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Varcarolis’s Canadian Psychiatric Mental Health Nursing Chapter 08: Ethical Responsibilities and Legal Obligations for Psychiatric Mental Health Nursing Practice Instructor’s Manual Thoughts About Teaching the Topic Learners often find it difficult to simply read information about legal and ethical issues. Clarification via classroom discussion is frequently necessary, with links to clinical practice experiences and documents. Further discussion in clinical conference will help in operationalizing concepts and practising skills related to ethical and legal responsibilities. Some learners find it easier to learn basic facts in an interactional format; for them computerassisted instruction may be useful for portions of the content. You may also want to include case studies that encompass a patient who is hospitalized involuntarily. Key Terms and Concepts abandonment advance directives assault autonomy battery beneficence bioethics competency confidentiality consequentialist theory deontology duty to protect duty to warn engagement ethics false imprisonment guardianship implied consent informed consent intentional torts justice malpractice moral agent moral distress moral residue moral uncertainty negligence nonmaleficence relational ethics Instructor’s Manual 8-2 respect for autonomy right to privacy right to refuse treatment tort law unintentional torts utilitarianism virtue ethics virtues Objectives Identify the differences between ethical responsibilities and legal obligations within the practice of psychiatric mental health nursing. Describe key elements of the common approaches that inform health care ethics. Identify the ethical nursing responsibilities related to psychiatric mental health research. 4. Identify relevant legislation enacted to protect, promote, and improve the lives of Canadians with mental illness. Chapter Outline Teaching Strategies Ethical Concepts 1. Ethics are an expression of the values and beliefs that guide practice. Three types of moral theories have traditionally been used as a foundation for the development of nursing ethics: deontological theory, consequentialist theory, and virtue theory. More recently, the developing theory of relational ethics—a developing ethical theory with the core elements of mutual respect, engagement, embodied knowledge, interdependent environment, and uncertainty—has also impacted the application of ethics within nursing. Deontology is a system of ethics with the central concepts of reason and duty: there is an obligation to act in accordance with particular rules and principles. The Canadian Nurses Association (2008) code of ethics (Box 8-1), Canadian Federation of Mental Health Nurses (2006) standards of practice (Box 8-2) and the Registered Psychiatric Nurses of Canada (2010) code of ethics and standards of practice (Box 8-3) are written from this perspective. The basic principles are as follows: Respect for autonomy—respecting the rights of others to make their own decisions (e.g., acknowledging the patient’s right to refuse medication). Nonmaleficence—the duty to minimize harm and do no wrong to the patient (e.g., by maintaining expertise in nursing skill through nursing education). Beneficence—the duty to act to benefit or promote the good of others (e.g., spending extra time to help calm an extremely anxious patient). 4. Justice—the duty to distribute resources or care equally, regardless of personal attributes (e.g., an intensive-care nurse devotes equal attention to someone who has attempted suicide as to someone who suffered a brain aneurysm). Other pluralistic deontologists have identified two other principles to consider when making ethical decisions in clinical settings. These additional principles are as follows: Principle of impossibility—the principle that a right or obligation that cannot be met within the current situation is no longer an obligation (e.g., a person does not have a right to receive an MRI if an MRI is not available, or a person does not have a right to be cured of schizophrenia when there are currently no permanent cures). Principle of fidelity or best action—maintaining loyalty and commitment to the patient to perform your duty in the best manner possible (e.g., if a patient requires a dressing change, it is your duty to use the greatest skill and care possible). Relational Ethics 1. 5 elements: Mutual respect—an intersubjective experience arising from a nonoppositional perception of difference. There is a recognition that individuals are affected by how others view and react to them as well as by their attitudes toward themselves and others. Engagement—the connection between the self and another. It is through this connection that nurses can develop a meaningful understanding of another person’s experience, perspective, and vulnerability. Embodied knowledge—our understanding of the other, incorporated with a scientific body of knowledge. Nursing knowledge and compassion are given equal weight; therefore, emotions and feelings are viewed to be as important as physical signs and symptoms. Interdependent environment—the recognition that we are not separate entities but that we exist as part of a larger community, society, and system. We are not merely affected by our environment; each action we take affects the environment, too. Uncertainty/vulnerability—a recognition that ethical dilemmas exist and, furthermore, that ethical deliberation and contemplation are