HNR 3013: Mental health Nursing (Theory) Lecture Delivered by: Dr. Saed Azizeh Asst. Prof. – HS– HNR- FWC- 2012010
Introduce the nurse-client relationship.
The nurse-client relationship is the foundation on which psychiatric nursing is established. It is a relationship in which both the nurse and the client must recognize each other as unique and important. It is also a relationship in which mutual learning occurs. The therapeutic interpersonal relationship is the process by which nurses provide care for clients in need of psychosocial intervention Therapeutic use of self is the instrument for delivery of that care. Interpersonal communication techniques (both verbal and nonverbal) are the “tools” of psychosocial intervention.
A therapeutic relationship is an interaction between two people (usually a caregiver and a care receiver) in which input from both participants contributes to a climate of healing, growth promotion, and/or illness prevention.
The nurse-client relationship is a therapeutic one in which both parties perceive the other as a human being. The nurse-client relationship is goal oriented, and ideally, the nurse and the client both decide what the goal will be. Most often, the goal is directed at learning and growth in order to bring about some type of positive change in the client’s life.
The goals of a therapeutic relationship should be based on a problem-solving model, meaning that a problem should be clearly identified and both the client and the nurse should work toward resolving that problem.
The nurse should work to:
Identify what is troubling the client.
Encourage the client to discuss changes he or she would like to make.
Discuss which changes are possible and which are not.
Help the client explore feelings about things that cannot be changed.
Discuss alternative strategies for creating changes.
Weigh the benefits and consequences of the alternatives.
Assist the client to select an alternative.
Encourage the client to implement the change.
Provide positive feed back for the client’s attempts to create change.
Assist the client to evaluate outcomes of the change.
Correct answer: A
The goal of a therapeutic nursing interaction is to promote client insight and behavioral change directed toward client growth.
Define therapeutic use of self.
Travelbee described the instrument for delivery of the process of interpersonal nursing as the therapeutic use of self, which she 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.”
Several characteristics that enhance the achievement of a therapeutic relationship have been identified. Discuss some of these characteristics.
Rapport implies special feelings on the part of both the client and the nurse based on acceptance, warmth, friendliness, common interest, a sense of trust, and a nonjudgmental attitude.
To trust another, one must feel confidence in that person’s presence, reliability, integrity, veracity صحه , and sincere desire to provide assistance when requested. Trust is the basis of a therapeutic relationship. The nurse working in psychiatry must perfect the skills that foster the development of trust.
To show respect is to believe in the dignity and worth of an individual regardless of his or her unacceptable behavior. The attitude is nonjudgmental, and the respect is unconditional in that it does not depend on the behavior of the client to meet certain standards.
The concept of genuineness refers to the nurse’s ability to be open, honest, and, “real” in interactions with the client. To be “real” is to be aware of what one is experiencing internally and to allow the quality of this inner experiencing to be apparent in the therapeutic relationship.
Empathy is the ability to see beyond outward behavior and to understand the situation from the client’s point of view. With empathy, the nurse can accurately perceive and understand the meaning and relevance of the client’s thoughts and feelings.
The therapeutic interpersonal relationship is the means by which the nursing process is implemented. Through the relationship, problems are identified and resolution is sought. Tasks of the relationship have been categorized into four phases. Describe each of these phases.
The preinteraction phase involves preparation for the first meeting with the client. Tasks include obtaining available information about the client from his or her chart, significant others, or other health team members, and examining one’s feelings, fears, and anxieties about working with a particular client.
The orientation phase is when the nurse and client become acquainted with each other. Tasks during this phase include creating creating an environment for the establishment of trust and rapport, establishing a contract for intervention that details the expectations and responsibilities of both parties, gathering assessment information, identifying the client’s strengths and limitations, formulating nursing diagnoses, setting goals that are mutually agreeable, developing a plan of action that is realistic, and exploring feelings of both the client and nurse.
The working phase is when the therapeutic work of the relationship takes place. Tasks during this phase include maintaining the trust and rapport that was established during the orientation phase, promoting the client’s insight and perception of reality, problem-solving, overcoming resistance behaviors on the part of the client, and continuously evaluating progress.
Describe transference and countertransference as potential issues in the working phase.
Transference occurs when the client unconsciously displaces to the nurse feelings formed toward a person from his or her past. Transference can interfere with the therapeutic interaction when the feelings being expressed include anger and hostility. Anger toward the nurse can be manifested by uncooperativeness and resistance to the therapy. Transference can also take the form of overwhelming affection for the nurse or excessive dependency on the nurse
Countertransference refers to the nurse’s behavioral and emotional response to the client. These responses may be related to unresolved feelings toward significant others from the nurse’s past, or they may be generated in response to transference feelings on the part of the client.
