Working Phase

2. Working Phase • Aims: • Starts with the commitment of the client to work on problem • Prioritizing client’s needs determines immediate problems that needs attention (safety & physical health problems then socially unacceptable behaviors) • Strategies • Communicating core values • Exploration strategies • Intervention strategies

3. Working Phase: Communicating core values • Communicating core communication during the working phase helps to maintain trust that helps to overcome resistance to interventions

4. Working phase: Exploration/ to reassess problem & explore relevant stressors

5. Working phase: Intervention Strategies • People intervene in daily situation through the use of verbal responses (talking). • Talking intervention skills are used to help client: • Solve problems • Teaching • Role playing • Giving information • Giving feedback • Helping with feelings • Promote a client’s levels of wellness

6. Problem solving process • Define the problem or conflict: • Analyze the nature of the problem or conflict: questions that you might use could include the following: • How do you view your problem • What are your feelings right now? • What resources do you have to resolve the problem • Who else is or may need to be involved? • How will you feel and behave when the problem has been resolved? • What do you expect will be different in your life and how do you feel about your self if the problem were resolved?

7. Problem solving process • Consider alternatives and their consequences: need creativity and some brain storming. Some of the following questions can be asked: • What are all the possible that the problem might be resolved? • What are the consequences of taking each action, pro and con • weight the advantages and disadvantages of each alternative: • Take action on the decision: Actions that follow a logical, incremental sequence are easiest to implement and provide the most satisfaction

8. Helping with feelings • A map of the helping process: • Exploring the territory : talking & reflecting on emotional issues • Identifying the feeling: name the underlying feeling • Releasing the feeling: expressing the feelings in the appropriate time, space, & psychological safety • Reflection after the feeling: helps develop insight, offering supportive attention, not to over-talk, merely just setting quietly, and touch might be used • Future planning: help in decision making

9. Teaching: role playing • It is a teaching - learning method used to train the student nurse in interpersonal skills and rehearsing of behaviors and interventions that focus in interacting with clients demonstrating different behavioral problems. It permits the students to observe themselves in action, get feedback, & rehearse new modified actions in a neutral safe environment. It is a method of learning that makes actual behavior the focus of change.

10. Teaching: role playing • Directions for developing the role play: • Preparing role play scenarios consist of the following steps: • Define the problem • Creating a readiness for role playing • Establish the situation by writing the verbatim • Casting the characters • Briefing and warming up • Acting • Stopping • Analyzing and discussing • Evaluation

11. Working phase: Intervention responses -Interpretation or re-framing • It is helping the client to find a new way of perceiving or interpreting the situation. • Such as seeing a diagnosis of cancer not as death but as a chronic illness and a better quality of life •  To use this skill the nurse has to identify the client's strength and the strengths and limitations of the situation and what is hoped for as an end result from the situation.

12. Working phase: Intervention responses-Giving information • Definition: • It is verbal communication of new data or facts to another person. • Purpose: • To inform person of possible options • To help person evaluate possible outcomes of all options and to selects the best alternative • To correct misconceptions • To increase the likelihood of patient compliance

13. Working phase: Intervention responses –Giving information • When: • Evaluate a client's need for information by: • Identify information presently available to the client – is it sufficient? Is there anything lacking? (What does client know signs & symptoms of illness? Does client know the causes? …etc.) • Assess the accuracy and validity of the client's present information; is there inaccurate information that needs correcting? • Look for signs of client receptivity to additional or new information before presenting it – is the client ready to hear the information? (Denial; confused due to medication; increased level of anxiety) (Does the client want to have more information?)

14. Working phase: Intervention responses –Giving information • What: • Determine the kind of information useful to each client- including unpleasant information (cases, signs & symptoms, treatment, diagnostic test, effect on relationship with others, prognosis) (negative & positive information have to be communicated) • Identify the most reliable source to deliver the information to the client (if the nurse does not know do not hesitate to say "I do not know" and refer to appropriate source. When clients are given accurate information about there illness they comply better with treatment • Identify whether the information should be presented all at once in a certain sequence

15. Working phase: Intervention responses –Giving information • How: • Limit the amount of information given at one time- two different pieces of information but no more • Present the information as clearly as possible; avoid jargon • Deliver the information in a sensitive and friendly manner • Be realistic, but avoid scare tactics • Ask for and discuss client's reaction to the information

