Friday, July 17, 2009
- Interaction between two or more people involving exchange of information between the sender and receiver
- The product of communication is message interpreted by the receiver
- Channels of communication: Verbal and Nonverbal
- Use of words. Content and context of words should be assessed
1. Written – ex: documents, mail, e-mail, records, text messaging
- Considerations: language, grammar, legibility of hand writing,
2. Spoken – consider: timbre and tone, rate and emphasis of speech, body language, mannerisms, emotion
- Monitor if congruent and incongruent to spoken words.
1. Kinesthetic/ gestures
2. Proxemics -
Distance zones (Hall 1966)
• Intimate zone: 0-18 inches
• Personal zone: 18-36 inches
• Social zone: 4-12 feet, therapeutic relationship happens
• Public zone:12-25 feet, sender and receiver remains strangers
5 types of touch (Knapp 1980)
• Functional professional
• Social polite
• Friendship warmth
• Love intimacy
• Sexual arousal
4. Cultural artifacts
5. Position – sitting position, posture
6. Physical appearance
7. Facial expressions
8. Vocal cues
- Focuses on the client needs and problems
- It is planned and directed
- Confidentiality is respected but information the professional nurse must share information to the treatment team
How to develop therapeutic communication skills?
1. Know yourself
2. Be honest
3. Be secure in ability to relate to people- don’t let behavior of others threaten or intimidate you
4. Be sensitive to the needs of others
5. Be consistent
6. Recognize symptoms of anxiety
7. Watch your nonverbal movements
8. Use words carefully
9. Recognize differences
10. Recognize and evaluate your actions and responses
-essential for attaining positive behavioral change
• Goal Directed
• Focused on the need of the patient
• Time limited
Components of Therapeutic Relationships
• Treating the client as a human being
• Suggesting without telling
• Keeping promises
• Providing schedules of activities
• Genuine interest
• Positive regards
Self Awareness and Therapeutic Use of Self
- To be able to use self as a therapeutic agent, nurses should be aware of their own self.
- This includes values, beliefs, attitudes, motivations, prejudice, strengths and weaknesses
- A nurse who successfully evaluated and accepted self will have better relationship with clients
- One tool that is useful in learning oneself is Johari’s Window
PHASES OF NURSE- CLIENT RELATIONSHIP (NCR)
A. Pre-interaction/Pre-orientation (For the Nurse)
- the core value and major goal of a nurse is self awareness
- begins when the client is assigned to the nurse
- includes gathering of data, planning for interaction
- nurse may feel little anxiety like in planning an interview
B. ORIENTATION (INITIATION)
- Begins when the nurse meets the client
- The nurse establish roles, the purpose of the meeting, the parameters of the subsequent meeting, assess/identifies the client’s problem, needs and clarifies expectations
- Levels of anxiety of both the nurse and client are identified
- The major goal in this stage is establishing rapport
- Set goals of relationship. –Contracts-
- Define responsibilities of nurse and client. Stage of testing.
- Establish boundaries of relationship. Stress confidentiality.
- The start of termination phase: “Good morning, full name, RN, shift, session, date start & end.”
ESSENTIAL ELEMENTS OF A NURSE- CLIENT CONTRACT
1. Names of RN and patient 5. Purpose of a relationship
2. Roles of RN and patient 6. Meeting location / time
3. Responsibilities of RN and patient 7. Condition for termination
4. Goals / Expectations 8. Confidentiality
C. WORKING PHASE
The most difficult and the longest phase
Promote acceptance of each other
Major task is identification and resolution of the client’s problem
Accept client as having value and worth as a unique individual.
Most problems encountered are resistance, transference and counter transference
NCP is a continuing process
- Identification of the problem/exploration
- The Core Value is Consistency especially for manipulative patients
Be consistent to patient with: BAAAM COPS
B orderline C onduct d/o
A ntisocial O ral/eating disorder
A lzheimer’s P aranoid
A utistic S uicidal
1. Maintaining the professional, therapeutic relationship
2. Gathering more data- recognize blocks to communications
3. Exploring perceptions of reality and keeping interactions reality oriented
4. Developing positive coping skills
5. Promoting positive self concept -reflection of feelings
6. Encouraging verbalization of feelings- by active listening
7. Facilitating behavior change
8. Working through resistance
9. Evaluating progress
10. Practice new coping behaviors
11. Promoting independence
Plan for termination of relationship: orientation phase
Begins when problems are solved
It is a weaning process
Major task is to assist the client in reviewing what has learned and applying it to interpersonal relationships
- Separation Anxiety:
S/Sx: Regression: Temper tantrums, thumb sucking, apathy, fetal position when crying.
