Describe essential elements to include in psychiatric interviews and the assessment process.

QUESTION

Case Study, Mohr

CHAPTER 10, the Interview and Assessment Process

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In completing the case study, students will be addressing the following learning objective:

Describe essential elements to include in psychiatric interviews and the assessment process.

The student nurse is accompanying the psychiatric nurse during the nursing interview and assessment of a newly admitted patient.  The psychiatric nurse told the student that preparation with subjective and objective data collection is an important part of the process.  The nurse explains that assessment has reference to the interviewer’s interpretation and prioritization of all data for the client.  The nurse must have self-awareness and self-knowledge to be objective and avoid influencing the responses of the client.  Anxiety on the part of the nurse may limit the ability for thorough data collection and interpretation.  Anxiety in the nurse may evoke anxiety on the part of the client. The psychiatric nurse stressed that a process recording, or written analysis of the interaction between the client and nurse, is essential for nurses to recognize the effects of their communication style in the assessment process.  A review of the client’s history is important, and a private setting for the interview is necessary.  The content of the nursing assessment should include the ability and reliability of the client’s response to questions of the interviewer and the skill of the nurse in identification of relevant facts.  The nurse should discuss with the client prior health history, any present illness, and the reason for seeking healthcare at this time.  Medication history with compliance and allergies of the client require investigation.   Substance use by the client, past illnesses, and family history need exploration.

(Learning Objective: 2)

a   The student nurse asked the clinical psychiatric nurse practitioner to explain what she considered the most essential part of the assessment process. How should the psychiatric nurse respond to the student’s question? Explain your answer.

ANSWER

The Importance of Establishing a Therapeutic Relationship in Psychiatric Assessment

Introduction

In psychiatric nursing, the assessment process plays a vital role in understanding the needs and experiences of the client. One of the most critical aspects of this process is the establishment of a therapeutic relationship. This essay will explore the significance of building a therapeutic alliance with the client and its impact on the assessment process in psychiatric nursing.

Understanding the Therapeutic Relationship

A therapeutic relationship serves as the cornerstone of effective psychiatric nursing assessment (Hartley et al., 2020). By establishing rapport, trust, and mutual respect, the nurse can create a safe and non-judgmental environment for the client.

Enhancing Data Collection

The therapeutic relationship fosters open communication and encourages the client to share their thoughts, feelings, and experiences. Through active listening, open-ended questions, and empathy, the nurse can gather accurate and comprehensive subjective data during the assessment process.

Holistic Assessment

With a strong therapeutic relationship, the nurse can assess the client’s mental status, emotions, cognition, and behavior in a holistic manner (Kornhaber et al., 2016). This includes observing non-verbal cues, evaluating distress levels, identifying risk factors, and recognizing protective factors.

Collaboration and Engagement

The therapeutic relationship establishes trust and confidence, leading to increased client engagement in their treatment plan. It allows the nurse to educate the client about their condition, treatment options, and self-care strategies, fostering collaboration in the decision-making process.

Overcoming Biases and Anxiety

By prioritizing the therapeutic relationship, the nurse can overcome personal biases and anxiety that may hinder the assessment process (Majid et al., 2011). Maintaining objectivity and avoiding influencing the client’s responses are crucial for gathering accurate data.

Conclusion

The establishment of a therapeutic relationship is a fundamental component of the psychiatric assessment process. By building rapport, trust, and mutual respect, the nurse creates an environment where the client feels comfortable sharing their experiences. This relationship enables the nurse to gather comprehensive subjective data, assess the client’s mental status holistically, and promote collaboration and engagement in the treatment process. Overcoming biases and anxiety through the therapeutic relationship allows for an objective and accurate assessment. By recognizing the importance of this relationship, psychiatric nurses can provide patient-centered care and ultimately improve outcomes for their clients.

References

Hartley, S., Raphael, J., Lovell, K., & Berry, K. (2020). Effective nurse–patient relationships in mental health care: A systematic review of interventions to improve the therapeutic alliance. International Journal of Nursing Studies, 102, 103490. https://doi.org/10.1016/j.ijnurstu.2019.103490 

Kornhaber, R., Walsh, K., Duff, J., & Walker, K. (2016). Enhancing adult therapeutic interpersonal relationships in the acute health care setting: an integrative review. Journal of Multidisciplinary Healthcare, Volume 9, 537–546. https://doi.org/10.2147/jmdh.s116957 

Majid, S., Foo, S., Luyt, B., Zhang, X., Theng, Y., Chang, Y., & Mokhtar, I. A. (2011). Adopting evidence-based practice in clinical decision making: nurses’ perceptions, knowledge, and barriers. Adopting Evidence-based Practice in Clinical Decision Making: Nurses’ Perceptions, Knowledge, and Barriers, 99(3), 229–236. https://doi.org/10.3163/1536-5050.99.3.010 

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