16. Working phase: Intervention responses - Confrontation • Definition: • It is a verbal response used to describe and identify a discrepancy or distortion apparent in a person’s communication • It is using the communication techniques of: • Stating observation • Presenting reality

17. Working phase: Intervention responses - Confrontation • Guidelines: • Trust is a necessary condition • Offer with care & empathy • Offer to help not to punish • Be descriptive rather than evaluative • Be concrete & specific not vague or general • Direct the confrontation towards the situation and not behavior that the client can change • Deliver confrontation in small doses • Avoid two successive confrontations • Word the confrontation tentatively; request but do not demand change • Confront when there is sufficient time to hear & understand the other person’s reactions to the situation

18. Working phase: Intervention responses - Confrontation • A useful model sentence for confrontation is: • “On one hand, you think/feel/behave … but on the other hand, you think/feel/behave … • Person’s reaction to confrontation: • Denial & anger • Confusion • False acceptance • Real acceptance

19. Working phase: Intervention responses - Feedback • Steps of giving feedback • 1. Check the reason for giving feedback • What are your motives? • What is the outcome of the feedback? • Is it helpful to the other person from his perspective? • Unhealthy reasons for feedback: • Getting revenge • Showing superiority • Feeling in control • Wanting to control other's behavior because of intolerance to it

20. Working phase: Intervention responses - Feedback • 2. Gain permission to give feedback: • Taking permission helps in making the other person more open to receive it & it checks the client's readiness for change • Permission can be asked verbally or nonverbally

21. The nurse is teaching a new mother who is learning to bath her newly born baby • Nurse: "I notice that you are holding your baby in a safe way, the baby seems enjoying the bath you are giving her, especially how you are talking to her. I'd like to suggest one thing for improvement (say it while looking at the mother and keep silent for few seconds for the mother to respond with yes or no verbal or non verbally- the mother may nod) • If the mother nods then continuo "when the umbilical cord gets wet there will be a chance for infection, I'd like to suggest several things to keep the cord dry if you like to hear (make eye to eye contact and continuo when the mother communicates interest in the information)

22. Working phase: Intervention responses - Feedback • 3. Be specific keep the feedback on the specific observable behavior without blaming • 4. Convey your perspective and remember it is not a matter of right or wrong it is another way of seeing things. "as I see it ….", "from my perspective .."

23. Working phase: Intervention responses - Feedback • 5. Use the formula of assertive feedback • When you ….. (describe the behavior without judging it) • The effects are …. (describe concretely how it affects your life in a practical sense) • I feel … (describe your feelings without blaming; the "I" statement implies ownership of your feelings) • I prefer … (describe what response or change you would like or, if possible, give the other person a chance to come up with a solution)

24. Working phase: Intervention responses - Feedback • 6. Invite comments from the receiver • Ask after finishing feedback "what do you think?" in order to know the effects on others • 7. Be genuine

25. Working phase: Intervention responses - Types • Encouraging plan formation • Giving feedback • Asking for validation • Anticipatory guidance • True reassurance • Self disclosure • Offering self • Encouraging evaluation • Mirroring • Matching responses • Using appropriate vocabulary • Focusing • Using metaphors • Reframing • Presenting reality • Role playing

26. Working phase: Intervention responses – Matching responses with verbal content • "I feel so discouraged. No matter how hard I try, I still can't walk withoutpain on the two parallel bars" • "You want to give up because you do not think you will be able to walk again" • "So you think you won't be able to walk independently" • "It sounds to me as if you don't feel your efforts are helping you regain control over your walking"

27. Working phase: Intervention responses – Using appropriate vocabulary • Use of simple language not the medical terminology (jargon) • Connect between the client's familiar ideas and words with the new information to be given • Use of frequent validation is important.

28. Working phase: Intervention skills –Reflecting • Directing back to the client’s questions, feelings, ideas; encouraging client to bring forth his/her own ideas, which the nurse thereby acknowledges • Client: “Do you think I should tell the doctor?” • Nurse: “You are wondering if it is important?”

29. Working phase: Intervention responses - Offering self • The nurse offers his or her presence, interest, and desire to understand without making any demands on the patient. • “We can sit here quietly; there’s no need to talk unless you want to.” • “I am here to help you” • “How can I help you?”

30. Working phase: Intervention responses - Presenting Reality • The nurse notices that the patient is misinterpreting reality • An effort is made to indicate what is real from unreal • “That’s a stain on the blanket, it is not a bug.” • “The scream came from the program on TV.”

