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Therapeutic Alliance And Treatment Delivery

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Question:

Discuss about the Therapeutic Alliance and Treatment Delivery.
 
 

Answer:

Introduction

The assessment focuses on the evaluation of the person-centred interventions requiring administration with the objective of decreasing the frequency of falls in the demented people. Evidence-based research literature advocates the elevated risk of falls in demented patients. The disorders related to Parkinson’s dementia and Lewy Body Dementia predominantly increase the likelihood of the affected patients in terms of experiencing falls while undertaking day-to-day activities (Aizen 2015). Limited evidence is available regarding the development of definitive strategies for reducing the frequency of falls and associated traumatic conditions in the demented people. Primary exercise approaches prove to be effective modalities that increase stamina and confidence of demented patients and reduce their risk of falls across the community environment. However, the method of their implementation for the target population remains debatable in the medical community. Evidence-based research literature advocates the pattern of dose-response relationship between the frequency of falls in demented people and the administration of psychotropic drugs (Jong, Elst & Hartholt 2013). The increased administration of psychotropic medication results in the reciprocal elevation of the falling frequency in the demented people. Therefore, medical professionals require administering person-centred approaches to streamline the pattern of medication management for the associated reduction in falling frequency in the demented population. Gait deterioration and cognitive decline include some of the significant factors that evidently contribute to the falls in elderly demented people (Segev-Jacubovski et al. 2011). The administration of multimodal cognitive interventions with the systematic utilization of therapeutic communication is therefore highly warranted for controlling the frequency of falling episodes in the patients affected with dementia and associated mental manifestations (Jootun & McGhee 2011). The presented research paper effectively explores the implication of the therapeutic relationship on the pattern of person-centred care of demented patients with the objective of substantially reducing their falling risk in the clinical as well as residential settings. The improvement in patient outcomes through the utilization of therapeutic communication will provide a new paradigm to dementia care in the medical facilities.

The literature review was undertaken with the objective of exploring the influence of therapeutic communication on improving the patient care outcomes in the dementia setting. Evidence-based analysis attempted to affirm the potential of an effective therapeutic relationship in terms of facilitating person-centred healthcare interventions requiring administration by medical professionals for reducing the falling frequency in the demented patients. The scientific databases including PubMed, CINAHL, Research Gate, Cochrane and ProQuest Central were researched with the objective of exploring the articles of interest while sequentially utilizing the search terms including therapeutic communication/Dementia/falls, therapeutic communication/cognitive/dementia/falls, dementia/trauma/therapeutic relationship, person-centred/dementia/therapeutic relationship and communication, nursing, dementia care and patient-centred dementia care.

 

The factors including medications, footwear, assistive devices, home features, caregiver support, age related deterioration, cognitive defect, gait abnormality, sensory deficit and behavioural manifestations elevate the likelihood of falls and associated complications in the demented patients. Each demented patient experience at least one fall per year under the influence of mental manifestation and potential risk factors. The caregiver requires effectively modifying the immediate environment of the demented individual in a manner to facilitate the performance of daily activities including housekeeping, toileting and dressing (Phelan et al. 2015). Furthermore, administration of personal assistance for the safe undertaking of the personal care of demented people is necessarily required for reducing the risk of falling episodes. Medical professionals and rehabilitation experts require interacting with the demented patients for regularly monitoring their daily activities in the context of improving the pattern of their safety and associated outcomes. This interaction warrants the administration of therapeutic communication with the objective of evaluating the treatment challenges and individualized healthcare requirements of the demented people (Velea & Purc?rea 2014). Demented patients affected with various co-morbid conditions require undertaking numerous treatment interventions under the recommendation of multiple healthcare professionals. Eventually, they might experience polypharmacy and other risk factors that could elevate the frequency of falling episodes and associated adverse manifestations (Hammond & Wilson 2013).

Utilization of dialogue and closeness interventions is required for evaluating the causative factors of the falling episodes among demented individuals (Struksnes et al. 2011). Medical professionals need to administer a questionnaire to the demented people with the objective of determining their environmental constraints as well as psycho-socio-somatic deficits contributing to the pattern of falling episodes. The questionnaire administration and collection of data require the systematic establishment of a therapeutic relationship with the demented patients in the context of motivating them for sharing their concerns and apprehensions regarding the falling episodes. The pattern of therapeutic relation also assists in mitigating the problematic behaviour of the treated patients in the clinical setting (Westermann et al. 2015). Furthermore, systematic documentation of patient concerns provides an insight to the medical professionals in terms of configuring patient-centred interventions for acquiring desirable healthcare outcomes (Struksnes et al. 2011).

Rehabilitation professionals require undertaking horticulture interventions to facilitate the pattern of a therapeutic relationship with the objective of enhancing person-centred outcomes (Detweiler et al. 2012). Horticulture therapy advocates the utilization of gardening interventions and plants for enhancing the focus and attention span of the demented patients while concomitantly reducing the level of their agitation, stress and antipsychotic medication requirement. This eventually reduces the risk of falls and associated traumatic conditions in the demented patients. The effective configuration of socializing environments through protective parks increases the plant contact of the demented people that relax their minds and provide them psychosocial stability (Detweiler et al. 2012). These modifications substantially decrease the falling episodes of the demented individuals. The therapeutic alliance of the medical professionals with the demented patients across the natural surroundings elevates their tactile and visual experience and motivates them for eating enhancement (Detweiler et al. 2012). The significant effects considerably improve the overall senses of the demented people that substantially decrease their risk of experiencing falls and associated adverse somatic complications (Detweiler et al. 2012). The pattern of therapeutic relationship improves the level of cortisol of the demented patients that resultantly improves their confidence and memory and reduce their predisposition towards the development of affective conditions and associated falling episodes.

