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Therapeutic Relationships Vidbeck pg144-155. Learning Outcomes. Describe necessary components in the nurse-patient relationship. Explain the importance of values, beliefs, and attitudes in the development of the nurse-patient relationship.

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Therapeutic relationships vidbeck pg144 155 l.jpg

Therapeutic RelationshipsVidbeck pg144-155


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Learning Outcomes

  • Describe necessary components in the nurse-patient relationship.

  • Explain the importance of values, beliefs, and attitudes in the development of the nurse-patient relationship.

  • Describe the importance of self-awareness and therapeutic use of self in the nurse-patient relationship.


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Learning Outcomes

  • Describe the differences between social and therapeutic relationships.

  • Describe and implement the phases of the nurse-patient relationship.

  • Explain the negative behaviors that can diminish the nurse-patient relationship.


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Therapeutic Relationships

  • The ability to establish therapeutic relationships with patients is one of the most important skills a nurse can develop.

  • Social Relation- (ex: family, friends) info unlimited, more emotionally invested. Can give advice.

  • Therapeutic Relation- (ex: pt/nurse) Info exchange limited, less emotionally invested. Cannot give advice.

    • Nurses carries the whole load.


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Therapeutic nurse-patient relationship

  • Purposeful and goal-directed

  • Has defined boundaries

  • Is structured to meet the patient’s needs

    • In Social relationship its give and take, but in an Nurse-Patient relationship its all about the pt.

  • Is safe, confidential, reliable, and consistent

    • Applies Physically and Mentally


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Therapeutic Relationships (cont’d)

  • Components include:

    • Trust

    • Genuine interest

    • Empathy (not sympathy)

      • Sympathy implies a feeling of recognition of another's suffering

        • Sympathy makes pt more dependant

      • Empathy is often characterized as the ability to "put oneself into another's shoes".

    • Acceptance of person, not necessarily his or her behavior

    • Unconditional positive regard

    • Self-awareness and therapeutic use of self


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Self-Awareness and Therapeutic Use of SelfUnderstanding how we present ourselves and how we are seen by others

  • Self-awareness:process of understanding one’s own values, beliefs, thoughts, feelings, attitudes, motivations, strengths, and limitations and how one’s thoughts and behaviors affect others

    • Self Disclosure- when your’e telling things to a pt that they don’t need to know. Info the pt doesn’t need to know unless its therapeutic

      • Ex: Where you live


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Therapeutic Use of SelfUse yourself as a tool to help pt grow/heal

  • Therapeutic use ofself:the nurse uses aspects of his or her personality, experience, values, feelings, intelligence, needs, coping skills, and perceptions to establish relationships with clients that are beneficial to clients


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Establishing the Therapeutic Relationship

  • Therapeutic relationships are focused on the needs, experiences, feelings, and ideas of the patient, not the nurse

  • The therapeutic relationship consists of three phases:

    • Orientation

    • Working

    • Termination


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Establishing the Therapeutic Relationship (cont’d)

  • In the orientation phase:

    • Information gathering, to use in interventions and to problem solve

    • The nurse and patient meet

    • Roles are established

    • Purposes and parameters of future meetings are discussed

    • Expectations are clarified

    • Patient’s problems are identified

    • Keep pt involved throughout


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Establishing the Therapeutic Relationship (cont’d)

  • The working phaseinvolves:

    • Problem identification

      • The patient identifies the issues or concerns causing problems (Caution: pt may not see what their “real” problem is)

      • Examination of the patient’s feelings and responses

  • Exploitation:

    • Development of better coping skills and a more positive self-image, behavior change, and independence


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Establishing the Therapeutic Relationship (cont’d)

  • In the working phase, the nurse must be acutely aware of 2 common elements can arise:

    • Transference: when patients unconsciously transfer feelings they have for significant persons in their life onto the nurse

    • Countertransference: when the nurse responds to the patient based on his or her own unconscious needs and conflicts


