Transcript for:
Building Trust in Nurse-Client Relationships

All right, we are going to describe how the nurse uses necessary components involved in building and enhancing the nurse-client relationship. Those components are trust, genuine interest, empathy, acceptance, and positive regard. We're going to be able to explain the importance of values, beliefs, and attitudes that help in the development of that nurse-client relationship. We're going to describe the importance of self-awareness and therapeutic use of self in the nurse-client relationship, identify self-awareness issues that can enhance or hinder the nurse-client relationship. We're going to define something called Carper's four patterns of knowing and giving. of knowing, and we're going to be able to give examples of each. Describe the differences between social, intimate, and therapeutic relationships. Define and implement the phases of the nurse-client relationships as outlined by Hildegard Peplau. Explain the negative behaviors that can hinder or diminish the nurse-client relationship. Explain the various possible roles of the nurse. teacher, caregiver, advocate, and parent surrogate in the nurse-client relationship, describe the goals of therapeutic communication, identify therapeutic and non-therapeutic verbal communication skills, distinguish between concrete and abstract messages, discuss boundaries in therapeutic communication with respect to distance and use of touch. Discuss nonverbal communication skills such as facial expression, body language, vocal cues, eye contact, and understanding levels of meaning and context. And given a hypothetical situation, select an effective therapeutic response to the client. So when we think about what a therapeutic relationship it is, so in nursing terms, it is the most important skill that a nurse can develop. It is a skill that is very crucial to having success when intervening with clients that require psychiatric care. It's just as important in every other nurse role that you have, but probably it definitely has more of an impact when you're looking at the mental health nurse. It's even more important. So some of the components that we need to have in order to develop a good working therapeutic relationship is one of the things is trust. So we need to let our patients know that we're dependable and that they can trust us. So we need to be caring and genuine when we talk to them. We need to let them know that we have interest in them and we really do care. We need to be able to understand where they're coming from and listen. We need to be consistent. If we tell them we're going to do something, we need to do it. If we say I'm going to come back in 10 minutes with a glass of ice water, then you need to come back in 10 minutes with a glass of ice water. You always need to be honest with them. Keep your promises and then listen. Listening is a very, very important skill. A lot of these people, these patients have a lot of things to say. and we're with them most of the time. So we really need to show up for them, be present, sit with them, and listen to them. We have congruence, which is when our words and our actions match. So when you tell a patient that you have to go, that you have to see another patient, but you're going to come back in 15 minutes, 45 minutes, make sure that you come back in that allotted time. trust between the nurse and the client will diminish when your words and your actions don't match. Now, it's very common as nurses, we're always running in opposite directions all throughout the day. So if you say, I'll be back in 45 minutes, the probability of you coming back in exactly 45 minutes is, it's highly unlikely because we are so busy. But if you happen to get there late, make sure that you say, I am so sorry. I know I told you I'd be back in 45 minutes. I did not forget about you. I got stuck in this room doing this. You know, the care I provide to you is important. Let me take care of whatever it is you need now. Be honest with them. Let them know that you have something else to do. We always want to make sure that what our voice or our body language says is consistent. So when we are standing in a room taking care of a patient and maybe the patient's going on talking about maybe something that doesn't even have to do with their health condition. Maybe they're just talking about the passing of their husband last month. And if you're sitting in the room and you're... Let me let this all in. If you're sitting in the room and you're sitting on the side of the bed or you're sitting in the chair and your arms are folded and you're really making good eye contact with them and you're listening to them, then they're going to feel like you are genuine. If you're standing in the doorway like this and you're tapping your foot and you're looking around and the patient says, I'm sorry, do you have something else to do? Am I, you know, inconveniencing you? No, it's fine. You go ahead and keep talking. I'm listening. you know, if we say that we're fine, but what we're showing them through our voice and our body language is not the same. So we always want to make sure that those things align. Then there's genuine interest. So this is when the nurse is comfortable with him or herself. It's when we have self-awareness of our strengths and our limitations, and we are clearly focused on the patient. Patients with mental illness more so than other patients can sense whether or not you are genuine. So we always want to make sure that we are portraying a sense of genuine interest to our patients. And then we want to have empathy. So empathy is one of the most essential skills that you can provide. It will help you to provide a higher quality care and it will help you deliver compassionate care. So you This empathy is the ability of the nurse to be able to perceive the meanings and the feelings of the client and to be able to communicate that understanding to the client. So it's basically us putting ourselves in the client's shoes. So they do say that both the nurse and the client give a gift of self when empathy occurs. The client feels safe that they can share anything with the nurse. And then the nurse listens closely enough to understand. So empathy is very different from sympathy. So sympathy is feelings of concern or compassion. This is when the focus shifts to the nurse's feelings. It's not about the patient anymore when we're talking about sympathy. The nurse does need to be aware that expressing sympathy, the nurse is projecting his or her own personal concerns. Just let a few students in. That we as the nurse are projecting our own personal concerns onto the client. When that happens, it will inhibit the client's ability to be able to express their feelings to us. So empathy is very different than sympathy. And then we need to have acceptance. So no judgments. at all, regardless of what your personal beliefs are. We're not asking that you believe what the patient is doing and that you condone it, but you cannot be judgmental. You need to set boundaries as needed, and you want to avoid judgment. Avoiding judgment is acceptance, but it doesn't mean that you have to accept inappropriate behavior. So when we say that, we just mean that you, especially with mental health patients, that you have to make sure that you set boundaries. so that you're safe and they're safe. Positive regard. So this is the unconditional, non-judgmental attitude. This sees the patient as a valuable person regardless of their behavior. So if you find yourself taking care of someone who maybe is a drug user or that they suffer from alcohol and maybe they've made some poor choices in their life, maybe they've crashed some cars, they wound up getting arrested and now they're in the hospital. So even though you don't condone the behavior that they have participated in, you still view them with positive regard. You see the patient as a valuable person. They do have something valuable about them. They've just made some mistakes. So let's see this video. Hmm, maybe it doesn't want to work. Oh well, I had a video here but well maybe it's trying to load. I don't think it's going to load. Okay, I'm not sure what's going on with that. Oh, where is it? Oh, it's over here. Oh, jeez. Did you share your sound? Staying out of judgment. Not easy when you enjoy it as much as most of us do. Recognizing emotion in other people and then communicating that. Empathy is feeling with people. And to me, I always think of empathy as this kind of sacred space when someone's kind of in a deep hole and they shout out from the bottom and they say, I'm stuck, it's dark, I'm overwhelmed. And then we look and we say, hey, and climb down. I know what it's like down here and you're not alone. Sympathy is, oh, it's bad, uh-huh. Uh, no. You want a sandwich? Empathy is a choice and it's a vulnerable choice because in order to connect with you, I have to connect with something in myself that knows that feeling. Rarely, if ever, does an empathic response begin. with at least. I had a, yeah. And we do it all the time because you know what? Someone just shared something with us that's incredibly painful and we're trying to silver lining it. I don't think that's a verb, but I'm using it as one. We're trying to put the silver lining around it. So I had a miscarriage. At least, you know, you can get pregnant. I think my marriage is falling apart. At least you have a marriage. John's getting kicked out of school. At least Sarah is an A student. But one of the things we do sometimes in the face of very difficult conversations is we try to make things better. If I share something with you that's very difficult, I'd rather you say, I don't even know what to say right now. I'm just so glad you told me. Because the truth is, rarely can a response make something better. What makes something better is connection. Okay, so that is the difference between sympathy and empathy. So we also have to have self-awareness. We've been talking about this throughout this course. So before we can sit in our client's shoes and understand what they're going through, we really have to have a good understanding of ourselves. So we need to know what's important to us. So we need to know our values. Values are those standards that give a person a sense of right and wrong, and they help establish a code of conduct or a code of living, how they live their life. Then we have our beliefs, which are ideas that each of us hold to be very true. It's what we believe in. It's what gives us hope. Motivation. So this is the reason one has for acting or behaving in a certain way. And then we have our feelings. So this is just... nothing more than an emotional state of reaction. And then our attitudes. So these are things like feeling hopeful or being optimistic, even in bad times, or being pessimistic, being positive, being negative. It's how we