difficult and at times unpleasant. Mental Health Legislation Legislation consolidates fundamental principles, values, goals, and objectives of mental health policies and programs. It provides a legal framework to ensure that critical issues affecting the lives of people with mental disorders, in facilities and in the community, are addressed (World Health Organization, 1996). In Canada, there are 12 different mental health acts, all of which allow for the involuntary confinement of people with mental illness to protect them from themselves and others from them (Browne, 2010). Each of the provinces and territories has developed its mental health act from a perspective that prioritizes either the respect of persons (autonomy) or the concern for welfare (beneficence). Guidelines for Adherence to Standards of Care When a peer suspects another colleague is not meeting or able to meet the standards of care, it is important to follow the channels of communication in an organization, but it is also important to protect the safety of the patients. If a supervisor’s actions or inactions do not rectify the dangerous situation, you have a continuing duty to report the behaviour of concern to the appropriate authority, such as the provincial or territorial nursing college or association. Civil Rights of People With Mental Illness Mentally ill individuals are guaranteed the same rights under international, national and provincial laws as any other citizen. Determination of legal competency may be necessary and is performed in the courts. A legal guardian is appointed for the person whose mental illness renders him or her incompetent. It is essential for the nurse to know provincial laws regarding care and treatment of mentally ill people and to be familiar with policies of the agency in which he or she works. Issues of consent, competency of patients, advance directives and involuntary treatment are all regulated, and nurses must adhere to these standards of care. Patients’ Rights Under the Law Right to Refuse Treatment A competent patient may refuse treatment or withdraw consent for treatment at any time. Community treatment orders (CTOs) are “legal mechanisms by which individuals with mental illness and a history of non-compliance can be mandated against their will to undergo psychiatric treatment in an outpatient setting” (Snow & Austin, 2009, p. 177). Authorization of Treatment Within the Canadian model, the patient or his or her family member is viewed as the most appropriate authority for making ultimate treatment choices with the value of informed consent to treatment. Provision of the Least Restrictive Type of Mental Health Care The use of the least restrictive means of restraint for the shortest duration is always the general rule. Rights Regarding Confidentiality 1. The Canadian Nurses Association (2008) asserts that it is a duty of the nurse to protect confidential patient information (Box 8-1). The following four situations warrant the violation of this right to privacy by the nurse: There is the potential for suspected harm to another. There is suspected harm to a child. There is the potential for harm to the patient’s self (suicide risk). There is the presence of a reportable communicable disease. Exceptions to the There exists under the law a duty to protect third parties of potential Rule: Duty to Warn and Protect Third Parties life threats. The duty to protect includes the following: assessing and predicting the patient’s danger of violence toward another, identifying the specific persons being threatened, and taking appropriate action to protect the identified victims. Duty to Protect Patients Common legal issues relate to failure to protect the safety of patients. Examples: injury, miscommunication, medication errors, abuse of the therapist–patient relationship, and misdiagnosis. Reporting of Abuse Under most provincial or territorial laws, a person who is required to report suspected abuse, neglect, or exploitation of a person in care and willfully does not do so is guilty of a misdemeanour crime. Confidentiality After Death A person’s reputation can be damaged even after death. Therefore, it is important after a person’s death not to divulge information that you would not have been able to share legally before the death. Protection of Patients A health care provider who believes that a patient is going to try to kill him- or herself has a duty to try to mitigate the risk for that person. For example, the nurse working on an inpatient unit would, in consultation with the other team members, develop a plan of care to mitigate the potential for the person to commit suicide. If a suicidal patient is left alone with a means of self-harm, the nurse who has a duty to protect the patient will be held responsible for the resultant injuries. For instance, leaving a suicidal patient alone in a room on the sixth floor with a window that opens demonstrates unreasonable judgement on the part of the nurse. Precautions to prevent harm also must be taken whenever a patient is restrained. Tort Law Torts are civil wrongs for which money damages are collected from the wrongdoer by the injured party. Intentional Torts These require a voluntary act with intent to bring about a physical consequence and include assault, battery, and false imprisonment. Many liability insurance policies do not cover intentional torts. Unintentional Torts These are unintended acts against another person that produce injury or harm. Negligence