Introduction

Chapter I: The Nursing Process: Geriatric Assessment

Chapter II: Psychological Assessment

Chapter III: Physical Assessment and Recording the Findings

Chapter VI: Drug Therapies for the Elderly Client

References

Chapter IV THE NURSE-PATIENT HELPING RELATIONSHIP

THE HELPING RELATIONSHIP WITH NURSE AND PATIENT

1. ROLES OF THE NURSE

As you use the nursing process daily with the patient or family in later maturity, you will be functioning in a variety of nursing roles.  You will be responsible for physical care, technical procedures and for creating an environment that is safe, comfortable, stimulating and health promoting.  You will often be called upon to teach informally and formally to enable the patient or family to manage self-care, learn about his or her illness, or response to a situation or better cope with his/her condition.  Referral to other sources of help may be necessary, for no one health team member can meet all the patient’s needs.  You may serve as counselor and you can always serve as a source of emotional and social stimulation and support.  Depending upon your behavior and the senior’s needs, you may be seen as a parental figure.

All of us need loving contact with other people in order to stay human in the fullest sense.  From the moment of birth, the infant cannot survive unless he or she is cared for by the nurturing person.  Likewise, the elderly person cannot survive either, emotionally or physically, unless someone cares about him or her.  Caring is essential to a relationship.

How the senior reacts to you, your attitudes, appearance and behavior will be influenced, at least initially, by past experiences with people.  If experiences have been pleasant with others, he or she will respond more quickly to your caring.  If he/she has primarily felt anxiety and tension in his/her contact with others, he/she is likely to be distant, to respond slowly or even to not respond at all and tell you to go away.  He/she may also test your intentions with overtly obnoxious behavior.  However, underlying this apparent rejection of you, there is usually a great need for interpersonal contact.  Knowing this should stimulate you to continue to reach out, to care.

Important in the total care of the senior is the establishment and maintenance of a relationship.  Your goals may be limited because you cannot always change the person’s pathology and you cannot reverse the aging process.  However, you can help him/her to accept and understand his/her situation; help him/her to find meaning in his/her life and to enjoy personal growth from the experience.  This total care involves not only physical care, but also genuine concern for the patients’ feeling of self-worth, regardless of social values or capacity for achievement.

The elderly patient presents the nurse with a variety of challenges and dilemmas.  The medical problems of the elderly are usually vary complex and require a great deal of time and energy to help solve.  The problems or obstacles encountered with treating the elderly are numerous.  Society holds many negative opinions and beliefs concerning the elderly.  The nurse must overcome these stereotypes and negative beliefs in order to effectively treat the patient.

The elderly patient has certain rights to medical and nursing care.

These rights are the same as any other patient:

1. The right to assessment.
2. The right of personal autonomy.
3. The right to participate in health care decision-making.

These rights indicate that the elderly have the right to be treated just like any other adult patient.  They are not to be treated like babies.  There are many aspects of these rights that are under controversy today.  This includes the right to die, quality of care, quality of life, Medicare and financial aspects, withholding treatment, patient dignity and others.  The nurse will certainly face ethical and moral dilemmas in the near future concerning these rights.  The nurse will have to be aware of these rights and be aware of court decisions affecting the care of the elderly in order to continue a therapeutic nurse-patient relationship.

Relationship can be defined as an interpersonal process in which one person facilitates the personal development or growth of another.  The process takes place over a period of time.  The process involves helping the other person to mature, to become more adaptive, more integrated and to open his or her own experience; or to find meaning in his/her present situation.

The nurse-patient relationship results from a series of interactions between a nurse and patient over a period of time.  The nurse will focus on the needs and problems of the person or family while using the scientific knowledge and specific skills of the profession.  This helping relationship develops through interest in, encounter with and commitment to the person.

CHARACTERISTICS OF THE HELPING PERSON

The capacity to be a helping person is strengthened by a genuine desire to be responsible and sensitive to another person.  In addition, experience with a variety of people increases your awareness of others’ reactions and feelings.  The feedback you receive from others will teach you a great deal on both the emotional level and cognitive levels.