look at the world and people around us. And then nurses should reevaluate any experience that they gain. So we need to be aware of the impact that we have on others. So we set our values. Those are those abstract standards that give us, that give a person a sense of right or wrong. And it establishes what they call that code of conduct. So it's how we live our life based upon the things that are the most important to us. So some examples of good values are honesty, especially in the nursing profession. You have to be honest. So if you don't get back to that patient's room within 45 minutes, it's okay. I say it all the time. I am so sorry. I did not forget about you. I've been running in 100 directions all day, and it really, it slipped my mind. And if I really just forgot, I will just say it. I just forgot. And the. People have so much more respect for you when you're honest with them and they're much more understanding. Another example is hard work, sincerity, cleanliness and orderliness. Just a few values. There's way more than we have on that list, obviously. So there is such a thing called a value clarification process. So this is a tool that will help you gain insight into yourself and what your personal values are. They do, it does work by a three-step process. So the three steps are choosing, prizing, and acting. So choosing is when the person considers a range of possibilities and freely chooses the values that fit good for them. It's what's important to them. Prizing is the second step. This is when the person considers the value. It is recognized as important to them. They cherish it and they publicly attach it to him or herself. And then acting is the third step. And that's when the person actually puts that value into action. They start living their life according to this value or this principle that is very, very important to themselves. So some examples are education. So if I had if education was an important value for me and it's how I chose to live my life, I might reflect this in. The way that I teach my children, I might decide to send them to private school because maybe I believe they get a better education in private school. And I'm going to set up that college fund and make sure that there's money there for my children when they decide to go to college because education is something that's important to me. And I myself, I'm going to make sure that I am educated to the highest of my own standards. So actually taking those values, recognizing them, owning them, and then putting them into work. And then another example they give is personal growth. or physical or mental health. So this is Hildegard Paplow. We talked about her last week. She developed what we call therapeutic use of self. So this is developing self-awareness and understanding our attitudes that nurses can use of aspects of personality, their experience, their values. feelings, intelligence, needs, coping skills, and perceptions to establish relationships that are going to be beneficial to clients, to our patients. Nurses are a therapeutic tool to develop therapeutic relationships, and the benefit, she'd said, of the therapeutic use of self was that we can help our clients grow, we can help them change, and then we can help them heal. So there is something called the Johari window. This also is another tool that can help you learn about yourself. So this actually works by creating a word portrait of a person in four areas, as you can see in the box in this picture there. And each box indicates how well that person knows him or herself and communicates with others. So there are four quadrants that we look at. One is open public self. So These are the qualities that one knows about themselves and others that also know about them. Number two is blind or unaware of self. So these are qualities that would only be known to others, ones that we wouldn't see. And then hidden, which are qualities that are only known to that person, to oneself. So not everyone knows these, just you do. And then unknown. This is an empty quadrant that symbolizes the qualities that are not. yet discovered by yourself and by others. So the goal obviously is to move from quadrants two, three, and four into one because you want your qualities to be known to you, and you also want them to be known to other people as well. So as you experience different things in your life, and you gain more self-awareness, and you grow, the hope is that you will move through these four quadrants. Then we have patterns of knowing. So Paplo identified preconceptions as barriers to developing therapeutic relationships. So somewhere along the line, the nurse has and maybe even the patient, it definitely could apply to the patient, has developed some type of preconception that this group of people behave like this, or all patients with drug addictions are terrible humans. They're always non-compliant. These are preconceptions, things that people hear from other people and they automatically believe them without experiencing them themselves, without experiencing it themselves. preconceptions prevent people from getting to know each other. Patterns of Knowing, which was developed by Barbara Carper, a professional at the College of Nursing at Texas Women's University, she states that the patterns of knowing are empirical, which is information that we would derive from any kind of nursing science. So what we learn in school, what we learn in nursing school, what we learn in college, what we read in evidence-based practice journals. Then she said there's also personal. So these are anything that we would learn from our life experiences. And then there's ethical. So that is anything that we would learn from moral nursing knowledge. And then there is aesthetic, which is from art of nursing. So these patterns of knowing provide the nurse with a clear method. for being able to observe the client and understand how the client relationship acts and what those interactions mean. It's an understanding of where knowledge comes from, and then it's also taking that knowledge and figuring out how it affects the behavior will also help the nurse to become more self-aware. So, wait a minute. Okay. Thought I missed a slide. All right. So when we talk about patterns of knowing, so information that's obtained from the science of nursing. So this is the example that your book gives is that a client with a panic disorder begins to have an attack. We know that a panic attack will raise the pulse rate. So these are things that we know that we learned from the science of nursing. An example. obtained from the art of nursing would be that the nurse has sensed previously the client's jumpiness and subtle differences in the client's demeanor and behavior before observing the outward signs of the panic attack. So we know, we've seen this before, we can sense it in the patient and we know that it's going to happen before those other signs happen. And then for obtained from the moral knowledge of nursing, this is although The nurse's shift has ended at seven o'clock. She's supposed to give report and go home. She feels obligated and she has stayed with the patient because they were in the middle. The patient was in the middle of having a heart attack, I mean, a panic attack. And for her, her moral drive required her to stay there and comfort the patient because that's what a caring nurse would do. And then what we obtained from life experience, well, this would be that the client's face shows panic. So the fifth pattern was developed by Munhall back in 1993. This is called the pattern of unknowing. So this is that the nurse admits lack of knowledge of client or understanding of the client's subjective world. This opens the way for an authentic encounter and the nurse is open to seeing and hearing the client's views without imposing any of his or her values or viewpoints, which just reading that, you could tell how beneficial that would be when you are building that relationship with the patient, because you don't have any predisposed ideas, preconceptions, or anything like that. So negative preconceptions can adversely affect that therapeutic relationship, because you already have something in your mind. You already feel some sort of way about something, and it's definitely going to affect the way you treat the patient. and what you think about them. And then it is important for the nurse to work on developing that openness and acceptance towards the clients. So we have many different types of relationships. They're all different, but they usually, but all of them usually fall under three categories. So that is social relationships, intimate relationships, and therapeutic relationships. So social relationships are intended for the purpose of having a friendship, socializing with others. Maybe you're seeking a companionship, someone just to go, you know, take a walk with at the park, someone to have dinner with. Or it also can involve task accomplishment. So when you guys get together in a study group and you work with each other, that's task accomplishment. That is a social relationship. Communication is usually superficial, but it does focus on the group sharing ideas, their feelings, and their experiences. We don't usually evaluate the outcomes of social relationships, but it is good for the nurse-patient relationship. If it becomes more social than therapeutic. Work to move the client forward cannot be accomplished. So they're saying that the patient-nurse relationship has to be therapeutic. Once it starts to be social and you move away from that work, that working relationship, then it's going to inhibit the patient from growing and learning and healing, ultimately. So then we have intimate relationships. So this is an emotional commitment of two people. Both parties in the relationship are concerned about individual needs met and assist with each with helping each other meet the needs of each other. It may include sexual and emotional. It is a sharing of mutual goals and this relationship has no place in the nurse place nurse patient relationship. Ms. Davis can you let Sophia in please? Yes she's not there. Yep. She's not there, but if she says it again, just let me know and I'll let her in. And then that therapeutic relationship. So this is very different than the social or the intimate relationship. So this relationship between the nurse and the patient is going to focus on the needs, the experiences, the feelings, and the ideas of the client only. It only involves those needs of the client. So the nurse and the client will agree about what areas they're going to work on, and then they will ultimately evaluate these outcomes together. The therapeutic relationship is usually you set very clear parameters and you focus on just the client's needs. The nurse is not concerned if the patient is grateful or not. At that point, if you are providing care