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Mental Health Nursing II
NURS 2310
Unit 3
Objective 1
Defining therapeutic milieu
The therapeutic milieu is a scientific
structuring of the environment in order to
effect behavioral changes and to improve
the psychological health and functioning of
the individual.
Within this structured environment, the
client is expected to learn adaptive coping,
interaction, and relationship skills that can
be generalized to other aspects of his or
her life.
Objective 2
Analyzing the nurse’s role in
maintaining the therapeutic milieu
in an inpatient psychiatric/mental
health setting
The nurse maintains the therapeutic milieu in
the inpatient setting by:
Encouraging health promotion
Providing therapeutic interaction
Allowing clients to participate in governing the
Expecting the client to take responsibility for his
or her own behavior
Utilizing peer pressure or peer support as a tool to
bring about acceptable group norms
Dealing with inappropriate behaviors as they
Avoiding restrictions and punishments
Objective 3
Reviewing the components
of nurse-client relationship
development and therapeutic
Therapeutic use of self:
Ability to use one’s personality consciously and in
full awareness in an attempt to establish
relatedness and to structure nursing interventions
Therapeutic communication:
Consists of verbal and nonverbal techniques that
focus on the client’s needs and advance the
promotion of healing and change
 Encourages the exploration of feelings and fosters
understanding of behavioral motivation
 Promotes trust, discourages defensiveness, and is
Active listening:
Being attentive to what the client is saying both
verbally and nonverbally
 Facilitative skills include –
– facing the client squarely
– observing an open posture
– leaning toward the client
– establishing eye contact
– maintaining a relaxed demeanor
Communication method that helps the client
consider a modification of behavior
Therapeutic relationship:
Interaction between two people in which input
from both participants contributes to a climate of
healing, growth promotion, and/or illness
 Goal-oriented
– goal of the relationship determined jointly by
nurse and client
– goal is most often directed at learning and
growth promotion in an effort to bring about
some type of change in the client’s life
– may be based on a problem-solving model
Conditions essential to the development of a
therapeutic relationship include:
 Rapport
– special feelings on the part of both the client
and nurse based on acceptance, warmth,
friendliness, common interest, a sense of trust,
and a nonjudgmental attitude
– establishing rapport may be accomplished by
discussing non-health-related topics
– the ability to be open, honest, and “real” in
Developing therapeutic relationships
 Trust
– confidence in another person’s presence,
reliability, integrity, veracity, and sincere
desire to provide assistance when
 providing a blanket when the client is cold
 providing food when the client is hungry
 keeping promises
 being consistent
 ensuring confidentiality
Developing therapeutic relationships
 Respect
– unconditional positive regard
 calling the client by name
 spending time with the client
 allowing sufficient time to answer the client’s
questions or concerns
 always being open and honest
 striving to understand the motivation behind the
client’s behavior
– process in which one is able to see beyond
outward behavior and accurately sense
another’s inner experience
Objective 4
Exploring the
phases of the
Phases of the therapeutic relationship:
Preinteraction phase
– Preparation for the first encounter with the
Orientation (Introductory) phase
– The nurse and client become acquainted
Working phase
– Accomplishment of the therapeutic work of
the relationship
Termination phase
– Bringing a therapeutic conclusion to the
Boundary issues within a professional
relationship may include:
 Transference
– When the client unconsciously attributes to the
nurse feelings and behavioral dispositions
formed toward a person from his or her past
– The nurse’s behavioral and emotional response
to the client which may be related to
unresolved feelings toward significant others
from the nurse’s past, or may be generated in
response to transference feelings on the part of
the client
Boundary issues (cont’d)
– May be appropriate when the information to
be shared is judged to be therapeutically
beneficial to the client
– Never used for the purpose of meeting the
nurse’s own needs
– Professional judgment
– Institutional policy
– Never financial
 suggest a donation elsewhere
Boundary issues (cont’d)
– Caring touch with no associated physical need
can be therapeutically appropriate
– Beware of situations in which touch may be
misinterpreted, culturally unacceptable, or
 paranoid patient
 psychotic client
Warning signs that may indicate a potential breech
in professional boundaries in the nurse-client
relationship include:
 Favoring one client’s care over another’s
 Swapping assignments with another nurse to care
for a particular client
 Giving special attention or treatment to one client
over others
 Spending free time with one particular client
 Sharing personal information or work concerns
with a client
 Continuing contact/communication with a client
after discharge
Objective 5
Correlating appropriate modes of
therapeutic communication with
specific psychiatric behaviors
Modes of therapeutic communication:
Using silence
– gives the client the opportunity to collect and
organize thoughts
– conveys an attitude of reception and regard
Giving recognition
– acknowledging
Offering general leads
– offers the client encouragement to continue
Making observations
– verbalizing what is observed or perceived
– repeating the main idea of what the client has said
Encouraging description of perceptions
– asking the client to verbalize what is being perceived
Therapeutic communication (cont’d)
– referring questions and feelings back to the client so
that they may be recognized and accepted
– taking notice of a single idea or a single word
– works well with the client who is moving rapidly from
one thought to another
– not to be used with a client who is anxious
Presenting reality
– when a client has a misperception of the
environment, the nurse defines reality
Voicing doubt
– expressing uncertainty as to the reality of percpetions
Objective 6
Exploring the
concept of
The therapeutic community holds that
everything that happens to the client or
within the client’s environment is
considered to be part of the treatment
Community factors, such as social
interactions, the physical structure of the
treatment setting, and schedule of
activities may generate negative
responses which are used as examples to
help the client learn how to manage stress
more adaptively in real-life situations.