The termination phase is the end of the nurse-client relationship. Termination of the relationship may occur for a variety of reasons: the mutually agreed-on goals may have been reached; the client may be discharged from the hospital; or, in the case of a student nurse, it may be the end of a clinical rotation.
Correct answer: D
In the pre-interaction phase, the nurse must clarify personal attitudes, values, and beliefs to become aware of how these might affect the nurse’s ability to care for various clients. This occurs before the nurse meets the client.
Boundaries are borders or limits in a relationship. They determine the extent of acceptable limits. Many different types of boundaries exist such as material boundaries, social boundaries, personal boundaries, and professional boundaries. It is important for both the nurse and the client to understand these boundaries.
Discuss common boundary concerns that may occur in the nurse-client relationship.
Self-disclosure on the part of the nurse may be appropriate when it is judged that the information may therapeutically benefit the client. It should never be undertaken for the purpose of meeting the nurse’s needs.
Gift giving may be part of the therapeutic process for people who receive care. Cultural belief and values may also enter into the decision of whether to accept a gift from a client. Accepting financial gifts is never appropriate, but in some instances nurses may be permitted to suggest instead a donation to a charity of the client’s choice. If acceptance of a small gift of gratitude is deemed appropriate, the nurse may choose to share it with other staff members who have been involved in the client’s care.
Touching is required to perform the many therapeutic procedures involved in the physical care of clients. Caring touch is the touching of clients when there is no physical need. Touching or hugging can be beneficial when it is implemented with therapeutic intent and has the consent of the client. There are times when touch should be avoided or considered with extreme caution.
When a nurse is acquainted with a client, the relationship must move from one of a personal nature to professional. If the nurse is unable to accomplish this separation, he or she should withdraw from the nurse-client relationship. Romantic, sexual, or similar personal relationships are never appropriate between nurse and client.
Certain warning signs exist that indicate that professional boundaries of the nurse-client relationship may be in jeopardy.
Read the warning signs on slides 21-23.
Boundary crossings can threaten the integrity of the nurse-client relationship. Nurses must gain self-awareness and insight to be able to recognize these warning signs.
Define interpersonal communication.
Interpersonal communication is a transaction between the sender and the receiver. In the transactional model of communication, both participants simultaneously perceive each other, listen to each other, and mutually are involved in creating meaning in a relationship.
The Transaction Model of communication describes communication as a process in which communicators generate social realities within social, relational, and cultural contexts. In this model, nurses don't just communicate to exchange messages; they communicate to: Create relationships.
Both the sender and receiver bring certain preexisting conditions to the exchange that influence both the intended message and the way in which it is interpreted.
Discuss some of these preexisting conditions.
Values, attitudes, and beliefs are learned ways of thinking. Children generally adopt the value systems and internalize the attitudes and beliefs of their parents. Children may retain this way of thinking into adulthood or develop a different set of attitudes and values as they mature. Values, attitudes, and beliefs can influence communication in numerous ways. For example, prejudice is expressed verbally through negative stereotyping.
Cultural mores, norms, ideas, and customs provide the basis for our way of thinking. Cultural values are learned and differ from society to society. Religion also can influence communication. Symbolic gestures, such as wearing a cross around the neck or hanging a crucifix on the wall can communicate an individual’s religious beliefs.
Studies of nonverbal indicators of social status or power have suggested that high-status persons are associated with gestures that communicate their higher-power position. For example, they use less eye contact, have a more relaxed posture, use louder voice pitch, place hands on hips more frequently, are “power dressers,” have greater height, and maintain more distance when communicating with individuals considered to be of lower social status.
Gender influences the manner in which individuals communicate. Most cultures have gender signals that are recognized as either masculine or feminine and provide a basis for distinguishing between members of each gender.
Roles have historically been identified as either male or female. For example, in the United States masculinity typically was communicated through such roles as husband, father, breadwinner, doctor, lawyer, or engineer. Traditional female roles included wife, mother, homemaker, nurse, teacher, or secretary. Gender signals are beginning to change in the United States as gender roles become less distinct.
Age influences communication, especially during adolescence. Words such as “dude,” “groovy,” “clueless,” “awesome,” “cool,” and “wasted” have had special meaning for different generations of adolescents. The technological age has produced a whole new language for today’s adolescents.
Developmental influences on communication may relate to physiological alterations. One example is American Sign Language, the system of unique gestures used by many people who are deaf or hearing impaired. Individuals who are blind at birth never learn the subtle nonverbal gesticulations that accompany language and can totally change the meaning of the spoken word.
The place where the communication occurs influences the outcome of the interaction.