for patients and you're like, I've been getting him cold drinks all morning and he didn't appreciate anything I did. Well, then that is focusing on you. So you guys need to be able to recognize that, that at that point, it is just you focusing on a, your own personal need. And that's something that we don't want to do. A nurse is monitoring the, to avoid the relationship turning into a social relationship. We know that that's not going to benefit the patient. So nurses who are self-aware and have self-confidence can establish appropriate therapeutic relationships with their patients. Paplo did study the interpersonal processes and the various phases of the nurse-client relationship. She studied this for over 35 years, so she has a lot of experience. She developed the phases of nursing-client care relationships. So there were three phases. It was the orientation phase. the working phase, and the termination phase. So the phases are not exactly clear-cut, but they do overlap in some areas, and they are said to interlock. So there is a table in your book, 5.3, if you want to take a look at that. We're going to talk about it, but it goes into much more detail in your book. So the orientation phase. So this is at first, before the patient even, before the nurse even meets the patient. So For me, when I do this at my job, I get report from the nurse in the emergency room, and she tells me a little bit about the patient. And then before I meet that patient, I go through the chart, and I look at their past medical history, and I look at their labs, and I look at what's been documented since they've been in the emergency room, what orders they've had. I'm trying to gather my own type of report before I even see the patient. So the nurse should review the chart before meeting the patient. And then you're going to have to do a self-assessment of your personal strengths and weaknesses. So maybe you are getting, you're going to be getting a patient from the emergency room that has dementia. Maybe your mom has dementia and she's in a long-term care facility because that's, you know, where she requires a higher level of care. And maybe that's really hard for you. So maybe you know that getting this patient is going to provoke maybe some type of a sad feeling. in your mind. So that's an opportunity for you to do a self-assessment, look at what your strengths are, recognize where your weaknesses are, and make the changes that you need so that you can meet the needs of this patient. So when you meet the patient, when the nurse meets the patient, that is going to be the very beginning of that trust building from the minute that you guys lay eyes on each other. That's when that trust building starts. This is where you're going to be establishing your roles. Hi, my name is Trish. Welcome to Unit 45. I'm going to be your nurse today. I'll be with you till seven o'clock tonight. This is Marie. She's going to be your tech tonight. You'll put your information on the board. You're establishing them roles. Who is who? Then there's going to be a discussion of purposes and then parameters of future meetings. So parameters of future meetings is something that you're going to see probably more so in the outpatient setting. You will go over with your patients what your goals are when they're admitted into the hospital. So I see you came in with congestive heart failure. So we are going to be waiting you every day. We are going to make sure that you have the oxygen that you need. We're going to be, you know, monitoring your fluid intake. So you're going to be having that discussion of purposes. So what are you going to be doing to manage the client's care? And then clarification of expectations. You always want to ask the patient. That's one of the things I ask them every morning. What do you want to accomplish today? What are your goals? Well, I want to go home. Or you know what? I've been here for four days and I have not been out of the bed yet. I really want to sit in a chair. Or I just want to get a bath. I always ask what their goals are. So that way I'm on the same page with the patient. And then you want to do an identification of the client's problem. So tell me a little bit more about why you came to the emergency room. And sometimes they'll be like, really? I already told them down there. Well, you're new to me and I want to be able to give you the best care again. So just tell me again, just a little run through what happened. You had a fall at home, who was with you, blah, blah, blah, blah, blah. So just kind of go over those problems again, and then look for any other problems when you're doing that physical assessment that maybe weren't addressed in the emergency room. And then that nurse client contract slash confidentiality. We don't really sign a contract with patients in the hospital that says, I'm going to take care of you and these are our expectations. So that would probably be more so in the outpatient setting you're going to be talking about when you're going to be having meetings, where they're going to take place, how long are your sessions going to last. So remember, we talked how a lot of mental health issues are treated in the community, right? We only treat them in the hospital if they're having a crisis. So most of... This client contract information you would see in that outpatient center. You're going to come to me every Tuesday. We're going to meet from six to nine, all that kind of stuff. You're going to explain to them exactly what you're going to cover during that time. The client will know his responsibilities. And then, of course, the nurse will know her responsibilities. Duty to warn and self-disclosure. Duty to warn, if a client were to say to you, I'm going to kill my wife, I can't take her any longer, she's really just getting on my nerves. So then you are required as the nurse to notify the intended victims and the police. Okay, so duty to warn, you must report any type of a homicidal threat to your nursing supervisor and also the attending physician so that they can contact the police and then the intended victim. And then self-disclosure, that is when the patient reveals personal, it's revealing personal information such as biographical information and personal ideas, their thoughts, feelings about oneself to clients. So this is kind of tricky. So I personally feel that, and your book does too, that there are some times when feeling self, revealing things about yourself can help develop that therapeutic relationship. For me, sometimes I, even though I've gotten better because I've been a nurse for a while, I still struggle sometimes to start conversations with people, sometimes, and I don't know what to say. So I may say, I don't know, I might just bring up where they live. Do you live close to the hospital? How far away are you? Oh, well, I live in Forest Hill. Where do you live? So some things. It's okay, I feel like, to disclose. But remember, we have to keep it from going into that social aspect. And I feel like sometimes that it does, and it doesn't always hinder the relationship. For some people, it makes them feel like they can really trust you because you've opened up. But when you're dealing with mental health patients, those patients can definitely take advantage of that situation. So you just have to, you know, it's just a client-by-client basis, I feel like, how much information you disclose and how much you decide not to. You wouldn't tell them where you live, obviously. I live at 123 Timbuktu Lane. You would never want to tell any patient, a mental health patient or not, where you live, but some information is okay. So after we go through the orientation phase, the next phase is the working phase. So this is divided into two sub-phases. We have problem identification and exploitation. So problem identification, this is going to be your issues or your concerns that are identified by the client. This is an examination of what the client feels and what their responses are. So they're coming to you. They're meeting with you every week. You agree that you're going to meet Tuesday at nine o'clock. And this is what we're going to talk about. You know, maybe he has trouble getting to work on time. He has trouble working with others. Whatever his issues are, you're going to identify those problems. And then you're going to make a list and a contract of how you're going to address them. And then exploitation. This guides the patient to examine feelings and responses. This leads to the development of better coping skills, a more positive self-image, a behavior change and independence. So, you know, mental health is a very gray area and it's very difficult. And if all of us had the best coping skills and we knew what was wrong with us, there would never be any need for mental health. But if we can guide the patient to. by using open-ended questions and things like that, that leads them to be able to discover things about themselves. And once they can discover it on their own, then they're more, you know, it's kind of like the light goes off and then they're more apt to keep coming back and keep engaging. And it's going to make them have more power over their mental health. So you also want to be aware of what we call transference and counter-transference. So we're going to talk about that on the next slide. So transference is when this happens when the client unconsciously will transfer to the nurse feelings that he or she had for significant others or even other people. So your book gives a good example. So if the client has had negative experiences with people in their life that they considered authority figures, maybe a teacher, maybe one of their parents. a principal in high school, that patient may display similar reactions of negativity and resistance to the nurse because some patients believe that they view the nurse as an authority figure. So that's transference. And you guys need to know the difference between transference and counter transference. It's going to be on your exam. So counter transference is when the nurse responds to the client based upon personal unconscious needs. So transference is They're both unconscious. Transference is when the patient does it to the nurse. Countertransference is when the nurse does it to the patient. So an example for countertransference is that the nurse is the youngest in her family and is often felt as if no one listened to her when she was a child. She may respond with anger to a client who does not listen or resist her help. As nurses, we do have a natural like or a dislike to patients. If the feelings are intensely negative or positive and not realistic, it is considered counter-transference. Okay. All right. So the termination of the resolution phase. So this is the final stage in the nurse-client relationship. This begins when all of the client's problems are resolved. It does. end