Therapeutic N-Pt Relationship Communication

1. Therapeutic N-Pt RelationshipCommunication

2. 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

3. 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

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

6. 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

7. 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

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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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…

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

17. 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

18. 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

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

20. 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

21. 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

22. 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

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

24. 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

25. 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.

26. 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

27. 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

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

29. 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

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

31. 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, ...

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

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

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

37. 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

38. 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

39. 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 • Pseudoscientific information from internet