Therapeutic nurse-patient relationship

Aquinas University Graduate School Legazpi City Advanced Psychiatric Nursing 2 Topic: Therapeutic Nurse-Patient Relationship * Nurse-Patient Communication * Nurse-Patient Relationship * Stages of Development of a Therapeutic Relationship * Nursing Process * Assessment * Nursing Diagnosis * Outcome Identification * Planning * Intervention * Evaluation Reported by: Christine Karen Belga, RM, RN Therapeutic nurse-patient relationship Communication * Communication, the process of sharing ideas, information, and messages with others in a particular time and place. Therapeutic relationships The therapeutic nurse-client relationship is the basis, the very core, of all psychiatric nursing treatment approaches regardless of specific aim. * Heldigard Peplau- She introduced the concept of nurse-client relationship in 1952 in her ground-breaking book Interpersonal Relations in Nursing. Goals in a therapeutic relationship: * Facilitating communication of distressing thoughts and feelings * Assisting clients with problem solving to help facilitate activities of daily living * Helping clients examine self-defeating behaviours and test alternatives * Promoting self-care and independence COMPONENTS OF A THERAPEUTIC RELATIONSHIP * P-OSITIVE REGARD-unconditional, non-judgmental attitude, implies respect irregardless of the patient’s behavior, background or lifestyle * A-CCEPTANCE-nurse does not become upset or respond negatively to a client’s outbursts, anger or acting out * G-ENUINE INTEREST-nurse is clearly focused and is comfortable with it and reliability himself/herself (client can detect artificial behavior) * E-MPATHY-ability of the nurse to perceive the meanings and feelings of the patient and communicates that understanding to the patient * T-RUST-patient is confident of the nurse and the nurse’s presence conveys integrity and reliability * SELF-AWARENESS & THERAPEUTIC USE OF SELF Self-awareness- process of developing an understanding of one’s own values, beliefs, thoughts, feelings, attitudes, motivations, prejudices, strengths and limitations and how these qualities affect others Therapeutic Use of Self-the nurse beginning to use aspects of his or her personality, experiences, values, feelings, intelligence, needs, coping skills and perceptions to establish relationship with clients Establishing Boundaries The client’s needs are separated from the nurse’s needs, and the client’s role is different from that of the nurse. Boundaries are at risk of blurring, which may lead to non-therapeutic relationship. * Overhelping * Controlling * Narcissism Role blurring is often a result of unrecognized transference or countertransference. Transference – the patient’s emotional response to the therapist Countertransference – counter-transference occurs when the therapist begins to project his or her own unresolved conflicts onto the client. THERAPEUTIC COMMUNICATION TECHNIQUES * ACCEPTING-indicating reception * BROAD OPENING-Allowing the client to take the initiative in introducing the topic * CONSENSUAL VALIDATION-Searching for mutual understanding, for accord on the meaning of the words * ENCOURAGING COMPARISON-Asking that similarities and differences be noted * ENCOURAGING DESCRIPTION OF PERCEPTIONS-Asking the client to verbalize what she or he perceives * ENCOURAGING EXPRESSION- Asking the client to appraise the quality of his or her experience * EXPLORING-Delving further into a subject or idea. * FOCUSING-concentrating on a single point * FORMULATING A PLAN OF ACTION-Asking the client to consider kinds of behavior likely to be appropriate in future situations * GENERAL LEADS-Giving encouragement to continue * GIVING INFORMATION-Making available the facts that the client needs * GIVING RECOGNITION-Acknowledging, indicating awareness * Making Observations-Verbalizing what the nurse perceives * Offering Self-Making oneself available * Placing Event in Time or Sequence-Clarifying the relationship of events in time * Presenting Reality-Offering for consideration that which is real * Reflecting-Directing client actions, thoughts, and feelings back to client * Restating-Repeating the main idea expressed * Seeking Information-Seeking to make clear that which is not meaningful or that which is vague * Silence-Absence of verbal communication, which provides time for the client to put thoughts or feelings into words, regain composure, or continue talking * Suggesting Collaboration-Offering to share , to strive, to work with the client for his or her benefit * Summarizing-Organizing and summing up that which has gone before * Translating into Feelings-seeking to verbalize client’s feelings that he or she expresses only indirectly * Verbalizing the Implied-Voicing what the client has hinted at or suggested * Voicing Doubt-Expressing uncertainty about the reality of the client’s perceptions Reminder: Allow client to express feelings more often than possible without being judgmental in order to understand what is going on with the client. This would facilitate better action in dealing with client’s concerns thus helping him arrive at solutions at