is a general tort for which anyone may be found guilty. Duty Standards of care are outlined by national and provincial or territorial guidelines. Standards of care are determined in a number of ways: the standard exercised by other nurses with the same degree of skill or knowledge in similar circumstances, statements written by professional organizations, hospital policies, and procedures. As a psychiatric mental health nurse, you have the duty to understand the theory and medications used in the care of psychiatric patients whether they are being treated in a community clinic, general practitioner’s office, medical unit, or psychiatric treatment unit. The staff nurse who is responsible for care delivery must be knowledgeable enough to assume a reasonable or safe duty of care for the patients. Breach of Duty This is an act or omission that breaches a duty of care and is responsible for injury to another person. Elements required to prove negligence are duty, breach of duty, cause in fact, proximate cause, and damages. Documentation of Care Purpose of Medical Records The purpose of a medical record is to provide accurate and complete information about the care and treatment of the patient and to give health care personnel responsible for that care a means of communicating with each other. Accuracy and timeliness are vital. Facility Use of Medical Records In addition to providing information to caregivers, the record can be used for quality improvement and risk management purposes. Medical Records as Evidence The chart is a recording of data and opinions made in the normal course of the patient’s hospital care. It is considered good evidence because it is presumed to be true, honest, and untainted by memory lapses. Medical records are used as evidence in personal injury cases to determine the extent of patient pain and suffering, to determine extent of injury in abuse cases, in fitness-to-stand-trial assessments, or determination of criminal responsibility in legal proceedings, in workers’ compensation cases, police investigations, guardianship proceedings, competency hearings, commitment procedures, professional and hospital negligence cases, and the like. Nursing Guidelines for Electronic Documentation Guidelines state that documentation should be accurate, descriptive, factual (as opposed to opinion), legible, timely, complete, and unchanged. Computerized charting makes it important to understand how to protect the confidentiality of records (e.g., entering only the records for which there is authorization and using passwords appropriately). Varcarolis’s Canadian Psychiatric Mental Health Nursing Chapter 09: The Nursing Process and Standards of Care for Psychiatric Mental Health Nursing Instructor’s Manual Thoughts About Teaching the Topic Since learners should be familiar with the nursing process by this time, the instructor will not need to spend a great deal of time reviewing basic information. One method of integrating this review involves the use of vignettes to give practice in formulating diagnoses and writing outcome criteria. (One such critical-thinking exercise is included at the end of the textbook chapter.) Work may be structured to be individual or performed in small groups. The instructor may also wish to emphasize the similarities and differences in assessment for psychiatric nursing and the various legal and professional responsibilities that set the context for psychiatric mental health nursing practice. For example, the assessment and treatment process may be different if a patient is under a treatment order or if a voluntary patient. Overall, the use of the patient history and mental and emotional status as assessment strategies is quite different from the data-gathering tools for most patients with medical– surgical problems. Key Terms and Concepts health teaching mental status examination (MSE) outcome criteria psychosocial assessment self-care activities standards of nursing practice Objectives Compare the different approaches you would consider when performing an assessment with a child, an adolescent, and an older adult. Differentiate between the use of an interpreter and the use of a translator when performing an assessment with a non–English-speaking patient. Understand the nursing-process steps used in psychiatric mental health nursing. Conduct a mental status examination (MSE). Perform a psychosocial assessment, including brief cultural and spiritual components. Explain three principles a nurse follows in planning actions to reach agreed-upon outcomes criteria. Construct a plan of care for a patient with a mental or emotional health problem. Identify two advanced practice psychiatric mental health nursing interventions. Instructor’s Manual Demonstrate basic nursing interventions and evaluation of care following the ANA’s Standards of Practice. Compare and contrast Nursing Interventions Classification (NIC), Nursing Outcomes Classification (NOC), and evidence-informed practice. Chapter Outline Teaching Strategies Canadian Standards for Psychiatric-Mental Health Nursing Nursing Processes Nursing Diagnoses Outcomes Identification • The use of the nursing process in psychiatric mental health nursing is aligned with standards of nursing practice, as outlined in the Code of Ethics and Standards of Psychiatric Nursing Practice (Registered Psychiatric Nurses of Canada, 2010) and Canadian Standards for Psychiatric-Mental Health Nursing (Canadian Federation of Mental Health Nurses, 