Unit 3: Assessment, communication and safety

Nursing Process

 Six-step problem-solving approach that is the cornerstone of clinical decision-making

 Used to facilitate & identify appropriate, safe, culturally competent, developmentally relevant, and quality care

 Not linear

 Collaborative process

 Art of mental health nursing and recovery practice

 Science of evidence-informed decision-making

Mental Status Examination

 A key component of healthcare assessments, evaluating cognitive, affective, and behavioral functioning.

 Used by the mental health team for ongoing patient assessment and treatment effectiveness, it helps collect and organize current objective data.

 The nurse observes and inquires about the patient’s behavior, nonverbal cues, appearance, speech, mood, thoughts, perceptions, cognitive ability, and insight.

 It serves not only to gather information but also to build rapport and communicate effectively, particularly during initial or routine patient interactions.

 Careful selection of time, place, and approach is crucial for successful implementation.

• Appearance

• Behavior

• Speech

• Mood

• Thought

• Perception

• Cognition

Psychosocial Assessment

 May offer a more comprehensive view than the MSE.

 The psychosocial history is often subjective, focusing on the patient's perceptions of their lifestyle and life in general.

 Trauma-informed care is essential, acknowledging patients’ complex trauma histories and ensuring they have choice, control, and safety.

 Also explores the patient’s social functioning and interactions within their systems.

 Nurses should be knowledgeable in growth and development, cultural and religious practices, pathophysiology, psychopathology, and pharmacology for effective mental health assessments.

Social Relationships

can be defined as a relationship that is initiated primarily for the purpose of friendship, socialization, enjoyment, or accomplishment of a task

Therapeutic Relationships

is defined as a helping relationship based on trust, respect, empathy, compassion, and authenticity.

Professional Boundaries

Establishing and maintaining boundaries is an essential competency for psychiatric mental health nurses

Created to protect the space between professional's power and patient's vulnerability

Breaches in therapeutic boundaries result in patient harm

Blurring of Boundaries

Happens:

1. When relationships slip into social context;

2. When nurse’s needs are met at the expense of patient needs

Transference

• Patient unconsiously projects emotions and behaviours from past significant figures onto the nurse.

• It is stronger with authority figures.

Counter-Tranference

• Nurse projects feelings from figures in their past onto the patient.

• The patient's transference often triggers counter-transference in the nurse.

• A common sign of this is the nurse's overidentification with the patient.

Peplau’s Model of Nurse-Patient Relationship

States that all nurses must have:

• Accountability

• Focus on patient needs

• Clinical Competence

• Delaying judgement

• Reflection

Phases of the relationship:

• Pre-orientation

• Orientation

• Working

• Termination

Accountability

Psychiatric nurses assume responsibility for their conduct and the consequences of their action

Focus on patient needs

the interest of the patient, rather then that of the nurse, other health care workers, or the institution, is given first consideration. The psychiatric nurse’s role is that of patient advocate.

Clinical Competence

The criteria on which the nurse base their conduct are principles of knowledge and the most appropriate actions for specific situations. This knowledge and action involve awareness and incorporation of the latest knowledge available from research.

Delayed Judgement

Ideally, nurses refrain from judging patients and avoid inflicting their own values and beliefs on others

Reflection

Is ideally done with the guidance of an experienced clinician or team and is essential to developing self-awareness and clinical competence in establishing therapeutic relationships.

Pre-orientation phase

Nurse prepares for the orientation phase

Orientation phase

• Establishing rapport

• Parameters of the relationship

• Formal or informal contract

• Confidentiality

• Terms of termination

Working Phase

• Maintain relationship

• Gather further data

• Enhance problem-solving skills, self-esteems, and language use

• Facilitate behavioral change & overcome resistance

• Assess problems & goals, and support practicing adaptive behaviours

Termination phase

• Summarize goals & objectives achieved

• Discuss ways for patient to incorporate new coping strategies

• Review situations of relationship

• Exchange memories

Factors that affect communication

• Personal factors

• Environmental factors

• Relationship factors

Consistency

ensuring that a nurse is always assigned to the same patient and that the patient has a regular routine for activities. Interactions are facilitated when they are frequent and regular in duration, format, and location. The importance of this extends to the nurse’s being honest and consistent in what is said to the patient.

Pacing

letting the patient set the pace and letting the pace be adjusted to fit the patient’s moods. A slow approach helps reduce pressure; at times, it is necessary to step back and realize that developing a strong relationship may take a long time.

Listening

letting the patient talk when needed. The nurses becomes a sounding board for the patient’s concerns and issues. It is perhaps the most important skill for nurses to master.

