good challenge Average challenge Negative challenge Bad negative challenge Effect on client Enlightening Thought-provoking Confusing Causes resentment Causes extreme resentment Professional interactionGrading of challenges

20. Professional interactionTherapeutic Relationship Frameworks • NURSING FRAMEWORK • Hildegard Peplau (1952) stated that professional knowledge and skills are required to work with people suffering from mental disorders • Caring is a major prerequisite • This should be combined with extensive understanding of pathopysiology, pharmacology, which should be the basis of assessment, communication, teaching and awareness of ethical and legal principles • Another major prerequisite is attentiveness to the patient´s experience • Thirdly, positive connectedness – genuine interest

21. Professional interactionTherapeutic Relationship Frameworks • Nursing Framework (cont´d) • Although Peplau formulated her model in the 50s her description of the therapeutic relationship in nursing is still valid: • The stages/phases: ¤ orientation ¤ working together ¤ resolution / termination

22. Professional interactionTherapeutic Relationship Frameworks • PSYCHOLOGICAL FRAMEWORK • Carl Rogers (1951) is a model that is distinctly humanistic in orientation • It focuses on the patient and the here and now • It focuses on how the patient subjectively feels and experiences things and is experienced by the therapist • He introduced the conditions: empathy, genuineness, unconditional acceptance and positive regard

23. Professional interactionTherapeutic Relationship Frameworks • EXISTENTIAL FRAMEWORK • Martin Buber (1970) emphasized equality between nurse and patient • Respecful partnership • The nurse and patient need to discover each other as unique individuals • He coined the terms ”confirming communication” (recognition of individuality) and ”disconfirming communication” (failure to recognize and affirm individuality)

24. Professional interactionTherapeutic Relationship Frameworks • Existential Framework (cont´d) • According to M. Buber nurses can unintentionally disconfirm psychiatric patients by discounting their comments as unimportant or wrong, by not picking up on themes, and by assuming that they cannot take responsibility. • Nurses confirm patients each time they make a special effort to acknowledge them as individuals. Even calling a patient by name signals a confirmation of unique individuality.

25. Professional interactionTherapeutic Relationship Conceptual Components • Casement (1991) suggested that the patient´s emotional experience of the relationship can be as important as the cognitive insights he or she gains about resolving mental conflicts. • Rieman (1986) identified feeling valued as a unique human being, being listened to and having one´s thoughts and feelings understood by another human being as the most significant curative factors identified by patients

26. Professional interactionThe difficulties of verbal communication • Mental illness may create significant barriers to communication. It is more difficult to use communication in the usual sense: • Living in a fantasy world constructed of hidden meanings that defend clients against being hurt – words serve as barriers rather than as bridges to relationships • Mentally ill patients tend to: generalize, embellish, delete, distort, omit data, or make shifts that are hard to follow • Metacommunication becomes important – neither verbal nor nonverbal, but a search into the nature of communication itself and the presence of lack thereof

27. Professional interactionThe difficulties of verbal communication ¤ Common speech patterns found in the chronically mentally ill: • Poverty of speech: one-word answers or phrases • Pressured speech: rapid speech with little change in intonation • Flight of ideas: rapid switching from one idea to another • Thought blocking: sudden stopping in the middle of sentences • Halting speech: slow speech with little change in intonation • Circumstantial speech: details have no relation to main issue • Loose associations: absence of logical connection between thoughts • Echolalia: repeating or echoing the sender´s comments • Confabulation: filling in blanks, replacing data with fantasy • Word salad: putting words together without making sense • Neologisms: nonsensical linking together of sounds • Double bind: two conflicting statements in the same message

28. Professional interactionTherapeutic communication • The primary purpose of therapeutic communication is to help patients to know themselves in ways that allow them to recognize possibilities in their lives and to alter ineffective life patterns (Wachtel, 1993) • The nurse´s role in the communication process is to help patients transform vague, tangential, or distorted statements into clear, concrete, workable statements that have a common meaning to both • The nurse helps the patient on the road to self-discovery and more adaptive ways of resolution

29. Professional interactionTherapeutic communication (cont´d) • The responsibilities of the nurse: • To create an atmosphere where the patient does most of the talking • To assist in full disclosure of difficult issues and feelings • To set the right boundaries making sure the conversations are purposeful and related to identified health-related goals • Documentation of important information and developing interdisciplinary care plans with other health team members

30. Social communication Can occur at any time and has no limitations Responsibility for structure and conduct rests with both parties Spontaneous, not necessarily goal-directed Needs and concerns of both parties can receive equal attention Purpose is to achieve greater intimacy Self-disclosure acceptable for both parties Social decorum and adherence to rules of etiquette are expected Can continue at any time depending on the willingness of the parties Therapeutic communication Communication occurs within designated time frames Responsibility for structure and conduct ultimately with the nurse Purposeful, goal-directed communication The focus is always on the needs and concerns of the patient The purpose is for the patient to achieve greater self-understanding Self-disclosure of nurse limited Social etiquette not always observed by patient in distress Formally terminates with the end of the session or the relationship Professional interactionImportant differences between social and therapeutic communication