when the relationship ends, both the nurse and clients have feelings about the termination. So you might not like each other and you might be glad that it's over and hope you never see each other again, or you may really, really miss them. There have been so many patients that I just didn't want to leave at the end of my shift. And that I just was sad that I would never be able to follow up with them again and know what happened to them because we just clicked and we got along and I just genuinely cared about them. but that relationship does end when the treatment ends. Clients may feel anger or abandonment or feel that determination as an impending loss. So for patients, this can be very traumatic. They, maybe they never had anyone in their life that showed up for them on a weekly basis or listened to them or really showed genuine interest in them. So maybe they've, having this nurse client relationship has really filled some type of a void for them, but now it's going to go. it's going to be over and they feel threatened. They don't want that to end. And then the client may avoid termination. They might all of a sudden decide to act angry or they might say, you know what? I can't leave. My issues are still unresolved. We never talked about this. We never talked about that. They may seem angry when in reality, they're not. They're just trying to think of a way to be able to preserve that relationship because they're not ready for it to end. So that is very common. And nurses should identify stalling maneuvers. So you need to be able to recognize these things in your patient. And then you want to remind them of all the newly learned behaviors that they've had. So, you know, if the patient was saying, I can't, you know, we still have to continue to meet. We didn't do this, this and this. Then you would respond with, look how far you've come. Look, this is where you were when you first started. Look what you're doing now. So that's how you kind of remind them of what they've learned and how far they've come. Then we have inappropriate boundaries. So this is when a relationship becomes social or intimate. So self-awareness obviously is essential to avoid this from happening. The nurse must maintain professional boundaries in order for you to be able to see optimal outcomes in your patients. It's just not possible to cross over and have that full-blown social relationship. or an intimate relationship and not compromise that nurse therapeutic relationship. Violations begin unintentionally and they are almost always come from a well-intentioned area. But it does have a negative effect on the relationship. Once the nurse gives patient information, it cannot be retracted. The damage is done. So like I said, if you're just talking with your patient and the patient says, how many kids do you have? I have four. Do you have any kids? And then... they say, yeah, I had this many. Well, do they go to school? Yeah. And then you're not thinking, well, where did they go to school? Well, once you give that information, you can't take it back. So you have to be careful how much you are giving. Feelings of sympathy and encouraging client dependency. So we don't ever want to allow our empathy to turn into sympathy. And this is really hard. And I feel like I still have to be aware of it now. It's something that I have to work on. It's something I really had to work on in the beginning because I always worked with the oncology population and I always felt so sorry for them. And it's okay if you feel sympathy. That shows that you're a caring person, but you definitely have to be aware of it and try not to let your empathy turn into sympathy. So sympathy can cause the nurse to compensate, to please the patient. which then will allow manipulation of the nurse because you feel sorry for them. So you're willing to go above and beyond and do things that you wouldn't normally do because you feel sorry for them. Non-acceptance and avoidance. So avoiding unacceptable or distasteful behavior will jeopardize the nurse-client relationship. So if you have a patient who is, say, sexually inappropriate, and he's been sexually inappropriate with... with the nurses before you. Maybe he's been sexually inappropriate with you and maybe it's not touching you or something like that, but it might be just the comments that he's making. When you don't address it and you can, avoiding it is acceptance in their mind, especially with the mental health patients. So they seem like, they see that as, okay, they like what I'm saying. They're not telling me any different. I'm just going to keep doing it. So avoiding it is basically condoning it. And then you need to continue that self-awareness and then resolve any prejudices that you may have. So some other roles that we have besides being a nurse, we are a teacher, a caregiver, we're an advocate and a parent surrogate. So during the working phase, the nurse is going to teach the patient how to cope with the issues that they're dealing with. They're going to identify those. issues and they're going to teach the patient how they can solve those issues. You're going to teach about medication regimens, so when they're going to take their medicine, certain side effects that they want to be aware for, when to increase their medicine, when to call the doctor back, and then you're also going to teach them about any community resources that might be helpful for them to be able to cope with their issues. We also are the caregiver. So we are implementing the therapeutic relationship that's going to build trust. It's going to allow us to be able to explore the feelings that our patients are feeling. Physical care can sometimes be confused with intimacy and sexual interest. I believe that in this day and age, because kindness is not something that we always see in people. especially in nursing, it can be misunderstood and people take it the wrong way. Well, she's really paying attention to me. She comes into my room every hour. She asked to rub my back. She really wants me. She wants to go out with me. That does happen. So you just have to be aware that that can happen and just kind of be aware of how you are portraying yourself to your patient. And then if that does come up, then you just have to be honest and you know, to the patient and just let them know that, no, I'm your nurse. This is not an acceptable relationship. I'm sorry if I made you feel like that. It's an uncomfortable situation. Hopefully you won't be in it, but it does happen. And then you want to consider those boundaries and parameters. So how did we get to this point? Did I, you know, did I overstep my bounds with that social relationship? Did I tell the patient too much? So we also are an advocate. You guys know that. We've been talking about that since week one. So this is where the nurse is going to ensure the client's privacy and their dignity. It's when we're going to make sure that they have informed consent for any thing that they're going to have done, whether it's mental health or if it's in the hospital setting. We're going to make sure that they have access to all the services they need, especially these mental health patients in the community. We need to make sure that they are set up for everything they need to be successful. We're going to provide safety from abuse and exploitation for the patient. So we need to advocate them and know what their situation is like outside or what it's like at home. And we need to advocate for something better for them. And then the nurse is also observant of other healthcare professionals and their safety. So this is something that you see with just a regular med-surg nurse in the hospital, but it's something more so that you're going to really pay attention to with these mental health patients because there's always a higher risk there for some type of abuse to happen because a lot of the patients that we deal with are not always mentally stable. So we know that it wouldn't take much for them to be able to... make a bad decision and decide to hurt someone. And then we have apparent surrogate. So this occurs when the client starts exhibiting child-like behaviors. The nurse responds accordingly without realizing and must set limits with non-judgmental attitude. So self-awareness, this is crucial in establishing the therapeutic nurse. client relationships. We've said that at least a hundred times. Helpful activities that can help you improve your self-awareness. You can attend workshops that talk about the clarification of different values, what your beliefs are and what your attitudes are. You can start journaling, pick up a journal, keep a journal of your thoughts, your feelings, what lessons you learned on your way home. You don't have to write it down. You can just turn down the radio and think about what happened during the day, what went well, what didn't go well, what you think you'd like to change, what you would do over again if you could. Listen to the feedback that you get from colleagues. So always be teachable. We don't know everything as nurses. This is the only profession where it's 100% okay to never know anything. And even after you've been a nurse for 30 years, you can still come and ask how to do something. And it's completely acceptable. So be teachable. Learn from what your other colleagues have to say about your strengths and your weaknesses. You can purchase books and read about support strengths and how to identify your weaknesses. And then developing a continual changing care plan for self-growth. And you always have to keep in mind that development of self-awareness is a continual process. It's an ongoing process. And I absolutely... could not agree with that more. I remember doing it when I first graduated as a nurse and I still do it now on my way home. I still think about the care I provided that day and what happened and what I would like to do different. So now we are going to talk about therapeutic communication. So the definition of communication, communication is just the exchange of information, the exchange of... thoughts and feelings between individuals. Families and groups. It can be through verbal communication, nonverbal, and also written forms. Communication is the main method that we implement the nursing process. So verbal. Verbal is a type of communication. This is where we use our words to speak to one person or to speak to a group of people. We have to talk about the context. So this is the environment, the circumstances, and the situation in which our communication occurs. It can include time. It can include a physical, social, and emotional, and cultural environments. We have non-verbal communication, and this is the way that an individual expresses him or herself without words. So this is our body language. So this is when We say that we're listening to our patients and we genuinely care. So if we are