Factors Affecting Health and Illness Physical Dimension
Genetic make-up, age, developmental level, race and sex are all part of an individual’s physical dimension and strongly influence health status and health practices. Examples: a. The toddler just learning to walk is prone to fail and injure himself. b. The young woman who has a family history of breast cancer and diabetes and therefore is at a higher risk to develop these conditions. Emotional Dimension
How the mind and body interact to affect body function and to respond to body conditions also influences health. Long term stress affects the body systems and anxiety affects health habits; conversely, calm acceptance and relaxation can actually change body responses to illness. Examples: a. Prior to a test, a student always has diarrhea. b. Extremely nervous about a surgery, a man experiences severe pain following his operation. c. Using relaxation techniques, a young woman reduces her pain during the delivery of her baby. Intellectual Dimension
The intellectual dimension encompasses cognitive abilities, educational background and past experiences. These influence a client’s responses to teaching about health and reactions to health care during illness. They also play a major role in health behaviors. Examples: a. An elderly woman who has only a third-grade education who needs teaching about a complicated diagnostic test. b. A young college student with diabetes who follows a diabetic diet but continues to drink beer and eat pizza with friends several times a week. Environmental Dimension
The environment has many influences on health and illness. Housing, sanitation, climate and pollution of air, food and water are aspects of environmental dimension. Examples: a. Increased incidence of asthma and respiratory problems in large cities with smog. Socio-cultural Dimension
Health practices and beliefs are strongly influenced by a person’s economic level, lifestyle, family and culture. Low-income groups are less likely to seek health care to prevent or treat illness; high-income groups are more prone to stress-related habits and illness. The family and the culture to which the person belongs determine patterns of livings and values, about health and illness that are often unalterable. Examples: a. The adolescent who sees nothing wrong with smoking or drinking because his parents smoke and drink. b. The person of Asian descent who uses herbal remedies and acupuncture to treat an illness. Spiritual Dimension
Spiritual and religious beliefs are important components of the way the person behaves in health and illness. Examples: a. Roman Catholics require baptism for both live births and stillborn babies. b. Jehovah Witnesses’ are opposed to blood transfusions.
Three Phases of Nurse-Client Relationship
Nurse-Client Relationship – the nurse and the client work together to assist client to grow and solve his problems. This relationship exists for the benefit of the client so that it is important that at every interaction, the nurse uses self therapeutically. This is achieved by maintaining the nurses’ self-awareness to prevent her unrecognized needs from influencing her perception of and behavior towards the client. Three Phases of Nurse-Client Relationship: 1. Orientation Stage • •
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Establishing therapeutic environment. The roles, goals, rules and limitations of the relationship are defined, nurse gains trust of the client, and the mode of communication are acceptable for both nurse and patient is set. Acceptance is the foundation of all therapeutic relationship o Acceptance of others requires acceptance of self first. o Rapport is built by demonstrating acceptance and non-judgmental attitude. Acceptance of patient means encouraging the patient verbally and nonverbally to express both positive and negative feelings even if these are divergent from accepted norms and general viewpoint. The nurse can encourage the client to share his/her feelings by making o the client understand that no feeling is wrong. Trust of patient is gained by being consistent. Assessment of the client is made by obtaining data from primary and secondary sources. The patient set the pace of the relationship. During this phase, the problems are not yet been resolved but the client’s feelings especially anxiety is reduced, by using palliative measures, to enable the client to relax enough to talk about his distressing feelings and thoughts. This stage progresses well when the nurses show empathy provide support to client and temporary structure until the client can control his own feelings and behavior. Reality testing – is accepting the patient’s perceptions, feelings and o thoughts as neither right nor wrong, but at the same time offering other options or points of view to the client in a non-argumentative manner
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for the purpose of helping the client arrive at more realistic conclusions. To provide structure is to intervene when the client loses control of his own feelings and behaviors by medications, offering self, restrain, seclusion and by assisting client to observe a consistent daily schedule.
2. Working/ Exploration/ Identification Stage – at this point, the client’s problems are identified and solutions are explored, applied and evaluated. •
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The focus of the assessment and of the relationship is the client’s behavior and the focus of the interaction is the client’s feelings. The nurse should realize that the client’s feelings of security are developed by being consistent at all times. Perception of reality, coping mechanisms and support systems are identified. The nurse assists the patient to develop coping skills, positive self concept and independence in order to change the behavior of the client to one that is adaptive and appropriate. The nurse uses the techniques of communication and assumes o different roles to help the client.