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Establishing the Therapeutic Relationship (cont’d)

  • The terminationakaresolution phase:

    • Begins when the patient’s problems are resolved

    • Ends when the relationship is ended

    • Deals with feelings of anger or abandonment that may occur

      • Anxiety (from readiness to be released) can lead to anger or nervousness

        • Remind then that their time there has been a benefit

    • Happens when problems subside

    • For closure, tell them “goodbye”


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Behaviors That Diminish Therapeutic Relationships

  • Inappropriate boundaries (relationship becomes social or intimate)

    • Feelings of sympathy and encouraging dependency (Nurse should show empathy and not sympathy)

    • Nonacceptance of the patient as a person because of his or her behaviors, leading to avoidance of the client

      Nurse self-awareness is the way to avoid such problems (Keep boundaries and set limits)


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Therapeutic Roles of the Nurse in a Relationship

  • Teacher

    • Expressing their feeling

    • Finding social support

    • Coping skills

    • Meds

  • Caregiver

  • Advocate

    • Act on their behave and make sure that they’re not being taken advantage of

    • Make sure they are safe

  • Parent surrogate

    • Not love/hug, but remind them of bathing, hygiene, wash hands, eat vegetables, etc.


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    Self-Awareness Issues

    • Self-awareness on the nurse’s part is crucial to developing therapeutic relationships

      • As a nurse, know your role. Keep treatment non-biased.

    • Values clarification, journaling, group discussions, and reading will assist with this process

    • Developing self-awareness is a continual, ongoing process; the nurse needs to plan for self-growth



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    Learning Outcomes

    • Describe the goals of therapeutic communication.

    • Identify therapeutic and nontherapeutic verbal communication skills.

    • Discuss boundaries in therapeutic communication.


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    Communication

    • The process people use to exchange information:

      • Verbal

        • Speech

      • Context

        • the set of facts or circumstances that surround a situation or event

      • Nonverbal

        • Eyes, Facial expression, Tone of voice

      • Congruency

        • The quality of agreeing; being suitable and appropriate

      • Incongruency

        • out of place, absurd behavior


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    Communication (cont’d)

    • Interpersonal interactions between the nurse and the patient

    • It focuses on the patient’s specific needs and is used to:

      • Establish the therapeutic relationship

      • Identify the patient’s most important concerns

      • Assess the patient’s perceptions

      • Facilitate the patient’s expression of emotions

      • Teach the patient and family necessary self-care skills

      • Recognize the patient’s needs

      • Implement interventions designed to address the patient’s needs

      • Guide the patient toward satisfactory and acceptable solutions


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    Essential Components of Therapeutic Communication

    • Privacy and respect for boundaries

      – Therapeutic communication is most comfortable at 3 to 6 feet; should not be less than 18 inches

    • Touching

      – Touch may be comforting and supportive

      –Touch also is an invasion of intimate and

      personal space (Telegraph when you’re about to touch the pt)

      – Nurse must evaluate whether the patient perceives touch as positive or threatening and unwanted; never assume that touching a patient is acceptable


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    Essential Components of Therapeutic Communication (cont’d)

    • Active listening- means refraining from other internal mental activities and concentrating exclusively on what the patient says

    • Active observation- means watching the speaker’s nonverbal actions as he or she communicates


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    Verbal Communication Skills

    • Use concrete messages

      • Use words that are clear and concise

      • Concrete messages are specific and clear

      • Concrete messages elicit more accurate responses


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    Verbal Communication Skills (cont’d)

    • Therapeutic communicationtechniques facilitate interaction and enhance communication between patient and nurse

    • Techniques that encourage the patient to discuss his or her feelings or concerns in more depth include:

      • Exploring- delving further into the subject

      • Focusing- concentrate ?’s on a certain point

      • Restating- clarification, repeating

      • Reflecting- good to help pt “open up”

      • Ask broad open-ended ?’s, make observations

        (NOTE: Refer to p. 107-111,table 6.1)


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    Verbal Communication Skills (cont’d)

    • Nontherapeutic communication includes:

      • Advising- Don’t give advice

      • Agreeing- Don’t agree w/ delusions or hallucinations- things that pt sees, hears, smells (but, don’t argue either)

        • “I know you see that giant Penguin, but I don’t.”