Characteristics of a helping person include:  being……

There are several more characteristics that correlate highly with being effective in a helping relationship.  One characteristic is being open, instead of closed, in interaction with others.  An additional characteristic is perceiving others a friendly and capable, instead of unfriendly and incapable.  Another characteristic is that of perceiving a relationship as freeing, instead of controlling another.

Establishing and maintaining a relationship or counseling another, does not involve putting on a façade of behavior to match a list of characteristics.  Rather, both you and, the patient will change and continue to mature.  As the helper, you are present as a total person.  You blend potentials, talents and skills.  You do this while assisting the elderly patient to come to grips with his/her needs, conflicts and self (Rogers 1976).

Working with another in a helping relationship is challenging and rewarding.  You will not always have all the characteristics just described.  At times, you will be handling personal stresses that will lower your energy and sense of involvement.  You may become irritated and impatient while working with the elderly client.  Accept the fact that you are not perfect and that you are always in the process of becoming.

Analyzing your behavior in relation to the person or family can help you determine your effect on them and can help you to be more effective.  Just as you help the senior to develop, you will also continue to expand your personality to better gain the above characteristics.  As you open a panorama of possibilities to another, your own potential unfolds.  Remember that the most important thing you can share with a patient is your own uniqueness as a person.

Nursing experience in itself can bring about a cool efficiency, an overt indifference and an impersonal attitude and environment for the patient.  The distant behavior that may result when the nurse is not rewarded by the work system for demonstrating helping characteristics seems to be an occupational hazard of nursing.  Yet, in an increasingly mechanical world, we have to remain human and treat our patients as human (Pollak 1976).

CHARACTERISTICS OF THE HELPING RELATIONSHIP

1. RAPPORT

A relationship begins with the ability to establish rapport, creating a sense of harmony between individuals.  In order to establish rapport quickly, you must have the following social skills (Rogers 1976).

1. A warm, friendly manner, appropriate smile and comfortable eye contact.
2. Ability to treat the other as an equal, to eliminate social barriers, to convey acceptance and to promote a sense of trust.
3. Ability to find a common interest or experience.
4. Ability to show a keen, sympathetic interest in the other, to give him or her full attention, to listen carefully and to indicate there is plenty of time.
5. Ability to accurately adopt his/her terminology and conventions and to meet him/her on his own ground.

2. TRUST

Trust is the firm belief in the honesty, integrity, reliability and justice of another person without fear of outcome, the inner certainty that the other person’s behavior is predictable under a given set of circumstances (Rogers 1976).

The capacity to develop a trusting relationship is built upon your attitude toward people, your flexibility in responding and what you are personally.  Techniques and knowledge are not enough.  You will learn through experience what aspects of your personality are more effective with, and helpful to, others.

Trust is based upon consistency rather than compatibility.  The senior cannot reveal him or herself nor share important information unless he/she can rely upon you.  He must believe that you will react with the same behavioral characteristics each time he or she meets with you.  He/she needs to know that you will keep content from the interview confidential, as mutually agreed upon.  You may have to delay obtaining certain information until a sense of trust is established.  This is because the elderly patient may feel very threatened by an interview or examination.  In addition, you must feel that you can predict the person’s behavior because you have an understanding of the person (Rogers 1976).

3. UNCONDITIONAL POSITIVE REGARD AND ACCEPTANCE

Two qualities often described as essential to a relationship are positive, warm feelings and acceptance.  Is it possible to give expert and professional care and not feel positively toward your patient?  Most patients would say “NO”.  The human spirit loses its sense of vitality and even the will to live when surrounded by hostile persons.