Territoriality is the innate tendency to own space. Individuals lay claim to areas around them as their own. This influences communication when an interaction takes place in the territory “owned” by one or the other.
Density refers to the number of people within a given environmental space. It has been shown to influence interpersonal interaction. Some studies indicate that a correlation exists between prolonged high-density situations and certain behaviors, such as aggression, stress, criminal activity, hostility toward others, and a deterioration of mental and physical health.
Distance is the means by which various cultures use space to communicate.
Hall identified four kinds of spatial interaction, or distances, that people maintain from each other in their interpersonal interactions and the kinds of activities in which people engage at these various distances. These include intimate, personal, social, and public distances.
Correct answer: B
A quiet corner of the day room provides for some privacy in a neutral space while not limiting access to help if safety issues arise.
Explain different methods of nonverbal communication.
Physical appearance and dress are part of the total nonverbal stimuli that influence interpersonal responses and, under some conditions, they are the primary determinants of such responses. This includes clothing, hair, tattoos, cosmetics, and jewelry.
The way in which an individual positions his or her body communicates messages regarding self-esteem, gender identity, status, and interpersonal warmth or coldness.
Touch is a powerful communication tool. It can elicit both negative and positive reactions, depending on the people involved and the circumstances of the interaction. It is a very basic and primitive form of communication, and the appropriateness of its use is culturally determined.
Facial expressions primarily reveal an individual’s emotional states, such as happiness, sadness, anger, surprise, and fear. The face is a complex multimessage system. Facial expressions serve to complement and qualify other communication behaviors and at times even take the place of verbal messages.
It is through eye contact that individuals view and are viewed by others in a revealing way. An interpersonal connectedness occurs through eye contact. In American culture, eye contact conveys a personal interest in the other person. Eye contact indicates that the communication channel is open, and it is often the initiating factor in verbal interaction between two people.
Paralanguage is the gestural component of the spoken word. It consists of pitch, tone, and loudness of spoken messages, the rate of speaking, expressively placed pauses, and emphasis assigned to certain words. These vocal cues greatly influence the way individuals interpret verbal messages.
Hays and Larson identified a number of techniques to assist the nurse in interacting more therapeutically with clients. These should serve to enhance development of a therapeutic nurse-client relationship. Table 6-3 in the text includes a list of these techniques, a short explanation of their usefulness, and examples of each.
Read the list of therapeutic communication techniques and their usefulness on slides 33-37.
Correct answer: A
The nurse is using the therapeutic techniques of “reflection” and “formulating a plan of action.” The use of these communication facilitators indicates that the nurse is supportive of the client’s feelings and appreciates the need for a safety plan.
Several approaches are considered to be barriers to open communication between the nurse and client. Hays and Larson identified a number of these techniques, which are presented in Table 6-4 in the text. Nurses should recognize and eliminate the use of these patterns in their relationships with clients. Avoiding these communication barriers enhance the nurse-client relationship.
Read the list of nontherapeutic communication techniques and their effects on slides 40-44.
Correct answer: C
Open-ended questions are phrased in a way that gathers as much information as possible. By the use of phrases such as “Tell me about…” or “Describe to me…” a varied and rich body of information can be assessed.
Describe the concept of active listening.
To listen actively is to be attentive and really desire to hear and understand what the client is saying, both verbally and nonverbally. With active listening the nurse communicates acceptance and respect for the client, and trust is enhanced. A climate is established within the relationship that promotes openness and honest expression.
Explain the acronym SOLER.
S: Sit squarely facing the client. This gives the message that the nurse is there to listen and is interested in what the client has to say.
O: Observe an open posture. Posture is considered “open” when arms and legs remain uncrossed. This suggests that the nurse is “open” to what the client has to say. With a “closed” posture, the nurse can convey a somewhat defensive stance, possibly invoking a similar response in the client.
L: Lean forward toward the client. This conveys to the client that you are involved in the interaction, interested in what is being said, and making a sincere effort to be attentive.
E: Establish eye contact. Direct eye contact is another behavior that conveys the nurse’s involvement and willingness to listen to what the client has to say. The absence of eye contact, or the constant shifting of eye contact, gives the message that the nurse is not really interested in what is being said.
Discuss process recordings.
Process recordings are written reports of verbal interactions with clients. They are verbatim accounts and used as a tool for improving interpersonal communication techniques. The process recording can take many forms, but usually includes the verbal and nonverbal communication of both nurse and client. An example of one type of process recording is presented in Table 6-5 in the text.
Define feedback.
Feedback is a method of communication that helps the client consider a modification of behavior. Feedback gives information to clients about how they are being perceived by others. It should be presented in a manner that discourages defensiveness on the part of the client.