      • Reassuring- Don’t give them false reassurances.

        • Can lead to pt no longer trusting you


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    Nonverbal Communication Skills

    • Facial expression

    • Body language

      • Gestures, posture

    • Vocal cues

      • Tone of voice

    • Eye contact

      • Some pts will not make eye contact

      • Can be a tale to their emotions

      • Don’t look in eyes all the time, b/c they think u can see what they are thinking

    • Silence

      • They may be processing info

      • Are they gathering their thoughts?


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    Understanding the Meaning of Communication

    • Messages often contain more meaning than just the spoken words

    • The nurse must try to discover all the meaning in the patient’s communication, not only the literal meaning of the words


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    Understanding Context

    • Understanding the context of a situation gives the nurse more information and reduces the risk of assumptions

    • To clarify context, the nurse must gather information from verbal and nonverbal sources and validate findings with the patient


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    Understanding Spirituality

    • Spirituality is a patient’s belief about life, illness, death, and one’s relationship to the health, universe

    • The nurse must first assess his or her own spiritual beliefs (self-awareness, remain unbiased)

    • The nurse must remain objective and nonjudgmental

    • The nurse must assess the patient’s spiritual needs


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    Cultural Considerations

    • The nurse must be aware of cultural differences in:

      • Speech patterns and habits

      • Styles of speech and expression

      • Eye contact

      • Touch

      • Concept of time

      • Health and health care

      • Be sensitive to their culture


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    Goals of a Therapeutic Communication Session

    • Establishing rapport (get along)

    • Identifying issues of concern

    • Being empathetic, genuine, caring, and unconditionally accepting of the person

    • Understanding the patient’s perception

    • Exploring the patient’s thoughts and feelings

    • Developing problem-solving skills

    • Promoting the patient’s evaluation of solutions

    • Make sure it is all pt oriented


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    Beginning Therapeutic Communication

    • Introduce and establish a contract

      • “I’m the nurse. I will… And I expect you to…”

    • Find patient-centered goals

      • Everyone is different. Depends on what the pt’s needs are.

        -Use directive or nondirective role appropriately, based on patient behaviors


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    Beginning Therapeutic Communication (cont’d)

    • Phrase questions appropriately

      • Ask for clarification

      • Manage patient’s avoidance of the anxiety-producing topic

        • Change subject for a minute

      • Avoid asking why

    • Guide the patient in problem-solving and empower the patient to change

      • Help them realize they can solve problems

    • Alert for inappropriate responses by nurse

      • Ex: Judging, arguing


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    Community-Based Care

    • Nurses are increasingly caring for patients in the family unit and in communities

    • Nurses need increased self-awareness and knowledge about cultural differences

    • Nurses need self-awareness and sensitivity to the beliefs, behaviors, and feelings of others

    • Nurses must collaborate with the patient and family as well as other healthcare providers


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    Self-Awareness Issues

    • Nonverbal communication is as important as verbal

    • Ask colleagues for feedback

      • “Am I getting the info that I need?”

    • Examine your communication skills


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    Patient’s Response to Illness


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    Learning Outcomes

    • Discuss individual characteristics and factors that influence a patient’s response to illness.

    • Explain the nurse’s role working with patients of different cultural backgrounds.

    • Describe cultural factors important in assessing and working with patients of different cultures.


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    Individual Factors

    • Age, stage of growth and development

    • Genetics and biologic factors

      • Just because your mom is psycho, doesn’t mean you’re going to be…

    • Physical health and health practices

    • Response to drugs

      • Not everyone reacts to meds the same

      • Elderly: slower metabolism, med stays in their system longer.