sitting on the end of the bed and we're really making good eye contact and we're looking at them or we're sitting in the chair next to them, they can tell that we genuinely care. If we're standing in the doorway like this with our arms crossed and we're tapping our foot, well, we may say that we care verbally, but our nonverbal body language tells us something different. Same thing with our tone of our voice. If the patient says, do you mind? Getting me a glass of water and you say, absolutely. I don't mind at all, Mr. Jones. I'll be right back. That makes you believe that I really don't mind. But if I say, yeah, I don't mind. I'll be right back. It definitely sounds different. So our tone of voice, making eye contact with people, making eye contact lets people know that you're interested in them. You care about them. And it is also a sign of confidence. So your speed, so the way you talk about them and the way that you hurry around the room, that makes your patients feel a certain way. If they feel like you're taking your time and you're really present with them, they don't feel like you're rushing them along. If you're rushing around and you're hanging IVs and you're talking and doing a hundred different things at one time, makes the patient feel like you're really not giving them a hundred percent of your attention. And sometimes that can be hard in nursing because honestly, you're one person caring for five people and all five of those people can just be. crashing around you and you do have to work kind of urgently and rush and do things, but you try and avoid that as much as you can. And then hesitations in speech, grunts and groans. We obviously don't want to grunt or groan when we are in our minds, you can, but we don't want to outwardly do that. Nonverbal is also our personal space. So that is, we're going to talk a little bit, I think on the next slide about that. So this is giving, you know, some people have their own idea of what's a comfortable personal space for them. I might like people to be three feet away from me. You might be comfortable with people just being a foot away from you. That's okay for your personal space. And then you want to think about your appearance. So the way that you look, the way you show up to work, or the way that you show up to clinical says a lot about you to your patients. So if you come every day and your uniform is pressed and you don't have any stains. It's, that is a good appearance. If you come in and you're wearing a black bra and it's showing through your white shirt, or you're all wrinkled and you have, you know, cat pee all over your clothes, well, then I think we know what your patients are going to think about you. It's not going to be a good first impression for sure. So our appearance is very important. So process. So this is going to be all of our nonverbal messages that the speaker uses to give meaning and context to our messages. So this requires listeners to be able to observe the behaviors and sounds that accent the words to be able to interpret the speaker's nonverbal behavior. So we have congruent messages and incongruent messages. So congruent is when this occurs when the process and the content agree. Incongruent is when the process and the content don't agree. So nonverbal processes represent a more accurate message than verbal content. So therapeutic communication. These are our interpersonal interactions. Remember, they always focus on our patient's needs. They are not about us. We always have to respect our patient's need for privacy, especially when we're taking care of patients in the mental health field. They sometimes don't have a lot of confidence and they are worried what other people will think about them. So we always want to make sure that we are respecting their privacy. And then we want to make sure that our communication is encompassing goals that help to facilitate that nursing process. Because if we can't implement our nursing process and evaluate what we've done, we won't know if our patient is meeting their goals and if the work has been complete or not. So our goals of therapeutic communication. So we want to be able to establish therapeutic relationships with our patients. We want that. We know that if we don't establish a therapeutic relationship, we're not going to be able to help the patient be successful. We're going to identify the patient's most important concerns. So what is important to them? Why did they come in today? What's bothering them? What do they want to work on? What do they want to accomplish? Maybe they won't be able to accomplish it today. So what are some short-term goals? What are your long-term goals? And then we want to assess the patient's perception. So how do they perceive things? The way that they perceive things does not mean that that's the way that they are, but they do perceive it and it is real to them. So we have to recognize that. We want to facilitate the patient's expressions of emotion. So dealing with mental health patients, we have to have them dig deep into their emotions to identify certain things about themselves, to learn about themselves. We want to make them feel comfortable enough so that they can do that. We want to be able to teach our patient and our family any kind of necessary self-care skills. We want to be able to recognize our patient's needs. implement interventions to be able to address those needs. And then we want to be able to guide the patient towards acceptable solutions so that they can better manage their mental health. So with therapeutic communication, we need to have respect for boundaries. And this is a two-way street. These are the boundaries that the nurse has. The patient has to respect them. And then we have to respect the boundaries that the patient has set. Privacy is desirable, but not always possible, especially with therapeutic communication and dealing with patients in mental health. So we have something called Proxemics. This is the study of distance zones between people during communication. So there's a couple of different distance zones. There's intimate, personal, social and public. So our intimate zone is about zero to 18 inches, not very far away. That's why they call it intimate. So you would see. Communication taking place in the intimate zone with parents with young children, people who mutually desire personal contact, that's something that they want. Maybe people who are whispering because they have to get close to each other. And then for some people, invasion of this zone is very threatening and it makes some people feel very anxious. So that's important for you guys to understand that being close to some people. in this 0 to 18 inch area can be threatening and make people anxious. Then we have the personal, so that's 18 to 36 inches, so it's a little bit further away than the intimate. This is a zone that you would see between family and friends who are just sitting around and they're talking. And we have social, which is a little bit more further than the personal. This is 4 to 12 feet, so this is acceptable for communication in the social atmosphere. in the work setting and in business settings. And then public, of course, is going to be the furthest. That's 12 to 25 feet. So this is an acceptable distance that you would see for a speaker who has an audience, very small groups or other informal functions. Therapeutic communication is most comfortable when the nurse and the patient are three to six feet apart. If the client invades the nurse's intimate space, which is that 0 to 18 inches, the nurse should set limits, but gradually, depending on how often the client has invaded the nurse's space and the safety of the situation. So just remember that. You always want to make sure that as the nurse, if your intimate space or whatever space is desirable for you, wherever your comfort level is, that you need to make sure that you set limits with your patients. So touch. So this is when the intimacy and communication increases. So the need for distance will decrease. So we do have five types of touch. We have functional professional, social and polite, friendship and warmth, love and intimacy, and then sexual and arousal. So with functional and professional, this is, you know, maybe The hospital administrator is doing rounds on the unit and they bring a new board member by and you happen to be at the nurse's station and they say, hey Tris, this is Melissa. She is going to be our newest board member. You shake hands, very functional professional relationship. Then we also have social and polite. So this is where maybe you're having lunch with friends and another friend comes along and you introduce them to each other. Maybe they sit down, shake hands, have a drink, they talk and we have friendship and warmth. So Maybe you're done having lunch with your friends now and you haven't seen your one friend in seven months because of COVID and you're getting ready to leave and you give each other a hug. That's friendship and warmth. And then you have love and intimacy and sexual arousal. And I don't think I have to describe those. I think we know which type of touches are involved with those. So comforting and supportive also and possible invasion of intimate and personal space. So we want to be. comforting with our patients. We want to be supportive for them, but we don't want to be vulnerable and have things cross the line. So where we're being invaded now with, because we've given the wrong signal. And a point to consider is how should touch be used in the mental health setting? So, you know, everybody has their own idea. Some people don't like to be touched. Some people do like to be touched. They find it very comforting. Maybe as the nurse, you're not a touchy person and you don't want to touch, so it's not something that you're ever going to do. So you just have to think about how you would incorporate it into your practice. And if we think of it in the context of the mental health setting, then, you know, I think it has to be, it's something that has to be explored with our patients to see how they feel about it before we would think about any kind of personal touch. All right, so. Active listening and observation. So nurses need to be able to receive the sender's messages in order to develop a therapeutic relationship. So we need to be active listeners. We need to, as best as possible, reframe from those other mental activities and really be present and show up and concentrate exclusively on what the patient's saying that we're with right then and there. So even though Mrs. Jones is in the room next door and she's so confused and she's screaming about all the wild animals that are running in and out of her room, and that is really like a typical day in nursing, that stuff happens. You have to just try and focus on what your patient is saying. And then we need to have active