31. Working phase: Intervention responses - Encouraging plan formation • Helps the client develop steps to make changes and solve problems • “Can you think of another way you might be able to handle a situation like this?” • “In what way can you make these visits less upsetting?”

32. Working phase: Intervention responses -Encouraging evaluation • “Does this feeling contribute to your discomfort”

33. Dysfunctional Communication • Acting on assumptions without validation • Assuming that….. others share your perception your perceptions won’t change your perceptions are complete others know how you think or feel • Decision-making by power • Stereotyped phrases • Sending mixed messages

34. Issues Occurring during the therapeutic relationship • The following issues occur during the nurse-client relationship and can become obsticles to therapeutic communication • Resistance • Transference • Counter-transference • Boundary violations

35. Resistance • It is the clients struggle against developing insight into the problem, against change or against taking responsibility for actions. • The client tries to redirect the focus of the session from self to superficial topics or to personal aspects of the nurse’s life, problems in the hospital • During an interaction, a client may redirect the focus away from self by changing the subject, talking about the weather, etc. • The nurse needs to recognize this as a divergent tactic, confront this behavior, and refocus the client.

36. Resistance • Causes of resistance • Discussed issue produces anxiety • Boredom • Repetition of materials discussed with other students • Inability to concentrate due to disorder • Behaviors that indicate resistance • Suppression of certain information. • Increase in the severity of illness.

37. Resistance • Behaviors that indicate resistance • Hopelessness and self devaluation. • Sudden improvement of the client’s condition. • Maintaining superficiality in the relationship. • Use of intellectualization. • Intellectual inhibition, the client’s mind goes blank being unable to think about the problem • Silent • Forgetful • Sleepy.

38. Transference • “ it is an unconscious response in which the patient experiences feelings and behaves toward the nurse in away that he used to behave toward a significant other from past that may have superficial resemblance to the nurse physical figure, voice or the pattern of relating”.

39. Types of transference • Hostile: anger expressed by becoming more depressed and discouraged. If the patient directs anger out side self will start to be critical and abusive toward the nurse, may start to compete with the nurse, detached, forgetful, irritable, preoccupied with child hood experiences, prolonged silence. • Dependent reaction transference: Submissive, Subordinate, Overvalue the nurses characteristics, complementing the nurse, clinging behavior.

40. Solving resistance and transference • Listening • Clarification • Reflection of feelings • Exploring other causes of behavior

41. Counter transference: • Over involvement is a form of counter transference. • It occurs when the nurse develops specific emotional response generated by the client's qualities or behaviors for example when client is needy and very grateful, or when the client reminds the nurse of a similarly unresolved care situation. • Over involvement leads the nurse to lose objectivity and necessary detachment. • Types: • Reactions of intense love or caring • reactions of intense disgust or hostility • Reactions to intense anxiety often in response to resistance by the client.

42. Boundaries & Space

43. Boundary Violations • When the nurse is thinking of doing something special, different, or unusual to the patient then she\he is violating boundaries. • Categories of boundary violation: • Role Boundaries: • code of conduct; hierarchy; senior /junior; job description and responsibilities “ Is this what a nurse does?” • Time boundaries: • length and frequency of contact and when “violation: Odd times of implementing intervention must be questioned”

44. Boundary Violations • Place and Space boundaries: • Environment; privacy neutral place of meeting • Money Boundaries: • Gift and services boundaries - Types: • to reciprocate for care given • to manipulate or change quality of care or nature of relationship • perceived obligation by the patient • Given to organization to recognize excellence of care.

45. Boundary Violations • Clothing boundaries • uniform limits that are appropriate not seductive. • Language boundaries • terms of address and use of name, tone of voice, choice of words • Self-disclosure boundaries • confidentiality inappropriate disclosure • Physical contact boundaries • therapeutic touch or caring as perceived by the client Sexual or caring in nature as perceived by the patient. (touching a person without asking)

46. Behaviors showing violation of boundaries Talking about intimate topics not related to treatment Falling in love new persons or who ever helps Being preoccupied with the person Going against personal values & rights to please others Giving more than normal for the sake of giving Giving more than expected to get some thing, allowing others to take as much as they can from you

47. Behaviors showing violation of boundaries Letting other direct your life Letting others describe your reality Letting other define you Believing that other can anticipate your needs Expecting other to fill in your needs automatically Falling apart so that someone will take care of you Flirting Telling all