his own pace. Nontherapeutic Communication Techniques * Advising-telling the client what to do-Agreeing- indicating accord with the client * Agreeing-Indicating accord with the client * Belittling Feelings expressed-Misjudging the degree of the client’s comfort * Challenging-Demanding proof from the client * Defending-Attempting to protect someone or something from verbal attack * Disagreeing-Opposing the client’s ideas * Disapproving-Denouncing the client’s behavior or ideas * Giving approval-Sanctioning the client’s behavior or ideas * Giving Literal Responses-Responding to a figurative comment as though it were a statement of fact * Indicating the existence of an external source-“ What makes you say that? “, “ What made you do that? “, “ Who told you that you are a prophet? ” * Interpreting-Asking to make conscious that which is unconscious * Introducing an unrelated topic-Changing the subject * Making stereotyped comments-Offering meaningless cliches or trite comments * Probing-Persistent questioning of the client * Reassuring-Indicating there is no reason for anxiety * Rejecting-Refusing to consider or showing contempt for the client’s behavior, ideas * Requesting an explanation-Asking the client to provide reasons for thoughts, feelings, behaviors, events * Testing-Appraising the client’s degree of insight * Using Denial-Refusing to admit that a problem exists PHASES OF THERAPEUTIC NURSE-PATIENT RELATIONSHIP The nurse patient relationship is an end result of series of interaction between the nurse and patient over a period of time with the nurse focusing on need and problem of patient and his family while using the scientific knowledge and specific skills of nursing profession. The nurse must possess: * Accountability * Focus on client needs * Clinical competence * Supervision Pre-interaction phase Pre interaction is a phase which a nurse goes through before actual interaction with the patient. This phase begins when the nurse is assigned a patient to develop therapeutic relationship with him till she goes to him for interaction Reactions of Nurse in Pre-Interaction Phase * The nurse thinks and feels about the patient before interacting according to her knowledge, fears and miss concepts. * She tries to collect information from secondary sources like the patient’s records, a resource person and other nurses working in the ward. INTRODUCTORY /ORIENTATION PHASE Begins when the nurse goes to the patient, introduces herself and gets introduction about him. The orientation phase ends when the nurse and he patient begin to accept each other as a unique human being. Establishment trust – trust is nurtured by demonstrating genuineness and empathy, developing positive regard, showing consistency, and offering assistance in alleviating the client’s emotional pain or problems. Four important issues need to be addressed: a) Parameters of the relationship b) Formal or informal contract c) Confidentiality d) Termination WORKING PHASE During the working phase, the nurse and client together identify and explore areas in the client’s life that are causing problem. Task of working phase * Maintain the relationship * Gather further data * Promote the client’s problem-solving skills, self-esteem, and use of language. * Facilitate behavioural change * Overcome resistance behaviours * Evaluate problems and goals and redefine them as necessary. * Promote practice and expression of alternative adaptive behaviours. The nurse’s awareness of personal feelings and reactions to the client is vital for effective interactions with the client. BARRIERS OF WORKING PHASE * Testing of the nurse * The patient tests the nurse for the ability and competence. * He may deliberately be aggressive to test whether he is able to arouse anger in the nurse * Progress of the patient * Difficulty in collecting and interpreting the data * Fear of closeness STRATEGIES TO OVERCOME BARRIERS * Learn the subject in depth * Taking help from supervisors and experts * Discussions with peer group TERMINATION PHASE Reasons for termination * Symptoms relief * Improved social functioning Greater sense of identity * Development of more adaptive behaviors * Accomplishment of the client’s goals * Impasses in therapy that the nurse is unable to resolve TASK OF TERMINATION * Bring a therapeutic end to the relationship. * Review feelings about relationship. * Evaluate progress towards goal. * Establish mechanisms for meeting future therapy needs. * Summarize entire communication and follow up treatments. BARRIERS OF TERMINATION PHASE * The patient may ask the nurse to write to him or come back from duty and see him. * Gift giving * The nurse may withdraw earlier from the patient due to her own anxiety she may not interact with the patient STRATEGIES TO OVERCOME * Nurse needs to explore her own feelings and thoughts about separation from the patient which will help her to accomplish the task of termination phase * The patient should be explained that ‘ every relationship terminates’ * Getting help from supervisors * After discharge the patient comes for intervention he or she should be referred to a second in charge.