observation. So this is when the nurse is going to watch the speaker's nonverbal actions that he or she is communicating. So just like um how we talk about us saying one thing to our patients, but then doing something else with our body language, we're going to be doing the same thing with our patients. So if you walk into your patient's room and you say, how are you doing today? How are you feeling? And they say, I'm fine. Do you have any pain? No. Are you feeling okay? Do you feel down today? I'm fine. Maybe the way they're telling you makes you believe differently. Or if you walk in and you say, how are you? And they're like, I'm really good today. So what they're saying is matching up with what you're seeing. So just be an active observer. Pep Lau used the first step in, she observed the first step in therapeutic communication. It is a common misconception that we must always be ready with the next question. So This causes miscommunication. It causes vague conversations and can be frustrating to both the nurse and the client. We don't always have to say anything. Sometimes we can just be present and listening. We don't always have to have something to say. Sometimes saying nothing is very beneficial. It doesn't always feel right inside because we always feel this need to say something to make them feel better, but it's not always necessary. So active listening and observation will help the nurse to be able to recognize the issue that is going to be most important to the patient that she's taking care of at that present time. It's going to help the nurse to further question, know what to ask the question. I can't talk. Know what further questions to ask the client. It's going to help the nurse to use additional therapeutic communication techniques to be able to help guide that client to really describe their perceptions, the way they see things, how they feel about things, what they're experiencing. It's going to help the nurse understand the client's perceptions of the issue instead of just jumping to conclusions. So a lot of times the way we perceive things, like I said, is not the way that it really is. And sometimes when we think that something is a certain way, we automatically jump to conclusions. I think we all have been guilty of doing that in our lives. So this is going to help us to be able to understand their perceptions and teach them how to not jump to conclusions. And then. Finally, it's going to help us interpret and respond to the message in an objective manner. So to be able to develop that therapeutic communication, the nurse has to ask specific questions to get the entire story. Especially most important with mental health is that we use those open-ended questions because we really need to get to the bottom of what is causing them. you know, what is bothering them, what their problems are. So we can't just assume what they are. We can't just guess and lead them in that direction. So we need to use those open-ended questions. We need to clarify any assumptions. So if we think that this is what the patient's saying or it's what we got from what they've told us, then we need to clarify that by reiterating, Mrs. Jones, what I'm hearing you tell me is that you get really upset when your husband doesn't take out the trash at night, whatever the problem is. So clarifying what you've heard to make sure that you're really understanding what the patient says. And then also developing that empathy with the patient, not sympathy, but empathy. And then knowing what empathy is. Before you can develop empathy, you have to have a good understanding of what it is. So empathy is that ability to place yourself into the experience of another person for a moment in time. So it is not us saying. to the woman who just lost her son. I know this is just terrible for you. It's an awful experience. Well, you can't say that if you've never really experienced it, but you can say, I can see how difficult this is for you. This is a really hard time for you. I'm sorry that you're going through this. I'm here to talk to you. Whenever you want me to listen, I'm here for you. Nurses develop empathy by gathering as much information about an issue as possible. from the client to avoid interjecting their personal experiences and interpretations of the situation. So we don't want to try and interpret the situation. We don't want to talk about our personal experiences. We just want to be present and we want to listen and we want to know what they're going through so we can try and understand what it is that they're feeling. So when we're speaking, we want to think about our words and what their meanings are. So when we talk about meaning... Usually more meaning than just spoken words. So spoken words can have a connotative and a denotative meaning. So when we talk about connotative meaning, this is the implied meaning or the slang. And then denotative is your dictionary meaning out of Webster's. So questions, we want to make sure that. our concrete questions are clear, that they're direct, and that they are easy for the patient to understand. So again, kind of like we do when we're educating our patients, we want to be able to ask questions that we know that they're capable of understanding and in their terminology. Abstract questions can be unclear, and it might be difficult for people of certain population groups to clearly understand and really be able to answer. Therapeutic techniques we're going to explore and focus, reinstating, reflecting. These are going to promote discussions of feelings or concerns in more depth. So again, using those open-ended questions, gearing the patient to explore new things. If he opens the door and he starts talking about one thing, so then you can encourage him to explore more. And as they start to explore, then they start learning things about themselves. and then you find certain things that you can focus on. Make sure that you are reinstating what you're understanding throughout this whole process so that you can make sure that you are addressing all their concerns and that you're all on the same page. You want to give recognition, acknowledgement, because this is going to indicate awareness. Make sure you're clarifying, paraphrasing what I hear you saying is this. Is this correct? Offering general leads and can... giving encouragement to continue. So you can lead your patients by talking about certain things and that opens the door for them to be vulnerable and really open up and talk about their issues. Broad openings allow that client to take initiative when you're introducing a certain topic. And then you can make observations. So verbalizing what the nurse perceives. So you can say, you know, Mrs. Jones, we were talking about your husband and how he doesn't help you out at home and you feel really stressed. And I noticed when we were talking about that, that you really seem to get angry. This must be a really important issue for you. Recognizing making observations and then presenting for reality. So this is offering for consideration for that what is real. So sometimes patients will. talk about the way that things should be or the way that they wish they could be or how they used to be. We always want to present things in the now and the real. We want to keep that focus on things that we can control now. So presenting reality. All right, so avoidance of non-therapeutic techniques. So we don't want to give advice. So giving advice to our patients is going to imply that only we know what's best for them and what our beliefs are. So again, this comes back to the nurse. These are things that when the nurse does this, she's centering on herself. We're not really paying attention to the client at that time if we're giving our own personal advice. We don't want to belittle the patient. So this implies that the nurse, that the discomfort is temporary, mild, self-limiting, or that it's not important. The client is focused on his or her own worries and feelings. And hearing the problems or feelings of others is not going to be helpful. There's no growth that's going to come from that environment. We don't want to challenge the patient. So if he or she can challenge the client to prove unrealistic ideas, the client is then going to realize that there is no proof and then will recognize reality, but causing the client to defend the delusions or misinterpretations more strongly than before. So challenging the patient. is sometimes good, but then we don't ever want to challenge them in the aspect of, well, I know better than you and what you're telling me is wrong. This is what I know. This is what I learned. We don't want to challenge them in that way. Reassuring. So this is an attempt to dispel the client's anxiety by implying that there is no sufficient reason for concern. This will completely devalue the patient's feelings. Vague reassurances without accompanying facts are considered to be very meaningless to the client. Giving approval, this tends to limit the client's freedom to think, their ability to speak out, and the ability for them to act in a certain way. This can lead to the client acting in a particular way just to please the nurse, so that they get the nurse's approval. Disapproval is going to imply that the nurse has the right to pass judgment on the patient and their thoughts and their behaviors. It also implies that the client is expected to do things that please the nurse, and that's not the way it is. The nurse really has nothing to do with that. We're just there to listen and help guide them. Asking unrelated personal questions. So we always want to avoid going into that social and definitely that intimate area. So we have to be very careful about the personal questions that we ask. Sometimes it'll make the patient feel like we're invading them. or we're using them for certain information, or it might give them the idea that we have more of an interest in them than just this therapeutic nurse-client relationship. Clients always have the right to not talk about issues or concerns if they choose. So if you are providing care to a woman who happened to be raped when she was in her younger 20s, and you know that this is probably the issue. that is causing damage in her everyday life. You cannot make her talk about it. You may know that she's going to gain a lot by talking about it and that she's going to be able to hopefully deal with her issues once she starts talking about it. Well, we can't force them to do it. We can only guide them and encourage them. And then interrupting the patient. So this makes the patient feel like the nurse isn't taking them seriously and what they have to say isn't important. So we always want to make sure that when we're listening to them, that we give them their time to talk and we try not to interrupt them. Cues and verbal or nonverbal messages that signal keywords or issues for the client. So