Harness Your Relationship-Building Power

APNA News: The Psychiatric Nursing Voice  |  November 2018 Members' Corner Edition

Imagine yourself just starting out as an inpatient psychiatric mental-health nurse. You are encountering patients who, for various reasons, often resist taking medications. For these new patients, the prospect of being stuck is discouraging. Plus, to you - the new nurse - the interactions with these patients seem to be going nowhere. Where do you start?

This concern was raised on the APNA Member Bridge All-Purpose Discussion Forum recently, and many members offered a wise path forward, emphasizing the importance of personal connections.  From resources to personal lessons learned, psychiatric-mental health nurses from across the country chimed in with advice and encouragement.

Sharon Van FleetSharon Van Fleet, MS, RN, PMHCNS-BC of Durham, North Carolina, advised looking beyond the issue of accepting medications to the formation of relationships. “The reality is that it is the therapeutic alliance that impacts ‘treatment adherence’ and outcome. We know that early, initial, active engagement can make a huge difference, even in severe illness.”

As you begin interactions, remember to be mindful of what the patient is experiencing. Van Fleet explains, “How often has someone been able to easily convince you of something about which you were scared or unfamiliar? Imagine now that the issue is one that is threatening how you view yourself and your future. Add to that, perhaps, a delusional system, or a disease that otherwise impacts your insight, judgment, problem-solving. Add to that likely trauma that impacts your ability to form trusting connections. Then add stigma and the horror of finding oneself on a psychiatric unit.”

“Through your collaboration and your humanity, you can form connections, through which you can demonstrate respect, positive regard and similar qualities... Empathize with their grief, loss and pain when they reveal them, and communicate hope for recovery, for the ability to still have a meaningful life.”

Now that you have an empathetic mindset, Van Fleet suggests proceeding with practical steps. “…Regularly check in with your assigned patients. Engage in 1:1 interaction with those who respond well to your efforts. Don't get discouraged about the others; … give them time to watch you, to get more comfortable with you in more brief interactions. Show that you are reliable, honest, approachable, consistent...and that you see them as people, not collections of symptoms.” With the benefit of hindsight, Van Fleet cautions, “Suspend any agenda, as much as you can, or you will turn them off. Coercion doesn't engage people in treatment.”

She continues, “Through your collaboration and your humanity, you can form connections, through which you can demonstrate respect, positive regard and similar qualities. See if there are small goals on which you can agree, even small steps that might engage them on their recovery journeys. Empathize with their grief, loss and pain when they reveal them, and communicate hope for recovery, for the ability to still have a meaningful life.”

For Van Fleet the benefit of building this rapport is clear: “It is through these efforts that you can establish a working alliance…where it becomes safe for them to look at possibility, including that of considering medications. They can start to look at their situations and ideally start to problem solve more realistically, when they feel safe to do so. They might start to talk to you about their more distressing symptoms, which then you and other team members can use to approach the benefits of medication.”

The reality is that seclusion and restraint methods are still used in some situations despite efforts to stop their use. Therefore, awareness of vulnerable individuals is essential. “The dangers inherent in the use of seclusion and restraint include the possibility that the person’s behavior is a manifestation of an organic or physiological problem that requires medical intervention and may, therefore, predispose the person to increased physiological risk during the time the individual is secluded or restrained.” (APNA Position Statement On the Use of Seclusion and Restraint.)

In her APNA Annual Conference President’s Address (2018), Immediate Past President Linda Beeber noted, “We underestimate the power of the relationship to save lives.” Van Fleet’s observations echo the idea that basic interpersonal skills can lead to more effective treatment. “Patients watch us. They watch how we are with each other, and how we are with other patients. When they see you interact effectively with others who are more engaged than they, there's an important message.”

As Linda Beeber said, “We can make miracles happen by expanding our therapeutic relationship superpowers.”

 

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