2006). Standards of practice are “authoritative statements that promote, guide, direct and regulate professional nursing practice” (College of Registered Nurses of Nova Scotia, 2012, p. 17). Both sets of standards of practice are provided on the inside back cover of the text. Each step in the nursing process includes collaboration with the patient: Data gathering is a transparent process (patient is aware of when, how, what, and why data is gathered about him or her). • Nursing diagnosis is a process that includes the patient’s definition of problems and patient education on the nursing perception of problems. •Outcome identification is mutually negotiated and respects the patient’s goals. Planning includes interventions to achieve goals and health teaching on best practice interventions. • Implementation includes patient actions. Evaluation includes patient evaluation of progress toward goals. Standard 1: Assessment A mental status examination (MSE) and the assessment of a patient’s psychosocial status are a part of any nursing assessment, along with assessment of the patient’s physical health. The MSE and psychosocial assessment are not limited to psychiatric patients. Initial assessment clarifies the patient’s immediate needs; ongoing assessment enlarges the database and identifies new problems. Time given for the assessment interview ranges from a single short interview in an emergency to many interviews. Purposes of the psychiatric assessment are: Establish rapport Obtain understanding of current problem Assess person’s current level of psychological functioning Identify goals Perform MSE Identify behaviours, beliefs, or areas of patient life to be modified to effect positive change Formulate a plan of care Primary source for data collection is the patient. Secondary sources include family, friends, neighbours, police, health care givers, medical records. Age Considerations A thorough physical examination must be completed before any medical diagnosis is made because a number of physical conditions mimic psychiatric disorders. See Box 8-1 for examples. Assessment of Children Useful tools include storytelling, dolls, drawing, and games to promote disclosure. Assessment of Adolescents Adolescents are particularly concerned about confidentiality; however, threats of suicide or homicide, use of illegal drugs, or issues of abuse cannot be kept confidential. The HEADSSS Interview (Box 8-2) is a structured tool useful in identifying risk factors. Assessment of Older Adults Be aware of physical limitations such as a sensory, motor, or medical condition that could cause increased anxiety, stress, or physical discomfort for the patient. Make accommodations at the beginning of the interview when possible. Language Barriers There are many opportunities for misunderstandings when assessing a patient from a different cultural or social background, particularly if the interview is conducted in English and the patient speaks a different language, or has English as an additional language. Psychiatric Nursing Assessment Gathering Data In addition to a review of systems, and exploration of lab data, a mental status exam (Box 9-3) is completed, including psychosocial assessment and history (Box 9-4). Use of a standardized nursing assessment tool facilitates the assessment process. Too rigid application of the tool decreases spontaneity. Learners are advised to maintain an informal style, using clarification, focusing, and exploration of pertinent data. Basic components of the psychiatric nursing assessment include patient history, the presenting problem, current lifestyle and life in general (subjective data), and the mental and emotional status (objective data). The nurse attempts to identify patient strengths and weaknesses, usual coping strategies, cultural beliefs and practices that may affect implementing traditional treatment, and spiritual beliefs or practices integral to patient lifestyle. At the conclusion of the assessment, it is useful to summarize pertinent data with the patient and make the patient aware of what will happen next. Spiritual or Religious Assessment It is important for nurses to support spiritual aspects of care, just as they do biophysical elements. Carson and Koenig highlight the necessity for mental health nurses and allied clinical staff to be conscious that their patients may have spiritual and religious needs. See text for questions that can be incorporated into the patient assessment. Cultural and Social Assessment One consequence of Canadian multiculturalism is an increased responsibility for nurses to “move beyond the superficial knowledge of a culture to seek and consider the personal meanings that individuals ascribe to their own ethnicity” (Racher & Annis, 2007, p. 263). Cultural safety is a concept that moves beyond understanding cultural differences toward an understanding of the power differentials in society and therefore also in health care. Chapter 7 offers a detailed discussion of the cultural implications for psychiatric mental health nursing and information for conducting a cultural and social assessment. Validating the Assessment Data obtained from the patient should be validated with secondary sources whenever possible. Family view is of particular importance. Examples are provided of other validating sources and what can be learned from them. Using Rating Scales Rating scales are used for evaluation and monitoring. Table 9-2 lists several in common use today. Standard 2: Nursing Diagnosis Formulating a Nursing Diagnosis 1. A nursing diagnosis has three structural components: Problem (unmet need). The nursing diagnostic title states what should change. Etiology (probable cause). Is linked to the diagnostic title with the words “related to.” Identifies the causes the nurse can treat through nursing interventions. Supporting data (signs and symptoms). State what the condition is presently like and validate the diagnosis. Standard 3: Outcomes Identification Determining Outcomes Outcomes are the measurable behaviours or situations that should be realistic and obtainable. Outcomes identification reflects hoped-for outcomes and the maximal level of patient health that can realistically be reached by nursing intervention. The Nursing Outcomes Classification (NOC) is mentioned as a source of standardized outcomes based on research and clinical practice. Goals should be realistic and acceptable to both patient and nurse and should be stated in observable/measurable terms. They should also indicate patient outcomes, include specific time for achievement, be short and specific, and be written in positive terms. Standard 4: Planning Consists of identifying nursing interventions that will help meet the outcome criteria and are appropriate to the patient’s level of functioning. Interventions are written for each goal. Interventions should be seen as instructions of all people working with the patient. Interventions need to be safe, appropriate, evidence-informed, and individualized. Nursing Interventions Classification (NIC) is a research-based standardized language of approximately 500 interventions nurses can use to plan care. Standard 5: Implementation Seven areas of implementation are at the basic level of nursing: coordination of care, health teaching and health promotion, milieu therapy, and psychobiological and integrative interventions. Advanced-practice interventions include psychotherapy, prescriptive authority and treatment, and consultation. Standard 5A: Coordination of Care The psychiatric mental health nurse coordinates implementation of the plan and provides documentation. Standard 5B: Health Teaching and Health Promotion Includes identifying health education needs and teaching basic principles of physical and mental health. Psychiatric mental health nurses employ a variety of healthpromotion and disease-prevention strategies. The text provides a thorough list of factors that will be considered when working with individual patients to reach their optimum level of wellness. Standard 5C: Milieu Therapy Includes providing for patient safety and comfort, setting limits, and re-teaching activities that meet patient physical and mental health needs. Standard 5D: Pharmacological, Biological, and Integrative Therapies An important nursing function is administration of medication and the attendant responsibilities of observing for therapeutic and untoward effects, monitoring therapeutic blood levels, and teaching the patient and family about the drug. Advanced-Practice Interventions Standard 5E: Prescriptive Authority and Treatment The advanced-practice registered nurse in psychiatric-mental health (APRN-PMH) is educated and clinically prepared to prescribe psychopharmacological agents in accordance with provincial and national laws and regulations. Standard 5F: Psychotherapy The APRN-PMH is educationally and clinically prepared to conduct individual, group, and family psychotherapy, as well as other therapeutic treatments for patients with a variety of mental health disorders. Standard 5G: Consultation The APRN-PMH consults with other clinicians to provide services for patients and effect change within the system. Standard 6: Evaluation Evaluation is an ongoing process throughout all phases of the nursing process. Documentation Documentation could be considered the seventh step in the nursing process. Documentation of patient progress is the responsibility of the entire mental health team. Varcarolis’s Canadian Psychiatric Mental Health Nursing, Chapter 10: Therapeutic Relationships Instructor’s Manual Thoughts About Teaching the Topic The nurse–patient relationship is the medium through which the nursing process is implemented and is the best predictor of patient outcomes. Understanding the purpose of a nurse–patient relationship, the characteristics of a therapeutic relationship, and the phases through which it will progress are important considerations. The importance of students understanding values as determinants of behaviour cannot be understated. Developing this awareness is an ongoing process that can be supported by the instructor, who encourages students to identify the personal and patient values that prompt emotional, cognitive, and behavioural responses in relationships with those under their care. Key Terms and Concepts clinical supervision contract empathy genuineness orientation phase preorientation phase rapport social relationship termination phase therapeutic encounter therapeutic relationship therapeutic use of self values working phase Objectives Compare and contrast the three phases of the nurse–patient relationship and the dimensions of the helping relationship. Compare and contrast a social relationship and a therapeutic relationship in terms of purpose, focus, communications style, and goals. Identify at least four patient behaviours a psychiatric nurse may encounter in the clinical setting. Explore qualities that foster a therapeutic nurse–patient