we have to be careful about those nonverbal messages that we send our patient. And we also have to be careful of certain terminologies and verbals. verbal words that we use when caring for certain patients with mental disabilities, mental instability. Sometimes cues are good. So we want to think about based upon the cues that we get can help us determine the next thing we're going to say, or the next thing that we're going to do when we're talking with the patient. So cue words can help the nurse know what to ask next or how to respond. So we have overt cues and covert cues. So overt cues are very clear, direct statements of intent. So if your patient were to say, I want to die, well, there's no misunderstanding that. We definitely know what the patient is intending to say. A covert cue is when it's a very vague or an indirect message that needs interpretation. So if your client says nothing, there's nothing anybody can do to help me. I don't think I can take it anymore. I'm done. That's it. I'm over this. So what does that mean? Does that just mean that you're overwhelmed and you're calling it a day and you're going to feel better tomorrow? Or does that mean nothing can help me? And I'm going to take my own life. So we don't really know what to think about that statement. So that's a covert cue. So an example that your book gives, the client says, oh, hi to the nurse. The patient's face is sad. Their eyes look teary. Their voice is low. And they have little inflection. The nurse says, based upon the cues and the nonverbal messages that she's getting, you seem sad today. And then. The client says, yes, it's the anniversary of my husband's death. So this is a great example of where the nurse was able to pick up on those cues. And with what she saw, based upon what the verbal information was, the patient said both of them matched up. Now, if that last statement from the client would have said, no, I'm perfectly fine. I don't know what you mean. Well, that's when things aren't on the same page. So we have the patient that's looking some sort of way. She said her eyes are teary. Her voice is low. but she's saying she's perfectly fine. So we know that that's not the case, that something's bothering the patient. And that's another nonverbal cue that you guys would want to pick up on. So our patient's facial expressions can tell us a lot. So some people are extra super expressive. They always smile. Their voice goes up and down. They might make different faces. They use their hands. We have impassive. So some patients don't. ever express themselves. You can never tell if they're happy. You can never tell if they're sad. They have what we call flat affect, or we could say that they're blunted or that they're constricted. Flat affect is usually the terminology we use in the nursing world. And then there could be confusing facial expression. So this is when the facial expression does not match what the patient says, like in the last example. body language. So we know how important our body language is and how it has to match up with what our verbal and what we're verbally saying. So we have an open body position, which is the one that you see on the left there. They both look very comfortable. They both look in tune to each other. It's a comfortable environment. The one on the right, that's that closed body position. So the legs are crossed. Her arms are crossed. If you have your hands in your pocket, this is indicating that may be defensiveness or non-acceptance or that you really just don't care. And for some patients, this can lead to paranoia, especially when you're working with mental health patients. So we have vocal cues. So this is our volume, our voice volume. So how loud we are, this is our tone, our pitch, the intensity in which we say something. Do we emphasize certain words? How fast are we talking? And any pauses that augment the sender's message. And then eye contact. So eyes often reflect our emotion. It is not an intense stare. So this is actually weird because this is something that I learned in nursing school that our eyes say a lot about us. And I kind of, I don't know, I just never really believed that you could really get that much from having, I mean, I knew that it was a sign of confidence and I knew that it was a sign of making your patients know that you're really present with them and that you're interested in them. But since I've had COVID, I, you know, I always have these masks on and I can't smile for my patients. And I am always the nurse. As soon as I walk in in the morning, whenever I come in the room, I smile because I always feel like that is something that can change their day, especially dealing with the cancer population. They're, you know, they're dealing with. this horrific thing. So I always just want to smile and I always want to make them feel comfortable. Well, I haven't been able to do that. And it really bothered me more than I thought. And I have probably had, if I've had one person, I've had 20 patients tell me you have the most caring, genuine eyes I've ever met. So our patients really do look at us and they can tell how genuine we are just by our eyes. So there is definitely truth to that. Eyes often reflect our emotions and if we care. And then silence. So these pauses sometimes can indicate that our client is thoughtfully considering a question before responding. It could be that the patient is struggling to find words. These pauses can sometimes be awkward. I've experienced that a few times. And then... A point to think about is your comfort level with silence. So some silence is good, right? Like we said, that the patient is reviewing things, thinking about what they want to say next. It could be that they're struggling to find the right words. And sometimes it just feels awkward. So you just have to learn to be comfortable with those silences. Try and understand where it's coming from and help things not be so awkward. And then understanding the spirituality of our communication. So we learned about this in funds. Spirituality is a client's belief about life, health, illness, death, and one's relationship with the universe. So we have to have self-awareness of our own spiritual beliefs and what's important to us. They are very highly subjective, right? Everybody believes what they believe, and that's completely okay. And it can be vastly different among people. We don't all believe the same thing. And nurses must remain objective and nonjudgmental regardless of our client's beliefs. So it doesn't matter what they believe. We cannot judge them, and we have to accept them. We cannot allow air spiritual beliefs. to alter the care that we provide to the patients, nor can we allow what our patients believe alter the care that we give to them because of their beliefs. We must ensure that the client is not ignored or ridiculed because of his or her beliefs and values that differ from those of the staff. So not too long ago, I had a patient who was, I believe, of the Muslim culture, and he was He needed to pray for whatever reason. And I don't completely understand the Muslim culture. I am ignorant in some aspects. I just don't understand because there's a lot of different variances. But he needed to pray in the morning from 9 to, I don't know what it was, 9 to 11 or 9 to 12. And the nurse that was taking care of him was livid because she thought that he was inconveniencing her day. She had five patients to take care of. She had to pass meds. And she stood outside at the nurse's station and just basically ridiculed this patient. What kind of a weirdo is he? He just doesn't get it. He thinks he's the only person that matters. I have five patients to give. I have to give meds to this patient. He wants me to rework my whole day around him. I mean, she was really going off about the patient. And I didn't say anything to her at that time. you know, we can't do that. We can't, even if it's something that we don't believe in, even if it inconveniences the way we have to rework our day, we have to do it. We have to respect other people and we have to respect what's important for them. And we have to make sure that we're being able to meet their needs. So she obviously didn't have any self, I don't want to say no self-awareness. She obviously didn't, she needs to work on her self-awareness because it obviously is interfering with the care that she provides. And even though it can make things difficult and you may have to, you know, really put things off or do things a certain way to make it happen, it's what we have to do as nurses. So self-disclosure. This occurs if the nurse shares personal information, experiences and attitudes and or feelings with a patient. So what can you disclose? We've been talking about this. So the rule of thumb is to self-disclose information. Only when it benefits the patient. It should be brief. It should be focused on the current issue. And only when trust and therapeutic relationship has already been established. When would it be appropriate for you to disclose? Well, if you are trying to enhance that trust, that would certainly be appropriate. If you are... trying to establish balance in the interaction. Do you feel like the person is doing more talking than the other person? So then you might want to interrupt and maybe, you know, make sure that it's equal. It's both giving. They're talking and you're talking. And then to make the nurse more personable. So I actually had a patient the other day that I took care of when I worked on Sunday. And it was my, I had never seen the patient before. It was my first day working with her. And when I went in and I was smiling and I was like, hi, Mrs. Jen, Jane, how are you? I'm going to be your nurse. And she was like, I'm good. very, just kind of like in a disgusted mood. And I'm like, how are you feeling? I'm fine. I said, are you having any pain today? I said, I was fine. And I was like, oh God, well, as soon as I get a patient like that, it's my goal. It's going to happen. I'm going to break them down. They're going to love me to death. I'm going to get through because there's some, you know, it's kind of like a challenge. So then I was like, okay. I was like, she wasn't allowed to eat anything. And I'm like, I know you're bummed. You can't have anything. Do you want me to order you something special for breakfast? And she like started looking at me. Like she was shocked almost that. I was being so nice. And then I saw her phone and I saw a picture of this cute, sweet little baby on her side. I was just assuming it was her grandchild because she was in her 70s. And I said, oh, I saw your phone. I said, is that your grandbaby? I said, I'm going to have a new grandbaby next week. Well, as soon as I talked about that baby, the doors just opened up. She started showing me pictures. And by the end of the night, when I left her, she was like, you were