Maintain boundaries do not give address and telephone numbers
Be firm and professional
Don’t promise that relationship will continue
Anticipate problems of termination:
Dependency on the nurse
Recalling of past negative experiences like rejection, depression, abandonment,
Regressive behaviors may surface
- Concerns with the admission in the hospital
1. Voluntary commitment
• client seeks help or requests the admission voluntarily
• signs consent for treatment
• may refuse any treatment prescribed
• if ready, they may also sign themselves out of the facility
• AMA or involuntary confinement may be issued if the client is assessed to still be needing further treatment
2. Involuntary commitment
• Client has legal capacity to consent to treatment but refuses to do so
• Client is unable to determine the need for examination
• Greatly disabled
• Impose threat to himself or others
• Common categories:
(1) Evaluation and emergency care – 48 to 72 hrs
(2) Certification for observation and treatment
(3) Extended or indeterminate care- needs prolonged psychiatric care typically for 60-180 days
Also called guardianship
Conservators are legally obligated to act in the best interest of their conservatee
Included are signing of informed consent, contracts, writing of checks, deciding on treatment modalities
Nurse must gain consent from conservator to prevent legal consequences
Criteria for having a conservator:
• Gravely disabled
• Unable to provide basic needs although resources exists
• Cannot act in their best own interest
1. Right to treatment using the least restrictive alternative/environment
• means that the client does not have to hospitalized if they are able to be treated in outpatient basis
2. Right to confidentiality
3. Right to freedom from restrain and seclusion
• restrain- direct application of physical force against will to restrict freedom
• Human or mechanical restrain
• seclusion- involuntary confinement to a specially constructed room with lock, window or camera
• short term use of restrain and seclusion are used only if the client becomes aggressive to himself or environment
• requires physician’s order every 12 hours
• assessed by nurses every 2-4 hours
• checks every 10-15 minutes for skin condition, blood circulation, side effects of medications and emotion
• nurse can approve seclusion and restrain in emergency situations if no physician is available but the client must be seen within 4hours
• document everything especially:
a. type of restraint
b. reason of restraint
c. length of restraint
d. observation to maintain safety
4. Right to give or refuse consent to treatment
5. Right to access to personal belongings
6. Right to daily exercise
7. Right to have visitors
8. Right to use writing materials and uncensored mail
9. Right to use the telephone
10. Right to access courts and attorneys
11. Right to employment compensation
12. Right to be informed of rights
13. Right to refuse electroconvulsive therapy or psychotherapy
Nurses are expected to met the standards of care
Torts – is a wrongful act which results to injury, damages or losses
Two types of torts: unintentional and intentional
A. Unintentional – failure to do reasonable and prudent person would do in similar situation
• Negligence - involves causing of harm by failing to do what a reasonable and prudent person would do in a similar condition.
• Elements: 1. duty to care, 2. An obligation of reasonable care, 3. Breach of duty, 4. Actual injury resulting from breach of duty
• Malpractice – is negligence that refers specifically to professionals like nurses and physicians
B. Intentional – voluntary act that cause harm to client
• Assault- involves any action that causes a person to fear being touched in a way that is offensive, insulting, or physically injurious without consent or authority
• Battery- involves harmful or not consented contact with the client wherein harm or injury may or may not have happened
• False Imprisonment- defined as the unjustifiable detention of a person examples are inappropriate use of restraint and seclusion
o Ethical Issues
• Important aspects in caring for any client. This may cause conflicts between clients and the medical team
• Ethical issues includes:
o Duty to Warn
• Includes threat to self and others
• Tarasoff vs the reagents of University of California
• Nurse should warn the significant others if client’s is seen to have plans of committing suicide
• Also nurses have the responsibility to warn individuals that the client threats to hurt
o Insanity Defense
• M’Naghten rule
• Is an argument that a person accused of a crime is not guilty because that person cannot understand the nature and implications of their actions and is not able to determine between right and wrong
• Upon meeting the criteria, a person may have a verdict of “guilty by reason of insanity”
Patient’s Bill of Rights
1. The patient has the right to considerate and respectful care.
2. The patient has the right and is encouraged to obtain from physicians and other direct caregivers relevant, current, and understandable information concerning diagnosis, treatment, and prognosis.
