Therapeutic nurse patient relationship

THERAPEUTIC NURSE PATIENT RELATIONSHIP-JOHARY WINDOW, PHASES, IMPASSES & MANAGEMENT

1. Therapeutic communication and nurse-patient relationship PREPARED BY Mrs. Divya Pancholi M.Sc. (Psychiatric Nursing) Assistant Professor SSRCN, Vapi

2. Communication It is a process of exchanging or sharing ideas, feeling, and information.

3. Communication Process 3 Sender Source Encoder Receiver Decoder message Channel Feedback

4. Elements of communication

5. Types of communication One way communication Two way communication Interpersonal communication Serial communication Verbal communication Non verbal communication Formal communication I nformal communication Visual communication Telecommunication

6. Therapeutic communication

7. definition It is an interpersonal interaction between the nurse and the patient during which the nurses focuses on the patient’s specific needs to promote an effective exchange of information.

8. Goals of therapeutic communication Establish a therapeutic nurse-patient relationship Identify the most important patient’s needs Assess the patient’s perception of the problem Facilitate the patient's expression of emotions Implement the interventions designed to address the patient’s needs

9. Principles/characteristics of therapeutic communication The patient should be the primary focus of interaction A professional attitude sets the tone of the therapeutic relationship Use self-disclosure cautiously and only when it has a therapeutic purpose. Avoid social relationship with patients Maintain patient confidentiality Assess the patient’s intellectual competence to determine the level of understanding

10. Conti… Implement interventions from a theoretic base Maintain a non-judgemental attitude. Avoid making judgements about patient’s behaviour Avoid giving advice. Guide the patient to reinterpret his or her experiences, rationally.

11. Therapeutic communication technique ( LIBR A R Y TH E S I SS S F INAL CH APTER) Listening Informing Broad opening Restating Reflection Theme identification Sharing perceptions Suggesting Silence Focusing Clarification Humor

12. listening It is an active process of receiving information . Responses on the part of the nurse such as maintaining eye to eye contact, nodding, gesturing and other forms of receptive non-verbal communication convey to the patient that he is being listened to and understood. THERAPEUTIC VALUE: Non-verbally communicates to the patient the nurse’s interest and acceptance.

13. Informing The skill of information giving. For example, “I think you need to know more about your medications.” THERAPEUTIC VALUE: Helpful in health teaching or patient education about relevant aspects of patient’s well-being and self care.

14. Broad opening Encouraging the patient to select topics for discussion. For Example, “What are you thinking about?” THERAPEUTIC VALUE: Indicates acceptance by the nurse and the value of patient’s initiative.

15. Restating Repeating the main thought expressed by the patient. For example, “You say that your mother left you when you were 5 year old.” THERAPEUTIC VALUE: Indicates that the nurse is listening and validates, reinforces or calls attention to something important that has been said.

16. Reflection Directing back the patient’s ideas, feelings, questions and content. For example: “You are feeling tense and anxious and it is related to a conversation you had with your husband last night.” THERAPEUTIC VALUE: Validates the nurse’s understanding of what the patient is saying and signifies empathy, interest and respect for the patient.

17. Theme identification This involves identification of underlying issues or problems experienced by the patient that emerge repeatedly during the course of the nurse-patient relationship. For example, “You are smiling, but I sense that you are really very angry with me.” THERAPEUTIC VALUE: Conveys the nurse’s understanding to the patient and has the potential for clearing up confusing communication.

18. Sharing perceptions Asking the patient to verify the nurses understanding of what the patient is thinking or feeling. For example: “You are smiling, but I sense that you are really very angry with me.” THERAPEUTIC VALUE: Conveys the nurse’s understanding to the patient and has the potential for clearing up confusing communication.

19. Suggesting Presentation of alternative ideas for the patient’s consideration relative to problem solving. For example, “Have you thought about responding to your boss in a different way when he raises that issue with you? You could ask him if a specific problem has occurred.” THERAPEUTIC VALUE: Increases the patient’s perceived notions or choices.