the best nurse I ever had. She was like, I'm sad that you're leaving. I really loved you. So I was, of course, happy because I was able to break through to that patient. But then I also gave her information about me. So I was able to disclose some information. I didn't tell her where I lived and give her my address, but I helped establish balance in our interaction. And then I hope I became more personable for her. And then, like the slide says, I was able to enhance that trust. And do not assume your experiences are the same as your patients. That is very true. Not all of our experiences are the same and we always need to keep that in the back of our mind. And then always make sure that we are maintaining those professional boundaries. We always have cultural considerations, so this is the need for awareness of cultural differences between our co-workers, our patients. our friends. So we need to be able to recognize certain speech patterns, certain habits, certain languages, styles of speech, the way that people express their needs. Eye contact, we know that eye contact can be a good thing, but then in some cultures, it is not seen as a good thing. It can be a sign of disrespect. Touch, whether or not it's acceptable for people to touch other people. any concept of time, expectations of health. So in some cultures, people do not recognize the need to go to therapy or to take any medication. They fully believe if they have any issues with their mental health, that it is solved by prayer. So we need to, if we're working in the mental health field and we're dealing with a patient of a certain culture, we need to understand that because our push to get them to go to outpatient therapy in the community and to take certain medications. probably isn't going to be successful because it's not what their culture recognizes. And then the use of health care. So do they even believe in seeking health care? And who makes the decisions for them? So in some cultures last semester, we learned that the patient does not always make their decisions for them. Sometimes it's the parent. Sometimes it's the husband. It's the wife. You know, it can be very different throughout different cultures. And then what are our goals during that communication session? So. We're really establishing that rapport. We're practicing empathy. We're showing the patient that we genuinely care about them and that we are unconditionally accepting of them, regardless of what they've done in their past, their present, what their behaviors are, or what their beliefs are. We want to be able to identify those issues of concern. So we want to formulate a list of a goal for the patient or many goals. that we're going to focus our interaction around. We want to be empathetic. So we're going to be genuine and caring, and we're going to accept that patient and really try to put ourselves in their shoes and understand what they're experiencing. And we want to try and understand the patient's perception so that we can formulate a client-centered goal for the interaction. We want to explore what the patient is thinking and what they're feeling. So we are going to be using those. broad statements, open-ended questions, developing problem-solving skills, and then we are going to promote the patient's evaluations of solutions. And if it's working for them, and if it's not, then we are going to have to evaluate their care and make changes in their outcomes. So when we talk about a therapeutic communication session, so when we initiate the session, this is the very first time we're meeting. There's going to be an introduction. It was going to be between you and your patient. Hi, my name is Mrs. Davis. I'm going to be your nurse. We're going to be meeting every Tuesday for the next six weeks. You're going to do that establishment of the contract for the relationship. So this is what I'm going to be providing for you. What do you want out of this relationship? What goals, what do you want to work on? What's bothering you? What's important to you? And then you want to use those broad opening questions to help guide that client to really understand. dig deep and identify those areas that are very concerning for them. And then you ultimately want to identify the area of major concern. What's the most important thing you want to try and take care of? So we have a non-directed role and a directed role. So a non-directed role uses broad opening, open-ended questions. So this is where the nurse uses active listening skills to help identify the topic of concern as... and you kind of like act as a guide. So you're looking at those cues, those nonverbal, that nonverbal information, verbal information, and you're guiding the patient. A directive role is more of yes or no questions, usually for the patients with suicidal thoughts or in crises who are out of touch with reality. So do you have any harm? Do you have any plans to harm yourself? Do you have any plans to harm? Anyone else? Do you have a plan in place for hurting yourself? So those are direct yes or no questions. And then we have assertive communication. So this is the expression of positive and negative feelings or ideas in an open, honest and direct way. So it recognizes the rights of both parties and is very useful in various situations, such as. resolving conflicts, solving problems, expressing thoughts and feelings in a safe manner. Using assertive communication is always going to work best when the speaker is calm and they speak specific factual statements. So they have to be truthful. You have to be calm. It is always the focus is on I statements when you're speaking and then It is useful to teach patients how to use this because we want them to be able to create boundaries in their life that will help preserve their mental health. And we want them to be assertive and take on that role in their relationships. And it is important in professional situations. So, you know, if you have a person who always wants you to cover for her patients. when she goes off the floor for a 30 minute lunch, but she always goes for 45 minutes every single time. And you've done this, I don't know, for a couple of weeks now. And then she comes back to you again and says, I'm going to go to lunch. Can you cover for my patients? Well, Susan, I'm not going to be willing to cover for your patients today. I wish I could, but every time that you go to lunch for 30 minutes, you always wind up being longer than 30 minutes. That makes me not get my entire lunch. And then I feel very overwhelmed having to care for 10 patients. So I am not going to be able to cover for you if you continue to take extended lunches. So that is an example of assertive communication. You're saying I, you're focusing on those I statements. You're being calm and you're stating the facts. Every time you go to lunch, you take 45 minutes. So assertive communication, it's very important. It's important to deal with just your regular patients, but it's even more so important to deal with your mental health patients because you need to create those boundaries and those patients need to be able to respect you. So four possible responses to assertive communication. So when you try to assert yourself, either the person's going to become aggressive, they might become passive aggressive, they might just be passive. or they might in turn be assertive. So it doesn't guarantee that the situation is going to change, but it does allow the speaker to express honestly the way that they feel about something and in a very direct manner. So maybe Susan is still going to go off the floor and go to lunch and leave me with her 10 patients, but I might feel better because I told her that I'm not going to do it and I feel better that I got it off my chest. It lets the speaker feel good about expressing the feelings and it may lead to a discussion about how they can solve the problem. So maybe Susan would say, you know what, Trish, you're right. I do that. And I really don't I don't mean to take advantage of you, but it just seems like the last couple of shifts have been horrible and I just really don't pay attention to time. So it can be good. Hopefully it doesn't come out aggressively. You know, Susan could always say, I don't care what you say and jump the counter and beat me up. Hopefully it doesn't end that way. Sometimes it does, especially with patients that have mental issues, but hopefully that's not the case. All right, so community-based care. So there are community care centers that continue to expand. We're putting more of our mental health back in the community, which is where we know we need it most. So when we do this, this is going to cause error. role as nurses to expand. We're going to have to be able to provide a higher level of care to more people. Many nurses in the community setting are major caregivers and resources for high-risk populations. So patients that have mental health issues, patients with drug abuse or alcohol issues, patients who are homeless that have lost jobs. There's a variety of high-risk populations in our communities. We are starting to be more responsible for primary prevention and health maintenance, which we know is important because we want to prevent things. We don't want the idea, regardless of what we see with Big Pharma and everything else, we don't want to just manage issues. We want to prevent them. We want to keep them from happening, and we want to avoid health issues. So the nurse needs that self-awareness. Well, the self-awareness and knowledge about cultural differences because we have such diverse cultures in our communities. Some nurses are home nurses and you're entering various homes, so you must be able to negotiate certain cultural content. You need to understand certain cultural customs, the behaviors that they display, what their practices are, how they handle certain things, and what remedies they use. And then we have to have assertive communication. We know that that's important because we need to be able to collaborate care with our patients, with their family members, their caregivers, and also with all the other health care providers that they see. Their primary care doctors, their physical therapists, things like that. So final thoughts for self-awareness. To identify issues, nurses need to be aware of the following. Non-verbal communication is just as important as verbal. What they don't say is just as important, if not more sometimes, as what they do say. Therapeutic communication is influential and extremely necessary in order for you to develop effectiveness with the interventions that you provide. Awareness of your own communication is the first step in improving your communication. Asking for feedback from colleagues is very important for growth. And then examination of communication is important so that you can identify weaknesses so that you can make improvements.