relationship and qualities that contribute to a nontherapeutic psychiatric nursing interactive process. Instructor’s Manual 10-2 Define and discuss the microcommunication skills of empathy, genuineness, and positive regard in a nurse–patient relationship. Identify two attitudes and four actions that may reflect the nurse’s positive regard for a patient. Analyze what is meant by boundaries and the influence of transference and countertransference on boundary blurring. Understand the use of nonverbal behaviour or body language in the context of the psychiatric nurse–patient relationship of attending behaviours. Discuss the influences of disparate values and cultural beliefs on the therapeutic relationship. Chapter Outline Teaching Strategies Concepts of the Nurse–Patient Relationship The nurse–patient relationship is the basis of all psychiatric mental health nursing treatment approaches, regardless of goals. A nurse– patient relationship incorporating principles of mental health nursing is clearly defined and different from other types of relationships. It has specific goals, such as facilitating patient communication of distressing thoughts and feelings; assisting patients with problem solving to help facilitate activities of daily living; helping patients examine self-defeating behaviours and test alternatives; and promoting self-care and independence. Social Relationships These relationships are primarily initiated for the purpose of friendship, socialization, enjoyment, or task accomplishment. Characteristics include mutually met needs and superficial communication. Communication techniques include giving advice and meeting dependency needs. Little evaluation of the interaction occurs. Therapeutic Relationships These focus on patient needs rather than nurse needs. Patient issues, problems, and concerns are explored, and potential solutions are discussed. New coping skills develop and behavioural change is encouraged. The nurse uses communication skills, understanding of human behaviour, knowledge of the stages and phenomena occurring in a therapeutic relationship, and personal strengths to enhance patient growth. Nurses’ roles include teacher, counsellor, socializing agent, liaison, and others. Relationship Boundaries and Roles Separating the patient’s needs from the nurse’s needs is how the nurse role and the patient role are differentiated. However, boundaries may blur when the relationship slips into a social context or when the nurse’s behaviour reflects getting self-needs met at the expense of patient needs. Resultant actions include overhelping, controlling, and narcissism (i.e., finding weakness, helplessness, and illness in patients in order to feel helpful). Transference A process whereby a patient unconsciously and inappropriately displaces onto individuals in his or her current life (therapist) those patterns of behaviour and emotional reactions that originated with significant figures from childhood. Transference occurs in all relationships; however, it is intensified in relationships of authority. Examples of transference are desire for affection and respect, gratification of dependency needs, hostility, competitiveness, and jealousy. Counter-transference The opposite of transference occurs when the therapist displaces onto the patient positive or negative feelings caused by people in the therapist’s past. Examples include overidentification with the patient, power struggles, and competitiveness with the patient. Working through transference and counter-transference issues is crucial to professional growth of the nurse and positive change in the patient. These issues are best dealt with through supervision by an experienced professional. Self-Check on Boundaries Readers are encouraged to be reflective about relationships with patients and others (Figure 10-1). Values, Beliefs, and Self-Awareness These are abstract standards representing an ideal. Values influence choices and provide a framework for life goals. They are largely culturally oriented and formed through the example of others (modelling). Nurses are required to plan and implement care for patients who have values that differ from their own. Self-awareness regarding their own values and sensitivity to the values unique to each patient are essential. Peplau’s Model of the Nurse–Patient Relationship Peplau’s model of the nurse–patient relationship is well accepted in Canada and the United States and has become an important tool for all nursing practice. In this professional helping relationship, relevant behaviours include accountability, a focus on patient needs, clinical competence, and supervision to validate performance quality. An abbreviated or limited relationship is referred to as a therapeutic encounter. The nurse–patient relationship is the medium through which the nursing process is implemented. There are four phases: preorientation, orientation, working, and termination. Preorientation Phase This phase involves the thoughts and feelings the nurse experiences prior to the first clinical session and planning for the first interaction with patients. Several student concerns are discussed, such as fear of physical harm and fear of saying the wrong thing. Orientation Phase The second phase ranges from a few meetings to a longer term, especially with chronically mentally ill patients. Initially, each interacts according to his or her background, standards, values, and experiences. Initial emphasis is on establishing trust. Four