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Therapeutic N-Pt Relationship

Communication

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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

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N-Pt Relationship

• Communication skills

• Respect and a desire to help

• Trust is based on confidentiality

• Understandingmental mechanisms

adaptation styles

coping strategies

therapeutic intervention skills

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Communication

• In-born nature

• Happened at anytime, anyplace,

• Multi-level

• Verbal & NonverbalProxemics - environmental, social, and

personal space

Kinesics - body movement

• Can be learned

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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

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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

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Thera. Commu. Tech (II)

• Making observation - comment on what have been seen

• reflecting

• Clarification - restate

• Focusing - single, important topic

• Exploring - getting more information

• Interpreting -

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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

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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

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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

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Phases of N-Pt Relationship• Preinteraction phase

self-awareness, self-exploration

• Introductory or orientation phasemaking a contract, building trust, setting goals

• Working phaseexplore stressors, promoting insight, reality testing, problem-solving, coping, identifying past ineffective behavior

• Termination phase goals, evaluation, referrals, separation, loss, emotional responses

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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

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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

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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…

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Termination Stage

• Evaluation; • summarize the objectives achieved• Referrals• Discussion of termination - emotional

responses; acceptance, denial, anger, regression.

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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

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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

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Process Recording (cont’d)

• Verbal interaction & nonverbal behaviors

• Analysis of content, mood, and interaction

• Share with colleagues

• Learning tool / professional growth

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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

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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

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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

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Empathy

Putting yourself in the other’s shoes• Being there

• Listening

• Assumption - as if

• Interpretation and validation

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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

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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.

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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

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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

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Cultural Issues

• Ethnocentrism – only acknowledging and valuing one’s own culture

• Cultural competent nursing– Sensitivity– Awareness– Knowledge– Encounter– Desire

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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

Nursing Diagnosis & Nursing Goals

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Behavioral Assessment

• Context, thought, and feeling associated with the behavior,

• Congruence of the behavior to the context

• Adapativeness of the behavior

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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, ...

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Anxiety, Coping & Crisis

Stressor Anxiety Neurochemical/

physiological

reactions

Adaptive

Coping behaviors Maladaptive

Dysfunctional

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Defense Mechanisms

• Compensation• Conversion• Denial• Displacement• Dissociation • Identification• Intellectualization• Projection

• Rationalization• Reaction

formation• Regression• Repression• Sublimation• Suppression• Undoing

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Defense Mechanisms (II)

• Primary gain – relief or expression of anxiety through symptoms of disorder.

• Secondary gain – attention and support received from others while ill.

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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

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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

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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

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