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The Nurse Client Relationship & Therapeutic Communication

SOCIAL / INTIMATE RELATIONSHIPS Mutual, considers both sets of goals, needs & feelings
THERAPEUTIC RELATIONSHIPS Client focused Exists for and because of needs & goals of the client Patients often get bored with talking about themselves and will try to talk about you
FACTORS THAT ENHANCE GROWTH IN OTHERS 1.Positive Regard 2.Genuineness 3.Empathetic vs. Sympathetic
Empathy 1. Direct identification with, understanding of, and vicarious experience of another person's situation, feelings, and motives. 2. The projection of one's own feelings or emotional state onto an object or animal.
Sympathy the sharing of another's emotions, esp of sorrow or anguish; pity; compassion.
BOUNDARIES Role of nurse and client should be well defined. Needs of client are separated from those of the nurse.
Blurring of Boundaries -Social or intimate context -Focus on needs of nurse -Over-helping -Controlling -Narcissism-Excessive love or admiration of oneself. -Over-identification
PHASES OF THE NURSE CLIENT RELATIONSHIP Phase One Pre-Interaction Phase Phase Two Orientation Phase (Assessment, Diagnosing & Planning) Phase Three: Working Phase (Implementation / Intervention) Phase Four: Termination Phase (Evaluation)
Therapeutic Communication Between the Nurse & Patient An exchange of information that facilitates a POSITIVE relationship. Involving the patient in his or her own care.
Goal of Therapeutic Communication: -Obtaining or providing information -Developing trust -Showing caring -Exploring feelings
Main points of therapeutic Communication Ask opened ended questions. Avoid "why" questions Use silence, wait for pt to respond. Encourage pt to share & express of feelings. Focus on pts feelings. Support the pts expression of feelings. Value a pts feelings.
Communication Rules to Follow Rule # 1 - Always clarify message. Rule # 2 - Be aware of non-verbal cues. Rule # 3 - When we communicate poorly it causes frustration, loss of respect and errors.
APPLICATION of Therapeutic Communication Skills Tactics to DO: Validate what you are hearing Use silence Use active listening Use of touch
APPLICATION of Therapeutic Communication Skills Tactics to Avoid: NO-argue, challenge, give false reassurance, coerce client into treatment, give approval/ praise Becomes tied to pt pleasing the nurse NO-Give Advice, NO Why Questions This implies criticism, can feel intrusive & judgmental-makes pt defensive
Anger & Aggression is harmful to the body systems if prolonged Myth -“ Getting it all out ” is a useful way to diminish anger TRUTH - Expressions of anger can lead to Increased anger & Negative physiologic changes.
Theories of Anger Behavioral Theory Emotions are learned responses Anger and aggression offer Rewards
Theories of Anger Cognitive Theory Event → Thought → Emotion → Behavior
Theories of Anger Biological Theory Correlated with physiologic signs, medical conditions, genetics
Feelings that Underlie Anger Discounted Embarrassed Frightened Frustrated Found Out Guilty Humiliated Hurt Ignored Inadequate Insecure Not Heard Out of Control of Situation Rejected Threatened Tired Vulnerable
Nursing Assessment of Anger & Aggression Past & Present Hx background information, culture & childhood environment -Assess usual coping methods -Assess meaning of current situation to patient
S/sx to identify Anxiety/Irritation before it escalates increased volume & rate of speech, rigid posture, increased demands, irritability, frowning, reddened face, pacing and/or twisting, jaw clenching, fists, wringing hands, staring with narrowed eyes into the eyes of another (crazy eyes).
Anger - Nursing Diagnosis Ineffective Coping Risk for Violence Directed at Self or Others
Anger GOALS / PLAN Pt will demonstrate one new constructive method for coping with anger by (date, end-of-shift). Pt will discuss issues before acting out his anger when he begins to feel angry. Pt will refrain from injury to self & others.
