Psychiatric Nursing (Notes)
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Therapeutic relationship – is a relationship that is established between a health care professional and a client for the purpose of assisting the client to solve his problems. Components of a Therapeutic RelationshipOne of the most important skills of a nurse is developing the ability to establish a therapeutic relationship with clients. For interventions to be successful with clients in a psychiatric facility and in all nursing specialties it is crucial to build a therapeutic relationship. Crucial components are involved in establishing a therapeutic nurse-patient relationship and the communication within it which serves as the underpinning for treatment and success. It is essential for a nurse to know and understand these components as it explores the task that should be accomplish in a nurse-client relationship and the techniques that a nurse can utilize to do so. TRUSTWithout trust a nurse-client relationship would not be established and interventions won’t be successful. For a client to develop trust, the nurse should exhibit the following behaviors:
GENUINE INTERESTAnother essential factor to build a therapeutic nurse-client relationship is showing a genuine interest to the client. For the nurse to do this, he or she should be open, honest and display a congruent behavior. Congruence only occurs when the nurse’s words matches with her actions. EMPATHYFor a nurse to be successful in dealing with clients it is very essential that she empathize with the client. Empathy is the nurse’s ability to perceive the meanings and feelings of the client and communicate that understanding to the client. It is simply being able to put oneself in the client’s shoes. However, it does not require that the nurse should have the same or exact experiences as of the patient. Empathy has been shown to positively influence client outcomes. When the nurse develops and utilizes this ability, clients tend to feel much better about themselves and more understood. Some people confuse empathizing with sympathizing. To establish a good nurse-patient relationship, the nurse should use empathy not sympathy. Sympathy is defined as the feelings of concern or compassion one shows for another. By sympathizing, the nurse projects his or her own concerns to the client, thus, inhibiting the client’s expression of feelings. To better understand the difference between the two, let’s take a look at the given example. Client’s statement: “I am so sad today. I just got the news that my father died yesterday. I should have been there, I feel so helpless.” Nurse’s Sympathetic Response: “I know how depressing that situation is. My father also died a month ago and until now I feel so sad every time I remember that incident. I know how bad that makes you feel.” Nurse’s Empathetic Response: “I see you are sad. How can I help you?” When the nurse expresses sympathy for the client, the nurse’s feelings of sadness or even pity could influence the relationship and hinders the nurse’s abilities to focus on the client’s needs. The emphasis is shifted from the client’s to the nurse’s feelings thereby hindering the nurse’s ability to approach the client’s needs in an objective manner. In dealing with clients their interest should be the nurse’s greatest concern. Thus, empathizing with them is the best technique as it acknowledges the feelings of the client and at the same time it allows a client to talk and express his or her emotions. Here a bond can be established that serves as a foundation for the nurse-client relationship. ACCEPTANCEClients are unpredictable. There are times that they outburst with anger or act out their inappropriate desires. A nurse, who does not judge the client or person no matter what his or her behavior, is showing acceptance. Acceptance does not mean accepting all the inappropriate behavior but rather acceptance of the person as worthy. When the client displays an improper behavior, the nurse can communicate with the client by being firm and clear without anger or judgment. In this way, the nurse allows the client to feel intact but at the same time aware that his certain behavior is unacceptable. Let’s take a look at the given example. Situation: A client tries to kiss the nurse. Inappropriate response: What the hell are you doing?! I’m leaving maybe I’ll see you tomorrow. Appropriate response: Adam, do not kiss me. We are working on your relationship with your girlfriend and that does not require you to kiss me. Now let us continue. POSITIVE REGARDPositive regard is an unconditional and nonjudgmental attitude where the nurse appreciates the client as a unique worthwhile human being that shows respect for the client regardless of his or her behavior background and lifestyle. The following ways are example of how to promote respect and positive regard to a client:
SELF-AWARENESSSelf-awareness is the process of understanding one’s own values, beliefs, thoughts, feelings, attitudes, motivations, prejudices, strengths and limitations. Before a nurse can understand clients he or she should be able to understand him or herself. The first step in preparing oneself to build a therapeutic nurse-patient relationship is to understand oneself. THERAPEUTIC USE OF SELFA nurse can only use his or her personality, experiences, values, feelings, intelligence, needs, coping skills and perceptions to build a relationship with clients (therapeutic use of self) when he or she has developed self-awareness and self-understanding. Therapeutic Technique1. Offering Self
2. Active listening
3. Exploring
4. Giving broad openings
5. Silence
6. Stating the observed
7. Encouraging comparisons
8. Identifying themes
9. Summarizing
10. Placing the event in time or sequence
11. Voicing doubt
12. Encouraging descriptions of perceptions
13. Presenting reality or confronting
14. Seeking clarification
15. Verbalizing the implied
16. Reflecting
17. Restating
18. General leads
19. Asking question
20. Empathy
21. Focusing
22. Interpreting
23. Encouraging evaluation
24. Suggesting collaboration
25. Encouraging goal setting
26. Encouraging formulation of a plan of action
27. Encouraging decisions
28. Encouraging consideration of options
29. Giving information
30. Limit setting
31. Supportive confrontation
32. Role playing
33. Rehearsing
34. Feedback
35. Encouraging evaluation
36. Reinforcement
Avoid pitfalls:
Non-therapeutic Technique1. Overloading
2. Value Judgments
3. Incongruence
4. Underloading
5. False reassurance/ agreement
6. Invalidation
7. Focusing on self
8. Changing the subject
9. Giving advice
10. Internal validation
Other ineffective behaviors and responses:
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