3. Termination/ Resolution stage •
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the nurse terminates the relationship when the mutually agreed goals are met, the patient is discharged or transferred or the rotation is finished. The focus of this stage is the growth that has occurred in the client and the nurse helps the patient to become independent and responsible in making his own decisions. The relationship and the growth or change that has occurred in both the nurse and the patient is summarized. Client may become anxious and react with increased dependence, hostility and withdrawal, these are normal reactions and are signs of separation anxiety, these feelings and behavior should be discussed with the client. The nurse should be firm in maintaining professionalism until the end of the relationship. She should not promise the client that the relationship will be continued. The time parameters should be made early in the relationship and meetings are set further and further apart near the end to foster independence of the patient and prepare the latter gradually for the separation. The nurse should not give her address or telephone numbers to the patient. Referral for continuing health care and support after discharge provides additional resources for the client and the family. The goal of the therapeutic relationship have been met when the patient has developed emotional stability, cope positively, recognized sources or causes of anxiety, demonstrates ability to handle anxiety and independence, and is able to perform self-care. Preparation of the termination phase begins at the orientation phase, o when the duration and length of the nurse-client relationship was established.
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It is normal for the client to experience separation anxiety such as sleeplessness, anorexia, physical symptoms, withdrawal and hostility. •
Therapeutic Relationship Therapeutic relationship – is a relationship that is established between a health care professional and a client for the purpose of assisting the client to solve his problems. 1. Empathy the nurse should be able to perceive and experience the feelings of the o patient to be able to understand the patient. •
Empathy is therapeutic but sympathy is not therapeutic because sympathy is pity.
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Sympathy leads the patient to develop a “poor me” self concept.
2. Ge Genu nuin ineeness ness o
this is manifested when the nurse is sincere and honest in her relationship with the patient. Consistency conveys sincerity that in turn foster the development of the patient’s trust. The nurse must maintain an honest and open communication.
3. Concre Concreten teness ess and specif specifici icity ty o
this pertains to the nurse’s ability to identify the client’s feelings and make the client be aware of them. Only when the nurse listens actively and is sensitive enough can she help the patient to gain awareness and insight regarding the latter’s feelings, thought and behaviors in relation to situations and person’s to the patients life in the past and in the present.
4. Respect o
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the nurse considers the patient, like any other human being with dignity, to be deserving of high regard. This is manifested when the nurse does not belittle or judge the patient’s feelings, verbalizations and behaviors. Respect is shown when the nurse realizes that several patients may have the same diagnosis but their individuality sets them apart and different from each other. As such, the nurse approach must be appropriate for each patient. Respect can be shown by being consistent yet flexible when the circumstance warrants being so.
*Transference – occurs when the client transfers conflict/ feelings from the past to the nurse. Ex. Client becomes overly dependent to the nurse because client may transfer the maternal longings to the nurse. * Counter-transference – when nurse responds to the client emotionally on a personal level. When the nurse begins to react to the patient personal level, often unaware of it and may lose her objectivity. The nurse should discuss with the other members of the health team any negative or strong feeling she has developed towards the client so she can be helped to maintain her focus and perspective. 5. Immed Immediac iacy y of relat relation ionshi ship p o
this refers to the nurse’s ability to recognize her own feelings as she deals and communicate with the patient. It also refers to the ability to realize when it is appropriate to share them with the patient.
6. Self Self-e -exp xplo lora rati tion on o
it is necessary that the nurse makes the patient realize the necessity of the patient exploring, identifying and understanding his own feelings and thought to be able to understand himself better, and find appropriate solutions to his problems.
7. Self Self – dis discl clos osur uree o
the nurse willingness to share her own points of view in a therapeutic manner can be an indication of genuineness, this encourages the patient to become more open to the nurse in return.
8. Conf Confro ront ntat atio ion n o
patients sometimes behave inappropriately because they perceive the environment unrealistically. It could also be due to excessive use of defense mechanisms. These in appropriate behaviors and unrealistic perceptions can be corrected by the nurse by pointing out the patient in a matter of fact and non-judgmental manner, the inconsistencies and discrepancies in the patients behaviors, perceptions, verbalizations and feelings. The nurse also set limits on the patients behavior.
