Below is an overview of a strength based approach towards client care and in accordance to domain 2 management of nursing care, competency 2.3 of Nursing Council of New Zealand, confidentiality and anonymity was maintained at all times. The assessment was commenced upon gaining verbal consent from the client with reference to The Health and Disability Rights Act (Ministry of Justice, 2004).
Mr Y is an elderly man who is now residing at a rest home was diagnosed with hypertension, meningitis, epilepsy, type 2 diabetes and korsakoffs dementia due to prolonged alcohol dependency (Ambrose, 2001). Mr Y is a person with a very delightful personality and is not fussed about anything. However hesitates to be the first one to start conversation. He starts to talk if the second person begins communication. He is independent with almost all activities of daily life however is supervised by staff as Mr Y is susceptible to wandering mostly in the afternoon so more care is provided accordingly.
The client has no nutritional complications and has three medium sized meals in a day. He has no bladder and bowel difficulties and therefore needs no incontinence products, neither in the day nor during the night. Mr Y has no sleep disturbances nevertheless exhibits some degree of anxiety and agitation at some point which is when he wants to be with his family. Mr Y has no family support as his sister who was the only support has moved abroad.
The clients change in behaviour is controlled by diversional therapies which includes activities with regards to his strengths and psychosocial activities. The client is well orientated to time people and places. A strengths based approach provides a new perception of potentials rather than complications, options rather than constraints and wellness rather than ill health and once this is seen, achievement can occur (Rapp & Goscha, 2006). Therefore with the advantage of the assessment various strengths of the client were identified.
Mr y is known to have a very pleasant voice and therefore sings very well. He is also a very talented guitar player and used to be part of the music club during his young days. Additionally Mr Y has a very intact long term memory as he was able to recognise his friends from his teen age days as well as he was reminiscing his memories from childhood during the interview. He enjoys spending time with everyone regardless of nationality and is very easy to get along with. Mr Y is always willing to take part in all activities such as playing bingo, card games, pool etc. but needs to be invited for the games by someone.
He is always willing to help with work for instance bbq, shopping and many other things if and whenever he is able to. The client was a very sporty and active person and used to play football in the league. The greatest strength of Mr Y is that he is still able to walk around and perform all his activities of daily life which keeps him physically and mentally fit.
This also slows down the progression of his declining physical and mental health (Faulkner, Taylor,2005). Conversely the client also displays feelings of being alienated and isolated which needs to be considered as studies of clients’ experiences of mental health services provide indication that being understood and listened to in a considerate and sensitive way ratifies their humanity and provides anticipation for their future (Shattell, Mc Allister, & Hogan, 2006).
The full assessment was carried out in compliance to all the competencies of domain 3- interpersonal relationship of nursing council of New Zealand. Firstly, researching about korsakoffs dementia and its effects on the patient before carrying out the assessment allowed attaining knowledge on a broader perspective. It also aided in critical thinking and client evaluation which limited assumptions and gave more meaning and understanding to the findings. After gaining consent from the registered nurse patient folder was accessed for clients past history and current health situation.
This provided a brief overview of the client and presented a definite baseline to commence with the assessment. Interpersonal relationships are the relations between two or more people. Skilful management of interpersonal relationships is critical to psychiatric-mental health nursing (Arnold & Boggs, 2007). Similarly, with Mr Y a therapeutic interpersonal relationship was established and maintained with regards to competency 3.1 of Nursing Council of New Zealand.
Primarily, to build up a therapeutic rapport with the client therapeutic use of ‘self’ was used as an essential tool to initiate a strong nurse-client relationship as suggested by Fourie (2005). It was made sure to focus on self-awareness including professional detachment and understanding of personal emotions, beliefs and values. Self-disclosure was used as a strategy to make the client feel comfortable as the client found himself in a mutual conversation and not in a state of being interrogated. It was noticed that after the assessor shared her own life experience with Mr Y he felt at ease and open up disclosing his personal information without hesitation.
