1. The Nurse Client Relationship & Therapeutic Communication

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TYPES OF RELATIONSHIPS

SOCIAL / INTIMATE RELATIONSHIPS


THERAPEUTIC RELATIONSHIPS

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

SOCIAL / INTIMATE RELATIONSHIPS

Mutual, considers both sets of goals, needs & feelings

FACTORS THAT ENHANCE GROWTH IN OTHERS

Positive Regard
Genuineness
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

expressing or feeling or resulting from sympathy or compassion or friendly fellow feelings

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

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:

DO NOT - argue, challenge, give false reassurance, coerce client into treatment, or give approval or praise
This becomes tied to pt pleasing the nurse

DO NOT - Give Advice, and no "Why" Questions!!
This implies criticism, can feel intrusive & judgmental, which serves to make the client defensive

Anger & Aggression

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.

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

Theories
Behavioral Theory

Emotions are learned responses
Anger and aggression offer Rewards

Theories
Cognitive Theory

Event → Thought → Emotion → Behavior

Biological Theory

Correlated with physiologic signs, medical conditions, genetics

Nursing Assessment of Anger & Aggression

Past & Present Hx
background information, culture & childhood environment
-Assess usual coping methods
-Assess meaning of current situation to patient

Identify Anxiety/Irritation before it escalates

S/S:
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).

Nursing Diagnosis

Ineffective Coping
Risk for Violence Directed at Self or Others

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.

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!
Name the underlying feeling leading to anger.
Be respectful and apologize when appropriate.
Indicate a willingness to search for solutions.
Use clear & concrete communication.
Be respectful.
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 position

Evaluation

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
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

Supportive/Therapeutic Groups
-Therapeutic groups VS Group therapy

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

Open space without barriers in seating

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

Membership
Open-ended groups

members leave and join at any time

Closed-ended groups

all 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

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