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    Individual Factors (cont’d)

    • Pts have different coping skills:

      • Self-efficacy

        • His/her perception of illness

      • Hardiness- ability to survive, resist illness

      • Resilience and resourcefulness- how u bounce back

      • Spirituality- being punished

      • Ask to self: how quick can pt bounce back? Or how do they respond to illness.

      • How we respond has to do w/ how hardy and resilient we are.


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    Interpersonal Factors

    • Sense of belonging

      • If pt feels valued or that they fit in, they will do much better in recovery/treatment

    • Social networks and social support

      • Fitting in family, job, friends

    • Family support


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    Cultural Factors

    • Beliefs about causes of illness

    • Factors in cultural assessment:

      • Communication

      • Physical space or distance

      • Social organization

      • Time orientation

      • Environmental control

      • Biologic variations

    • Socioeconomic status and social class


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    Cultural Patterns and Differences

    • Knowledge of expected cultural patterns provides a starting place for the nurse to begin to relate to persons from different ethnic backgrounds.

      • May see a mix of cultures

      • Look at the person/Indv.


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    Cultural Patterns and Differences (cont’d)

    • No Q’s specifically about diff cultures; but understand that they exist.

    • African Americans

      • Usually family-oriented, but client makes own decisions

      • Conversation animated

      • Handshakes and direct eye contact convey interest and respect

      • View mental illness as a spiritual imbalance or punishment for sin


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    Cultural Patterns and Differences (cont’d)

    • Filipinos

      • Greet others with smiles rather than handshakes

      • Facial expressions animated

      • Direct eye contact impolite, especially with authority figures

      • Mental illness viewed as having religious and mystical causes


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    Cultural Patterns and Differences (cont’d)

    • Mexican Americans

      • Touching prevalent among family, but not necessarily welcome from strangers

      • Direct eye contact with authority figures avoided

      • Silence denotes disagreement

      • Illness comes from imbalance between person and environment


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    Nurse’s Role in Working With Clients From Various Cultures

    • Nurse must learn about the client’s cultural values, beliefs, and health practices

      • Best source of information is the client:

        • “How would you like to be cared for?”

        • “What do you expect (or want) me to do for you?”


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    Self-Awareness Issues

    • Maintain a genuine, caring attitude

    • Ask how you can promote or assist with spiritual, religious, and health practices

    • Recognize your own feelings and possible prejudices

    • Remember that the patient’s response to illness is complex and unique



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    Learning Outcomes

    • Identify the factors that influence the assessing of a mental health patient.

    • Describe how to conduct a interview with a patient on a mental health unit.

    • Explain the components used to gather information in the psychosocial assessment of a mental health patient.

    • Identify other sources of data used in patient assessment.


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    Purposes of Psychosocial Assessment

    • To construct picture of patient’s current emotional state, mental capacity, and behavioral function

    • To form basis for plan of care

    • To establish clinical baseline to evaluate effectiveness of treatment and interventions


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    Factors Influencing Assessment

    • More of a nursing observation on a psych floor.

    • Patient’s participation/feedback

      • Answers may show signs of impaired thinking

    • Patient’s health status

      • Pain may hamper response/feedback

    • Patient’s previous experiences/misconceptions about health care

      • Consider possible previous abuse or forced admission

    • Patient’s ability to understand

      • Patient may be unable to read or have language barrier

    • Nurse’s attitude and approach

      • Safety 1st, for pt and for yourself


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    How to Conduct the Interview

    • Provide a comfortable, private, safe environment

    • Obtain input from family and friends (with patient’s permission)

    • Ask questions that are open-ended or closed-ended as needed (avoid “Yes or No” type Q’s)

      • “How can we help?”