Conditions that promote the therapeutic
community include:
 The fulfillment of basic physiological needs
 The conduciveness of the physical facilities
to achievement of the goals of therapy
 The existence of a democratic form of
 The assignment of responsibilities based
on each client’s capabilities
 The scheduling of a structured program of
social and work-related activities
 The inclusion of community and family
with regards to discharge planning
Objective 7
Examining the use of groups as a
therapeutic tool
Collection of individuals whose association is
founded on shared commonalities of interest,
values, norms, or purpose
 Membership is generally
– by chance (born into the group)
– by choice (voluntary affiliation)
– by circumstance (the result of life-cycle events over
which an individual may or may not have control)
Group Therapy = a form of psychosocial treatment
in which a number of clients meet together with
a therapist for purposes of sharing, gaining
personal insight, and improving interpersonal
coping strategies.
Use of a group as a therapeutic tool:
Instillation of hope
Imparting of information
Corrective recapitulation of the primary family
Development of socializing techniques
Imitative behavior
Interpersonal learning
Group cohesiveness
Existential factors
Objective 8
Identifying group types, roles,
functions, development and stages
Functions of a group:
Task completion
– enforcement of established norms
 Governance
– rules committees
Types of groups:
Task Groups
– accomplishing a specific outcome or task
– focus on problem-solving and decision-making
Teaching Groups
– exist to convey knowledge and information to a
number of individuals
Supportive/Therapeutic Groups
– concerned with preventing future upsets by teaching
effective ways of dealing with emotional distress
Self-Help Groups
– allow clients to talk about their fears and relieve
feelings of isolation while receiving comfort and
advise from others undergoing similar experiences
Member roles within groups:
Task Roles
Maintenance Roles
 Coordinator
 Compromiser
 Evaluator
 Encourager
 Elaborator
 Follower
 Energizer
 Gatekeeper
 Initiator
 Harmonizer
 Orienter
Individual Roles
 Aggressor
 Monopolizer
 Blocker
 Recognition
 Dominator
 Seducer
 Mute/Silent member
Phases of group development:
Phase I
Initial or Orientation Phase
Group activities – leader and members work
together to establish the rules that will govern
the group
Leader expectations – leader expected to orient
members to specific group processes, encourage
members to participate without disclosing too
much too soon, promote an environment of
trust, and ensure group rules don’t interfere with
goal fulfillment
Member behaviors – members have not yet
established trust; fear of not being accepted by
the group
Phases of group development (cont’d)
Phase II
Middle or Working Phase
Group activities – productive work toward
completion of the task is undertaken; problemsolving and decision-making occur
Leader expectations – role diminishes and
becomes one of facilitator
Member behaviors – trust established among
members; members turn to each other more
often, and less so to the leader; members
accept criticism from others and use it
constructively to create change
Phases of group development (cont’d)
Phase III
Final or Termination Phase
Group activities – termination process discussed in
depth for several meetings before the final
Leader expectations – the leader encourages
group members to reminisce about what has
occurred, review the goals, and discuss actual
Member behaviors – grief response may be
evident; may lead to discussion of previous
losses; successful termination of the group may
help members develop the skills needed when
losses occur in other dimensions of their lives.