Therapeutic and Non-Therapeutic Communication Quick Checklist for Effective Communication: Communication: (1) Open ended questions (2) Focus on feelings (3) State behaviors observed (4) Reflect, restate, rephrase verbalization of patient (5) Neutral responses
Effective Communication: (1) Appropriate (2) Simple (3) Adaptive (4) Concise (5) Credible Therapeutic Technique 1. Offering Self • •
making self-available and showing interest and concern. “I will walk with you”
2. Active listening •
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paying close attention to what the patient is saying by observing both verbal and non-verbal cues. Maintaining eye contact and making verbal remarks to clarify and encourage further communication.
3. Exploring •
“Tell me more about your son”
4. Giving broad openings •
What do you want to talk about today?
5. Silence •
Planned absence of verbal remarks to allow patient and nurse to think over what is being discussed and to say more.
6. Stating the observed •
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verbalizing what is observed in the patient to, for validation and to encourage discussion “You sound angry”
7. Encouraging comparisons •
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asking to describe similarities and differences among feelings, behaviors, and events. • “Can you tell me what makes you more comfortable, working by yourself or working as a member of a team?” •
8. Identifying themes • •
asking to identify recurring thoughts, feelings, and behaviors. “When do you always feel the need to check the locks and doors?”
9. Summarizing
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reviewing the main points of discussions and making appropriate conclusions. “During this meeting, we discussed about what you will do when you feel the urge to hurt your self again and this include…”
10. Placing the event in time or sequence • •
asking for relationship among events. “When do you begin to experience this ticks? Before or after you entered grade school?”
11. Voicing doubt •
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voicing uncertainty about the reality of patient’s statements, perceptions and conclusions. “I find it hard to believe…”
12. Encouraging descriptions of perceptions •
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asking the patients to describe feelings, perceptions and views of their situations. “What are these voices telling you to do?”
13. Presenting reality or confronting • • •
stating what is real and what is not without arguing with the patient. “I know you hear these voices but I do not hear them”. “I am Lhynnelli, your nurse, and this is a hospital and not a beach resort.
14. Seeking clarification •
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asking patient to restate, elaborate, or give examples of ideas or feelings to seek clarification of what is unclear. “I am not familiar with your work, can you describe it further for me”. “I don’t think I understand what you are saying”.
15. Verbalizing the implied •
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rephrasing patient’s words to highlight an underlying message to clarify statements. Patient: I wont be bothering you anymore soon. Nurse: Are you thinking of killing yourself?
16. Reflecting •
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throwing back the patient’s statement in a form of question helps the patient identify feelings. Patient: I think I should leave now. Nurse: Do you think you should leave now?
17. Restating
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repeating the exact words of patients to remind them of what they said and to let them know they are heard. Patient: I can’t sleep. I stay awake all night. Nurse: You can’t sleep at night?
18. General leads • • •
using neutral expressions to encourage patients to continue talking. “Go on…” “You were saying…”
19. Asking question • •
using open-ended questions to achieve relevance and depth in discussion. “How did you feel when the doctor told you that you are ready for discharge soon?”
20. Empathy • •
recognizing and acknowledging patient’s feelings. “It’s hard to begin to live alone when you have been married for more than thirty years”.
21. Focusing • • •
pursuing a topic until its meaning or importance is clear. “Let us talk more about your best friend in college” “You were saying…”
22. Interpreting Interpreting • • •
providing a view of the meaning or importance of something. Patient: I always take this towel wherever I go. Nurse: That towel must always be with you.
23. Encouraging evaluation • • •
asking for patients views of the meaning or importance of something. “What do you think led the court to commit you here?” “Can you tell me the reasons you don’t want to be discharged?
24. Suggesting collaboration • •
offering to help patients solve problems. “Perhaps you can discuss this with your children so they will know how you feel and what you want”.
25. Encouraging goal setting •
asking patient to decide on the type of change needed.
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“What do you think about the things you have to change in your self?”
26. Encouraging formulation of a plan of action • •
probing for step by step actions that will be needed. “If you decide to leave home when your husband beat you again what will you do next?”
27. Encouraging decisions • •
asking patients to make a choice among options. “Given all these choices, what would you prefer to do.
28. Encouraging consideration of options • •
asking patients to consider the pros and cons of possible options. “Have you thought of the possible effects effec ts of your decision to you and your family?”
29. Giving information • •
providing information that will help patients make better choices. “Nobody deserves to be beaten and there are people who can help and places to go when you do not feel safe at home anymore”.