      • Very important to obtain “accurate” input


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    Content of the Assessment

    • History- very important

    • General appearance and motor behavior (Slide 62)

      • Observe: Grooming habits, style

    • Mood and affect* (Next slide)

    • Thought process and content* (Slide 55)

      • Does he know the time and place?

      • Is pt oriented or in touch w/ reality?

    • Sensorium and intellectual processes

      • Ability to problem solve

    • Judgment and insight

    • Self-concept

      • Many clients don’t think they need to be there

    • Roles and relationships

      • Have they severed relationships?

    • Physiologic and self-careconcerns

      • Are they misinterpreting pain or physical problems?


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    Mood and Affect AssessmentHelps w/ diagnosis

    Mood- is pervasive and sustained quality of person’s emotional tone: described as euphoric, dysphoric, euthymic, or labile (rapidly changing)

    Affect-outward expression of emotion: described as blunted, flat, inappropriate/incongruent to verbal, appropriate, hyper-reactive, or restricted/constricted


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    Thought Processes and Content

    Thought process- how patient thinks

    Thought content- what patient actually says

    Common terms in assessing :

    Delusions-false fixed ideas. Ex: someone is out to get them (persecutory, paranoid, grandiose, somatic)

    Hallucinations-something heard (#1), smelled, or seen (#2)

    Ideas of reference- interpretation of external events having reference to one's self (thoughts directed towards him)

    Loose associations-jump from one subject to another (random thoughts/ideas)

    Tangential thinking-talking to them and their mind just wanders off

    Abstract thinking- understand the glass house thing


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    Thought Process and Content (cont’d)when talking to them, make sure to give them time to answer

    Thought blocking- stopping abruptly when thinking (for some reason pt can’t think right now)

    Thought broadcasting- others can hear your thoughts

    Thought insertion- others are putting thoughts in head, controlling them

    Thought withdrawal- others are taking thoughts from head

    Word salad- putting words together that have no meaning/ connection/ relation

    Concrete thinking- form logical thought

    Phobic- fearful of item/ situation/ environment

    Reality oriented-


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    Data Analysis

    After completing the assessment the nurse analyzes all the data to help in forming the patient’s plan of care

    Other data may be gathered from the following

    • Psychosocial assessment

    • Psychological tests

    • Psychiatric diagnoses

    • Mental status exam


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    Psychological Tests

    • Psychological tests are another source of data to use in planning care

      • Intelligence tests assess cognitive abilities and intellectual functioning

      • Personality tests evaluate self-concept, impulse control, reality testing, and major defense mechanisms


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    Psychiatric Diagnoses

    • Based on the DSM-IV-TR multiaxial system:

      • Axis I: clinical disorders

      • Axis II: personality disorders, mental retardation

      • Axis III: general medical conditions

      • Axis IV: psychosocial and environmental problems

      • Axis V: global assessment of functioning (GAF)


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    Mental Status Exam

    Focuses on the patient’s cognitive abilities:

    • Orientation to person, time, place, date, season, day of the week

    • Ability to interpret proverbs

    • Ability to perform math calculations

    • Memorization and short-term recall

    • Naming common objects in the environment

    • Ability to follow multi-step commands

    • Ability to write or copy a simple drawing


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    Self-Awareness Issues

    • Judgments are not part of the assessment process

    • Be open, clear, and direct when asking about personal or uncomfortable topics

    • Examining one’s own beliefs and gaining self-awareness is a growth-producing experience

    • The nurse must not allow personal beliefs to interfere with the nurse–patient relationship and the assessment process


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    Appearance/Motor behaviorCont. from slide 53

    • Neologism- invented words; a word coined by a psychotic or delirious patient that is meaningful only to the patient.

    • Psychomotor retardation- overall slowed movements

    • Waxy flexibility- maintain of posture even if uncomfortable or awkward

    • Automatism- repeated purposeful behavior

      • Tapping/clicking related to anxiety


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