20. Silence Lack of verbal communication for a therapeutic reason. For Example, Sitting with a patient and non-verbally communicating interest and involvement. THERAPEUTIC VALUE: Allows the patient time to think and gain insight, slows the pace of the interaction and encourages the patient to initiate conversation while enjoying the nurse’s support, understanding and acceptance.

21. Focusing Questions or statements that help the patient expand on a topic of importance. For Example: “I think that we should talk more about your relationship with your father.” THERAPEUTIC VALUE: Allows the patient to discuss central issues and keeps the communication process goal-directed.

22. Clarification Attempting to put vague ideas or unclear thoughts of the patient into words to enhance the nurse’s understanding or asking the patient to explain what he means. For example: “I am not sure what you mean. Could you tell me about that again?” THERAPEUTIC VALUE: It helps to clarify feelings, ideas and perceptions of the patient and provides and explicit correlation between them and the patient’s actions.

23. Humor The discharge of energy through comic enjoyment of the imperfect. For example, “That gives a whole new meaning to the word nervous,” said with shared kiddling between the nurse and patient. THERAPEUTIC VALUE: Can promote insight by making repressed material conscious, resolving paradoxes, tempering aggression and revealing new options, and is a socially acceptable form of sublimation.

24. Therapeutic nurse-patient relationship

25. Definition Relationship - A relationship is defined as being related or state of affinity between two individual. Therapeutic nurse patient relationship- I t is an interaction process in which the nurse fulfils her role by using her professional knowledge and skills in such way that she is able to help the patient physically, socially and emotionally.

26. Types of relationship

27. 1. Social relationship It is defined as a relationship that is primarily initiated with the purpose of friendship, socialization , enjoyment or accomplishing task. Mutual needs are met during social interaction. E.g. participants share ideas, feelings and experiences.

28. 2. Intimate relationship It occurs between two individuals who have an emotional commitment to each other. Those in an intimate relationship usually react naturally with each other. Often the relationship is a partnership wherein each member cares about the other’s need for growth and satisfaction.

29. 3. Therapeutic relationship This relationship differs from both a social and intimate relationship in that the nurse maximizes inner communication skills, understanding of human behaviour and personal strengths, in order to enhance the patient’s growth. The focus of the relationship is on the patient’s ideas, experiences and feelings.

30. Goals of therapeutic nurse- pATIENT relationship Facilitating communication of distressing thought and feeling. Helping client examine self-defeating. Assisting client with problem solving. Behavior and test alternatives. Promoting self-care and independence.

31. Components of therapeutic nurse-patient relationship

32. 1. Rapport Rapport is a relationship or communication , especially when useful and harmonious. It is the crux of a therapeutic relationship between the nurse and the patient. It is- A willingness to become involved with another person Growth towards mutual acceptance and understanding of individuality The nurse establishes rapport through demonstration of understanding, warmth and non-judgemental attitude. A skilled nurse will be able to establish rapport that will alleviate the patient’s problems. When rapport develops, the patient feels comfortable with the nurse and finds it easier to self-disclose. The nurse also feels comfortable and recognizes that an interpersonal bond or alliance is developing.

33. 2. Empathy Definition: It is the ability to fell with the patient while retaining the ability to critically analyse the situation . OR It is the ability to put oneself in another person’s circumstances and feelings. The nurse need not necessarily have to experience it, but has to be able to imagine the feelings associated with the experience. In empathy, nurse receives information from the patient with an open, non-judgemental acceptance, and communicates this understanding of the experience and feelings so that the patient feels understood.

34. DIFFERENCE BETWEEN EMPATHY AND SYMPATHY

35. 3. Warmth Warmth is the ability to help the patient feel cared for and comfortable. It shows acceptance of the patient as a unique individual. It involves a non-possessive caring for the patient as a person and willingness to share the patient’s joys and sorrows.

