Therapeutic N-Pt Relationship
Communication
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 Understanding
mental mechanisms adaptation styles coping strategies therapeutic intervention skills
Communication
In-born nature Happened at anytime, anyplace, Multi-level Verbal & Nonverbal
Proxemics - 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 clients 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 Verbalizing the implies - rephrasing, reflecting Clarification - restate, elaborate Focusing - single, important topic Exploring - getting more information Interpreting Consensual validation - mutual agreement
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Thera. Commu. Tech (III)
Giving information - decision making Presenting reality - but no argument Voicing doubt - uncertainty about pts 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 (contd)
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 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
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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 - domestic, 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, acting-out...
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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 pts problems, elicits pts input, selects interventions evaluates the effectiveness of care learns about self
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Process Recording (contd)
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 others 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 Earths 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 ones own culture Cultural competent nursing
Sensitivity Awareness Knowledge Encounter Desire
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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
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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 Patients strength and weakness Continuum of care - education, referral, ...
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Anxiety, Coping & Crisis
Stressor Anxiety Neurochemical/ physiological reactions
Adaptive Maladaptive Dysfunctional
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Coping behaviors
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 38 Pseudoscientific information from internet
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