Anger Nursing Interventions Understand pts verbal & non-verbal cues Understand pts triggers Help pt identify thoughts that increase anger Be aware of pts past aggressive behavior Acknowledge pts distress to reduce their anxiety Validate pts anger
Anger feelings Name the underlying feelings leading to anger Be respectful and apologize when appropriate. Indicate a willingness to search for solutions. Use clear & concrete communication. Be respectful.
Working with an angry pt Do not reinforce the behavior. Understand your own responses to pt behavior Set Limits on abusive behavior/language Be prepared for escalation -Seclusion -Restraints Rule of thumb: always use the least restrictive approach FIRST !
Stress Reduction Methods Group or social supportCreative imagery Thought stopping Meditation Yoga Biofeedback Breathing exercises Time management Self-hypnosis Proper nutrition Regular exercise Relaxation response -Quiet environment -Passive attitude -Comfort positio
Evaluation of anger Has pts agitation, aggressiveness or anger: Diminished? Resolved?
Group Interventions Functions of a Group: -Socialization -Support -Task completion -Camaraderie -Information sharing -Normative -Empowerment -Governance Clients can learn from each other Support that they find often brings about changes in them
MHN wants to strive We want to strive to empower patients to be involved in their own recovery; be their hope when they have none.
Types of Groups Task Groups accomplishing a specific task with a specific outcome
Teaching Groups Leader has knowledge and shares with others who need it
Therapeutic groups Therapeutic groups focus on interaction between group members; leader keeps them on track and facilitates productive group interaction;
Group therapy typically led by psychologists, advanced degree nurses, social workers
Self-Help Groups Leader is a member and likely has same issue as other group members
Physical Conditions that influence Group Dynamics Space Open space without barriers in seating
Physical Conditions that influence Group Dynamics Size Group size 2-15 depending on the topic 7-8 patients is best according to research; too much lose control; too few not enough interaction
Group Membership Open-ended groups members leave and join at any time
Closed-ended groups all group members join at same time and task is met and group comes to end
Curative Factors of Groups Instilling Hope Other members with similar problems discuss their ways of overcoming issues
Universality I’m not alone
Imparting information Learning from each other
Altruism concern for the welfare of othersSomeone helps someone else with their problem
Corrective recapitulation Corrective recapitulation of the primary family group Re-experience conflicts in safe place and get feedback
Development of socializing techniques Helps people get to socialize correctly Imitative behavior Interpersonal learning Group cohesiveness - sense of belonging
Catharsis-expressing feelings safely express feelings + or – in a public setting
Catharsis in medicine Purgation, especially for the digestive system.
Catharsis in psychology Psychology a. A technique used to relieve tension and anxiety by bringing repressed feelings and fears to consciousness. b. The therapeutic result of this process; abreaction.
Phases of Group Development Phase I Initial or Orientation phase-Establish rules and goals -Promotion of trust -Members are superficial and overly polite
Phases of Group Development Phase II Middle or Working phase-Productively work on tasks -Leader becomes more of a facilitator -Member cohesiveness exists -Conflict is managed by group members
Phases of Group Development Phase III Final or Termination phase -Group members may feel a sense of loss -Some members have feelings of abandonment -Grief for previous losses may be triggered -Discussion of feelings of loss -Reminisce about group accomplishments
As group nears completion Old behaviors may come back because of sense of loss due to end of group
Autocratic leadership focus is on the leader
Democratic leadership focus is on the members
Laissez-faire leadership there is no focus
Group Member Roles Members play one of three types of roles within a group: -Task roles -Maintenance roles -Individual (personal) roles
Psychodrama A type of group therapy that employs a dramatic approach Members become “actors” in life-situation scenarios Protagonist: Selected to portray life situation Other members: Play roles of people whom the protagonist has unresolved issues Dir-grp l
Family Therapy Focus is on treatment of family as a unit . Family therapy is a form of psychotherapy that involves all the members of a nuclear or extended family.
Family Therapy Goal is to identify and change relationship patterns that are:-Problematic -Maladaptive -Self-defeating -Repetitive
Genograms A family tree diagram that represents the names, birth order, sex, and relationships of the members of a family. Therapists use genograms to detect recurrent patterns in the family history and to help the members understand their problem(s).