36. 4. genuineness Genuineness involves being one’s own self. This implies that the nurse is aware of her thoughts, values and theory relevance in the immediate interaction with a patient. The nurse’s response to the patient is sincere and reflects her internal response. It is also important that the nurse’s verbal and non-verbal communication corresponds with each other.

37. Characteristics of therapeutic nurse-patient relationship Therapeutic relationship is the corner-stone of psychiatric mental health nursing, where observation and understanding of behaviour and communication are great importance. It is a mutual learning experience and corrective emotional experience for the patient. Nature of therapeutic nurse-patient relationship is characterized by the mutual growth of individuals.

38. CONTI… It is based on belief that the patient has potential, and as a result of the relationship, will grow to his fullest potential. In therapeutic relationship the nurse and patient work together towards the goal or assisting the patient to regain the inner resources in order to meet life challenges and facilitate growth. The interaction is purposefully established, maintained and carried out with the anticipated outcome of helping the patient to gain new coping and adaptation skills.

39. Dynamics of therapeutic nurse-patient relationship

40. 1. Therapeutic use of self It is defined as, “ the ability to use one’s personality consciously and in full awareness in an attempt to establish relatedness and to structure nursing interventions.” Peplau described that nurses must clearly understand themselves to promote patient’s growth, change and heal.

41. 2. Gaining self-awareness Self Awareness is the process of understanding one’s own beliefs, thoughts, motivations, biases and limitations and recognising how they affect others. Without self-awareness, nurses will find it impossible to establish and maintain therapeutic relationships with patients.

42. Johari window / therapeutic window It is a representation of the self & a tool that can be used to increase self-awareness. Increased self-awareness allows an individual to accept the differences in others, & to observe each [person’s right to respect & dignity.

43. Johari Window KNOWN TO SELF UNKNOWN TO SELF KNOWN TO OTHERS 1 2 OPEN /PUBLIC SELF Behaviours, feelings and thoughts Known to the individual and others BLIND / UNAWRE OF SELF/ THE UNKNOWING SELF Things that other know but the individual does not know UNKNOWN TO OTHERS 3 4 PRIVATE / HIDDEN SELF Things about self known only to self UNKNOWN SELF Aspects of the self that are unknown to the individual and to others

44. Description of johari window Step 1: Nurse has to appraise her own qualities by creating list of them: values, attitudes, feelings, strengths, behaviours, accomplishments, needs, desires and thoughts. S tep II: To find out the perceptions of others by interviewing them and asking them to identify qualities, both positive and negative, they see in the nurse. Step III: To compare lists and to assign qualities to the appropriate quadrant.

45. Conti… If quadrant 1 is the longest list, this indicates that the nurse is open to others, A smaller quadrant 1 means that the nurse shares little about herself with others. If quadrant 1 and 3 both are small, the person demonstrates little insight. The goal is to work towards moving qualities from 2,3 and 4 into quadrant 1 (Qualities known to self and others) which indicates that the nurse is gaining self-knowledge and awareness.

46. 3. power The appropriate use of power in a caring manner enables the nurse to work with the patient towards the patient’s goals and to ensure that the patient’s goals the patient’s vulnerable position in the nurse-patient relationship is not taken advantage of.

47. 4. trust To maintain trust in the relationship, it is important that the nurse keeps promises to patients. If trust is breached, then it becomes very difficult to re-establish it.

48. 5. intimacY Intimacy relates to the kinds of activities nurses perform for the patients that create personal and private closeness on many levels. This can involve physical, psychological, spiritual and social elements.

49. 6. RESPECT Respect for the dignity and worth of the patient is fundamental to the relationship. The nurse needs to know and understand the culture and other aspects of the patient’s individuality and to take these into account when providing service.

50. Therapeutic impasses- definition They are the blocks in the progress of therapeutic nurse-patient relationship.

51. Therapeutic impasses

52. 1. resistance Causes: Client’s unwillingness to change when the need for change is recognized A reaction by the patient to the nurse who has moved too rapidly or too deeply into the client’s feelings Intentionally or unintentionally communicated lack of respect Inappropriate role model of therapeutic behaviour Secondary gain Favourable environment Interpersonal changes Situational changes Material advantages Pateint’s attempt to remain unaware of anxiety producing aspects within himself.

