#2 Psych Nursing - Therapeutic Use of Self

therapeutic use of self (define)

Honing a special set of attitudes and skills that allow the nurse to serve as a therapeutic agent of change for others. Integration of theory, experience and self-awareness to promote behavioral change in patients.

therapeutic communication (define)

Interactions between nurse and patient that is focused on the patient, the patient's needs, and aimed at promoting positive outcomes for patient.

therapeutic communication techniques

active listening, silence, giving recognition, offering general leads, sequencing the events in time, encouraging descriptions and/or comparisons, restating, clarifying, reflecting, exploring, validating and voicing doubt.

reflexivity

examining personal forces of socialization to determine (as objectively as possible), their effect of attitudes, values, beliefs and reactions.

Why is reflexivity important?

Decreases the power of socializing forces and increases capacity for exercising critical thinking, individual choice and self-determination.

self-awareness

the ability to observe one's emotions, assess their impact on self/others, use "gut feelings.

self-management

the ability to exercise control over one's emotions and impulses and effectively adapt to change.

social awareness

the ability to observe social influences, assess social networks, and apply social awareness in interactions with others.

relationship management

the ability to engage in meaningful relationships, manage interpersonal conflict, and apply relationship skills in developing and leading others.

What is the foundation of psychiatric nursing?

Interpersonal relationships

Peplau's phases of interpersonal relationships: orientation

Nurse as stranger (participant-observer), explain roles and boundaries, patient assessment, self-assessment. Includes APIE.

Peplau's phases of interpersonal relationships: working (2 parts)

Strengthen trust, focus on the patient, nurse as teacher/leader/resource/counselor. Includes APIE.

Peplau's phases of interpersonal relationships: identification (part 1 of working)

ID patient needs, explore patient goals, collaborate on mutual goals. Includes planning.

Peplau's phases of interpersonal relationships: exploitation, "bulk of work" (part 2 of working)

Examine feelings & patterns, role of surrogate, manage transference/countertransference, foster pt independence. Includes implementation.

Peplau's phases of interpersonal relationships: resolution/termination

Evaluate pt readiness, summarize goal progress, validate feelings. Includes APIE, focus on evaluation.

Peplau's levels of anxiety: Mild anxiety

Positive state of heightened awareness and sharpened senses. Optimal for learning and problem-solving.

Peplau's levels of anxiety: Moderate anxiety

Decreased perceptual field (focused on immediate task), requires guided redirection to learn or solve problems.

Peplau's levels of anxiety: Severe anxiety

Feelings of dread/terror. Focused on selective details, unable to redirect verbally, physiologic symptoms of tachycardia, diaphoresis, hyperventilation.

Peplau's levels of anxiety: Panic

Loss of rational thought, delusions or hallucinations, immobilized or mute. Overwhelming impulse to fight or flee. Risk for violence, self-injury.

transference

patient's emotional response to health care provider (pt may feel/think nurse reminds him/her of relative or past romantic interest b/c of emotional or physical similarity).

countertransference

When health care professional develops positive or negative emotional response to patient's transference (ex: older patient reminds nurse of deceased grandmother, nurse starts to avoid pt).

Humanistic psychology (theorist and principle)

Carl Rogers (1902-1987). Individuals have a "self-actualizing tendency," to develop their fullest potential.

Humanistic psychology approach

Non-directive and reflective. Accurate empathy, congruence of mind and body, unconditional positive regard and non-possessive warmth.

Daniel Siegel's "mindsight

Being fully present, joining and seeking emotional resonance fosters a sense of "feeling felt," human capacity to perceive the mind of the self and others.

mirror neuron system (location and importance)

Located in inferior frontal cortex, parietal lobe, superior temporal sulcus. Type of brain cell that responds equally when we perform an action and when we witness someone else perform the same action.

Spindle neurons (location and importance)

Located in anterior insula, single axon and dendrite. Allow for rapid emotional and intuitive judgment.

Possible negative impacts of therapeutic use of self on nurses

Toll of "emotional labor," nurse's needs for approval & respect & caring, role strain and burnout, retreat into task orientation, misuse of power differential, blurring and violation of boundaries.

professional boundaries

exercising the legal and ethical responsibility to safeguard the boundary between nurse and patient, protecting the patient's best interests even if he/she tests limits.

boundary testing

inviting a social relationship or role reversal, soliciting nurse's personal information, violating nurse's personal space.

boundary crossing

transient, inadvertent, with therapeutic intent.

boundary violations

excessive personal disclosure, keeping secrets or withholding information from team, sexual misconduct.

In which stage of Peplau's interpersonal relationship stages should professional boundaries be established?

Orientation.

proxemics: dimensions of personal space (3 types)

social (9 ft), personal (4 ft), intimate (1.5 ft).

therapeutic communication: therapeutic intent

establish and build trust; join with pt as basis for collaboration; achieve therapeutic goals; promote, develop and exercise effective coping; model, teach, facilitate, empower, advocate.

Active listening posture: SOLER

sit, open (uncross arms and legs), lean (forward), eye contact, relax.

Approach to interviewing: OARS

Open-ended questions, affirmation, reflection, summarization.

Priorities in clinical situations: #1 Protect safety of patient and others.

Assess safety risk, assure team communication and support, mobilize least restrictive intervention, remove others in close proximity, preserve patient privacy and integrity.

Priorities in clinical situations: #2 De-escalate patient anxiety.

Modify the environment to decrease stimulation, establish safe space and 1:1 and alliance, recognize and manage own anxiety, seek to understand, validate, reflect, empathize.

Priorities in clinical situations: #3 Explore patient's thoughts and feelings.

Resist premature reassurance and closure, avoid assumptions and judgmental responses, clarify, restate/paraphrase, reflect, summarize.

Priorities in clinical situations: #4 Invite problem-solving and collaboration.

Resist telling, suggesting, advising. Empower, foster independence.

Psychiatric interview topics

Presenting problem, hx of problem, recent stressors/losses, support system and resources, med hx, family med/psych hx, pt's psychosocial/developmental hx, review of psych sx, MSE, goals for tx.

Mental Status Exam (MSE)

appearance, response to interview, behavior and activity level, speech, mood and affect, thought process, delusions/hallucinations, judgment and insight, orientation and cognition.