14. Therapeutic and Abusive Relationships

how do nurses assess violence?

how do nurses intervene with violence?

community violence directly relates to what?

home violence

gun violence risk factors

hx of aggressive behavior, make, poverty, substance use, culture

gun education!

store unloaded and in a locked container. only adults should know where it is. store ammunition separate and never leave guns unattended

what is in place to allow teenagers 15 years or older to consent to emergency procedures related to gun violence or other violence?

mature minors doctrine

sexual violence

usually victim knows perpetrator

alcohol increases risk 8X

highest number of victims in 12-24 year range

sexual assault

includes unwanted advances, harassment, rape, drug-facilitated assault, incest, trafficking, FGM

what do SANE nurses do?

they have specialized training to care for SA patients. competent in conducting medical and legal evaluations. can be expert witness in court

what is the MOST ESSENTIAL thing a SANE nurse can do when providing care?

ask for consent at each and every single step

pt interview - signs of human trafficking

pt reluctant to describe event that led to the visit. they are vague, inconsistent with answers, don’t have an ID, and don’t really know where they are

assessment signs of human trafficking

unexplained bruises, burns, lacerations

bite marks

vaginal or anal tearing, STIs, pregnancy

nutritional deficit, SUD

what should a nurse do when human trafficking is suspected?

get the patient alone to interview. get a professional interpreter if needed. alert the team, it will be an effort to get them away from whoever is with them

prevention for individual and family violence

prevention for community violence

interventions for family and community violence

what are the characteristics of child abusers?

low understanding of normal child development

history of abuse of substance use

caregivers are not biological

how do we care for sexual assault?

provide consistent, immediate, and objective care in a safe and private environment. give appropriate STI prophylaxis and emergency contraception. use trauma-informed care

abuser characteristics in the tension-building phase

edgy with minor explosions

may verbally abuse, slap, and hit

victim in tension building phase

tense, afraid, “walking on eggshells”

helpless, becomes compliant, accepts blame

abuser in honeymoon phase

loving behavior, gifts and flowers. sorry and promises to change

victim in honeymoon phase

trusting, hoping for change, wants to believe promises

victim in serious battering phase

tension becomes unbearable and victim may provoke to get it over with. they may try to cover up the injury or get help 

how can nurses counsel patients going through violence?

SUPPORT - right to live without fear

SAFETY PLAN 

Facilitate access to resources - shelter, safe house

types of child neglect

physical (food, clothes, shelter, medical care)

emotional (not caring, nurturting, or accepting. ignored)

types of child abuse

physical (physical force that can result in physical harm)

sexual

emotional (harm a child’s self-worth or emotional well being. name calling, shaming, rejecting, withholding love, threatening)

what are the characteristics of a therapeutic relationship?

focus is on the PATIENT’S ideas, experiences, and feelings. PROGRESS IS EVALUATED

how is progress evaluated in a therapeutic relationship?

1. pts needs are identified and explored

2. clear boundaries

3. encourage problem solving

4. help pt develop new problem solving skills

5. support behavior change

goals and functions of a therapeutic relationship

facilitating communication

assisting with problem solving

helping pts examine self-defeating behaviors

promoting self care

providing education

promoting recovery

examples of nurse responses to patient behaviors

preorientation phase

before you meet the pt! get info from chart and staff reports

orientation phase

introduction - names and purpose

establish rapport - understanding, empathy

specify a contract - 

explain confidentiality

working phase

1. gathering data

2. identifying problem solving skills and self esteem - what works and doesn’t work?

3. education about disorder

4. sx management

5. education about meds

6. eval progress

termination phase

summarize achievements

discuss ways to apply coping strategies

review situations that occurred

validate experience, acknowledge that it mattered. this facilitates closure

what 3 things can make a powerful impact on a pt?

genuine concern + positive regard + empathy

what are some patient barriers to forming therapeutic relationships?

nurse behaviors that indicate boundary crossing

spending more time with one patient than others, doing tasks for the pt that they can do by themselves, sharing personal information, thinking about the pt outside of work, being defensive when others comment on “special attention”, accepting personal comments and questions by the pt

signs of countertransference (nurse to pt)

strong feelings, reactions to a behavior, identifying with a pt, power struggling

what are 2 common circumstances of boundary crossing?

1. relationship slips into a social context

2. nurse’s need for attention, affection, and support are met at the expense of the patient’s needs

how do you apply therapeutic boundaries?

who is at risk for violence?

who is at risk for sexual assault?

social and community factors that influence violence

education needs of families experiencing violence

education needs of communities experiencing violence

education needs of patients experiencing violence

how can the nurse respond when a pt threatens suicide?

assess plan and lethality. tell the pt that this is serious and that you don’t want harm to come to them. tell them that this needs to be shared with other staff

how can the nurse respond when the pt asks them to keep a secret?

you can’t promise that! it might be important for health or safety. be honest: “I can’t promise to keep a secret. it might be important for me to share with other staff.”

then the pt can decide if they want to share

how can the nurse respond when a pt asks a personal question?

you may or may not answer, but do your best to reflect it back to the pt.

“are you married?”

“yes. do you have a spouse?”

how can the nurse respond if a patient makes sexual advances?

“I’m not here to talk about that. This time is to focus on your problems and concerns”

restate the nurse’s role. you can leave and come back. reassign if you have to

how can the nurse respond if a patient cries?

stay with them and say that it’s okay to cry. you can ask “what are you feeling right now?” or make observations/reflections

how can the nurse respond when a pt leaves before session is over?

some pts can’t sit there for a long time. they might feel anxious. check back in later

how can the nurse respond if the pt doesn’t want to talk?

you can just sit with them. maybe spend 5 minute intervals with them throughout the shift. reinforce presence and trust - they can rely on you

how can the nurse respond if the pt gives them a present?

expensive or money - refuse

inexpensive at the end of care - you can take. at the beginning - no. it’s your job to care 

how to respond when another pt interrupts?

“I am with this pt for the next 20 minutes. but at 10:00am, I can come talk to you for 5 minutes”