The therapeutic use of self also lowers the anxiety level of the client and forms a positive link between the efficacy of the nurse-client relationship and improved outcomes for client with mental illness (Howegego, 2003). It is likewise important that the therapeutic bond which is developed is maintained throughout the clients’ time of care. Therefore to maintain a therapeutic relationship with the client empathy, appropriate body language and proper communication skills were used.
During the communication with the client it was made sure to be present with Mr Y physically, emotionally and cognitively which enables one to understand the clients subjective experience, thoughts and feelings as much as possible. Additionally with reference to competency 3.3 of Nursing Council of New Zealand effective communication was carried out with the client. It was achieved through use of non-verbal cues such as maintaining an eye contact during conversation however avoiding a fixed gaze or stare. As proposed by Stein-Parbury (2005) appropriate body language was also used for instance it was ensured to sit down at the level of the client not too far or too close to him, apposite facial expression which tells the client that the assessor is genuinely interested in whatever he is saying and eluding things such as raising eyebrows, putting hands on hips while standing etc.
Congruence between verbal message and body language is very crucial to maintain a therapeutic relationship (Raydon, 2005). Client’s full attention was gained before initiating verbal communication. As mentioned by Rimondi (2010) open ended questions asked during interviews gives the client more opportunity to speak more disclosing more information at a deeper level. Use of open ended questions incorporated with active listening skills and appropriate body language helped to maintain a therapeutic bond with the client. Use of open ended question also allows to adhere with competency 3.2 which speaks of partnering with the client .
These strategies enabled a more person centered approach developed by Dr Thomas Kitwood (Warchol, 2006) which takes into account the standpoint of the person with dementia. Person cantered planning incorporated with a strength based approach was used during this assessment which provides a way of listening to and working with the person, their ideas and aspirations in partnership. This strategy works with respect to competency 3.2 of Nursing Council of New Zealand which states about practising nursing in a negotiated partnership with the client where and when possible. Mr Y was always ensured that he is being respected, listened to and is treated as an individual (Hupcey & Miller, 2006).
In accordance to competency 3.3 it is very essential to employ appropriate language to the context for example during the assessment reflective listening such as echoing client communication was used to redirect the content and feelings back to the client (Stickly & Freshwater, 2006). Paraphrasing was also a technique used to confirm the client that the assessor has heard and understood the clients subjective experience and perception. This allows the client to have trust and faith in the assessor and feels safe in their care (Stein-Parbury, 2005). For example the client mentioned “I feel really happy to be with family. I feel more energetic”. To paraphrase it was said that “that’s nice you feel more comfortable and happy with your family being around”.
This indicates that the client was actively listened to. As mentioned in the strengths assessment, Mr Y enjoys music and singing and is a very good guitar player. There is a guitar at the facility which is given to the client most of the time and he plays it. This was seen to be a good way to uplift his mood as it appeared to encourage Mr Y in reminiscing his past memories as an independent person (Perkins, 2004). Subjective data was also gained while taking him for a walk in the afternoon as mentioned in his strengths assessment.
This makes the client feel involved in the day to day conversation as normal people. Mr Y has a very strong connection with his traditional cultural beliefs and values. As suggested by Wepa (2005) cultural safety is one of the most vital aspects to consider while working with this client. A good therapeutic relationship was maintained by having enhanced responsiveness to Mr Y’s cultural and spiritual needs (Ramsden, 2002). For instance engaging in the context of what is Tapu (forbidden) that is avoided touching his head and actively listened to when he spoke about his cultural norms.
The client was always greeted in his own mother tongue which made him feel special. Mr Y was always treated with respect, dignity, genuineness and honesty. This was interwoven with trained empathy to enhance the therapeutic relationship and trust (Welch 2005). Additionally to maintain the therapeutic bond with the client nurses coming from a different cultural background should be culturally competent to ensure that Mr Y feels culturally safe in their care which again enhances trust in Mr Y for care provider (Daly, Speedy & Jackson, 2009). Nurses should avoid being judgmental.