Realistically, it is not possible to like everyone.  Similarly, it is not possible to establish and maintain a relationship with everyone.  However, you will find some patients you will be genuinely interested in and can feel affection for.  Likewise, other nurses will respond the same way to other patients.  There are a few “cantankerous” or “repulsive” people whom no one seems to feel any rapport with or interest in.  Perhaps your willingness to reach out will make a difference.  Your ability to stimulate a more likable behavior in that person may also make a difference.  Also your willingness to learn more about his or her uniqueness, will be the result of our unconditional positive regard, belief in the dignity, worth and importance of the person, regardless of his or her behavior (Murray 1980 (Pollak 1976).

4. EMPATHY

Unconditional positive regard and acceptance are easier to achieve if you have developed empathetic understanding of people.  Empathy is feeling with the person and simultaneously understanding the dynamics of his or her behavior.  As you and the senior feel and think together, your feelings for him or her impels you to act.

Empathy is the ability to sense the patient’s private world as if it were your own.  You can do this without ever losing the “as if” quality.  You can sense the patient’s anger, fear or confusion as if it were your own.  You can do this without your own feelings getting bound up in the interaction.

You are empathetic to the degree that you are able to abstract from your own life experience, by way of recall or generalizations, common factors that are applicable to the patient’s problems.

Certain qualities enhance empathetic skills.  The ability to empathize varies with the patient, time and nurse.  Certainly, a general interest in people, basic knowledge of human behavior and a warm, flexible personality encourages empathy.

Other characteristics that enable you to be more empathetic are:

• Similarity in values, experiences, social class, culture, economic level, religion, age, personality or sameness of sex.
• Ability to be alert, to listen with the “third ear”, to become involved in another, to abandon self-consciousness.
• Ability to cope with egocentricity, anxiety, fears, feelings or stresses that block listening to and feeling with another.
• Variety of life experiences that help you to acquire a broad understanding of people, flexibility and spontaneity.
• Ability to maintain an adequate health and energy level.
• Ability to interpret correctly and to avoid distorting perceptions.

        Empathy involves the following dimensions:

• Tone – expressing warmth and spontaneity nonverbally and verbally.
• Pace – timing remarks or behavior appropriate to the patient’s feelings and needs.
• Perception – abstracting the core or essential meaning of patient concerns; discussing them with him/her in acceptable terms.
• Leading – formulating questions or statements that move the interview in the direction of the patient’s concerns.

      Empathy is not the same as sympathy or pity:

• The sympathetic person becomes stricken with emotion because he or she projects himself or herself into the other person’s place.  The empathetic person shares the experience but maintains objectivity.  The sympathizer may be secretly happy that a certain situation has not occurred to him/her, or he/she may feel guilty in his/her own good fortune.  Empathy can be found in any situation, in grief, in joy.

Pity is contrary to helping.  To cause another to feel like a victim debases the person right now.  It also conveys that he will remain debased and helpless.  Pity conveys that the other person receives help because you are obligated and pseudo altruistic.  Spontaneous and genuine helping is “one-on-one” human being with another, simply because you are both human.

How do you communicate empathy?  Use verbal and nonverbal communication so that the senior experiences a feeling of being understood.  Your statements serve as an emotional mirror or as a reflection of his or her feelings without distorting or giving him or her advice.  For example, you may say:  “It seems as if you are very discouraged with P.T.” or “It sounds as if you are quite concerned about whether you made a right decision”.  Avoid a response like, “I know how you feel”.  Such a response makes the senior unsure about your truly understanding of him/her.  It is a rote response and is not based on a genuine understanding of his/her current feelings.

Talk on the senior’s level of understanding and adjust your tone of voice to his or hers.  For example, if you use a declarative, harsh tone of voice, it will seem as if you are telling the patient what he/she thinks and how he/she feels.  That is not an example of reflecting his/her feelings.  Using language that he/she does not understand will convey a lack of respect, regardless of the accuracy of your interpretation.

Evaluate the elderly person’s true feelings.  Sometimes he/she is not ready to admit certain feelings and needs time to deny them.