Verbal Communication

• Communicates beliefs, values, perceptions, & meaning

• 10% of communication

• All words a person speaks

• Can convey understanding or judgement; clear or conflicting messages; honest or distorted feelings

Nonverbal Communication

• 90% of communication

• May be conscious or unconscious

• Includes tone, physical appearance, facial expressions, body posture, eye contact, hand gestures

Silence

(Therapeutic Communication)

can sometimes intimidate both interviews and patients. May provide meaningful moments of reflection for both participants, giving an opportunity to contemplate thoughtfully what has been said and felt, weight alternatives, formulate ideas, and gain a new perspective on the matter under discussion.

Active Listening

(Therapeutic Communication)

in the nurse-patient relationship includes the following aspects:

• Observing the patient’s non-verbal behaviors

• Understanding and reflecting on the patient’s verbal message’

• Understanding the patient in the context of the social setting of the patient’s life

• Detecting “false notes” (e.g., inconsistencies or things the patient says that need more clarification)

• Providing constructive feedback about the patient that they might not be aware

Clarifying techniques

(Therapeutic Communication)

Understanding depends on clear communication, which is aided by the nurse’s verifying their own interpretation of the patient’s messages. The nurse can request feedback on the accuracy of the message received from the verbal and non-verbal cues.

1. Paraphrasing

2. Restarting

3. Reflecting

4. Exploring

Asking questions

(Therapeutic Communications)

Open-ended and closed-ended questions

Excessive questioning

(Non-therapeutic Communication)

Asking multiple closed-ended questions consecutively and rapidly, casts the nurse in the roles of an interrogator who demands information without respect for the patient’s willingness or readiness to respond. This approach conveys a lack of respect for and sensitivity to the patient’s needs.

Giving approval or disaproval

(Non-therapeutic communication)

A patient may be feeling overwhelmed, experiencing low self-esteem, feeling unsure of where their life is going, or desperately seeking recognition, approval, and attention. Yet when people are feeling vulnerable, a value comment may be misinterpreted. To continue to please the nurse, the patient may continue bad behavior. The behavior may indeed be useful for the patient, but not when done to please another person. Also, when the person to please is not around the motivation may not be there either.

Giving advice

(Non-therapeutic communication)

Although we ask for and give advice all the time in daily life, giving advice to a patient is rarely helpful. Often when we seek advice, our real motive is to discover whether we are thinking along the same lines as someone else or if they would agree with us. When a nurse give advice or offers a solution, the nurse is interfering with the patients ability to make personal decisions.

Asking “why” questioning

(Non-therapeutic communication)

Very often these types of questions imply criticism. We may ask our friends or family these questions tog et context. With people we do not know, especially those who may be anxious or overwhelmed, this questions from a person in authority can be perceived as instrumental and judgmental, serving only to make the person feel the need to justify behavior and respond defensively.

Assertive Communication

Clearly expressing needs with respectful language and behaviours in order to:

• Challenge & promote alternates

• De-escalate behaviours

• Provide & provoke new lines of thinking

• Advocate for oneself or others

Communication Style

(Culture)

People may communicate in an intense and highly emotional manner. Some may consider it normal to use dramatic body language when describing emotional problems, and others may perceive such behaviors as being out of control or reflective of some degree of pathology.

Eye contact

(Culture)

The presence or absence of should not be used to assess attentiveness, judge truthfulness, or make assumptions about the degree of engagement one has with a patient. Cultural norms often dictate a person’s comfort or lack of comfort with direct eye contact. Some cultures consider direct eye contact disrespectful and improper.

Touch

(Culture)

The therapeutic use of touch is a basic aspect of nurse-patient relationship and is generally considered a gesture of warmth and friendship; however, the degree to which a patient is comfortable with the use of touch is often culturally determined.

Cultural Filters

It is important to recognize that it is impossible to listen to people in an unbiased way. In the process of socialization we develop this through which we listen to ourselves, others, and the world around us. This is a form of cultural bias or prejudice that determine what we pay attention to and what we ignore.

Setting

• The quality of interaction relies on the nurse and patient feeling safe; creating a secure environment is crucial for the therapeutic relationship.

• An ideal setting includes a private, yet visible, space like a healthcare setting or conference room.

• When the interview occurs in the patient’s home, the nurse can assess the patient in their everyday context.

Seating

• Create a non-threatening environment by:

• Ensuring both nurse and patient are at the same height (sitting or standing).

• Using a 90 to 120-degree angle or side-by-side position to reduce intensity and allow for comfortable looking away.

• Ensuring the patient is not positioned between the nurse and the exit, also avoiding configurations that make the patient feel trapped.

• Avoiding a desk barrier between the nurse and the patient.