30. Limit setting •
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discouraging nonproductive feelings and behaviors, and encouraging productive ones. “Please stop now. If you don’t, I will ask you to leave the group and go to your room.
31. Supportive confrontation confrontation • •
acknowledging the difficulty in changing, but pushing for action. “I understand. You feel rejected when your children sent you here but if you look at this way…”
32. Role playing •
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practicing behaviors for specific situations, both the nurse and patient play particular role. “I’ll play your mother, tell me exactly what would you say when we meet on Sunday”.
33. Rehearsing •
asking the patient for a verbal description of what will be said or done in a particular situation.
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“Supposing you meet these people again, how would you r espond to them when they ask you to join them for a drink?”.
34. Feedback • •
pointing out specific behaviors and giving impressions of reactions. “I see you combed your hair today”.
35. Encouraging evaluation • •
asking patients to evaluate their actions and their outcomes. “What did you feel after participating in the group therapy?”.
36. Reinforcement Reinforcement • •
giving feedback on positive behaviors. “Everyone was able to give their options when we talked one by one and each of waited patiently for our turn to speak”.
Avoid pitfalls:
1. Givi Givin ng adv advis isee 2. Talk Talkin ing g abou aboutt you yourr sel self f 3. Tell Tellin ing g cli clien entt is is wro wrong ng 4. Entering Entering into into halluci hallucination nationss and delusions delusions of client client 5. Fals Falsee reas reassu sura ranc ncee 6. Cliché 7. Givi Giving ng appr approv oval al 8. Asking WHY? 9. Chan Changi ging ng subj subjec ectt 10. Defending doctors and other health health team members. Non-therapeutic Non-therapeutic Technique 1. Overloading •
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talking rapidly, changing subjects too often, and asking for more information than can be absorbed at one time. “What’s your name? I see you like sports. Where do you live?”
2. Value Judgments •
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giving one’s own opinion, evaluating, moralizing or implying one’s values by using words such as “nice”, “bad”, “right”, “wrong”, “should” and “ought”. “You shouldn’t do that, its wrong”.
3. Incongruence •
sending verbal and non-verbal messages that contradict one another.
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The nurse tells the patient “I’d like to spend time with you” and then walks away.
4. Underloading •
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remaining silent and unresponsive, not picking up c ues, and failing to give feedback. The patient ask the nurse, simply walks away.
5. False reassurance/ reassurance/ agreement • •
Using cliché to reassure client. “It’s going to be alright”.
6. Invalidation • • •
Ignoring or denying another’s presence, thought’s or feelings. Client: How are you? Nurse responds: I can’t talk now. I’m too busy.
7. Focusing on self • •
responding in a way that focuses attention to the nurse instead of the client. “This sunshine is good for my roses. I have beautiful rose garden”.
8. Changing the subject • • •
introducing new topic inappropriately, a pattern that may indicate anxiety. The client is crying, when the nurse asks “How many children do you have?”
9. Giving advice •
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telling the client what to do, giving opinions or making decisions for the client, implies client cannot handle his or her own life decisions and that the nurse is accepting responsibility. re sponsibility. “If I were you… Or it would be better if you do it this way…”
10. Internal validation •
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making an assumption about the meaning of someone else’s behavior that is not validated by the other person (jumping into conclusion). The nurse sees a suicidal clients smiling and tells another nurse the patient is in good mood.
Other ineffective behaviors and responses:
1. Defendi Defending ng – Your Your doctor doctor is is very very good good.. 2. Requesting Requesting an explana explanation tion – Why Why did did you you do that? 3. Reflecting Reflecting – You are not not suppo suppose se to to talk talk like like that! that!
4. Literal respon responses ses – If If you feel empty empty then then you should should eat more. more. 5. Look Lookin ing g too too busy busy.. 6. Appeari Appearing ng unco uncomfo mfortab rtable le in sile silence nce.. 7. Bein Being g opini opinion onat ated ed.. 8. Avoi Avoidi ding ng sens sensit itiv ivee topic topicss 9. Arguin Arguing g and and tellin telling g the the client client is is wrong wrong 10. Having a closed posture-crossing arms on chest 11. Making false promises – I’ll make sure to call you when you get home. 12. Ignoring the patient – I can’t talk to you right now 13. Making sarcasti sarcasticc remarks 14. Laughing Laughing nervously nervously 15. Showing disapproval – You should not do those things.