53. Forms of resistance Suppression Repression Intensification of symptoms Hopeless outlook Self devaluation Forced flight of ideas Intellectual inhibitions Acting out Irrational behaviour Superficial talk No insight Refuses to assume responsibility

54. MANAGEMENT Active liste n ing Clar i fica t i o n – Give f o r f o cused i d e a o f wha t i s h a p p e n in g . Refl e ction – Hel p s t h e p a ti e n t to b e come aw a re o f wh a t h a s b e e n g o i n g i n h i s m i n d . Explore b e h a vior to fi n d p ossibl e re a son. M a in t ai n o p e n com m u n icati o n with sup e rvisor

55. 2. transference Un conscious response of the client in which he experiences feelings and attitudes towards the nurse, associated with significant figures i n h is e a rly lif e . Such respo n se ut i liz e t h e d e fe n se m e cha n is m o f disp l ace m e n t . T ra n sfere n ce re a ctio n s ar e h a rmf u l to t h e th e ra p e u tic pr o cess o n l y i f th e y r e m a in ignored or unexplained. Types: Hostile transference Dependent reaction transference

56. Hostile transference Client will internalize the feelings of anger and hostility as depression and discouragement. Detachment, forgetfulness, irrelevant chattering, go back or preoccupied with his childhood experiences. The client may express doubt about nurse’s training, experience or personal adjustment. The client externalizes his hostility into critical, irritable and defiant.

57. II. Dependent reaction transference This reaction exhibits in the clients who are submissive, subordinate, who will regard the nurse as “God like” figure. Client over values the nurse’s characteristics and qualities. The client continues to demand more form nurses. If his needs were not fulfilled, he will become hostile and contempt.

58. MANAGEMENT N o n e e d t o termin a te r ela ti o n s h i p u n l e s s p oses a se rio u s b a r r ie r t o t h e r a p y o r s af et y . Nur s e s ho ul d wor k with pa t ie n t i n so rt i n g ou t p ast fro m the p r e s e n t Ass i st p a ti e n t i n id e n ti f y i n g t h e tra n s fe r e nce & reas s ign a n ew & more ap prop ri ate meaning to the cu r r e n t nu r se p ati e n t r ela ti o n s h i p. The g o a l is to g uid e t h e p ati e n t to in d e p e n d e nce by teachin g them a s su me r esp o ns i b i li t y for t h e i r o wn be h a v io r s, fee l ing & thou gh t s & to as s ign the co r r e ct mea n i n g to the re la ti o n s h i p b a s e d o n t h e present circumstances instead of past.

59. 3. Counter transference The nurse’s specific emotional response generated by the client’s qualities. Types: Reactions of intense love or caring Reactions of intense disgust or hostility Reactions of intense anxiety often in response to resistance by the patient

60. Forms of countertransference displayed by nurses Difficulty in empathizing with patient in certain problem areas Recurrent anxiety, unease or guilt related to patient Personal or social relationship with patient Encouraging patient’s dependency, praise or affection Sexual or aggressive fantasies towards patient Arguing with patient or tendency to “push” patient before he is ready Feeling angry or impatient because of patient’s unwillingness to change

61. MANAGEMENT Nee d n o t t e rmi n at e re l at i o n ship. Su p p o rt t h e n u rse. As s is t h e r i d e n tifyi n g co u nt e rtra n sfere n c e . Dis c us s wit h sup e riors. Se l f exa m i n a t i o n. Pursue to fi n d o u t source o f pr o bl e m. Exercise contr o l cou n ter t ra n sfere n c e . Pe e r cons u lt a ti o n & p ro f essio n a l m e e t i n gs.

62. 4. Boundary violation It occurs when the nurse goes outside the boundaries of therapeutic relationship and establishes a personal, social relationship with the client.

