Week 2

Why is Therapeutic Relationship Important

Why is Therapeutic Relationship Important

It is one of the most important skills a nurse can develop

It is crucial to success of interventions with clients requiring psychiatric care

Components of Therapeutic Relationship: Trust

Behaviors: caring, interest, understanding, consistency, honest, keeping promises, listening

Congruence

Components of Therapeutic Relationship: Genuine interest

Self comfort, self awareness of strength and limitations, clear focus

Components of Therapeutic Relationship: Empathy

Ability to perceive clients meanings and feelings to communicate that understanding. Client and nurse giving gift of self

(Different from sympathy where feelings of concern or compassion may project nurses personal feelings)

Components of Therapeutic Relationship: Unconditional Positive Regard

Acceptance (no judgements; set boundaries)

Positive Regard (Unconditional nonjudgmental attitude)

Therapeutic Use of Self

Use of aspects of personality, experience, values, feelings, intelligence, needs coping skills, perceptions to establish relationships with clients

Concept made by Hildegard Peplau

Personal actions rise from conscious and unconscious responses

Therapeutic Roles of the Nurse in a Relationship

Teacher: Coping, problem solving, medication regiment

Caregiver: therapeutic relationship, physical care

Advocate: ensuring privacy and dignity, informed consent, access to services, safety from abuse and exploitation

Basic Communication: Intrapersonal

Self Talk

Basic Communication: Interpersonal

Exchange of information with individuals or small groups

Basic Communication: Public communication

Large group presentation

Basic Communication: Transpersonal communication

Addresses an individual spiritual needs (includes intervention to meet needs)

Verbal Communication

Content: literal words spoken, environment, circumstances,

Context: situation in which communication occurs

Vocab: age, language, literacy

Denotative/Connotative meaning: using words that have the same meaning to both sender and receiver

Timing/Relevance: Anger, rage, pain, loose, grief

Pacing: Flow of information

Intonation: The feeling behind the words

Verbal Communication Skills

DO

1. Give Concrete messages (no abstract)

2. Promote discussion or feelings in depth

3. Give feedback by making observations or presenting reality

DO NOT

1. Advise

2. Belittle

3. Challenge

4. Probe

Nonverbal Communication

Process: all messages used to give meaning context to message.

Congruent or incongruent messages

Appearance: Posture, Gait

Facial Expressions: Eye contact, Gestures

Sounds: Territorial, Personal Space

Silence

Nonverbal Communication Skills

DO

1. Positive Facial Expression

2. Open Posture

3. Eye Contact

DO NOT

1. Closed body Position

2. Confusing

Proxemics: Distance Zones

• Intimate (0–18 in)
• Personal (18–36 in)
• Social (4–12 ft)
• Public (12–25 ft)

Therapeutic communication is comfortable: 3-6 feet

Therapeutic Communication should be:

Purposeful, Patient centered, Problem Driven

Attend to client needs

Express empathy and concern

Obtain info and give feedback

Intervene to promote progress and safety

Evaluate progress towards goal and objectives

Therapeutic Communication Goals:

Establish therapeutic nurse-client relationship

Identify clients concern

Assess clients perceptions

Facilitate clients expression of emtoions

Teach clients and family self care skills

Recognize clients needs

Implement interventions for clients needs

Guide clients towards acceptable solutions

Therapeutic Nurse Client Relationship

Client focused

Identify client needs

Discuss problem solving

Develop coping skills

Promote Autonomy

Essential Components of Therapeutic communications

Attentive and active listening: Eye contact, body language, vocal quality, verbal tracking

Caring attitude

Honesty

Trust

Empathy

nonjudgmental attitude

Therapeutic Communication: Touch

5 types

1. Functional-Professional

2. Social-Polite

3. Friendship-Warmth

4. Love-Intimacy

5. Sexual-Arousal

Nurse must evaluate touch based on clients preferences history and needs

Effective Skills and Techniques for Therapeutic Communication

1. Silence

2. Active Listening

3. Clarifying

4. Focusing

5. Ask Questions

6. Present Reality

7. Summarize

8. Offer self

9. Touch (IF APPRORPIATE)

Barriers to Effective Communication

1. Asking Irrelevant Personal Questions

2. Offering Personal Opinion

3. Giving advice

4. False Reassurance

5. Minimize Feelings

6. Changing Topics

7. Excessive or Probing Questioning

8. Approving or Disapproving responses

Meaning

Messages often contain more meaning than just a spoken word

Context

Validation with client findings from verbal and nonverbal info

Assessment focuses on who, what, when, how, and why

Spirituality

Self awareness of one own spiritual beliefs

Need to objectivity and non judgmental attitude about client beliefs

Nurses Role in working with clients with different cultures

1. Seek knowledge about clients cultural values, beliefs, health practices

2. Client is best source of info

3. Get general knowledge to guide nurse on preferences, health practice and beleifs

4. Wide variation among members to any cultural group

Therapeutic Communication Session: Initiation

– Introduction
– Establishment of contract for relationship
– Identification of major concern

• Nondirective role: broad openings, open-ended questions
• Directive role: direct yes-or-no questions; usually for clients with suicidal thoughts, in crisis, or who are out of touch with reality

Therapeutic Communication Session: Goals

– Establishing rapport
– Actively listening
– Gaining in-depth understanding of client’s perception of issue
– Being empathetic
– Exploring client’s thoughts and feelings
– Facilitating client’s expression of thoughts and feelings
– Guiding client in developing problem-solving skills
– Promoting client’s evaluation of solutions

Milieu Therapy

• Designed initially as a way to manage children and adolescents in an inpatient setting

• Focuses on having an environment that is supportive, therapeutic, and safe.