3. The patient has the right to make decisions about the plan of care prior to and during the course of treatment and to refuse a recommended treatment or plan of care to the extent permitted by law and hospital policy and to be informed of medical consequences of this action. In case of such refusal, the patient is entitled to other appropriate care and services that the hospital provides, or transfer to another hospital. The hospital should notify patients of any policy that might affect patient choice within the institution.
4. The patient has the right to have an advance directive (such as a living will, health care proxy, or durable power of attorney for health care) concerning treatment, with the expectation that the hospital will honor the intent of that directive to the extent permitted by law and hospital policy.
5. The patient has the right to every consideration of privacy. Case discussion, consultation, examination, and treatment should be conducted so as to protect each patient’s privacy.
6. The patient has the right to expect that all communications and records pertaining to his or her care will be treated as confidential by the hospital, except in cases such as suspected abuse and public health hazards, when reporting is permitted or required by law. The patient has the right to expect that the hospital will emphasize the confidentiality of this information when it releases it to any other parties entitled to review information in these records.
7. The patient has the right to review the records pertaining to his or her medical care and to have the information explained or interpreted as necessary, except when restricted by law.
8. The patient has the right to expect that, within its capacities and policies, a hospital will make a reasonable response to the request of a patient for appropriate and medically indicated care and services.
9. The patient has the right to ask and be informed of the existence of business relationships among the hospital, educational institutions, other health care providers, or payers that may influence the patient’s treatment and care.
10. The patient has the right to consent or decline to participate in proposed research studies or human experimentation affecting care and treatment or requiring direct patient involvement, and to have those studies fully explained prior to consent. A patient who declines to participate in research or experimentation is entitled to the most effective care that the hospital can otherwise provide.
11. The patient has the right to expect reasonable continuity of care when appropriate and to be informed by physicians and other caregivers of available and realistic patient care options when hospital care is no longer appropriate.
12. The patient has the right to be informed of hospital policies and practices that relate to patient care, treatment, and responsibilities. The patient has the right to be informed of available resources for resolving disputes, grievances, and conflicts, such as ethics committees, patient representatives, or other mechanisms available in the institution. The patient has the right to be informed of the hospital’s charges for services and available payment methods.
American Hospital Association. (1992). A patient’s bill of rights. Chicago: AHA
American Nurses Association Code of Ethics for Nurses
1. The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.
2. The nurse’s primary commitment is to the patient, whether an individual, family, group, or community.
3. The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.
4. The nurse is responsible and accountable for individual nursing practice and determines the appropriate delegation of tasks consistent with the nurse’s obligation to provide optimum patient care.
5. The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.
6. The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action.
7. The nurse participates in the advancement of the profession through contributions to practice, education, administration, and knowledge development.
8. The nurse collaborates with other health professionals and the public in promoting community, national, and international efforts to meet health needs.
9. The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of the profession and its practice, and for shaping social policy.
World Health Organization defines mental health as "a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community”
in contact with reality and the environment in ways that are in accord with oneself and possess the ability to love, work and resolve conflicts within a framework of reasonability
A state of emotional, psychological and social wellness evidenced by satisfying interpersonal relationships, effective behavior and coping, positive self concept and emotional stability
Simultaneous success at working, loving and creating with the capacity for mature and flexible resolutions of conflicts between instincts, conscience and important other people and reality (American Psychiatric Association, 1980)
State of imbalance characterized by a disturbance in the persons thoughts, feelings, and behavior.