issues are addressed: (1) parameters of the relationship (i.e., purpose of the meetings); (2) a formal or informal contract (i.e., an agreement on specific places, times, dates, duration of meetings, and goals for meetings); (3) confidentiality (i.e., the information the patient shares with the nurse will be shared with the treatment team, but not with others with no need to know); (4) termination (i.e., the patient should know the date of termination if the relationship is not open ended). During this phase, the nurse will need to be aware of transference or counter-transference issues; respond therapeutically to patient “testing” behaviours; promote an atmosphere of trust; foster patient articulation of problems; and establish mutually agreed-upon goals. Establishing Rapport A major emphasis during the first few encounters with the patient is providing an atmosphere in which trust and understanding, or rapport, can grow. Confidentiality The patient has a right to know who else will be given the information shared with the nurse and that the information may be shared with specific people. The patient also needs to know that information will not be shared with others outside of the treatment team except in extreme situations. Terms of Termination Termination is the last phase in Peplau’s model, but planning for termination actually begins in the orientation phase. The date of termination should be clear from the beginning, if possible. Working Phase In the third phase, tasks include maintaining the relationship; gathering further data; promoting patients’ problem-solving skills, self-esteem, and use of language; facilitating behavioural change; overcoming resistance behaviours; evaluating problems and goals and redefining them as necessary; and fostering practice of alternative adaptive behaviours. Unconscious motivation and needs may cause the patient to experience intense emotions and prompt patient behaviours such as acting out anger inappropriately, withdrawing, intellectualizing, manipulating, and denying. Transference and counter-transference may be experienced. Termination Phase The final stage of the relationship arouses strong feelings in both patient and nurse that need to be recognized and worked through. This phase will provide an excellent learning experience for both patient and nurse and is a time for summarizing goals, reviewing situations that occurred, and evaluating progress. What Hinders and What Helps the Nurse–Patient Relationship Canadian mental health nursing researcher and leader Cheryl Forchuk and others tells us the importance of consistent, regular, and private interactions with patients in developing therapeutic relationships. The following behaviours were inherent in a mutually satisfying relationship: consistency, pacing, listening, positive initial impressions, promoting patient comfort and balancing control, trust on the part of the patient, and active participation by the patient in the relationship. The specific behaviours that hampered development of positive relationships were inconsistency, unavailability, lack of self-awareness on the part of the nurse, and negative feelings on the part of the nurse. Factors That Enhance Growth in Others The following factors are considered crucial in effective helpers: genuineness, empathy, and positive regard. Genuineness Explained by Rogers as congruence, genuineness is awareness of feelings as they arise in the relationship and the ability to communicate them when appropriate. Genuineness, or congruence, are demonstrated by not hiding behind the role of nurse, by listening to and communicating without distorting others’ messages, and by being clear and concrete. Empathy Versus Sympathy Empathy is the ability to see things from the other person’s perspective, to experience what the other is feeling, and to communicate this understanding, which denotes acceptance. It is not to be confused with sympathy, which has more to do with compassion and pity. Sympathy is not objective; empathy is objective. Positive Regard Positive regard implies respect. It is the ability to view another as being worthy of being cared about and as someone who has strengths and achievement potential. Attitudes and actions that convey positive regard are willingness to work with patients to help them develop their own resources, attending, and suspending value judgements. Attitudes One attitude through which a nurse might convey respect is willingness to work with the patient. Actions Some actions that manifest an attitude of respect are attending, suspending value judgements, and helping patients develop their own resources. Attending Attending refers to a special kind of listening that refers to an intensity of presence or being with the patient. Suspending Value Judgements Nurses are more effective when they guard against using their own value system to judge patient’s thoughts, feelings, or behaviours. Helping Patients Develop Resources These actions involve being aware of patients’ strengths and encouraging them to use their own resources and to work at their highest level of functioning. It conveys respect for the patient, minimizes helplessness and dependency, and validates potential for change. Instructor Manual for Varcaroliss Canadian Psychiatric Mental Health Nursing Margaret J. Halter, Cheryl L. Pollard, Susan L. Ray, Mary Haase, Sonya Jakubec, Elizabeth M. Varcarolis 9781926648330, 9781771721400

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