Working in accordance to competency 3.2 Nursing Council of New Zealand, it was ensured not to advice against the client undertaking a particular activity, but instead work with the person to explore the advantages, disadvantages, required steps and possible concerns of an action so the client can make an informed choice (Elder, Evans& Nizette, 2009). This way health professionals are able to help the patient to achieve their desired goal. Mr Y like any other individual has goals which he aspires to achieve.
Firstly, knowing that he has a deteriorating health he aims to stay independent with his activities of daily life for as long as possible. With reference to competency 3.2 of nursing council of New Zealand nurses role is to practice partnering with the client and helping him to be physically and mentally fit.
This can be done by considering Mr Y’s strengths from the past and present (refer to strengths assessments). The client used to be a very active and sport loving person therefore involving him in more indoor games such as pool, bowling and any other games of his interest is a good way of keeping him entertained as well as active. Asking him what he prefers will keep him involved and interacted. Since Mr Y enjoys going out for afternoon walk the nurses should include this in his care plan so that he could be taken out for walks accordingly. As recommended by Kopelman, Thomson Marshall and Guirenni (2009) clients with korsakoffs dementia has damaged brain cells which affects cognitive, physical and social functioning of the client.
Mental health nurses have the responsibility to ensure that the diet of Mr Y includes thiamine and other metabolites such as magnesium (parenteral, oral) to improve the metabolic pathway in the brain and in manufacturing energy in cells. It is very important for nurses to consider the underlying cause of Mr Y’s declining health which is his chronic alcohol dependency. Therefore abstinence from alcohol is the cornerstone for his rehabilitation and is the most judicious intervention to slow down the effects of his dementia and to achieve his goal of being independent for as long as possible.
As mentioned in the overview of Mr Y in the earlier paragraph the client exhibits some form of anxiety and wandering. Nurses together with other health professionals should encourage Mr Y to participate in the diversional therapies provided by the facility including activities with regards to his strengths. Focusing on strength based activities helps people to overcome current difficulties refraining from a pessimistic world view to an optimistic one which instils hope. Nurses should always avoid to impose their own ideas but should work in partnership with the client to explore ways which works for Mr Y (Elder, Evans& Nizette, 2009).
Mr Y must be promoted with psychosocial activities such as always to be provided a safe environment and to be given encouragement. For instance Mr Y should be encouraged to play guitar for all the residence in the facility. This will remind him of the days when he used to play on stage and he would feel motivated and worthwhile therefore will be able to control his anxiety to some extent by keeping himself engaged with meaningful work and be diverted from distressing thoughts (Elder, Evans& Nizette, 2009). To avoid Mr Y wandering to places nurses should consider the use of arrows indicating the way to the lounge, dining room toilets etc.
This helps Mr Y to find his way independently without confusion (Kopelman, Thomson, Marshall and Guirenni, 2009). Secondly, Mr Y would prefer to be an active member of the facility and avoid being isolated. As mentioned above Mr Y hesitates to start conversation therefore if not approached by anyone he tends to isolate himself in his room. Though nurses have a very busy profession they should be responsible to ensure that Mr Y is informed about all activities held at the facility. As suggested by Faulkner and Taylor (2005) exercise is a good way to deal with social isolation and since the client is said to be a sporty person it would be reasonably easy to include physical exercise in his care plan.
It is also advisable to involve Mr Y in group activities rather than individualised intervention such as group singing competions, watching TV in the lounge with other residents, playing pool in groups, sharing past life experience within groups etc. these psychosocial group activities will allow the client to developing more new friendships hence reducing loneliness and give him enough confidence to openly start communication with people (Routasalo, Tilvis, Kautiainen & Pitkala, 2009).
To conclude it can be said that strengths based care proposes that every person has talents, goals confidence and aspirations regardless of their mental status. However any approach towards client care is helpful if commenced after build-up of a strong interpersonal nurse-client relationship. Therefore it is important for nurses and all other health care professionals to focus on strengths of the person instead of the pathology when treating them. Strength based care encourages the client, provides self-confidence and instils a hope which helps them to thrive towards better health.
Courtney from Study Moose
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