A clinically significant behavioral or psychological syndrome or pattern the occurs in an individual and that is associated with present distress or disability or with a significantly increased risk of suffering, death, pain, disability or important loss of freedom
Not limited to relations between person and society
Incidence and Prevalence of Mental Health
• 5.7% of American adults over the age of 18 have a serious mental disorder in any 12 month period
• 25% of Americans are affected by mental and addictive disorders each year
• Anxiety disorders accounts as having the highest percentages of mental illness
Elements of Mental Health
2. perceives reality accurately
3. personal growth / achieves a unifying, integrated outlook in life
4. sense purpose and meaning- maximizes one’s potential
5. positive relations with others
6. environmental mastery
7. autonomy or self-determination
Factors that Influence Mental Health
1. inherited characteristics
2. nurturing during childhood
3. life circumstances
General Causes of Mental Disorders
a. Genetic theory- temperament
b. Neurotransmitter- dopamine is associated with schizophrenia
c. Brain abnormality- post traumatic stress syndrome
f. Physical illness
a. Coping skills, interpersonal relationships
b. Early childhood experiences
3. Psychosocial / sociocultural
a. Poverty and deprivation
b. role overload
c. relocation and culture shock
Diagnosis of Mental Illness
• Health History
o current symptoms and previous history or mental disturbances
o current and previous role and social functioning
o history from significant others
• Physical Examination
o History and PE should be comprehensive to rule out treatable physical illness
o Includes neurologic assessment
o No specific diagnostic tests for diagnosing a specific mental illness
o Therapeutic drug levels may be ordered throughout the course of treatment
o Brain Imaging, CT scan, MRI, Electrocephalogram may be acquired
DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS 4TH EDITION
• Published by the American Psychiatric Association
• Provides a common language for mental health professionals
• Lists of specific criteria necessary for assignment of a special mental disorder diagnosis
- A normal human behavior or emotion
- A strong and uncomfortable emotional response to a real or perceived provocation
- Positive force leading to problem solving and productive change when appropriately handled
- Potentially destructive and life-threatening when inappropriately channeled (denial, suppression)
o Expression of anger through aggressive but safe means like hitting a punching bag and yelling
o Increases anger rather than alleviating
· Assertive Communication
o Use of word “I” in accepting one’s anger
· I am angry about your constant nagging.
Anger Control versus Anger Suppression
· Utilizing Assertive communication
· Use of non-aggressive means like walking or talking
· Common in women
· Prevents the expression of anger and keeping it
· Prone to somatic and psychological complications
- Also known as verbal aggression
- An emotion expressed through verbal abuse, uncooperativeness, threatening behaviors, and lack of concern for laws and norms
- Expressed when threatened or powerless
- Intended to intimidate
Passive Aggressiveness/ Passivity
- Indirect and subtle expression of anger toward others
- People who are afraid of rejection or punishment
Intermittent Explosive Disorder
- Aggression as its main symptom
- An impulse control disorder
- Failure to resist aggressive impulses
- Aggressive episodes are out of proportion
- Behavior is not caused by a physiologic effect or drugs
- Serotonin, GABA, and Dopamine derangements
- Brain Damages and trauma
- Hormonal Imbalances
- Alcohol or Drug Abuse
- Nutritional Deficiencies
- Medication Non-Compliance
Best Predictors of Potential Violent Behavior:
- Excessive alcohol intake
- History of violent acts, with arrests or criminal activity
- History of childhood abuse.
Signs of Impending Violence:
- Recent acts of violence inc. property violence
- Verbal and physical threats.
- Carrying weapons or other objects that may be used as weapons.
- Progressive psychomotor agitation.
- Alcohol or other substance intoxication.
- Paranoid features in a psychotic patient.
- Command violent auditory hallucinations.
- Brain diseases
- Catatonic excitement
- Certain manic episodes
- Certain agitated depressive episodes
- Personality disorders
l Empathy is critical to healing.
l Note vulnerability of selected close relatives.
l No single approach is appropriate for all persons in similar situations.
When you don’t know what to say, the best approach is to LISTEN.
l Major indications for the use of psychotropic medication:
1. violent and assaultive behavior
2. massive anxiety/panic
Onset and Clinical Course
- Sudden and explosive
- Often in 5 stages known as the assault or aggression cycle
- Triggering and Escalation Phases are the most critical stages for preventing physical aggression
Use of Restraints:
Ø Preferably five or a minimum of four persons should be used to restrain the patient. Leather restraints are the safest and surest type of restraint.
Ø Explain to the patient why he or she is going into restraints.
Ø A staff member should always be visible and reassuring the patient who is being restrained.
Ø Patients should be restrained with legs spread-eagled and one arm restrained to one side and the other arm restrained over the patient's head.
Ø Restraints should be placed so that intravenous fluids can be given, if necessary.
Ø The patient's head is raised slightly to decrease the patient's feelings of vulnerability and to reduce the possibility of aspiration.
Ø The restraints should be checked periodically for safety and comfort.
After the patient is in restraints, the clinician begins treatment, using verbal intervention.
Ø Even in restraints, most patients still take antipsychotic medication in concentrated form.
Ø After the patient is under control, one restraint at a time should be removed at 5-minute intervals until the patient has only two restraints on. Both of the remaining restraints should be removed at the same time, because it is inadvisable to keep a patient in only one restraint.
Ø Always thoroughly document the reason for the restraints, the course of treatment, and the patient's response to treatment while in restraints.