Nurses Role in Group Interventions Nurses in psychiatry lead therapeutic groups such as: -Educational -Assertiveness training -Parenting -Transition to discharge -Other therapeutic groups
psych nursing minimum training MSN in psych nursing as minimum training for group psychotherapy
Community Mental Health Nursing Public Health Model Primary Prevention reducing incidence of mental disorders within the population; any intervention done with a group that is at risk for a problem
Community Mental Health Nursing Secondary Prevention the problem has occurred; how can the course of the problem be shortened or how can the problem be controlled
Community Mental Health Nursing Tertiary Prevention the disease is present; can’t shorten; can’t control symptoms; how do we prevent bad outcomes and promote maximum function
Maturational Crisis 1. Adolescence Identity v Role confusion Self esteem, body image, what will I do for career, what are my ideals and values; sexuality; drug and alcohol exposure Primary Prevention educational; DARE program Secondary Prevention Alcoholics anonymous, Narcotics Anon
Maturational Crisis 2. Marriage One of the most common crises in America Primary Prevention premarital classes and counseling sessions Secondary Prevention Marriage counseling; to prevent divorce, abuse, homicide, suicide, etc…
Maturational Crisis 3. Parenthood Total responsibility for a human being that can do nothing for itself; sleep patterns are disturbed; economic challenges
Maturational Crisis Parenthood Primary Prevention teaching child development and parenting skills while parents to be are pregnant; provide day care resources
Maturational Crisis Parenthood Secondary Prevention parents aren’t coping well with new parenting duties; getting counseling to prevent bad outcomes; such as abuse; neglect; homicide; etc..
Maturational Crisis 4. Midlife Aging; relationships with kids and parents change; body changes; hormonal changes Primary Prevention teaching stress management techniques; medications for hormonal changes Secondary Prevention Counseling if there are issues
Maturational Crisis 5. Retirement Negative feelings about lack of productivity; financial issues Primary Prevention financial planning; hobbies; Secondary Prevention helping remain independence with activities; exercise programs
Situational Crisis 1. Poverty Neglect medical health; nutritional deficiencies; correlation between poverty and mental health issues Primary Prevention Educating unemployed about resources Secondary Prevention Community shelters; food banks
Situational Crisis 2. High rate of life change events Spouse dies; child dies; sibling dies Primary Prevention Education of support groups; encouraging family and friends to be supportive; hospice Secondary Prevention Helping patients work through grieving process; and in support groups
Situational Crisis 3. Environmental conditions Tornados, floods, tsunamis, Primary Prevention Alerts Secondary Prevention Getting resources like red cross to come in to assist
Situational Crisis 4. Trauma Traumatic events; experiences outside the normal range of human experience; military combat; assault victims; POW; tortured vicitms; kidnappee; hostage
Situational Crisis Trauma Primary prevention Teaching vulnerable populations to defend themselves and to escape those situations
Situational Crisis Trauma Secondary prevention Self defense class to avoid another abuse; counseling
Tertiary Mental Health Care Individuals with severe and persistent mental illness -Historical and epidemiological aspects Approximately 100,000 persons with mental illness reside in public mental hospitals Deinstitutionalization of persons with chronic mental illness began in the 1960s Large segments of people with chronic mental illness are left untreated
Mental health illnesses related to age Many mental health illnesses don’t show themselves until adolescence or later
The Homeless Population Approximately 25 to 33% of homeless pop suffers from some form of mental illness Interfering Factor – residential instability Hlth Issus: Alcoholism is common Thermoregulation Tuberculosis on the rise Dietary deficiencies STDs Spl hlth nds of HL c
Community Resources for Homeless Types of resources available: -Homeless shelters -Healthcare centers and store-front clinics -Mobile outreach units
Tertiary Community Services Treatment alternatives -Community mental health centers -Assertive Community Treatment (ACT) -Day-evening treatment/Partial hospitalization programs -Community residential facilities -Psychiatric home health care
Care for the Caregiver Rest / relaxation periods
Created by: mgyger