Reflect the senior’s feelings frequently for correction, disapproval or approval.  Remain open to his/her response.  A patient who is free to correct you moves on to a higher level of self-understanding.  If he/she cannot refute your reflection, he/she then can build up defenses.  This leads to withdrawal, thereby defeating the primary purpose of the relationship.  Some examples of how to begin your reflections are:  “If I understand you correctly, you feel…..” or you might say, “Is that right?”.

Respond actively and frequently enough to the senior, without interrupting him/her.  This indicates that you are focusing on his/her speech and feelings.

The ultimate purpose of the empathetic response is to convey to the person a depth of understanding about him/her and his/her predicament so that he/she can expand and clarify his/her understanding of self and others.  The patient receives relief from loneliness and overcomes feelings of isolation and aloneness with his problems.  Your willingness to understand how the senior feels about his or her world implies that his/her point of view is valuable.  Also, the focus of evaluation is within the patient, so that he becomes less dependent on the opinions of others and grows to value him or herself.  Empathetic understanding is not a passive process.  It will not happen without effort.  You must concentrate intensely on the person.  Intense concentration allows you little time to reflect on personal needs, values and ideals.  It prevents judgmental thoughts or behavior.

Improvement in patients’ conditions is correlated with empathetic responses, regardless of their diagnoses.  Not only are high empathetic levels correlated with improvement, but it is found that low levels of empathy contribute to increased disturbance in patients.  The lack of empathy displayed by nurses could, therefore, be hindering their patient’s recovery.

5. GOAL FORMULATION

A helping relationship differs from a social relationship.  In the helping relationship there is explicit formulation of goals.  You may have certain goals that you hope to accomplish, but the senior must actively participate with you in setting mutual goals.  As the relationship progresses, new problems or concerns will be identified and new goals will have to be set.  The relationship is structured in that you share with the patient what he or she can expect.  You then listen to what the patient expects of you.  Together you determine the course of the relationship.  Intentions and expectations are verbally and nonverbally conveyed to each other.  Expectations will usually change as the relationship progresses.

General goals of the nurse-patient relationship include:

1. Increasing the senior’s self-esteem and promoting a positive self-concept and sense of security.
2. Decreasing the senior’s anxiety to a minimum.
3. Providing a gratifying, positive experience.
4. Assisting the senior in improving communication skills and in participating comfortably with others.
5. Providing the opportunity for the person to grow emotionally.
6. Helping the senior find meaning in his/her life situation.
7. Maintaining and stimulating the person biologically, mentally, emotionally and socially.
8. Gather data to gain in-depth assessment to provide individual care.

6. HUMOR

Intense interaction between two or more people cannot endure unless a sense of humor surfaces at times.  Humor is the ability to see the ludicrous or the incongruities of a situation, to be amused by one’s own imperfections or the whimsical aspects of life, to see the funny side of an otherwise serious situation.  Humor does not necessarily mean joking and teasing.  It does not involve the put-down of another and it does not always evoke laughter.  Humor may be expressed as a tiny smile that lingers or the mental chuckle that occurs when you are sober-faced.

The purposes of humor include:

• Releasing tension, anxiety or hostility.
• Cautiously distracting from sadness, crying or guilt.
• Decreasing social distance.
• Conveying a sense of empathy to another.
• Expressing warmth and affection.
• Encouraging learning or task accomplishment.
• Denying painful feelings or a threatening situation.

The elderly patient often has experienced use of humor beneath those steely eyes and tight lips.  He may test you with a few dry statements to see if you are really alert and if you can make the cognitive connections he insinuates.  Too often these dry statements receive only a grunt in reply, or worse, they are ignored and the senior is labeled senile, confused or crazy.

If you do not respond to his humor, he/she loses emotional and social input and self-esteem.  Although underneath he/she may consider you his/her inferior – less educated, less experienced, less wise.  You lose when you cannot expand your mind with the humorous.  You dry up emotionally and you have lost an opportunity to learn, to mature and to enjoy.

Next: Chapter V THE CHARACTERISTICS AND CRISES OF LATER MATURITY