63. POSSIBLE BOUNDARY VIOLATIONS Nurse accepts free gifts from the patient Having personal or social relationship with patient Nurse attends a social function of patient Nurse regularly reveals personal information to patient Nurse routinely hugs or has physical contact with patient

64. Types of Boundary violations Role boundaries Time boundaries Place and space boundaries Money boundaries Gift and service boundaries Clothing Boundaries Language boundaries Self-disclosure boundaries Post-discharge social boundaries Physical contact boundaries

65. MANAGEMENT Nurses have to follow certain limitations in establishing and maintaining therapeutic nurse-patient relationship Too personal involvement in client's affair has to be avoided Ambiguity and misunderstanding with other staff has to be avoided Adverse feelings, e.g. sexual and other temperaments with the client have to be avoided Ethics and moral principles have to be followed.

66. 5. Gift giving Offering voluntarily some valuable item or material to others as a form of gratitude. Type of Gifts: Tangible: sweets or Bouquet Intangible: Expressing thanks, warmth

67. Common INTERVENTIONS TO OVERCOME THERAPEUTIC IMPASSES Nurse must have knowledge of the impasses and recognise behaviours that indicate their existence. Nurse must reflect on feelings, explore reasons behind such behaviours. Co-workers are more likely than other to recognise the phenomenon initially and give feedback to the nurse about it. Nurse must examine their strengths, weaknesses, prejudices and values before they can interact more appropriately with patients. Transference reactions of patients must also be examined, gently but directly.

68. Conti… Nurses must be open and clear about their genuine reactions when patients misperceive behaviour. Nurses should also state actions that they can and cannot take to meet patient’s needs. Limit setting is useful when patients act inappropriately towards the nurse. Maintain open communication with her supervisor, who can then guide her in making adequate progress in handling such resistance reactions.

69. Phases of therapeutic nurse patient relationship GIVEN BY PEPLAU

70. 1. Pre-interaction phase

71. description Th i s p h as e b e gi n s w h e n t h e n urs e is assign e d to in i ti a te a t h e ra p e u tic rel a ti o nshi p & includ e d al l that the n u rse th i nks , fe e l s o r d o e s i m m e d ia t el y pri o r to t h e first i n t e racti o n wit h t h e p a ti e n t .

72. Tasks for pre-interaction phase Nurse explores own fears and anxieties Analyze own professional strengths and limitations Gather data about patient whenever possible Plan for first meeting with patient

73. Problems encountered Difficulty in self-analysis & se l f acce p t a nce . Anxiety Nurse experience boredom, anger, indifference and depression.

74. Ways to overcome 1. Help from Peers and supervisor in self analysis and facing reality: The nurse needs help from her supervisor and peers in self-analysis and facing reality in order to help patients do likewise. The nurse may in consultation with her supervisor, identify in writing goals for the initial interaction and decide the methods to be used in achieving goals.

75. Conti… 2. Analyse herself & recognise her strengths and weaknesses: The nurse also needs to be consciously aware of the reasons for choosing a particular event. The nurse who is able to use this information in relating to patients in a natural, congruent and relaxed manner.

76. 2. Introductory / orientation phase

77. description It i s d u ring the i n tro d uctor y p h as e th a t t h e n u rse & p a ti e n t m e e t for the first ti m e. One of the n u rse ’ s pri m ary concerns is to fi n d o u t wh y the p a ti e n t sou g h t h e lp.

78. Tasks of Introductory/ orientation phase Establish rapport, trust and acceptance Establish communication, assist in the verbal expression of thoughts and feelings Gather data, including the patient’s feelings, strengths and weaknesses Define patient’s problems, set priorities for nursing intervention Mutually set goals

79. Problems encountered Problem is related to the manner in which the nurse and patient perceive each other. Problems related to establishing an agreement between the nurse and patient.