• Focus of this type of therapy is patients will improve through an educational process and structured systems

Milieu Therapy Characteristics: Physical Setting

– Clean and orderly – Comfortable – Physical space
– Quiet area for sleep – Meals – Social access
– Nursing station availability

Milieu Therapy Characteristics: Health Care Team Responsibilities

– Promotion of independence and self reliance
– Apply rules of fair treatment – Model good social behavior
– Work cooperatively as a team member

Milieu Therapy Characteristics: Emotional Climate

– Client should feel safe from harm – Client should feel supported and
encouraged

Physical Safety

• Nursing stations placement
– Should have direct oversight of clients
– Should be open and encouraging of clients needs

• Special safety features
– Special needs patients should have individual rooms and observable from the nursing station
– Power cords, electrical outlets, sharp corners, low beds
– Evacuation protocols

• Self harm and harm to other prevention
– Removal of sharps – ropes – cords – poisons
– Light bulbs – Toilet tank tops – Plastics – Cans - Glass

DSM IV: AXIS 1

Clinical Disorders

DSM IV: AXIS 2

Personality Disorder and Mental Retardation

DSM IV: AXIS 3

General Medical Conditions

DSM IV: AXIS 4

Psychosocial and Environmental Problems

DSM IV: AXIS 5

Global Assessment of Functioning

Seclusion and Restraint

• Only to be used after all less restrictive measures have been exhausted
• Solid staff development in seclusion and restraint use
• Policies and Procedures
• Documentation

Diverse Practice Setting: Acute Care

– Locked facilities – Stabilization of acute symptoms
– Privately or county owned
– Managed by Nurses – Treatment team approach

Diverse Practice Setting: Community Settings

– County mental health – Clinics – Schools – Partial hospitalization programs – Telephone crisis -

Diverse Practice Setting: Forensic

– Jail, prison, state hospitals
– Nurses work with perpetrators and victims of valiance, abuse, criminal behavior such as fire setting and drug addition

Diverse Practice Setting: State Hospitals

– Treatment of the chronic mentally ill
– Long term treatment – Managed by Nurses –Treatment team approach

Community Based Programs

Partial Hospitalization
• Assertive Community Treatment (ACT)
– Nontraditional care management
– Intensive case management (crisis intervention)

• Community Mental Health Centers
– Educational groups
– Medication dispensing
– Individual counseling programs

• Psychosocial Rehabilitations Programs
– Day programs for older adults

• Home care
– Provides for services within the home

Legal Holds

1. Voluntary (not a hold)

2. 5150: Mental Health Crisis (held for 72 hours)

3. 5250: Suicidal or hurting others (held for 14 days)

4. 5260: Continued risk of suicide (additional 14 days)

5. 5270: Gravely disabled (additional 30 days)

Riese Hearing

• Clear and convincing evidence that-
• Informed Consent was given that includes why the medication is need, likelihood of improvement, alternative treatment available.
• Documentation of refusal.
• Petition and Notice
• Presentation of the case

Firearms Advisement

• 2008 Dangerous Weapons Control Law
• 8100 Thru 8104 Welfare and Institutions Code
• Danger to self or other
• 5150 5250

Conservatorship/Guardianship

• Legal guardianship; separate from civil commitment
– Grave disability
– Incompetency
– Inability to provide self with food, clothing, shelter
– Inability to act in own best interests

• Loss of right to enter into contracts
• Consent to be obtained from legal guardian who speaks for client
• Conservator sometimes refers to person who manages client’s financial affairs

Rights of Clients

• Clients retain all civil rights afforded to all people
– Except right to leave hospital in case of involuntary commitment
• Principles for the Provision of Mental Health and Substance Abuse Treatment Services (American Psychiatric Association [APA])
– Mental health patient’s bill of rights

Least Restrictive Environment

• Right to treatment in least restrictive environment appropriate to meet client’s needs
• Free of restraint or seclusion unless necessary

• Restraint: direct application of physical force to person without permission
– Human
– Mechanical

• Seclusion: involuntary confinement in specially constructed, locked room equipped with security window or camera for direct visual monitoring

• Restraint/seclusion only for shortest time necessary
– Permitted only when client is imminently aggressive/dangerous

Confidentiality

• Health Insurance Portability and Accountability Act (HIPAA) of 1996
• Civil (fines) and criminal (prison sentences) penalties for violation of client privacy
• Duty to warn third parties: exception to client’s right to confidentiality

Tarasoff

• Duty to Protect
• Duty to Inform
• Duty to Report (Child/Elder Abuse, Domestic Violence)
• Charting

Assessment of Violence
• Establish the four important parameters: type of harm, seriousness of harm, imminence of harm, likelihood of harm.

Discharge the Duty
• Changing the treatment program for the patient, requesting the
patient be voluntarily committed, civil commitment, warning the
potential victim, warning others who would be likely to notify the
victim, and contacting the police in the area of the victim or the
patient.

Torts

• Wrongful act, resulting in injury, loss, or damage

Unintentional Tort

– Negligence
– Malpractice
• Elements to prove malpractice
– Duty
– Breach of duty
– Injury or damage
– Causation

Intentional torts

– Assault: making a threat to a client’s person
– Battery: touching a client in a harmful or offensive wayh
– False imprisonment: confining a client to a specific area
– Three elements to prove liability

• Willful, voluntary act
• Intention to bring about consequences or injury
• Act was a substantial factor in injury or consequences