80. Barriers to the Introductory/ orientation phase Contract? Why? Not going to stay for long? Social class Anxiety, not caring for patient needs Transference Counter transference

81. Ways to overcome Formulating a contract: Elements of a nurse-patient contract: Exchanging names of nurse and patient Explanation of roles of nurse and patient Explanation of responsibilities of nurse and patient Discussion of purpose Discussion of date, time and place Description of meeting conditions for termination Confidentiality

82. 3.Working phase

83. description M o st o f the t h er a p e ut i c wor k i s carried o u t d u ri n g t h e worki n g p h ase. The n u rse & t h e p at i e n t e xplore rel e vant stres s or s & pr o m o te the d e velo p m e n t of i n sig h t i n t h e p a ti e n t .

84. Tasks of Working phase Collection of data from patient, source files Helps patient identify his problems Helps patient to communicate Helps patient to socialize To understand his active participation in the experience To find out alternative solutions To try out new behaviors Prepares for termination of treatment

85. Barriers in the Working phase Testing of the nurse by the patient Delayed progress Difficulty collecting and analyzing data The nurse’s fear of closeness Life stresses of the nurse Resistance behaviors Transference and counter transference reactions

86. Ways to overcome Conferences with supervisors and group discussions with other members of the staff. He helps the nurse to increase her ability to collect and interpret data, apply concepts and synthesize the data obtained. There will be times when the nurse believes she is making little or no progress, either in helping the patient or in gaining knowledge. This time emotional support is needed and the task of supervisor to encourage the nurse to proceed. Most nurses may exhibit a reluctance to write and analyse process records or to engage in a discussion with the supervisor about the content of records. Discussion of the meaning of behaviour and ways to overcome it is essential.

87. Conti… HANDLING RESISTANCE: By listening carefully and find out about any resistance, reasons for resistance. Nurse should maintains open communication with her supervisor, who can then guide her in making adequate progress in handling such resistance reactions.

88. 4. Termination phase

89. Factors of readiness of patient for Termination phase Signs and symptoms reduced Socialization occurs Communication improves Able to manage activities of daily living

90. Causes of termination Ready Patient leaves, does not return Duty changes, training experience over Discharged from hospital

91. Preparation for termination Decide about termination Inform the patient Encourage patient to express his feelings about termination: fears, anxieties

92. Tasks for termination Establish reality of separation Mutually explore feelings of rejection, loss, sadness, anger and related behavior Review progress of therapy and attainment goals Formulate plans for meeting future therapy needs

93. PROBLEMS ENCOUNTERED Patients may perceive termination as desertion and may demonstrate angry behaviour. Some patients attempt to punish the nurse by not talking during the last few interactions or by ignoring termination completely , they may act as if nothing has changed and the interactions will go on as before. Other patients react to the threatened loss by becoming depressed or assuming an attitude of not caring. Fault finding behaviour: Patient may state that the therapy is not beneficial or not working , he may refuse to follow through or something that has been agreed upon before.

94. Conti… Resistance comes in the form of “Flight to health”, which is exhibited by a patient who suddenly declares that there is no need for therapy, he claims to be alright and wants to discontinue therapeutic relationship, this may be a form of denial or fear of the anticipated grief over separation. “Flight to illness” occurs when a patient exhibits sudden return of symptoms, this is an unconscious effort to show that termination is inappropriate and the nurse is still needed, the patient may disclose new information about him or more problems or even threaten to commit suicide in an attempt to delay parting. Nurse’s inability or unwillingness to make specific plans and implement them.

95. WAYS TO OVERCOME Nurse should be aware of the patient’s feelings and be able to deal with them appropriately. Nurse can assist the patient by openly eliciting his thoughts and feelings about termination. The nurse showing less interest in the patient than shown earlier and may be disengaging self form the patient several days before the final interaction. The task of supervisor is to discuss frankly with the nurse the meaning of the behaviour. Supervisor then initiates action to assist the nurse to persevere and intensify her efforts to prepare both self and patient for his eventual release form the hospital.

96. ROLE OF NURSE IN THERAPEUTIC NURSE-PATIENT RELATIONSHIP ROLES OF NURSE SURROGATE COUNSELLOR RESOURCE PERSON TEACHER STRANGER LEADER