Practice change implementation for the demented people requires the systematic configuration of a proactive plan for the acquisition of the desirable patient-centred outcomes for the demented patients. The administration of the person-centred fall reduction interventions requires active collaboration between the clinicians, nurses, rehabilitation experts, physicians and other members of the healthcare team. Accordingly, the therapeutic alliance with the demented patients would require configuration for effectively decreasing the frequency of the falling episodes (Bunn et al. 2014). The establishment of the change process would require the systematic deployment of BEET (Building Effective Engagement Techniques) tool for controlling the elevated frequency of falling episodes among the demented patients. Undoubtedly, the deployment of effective patient-physician engagement interventions increases the quality and efficiency of patient-centred medical services in a matrix environment (IOM 2013). BEET tool is categorized into the following subsections.

  1. Puzzle and purpose include the research question (indicating the practice change requirement) and associated rationale.
  2. Evidence includes evidence-based findings that advocate benefits of the recommended practice change requirement.
  3. Context indicates the target population requiring the change intervention for the systematic acquisition of the patient-centred outcomes. It also includes the medical professionals who need to be part of the change process.
  4. Facilitation includes the recommended strategies warranting implementation for bringing the desirable change in the healthcare management of the demented patients.
 

Puzzle and Purpose

Healthcare professionals require using positive language with the demented patients and must not criticise them for their psychosocial deficits while extending therapeutic communication. The clinicians and nurses should not set any pre-condition while configuring the pattern of a therapeutic relationship with the treated patients. The following question is configured with the objective of acquiring the person-centred outcomes.

“How can we configure the therapeutic relationship with the demented people for implementing person-centred care and reducing their frequency of falls?”

The puzzle remains entirely positive in the context of improving the wellness pattern of the demented population. The puzzle does not hinder the administration of patient-centred care to the target population while imposing any constraint and does not define any pre-condition or assumes any predefined solution to the problem. The problem states the requirement of effectively engaging the nurse practitioners, physicians and rehabilitations experts and facilitating the process of mutual collaboration for improving patient communication and the resultant patient-care outcomes (i.e. risk reduction in relation to the falling episodes). The configured puzzle is framed in a positive format and does not invite criticism of any type because of the absence of pre-condition. The puzzle remains open in terms of acquiring a range of interventions warranted to improve the therapeutic relationship pattern for reducing the risk of falls in the demented patients. The straightforward answering (i.e. yes or no) cannot (objectively or subjectively) accomplish the requirements of the posted question/puzzle. These facts rationally indicate that the puzzle is configured in a manner to acquire innovative and comprehensive solutions with the objective of improving the person-centred care of the demented patients through improved communication pattern for reducing the length and severity of their adverse complications. Outcomes of the puzzle resolution would indicate the considerable reduction in the falling episodes and associated traumatic conditions of the demented people through the establishment of their improved cognition. The healthcare teams would find a range of evidence-based methods in the healthcare setting for improving the person-centred outcomes. The puzzle finally proposes the engagement of the healthcare professionals, demented patients and their family members in the process of their medical-decision making in the context of reducing their predisposition towards experiencing falling episodes.

Indeed, substantial evidence is available in the clinical literature that advocates the requirement of undertaking the recommended practice change with the objective of improving the patient-centred outcomes in the demented people.

The configuration of an effective therapeutic relationship would require the active engagement of nursing professionals, physicians, patients and their caretakers in the clinical setting. Nurse professionals must undertake informed decision-making and systematically involve the demented patients as well as their family members in the process of their medical care and treatment (Smebye, Kirkevold & Engedal 2012). The multidisciplinary (i.e. team based) collaboration between the healthcare professionals and direct engagement of nurses in the process of patient communication will substantially decrease the scope of patient care errors and increase the pattern of compliance, satisfaction and trust of the demented patients on the recommended person-centred approaches (Wen & Schulman 2014). Resultantly, the improvement in the healthcare outcomes will enhance the cognitive and somatic capacities of the treated patients. This will eventually reduce their falling episodes and associated traumatic manifestations.

 


The dynamic therapeutic alliance and elevated clinician’s competence leads to improved patient care outcomes (Campbell et al. 2015). The shortage of nursing staff and their excessive workload might constrain them in terms of investing additional time in improving the pattern of interpersonal relationship with the treated patient while utilizing therapeutic communication (Alghamdi 2016). Eventually, this could impact the acquisition of the treatment outcomes and the demented patient might continue to experience falls and trauma at the same pace. The nurse professionals therefore, require developing transformational leadership skills in the context of effectively delegating their daily work requirements for reducing the level of their stress and additional time consumed in undertaking the daily job roles (Negussie & Demissie 2013). The hospital administration must also consider the provision of financial incentives in the context of accomplishing additional patient requirements by the nurse professionals. In this manner, nurse professionals will acquire motivation and enthusiasm with the objective of potentially configuring a therapeutic relationship with the demented patients for reducing the frequency of their falling episodes. An additional intervention for improving the desirable patient-centred outcomes includes the administration of counselling and training sessions to the registered nurses in relation to improving their work management skills in the clinical settings. This will substantially improve their capacity of utilizing therapeutic communication while handling dementia patients for the systematic accomplishment of the patient care goals.

Indeed, BEET tool is an effectively modality for systematically engaging the medical professionals and the treated patients in terms of bringing the desirable patient care outcomes. The presented context requires the effective implementation of the Top-14 best practice recommendations with the objective of improving the therapeutic relationship of the demented patients with the treating clinicians for acquiring the goal-oriented patient-centred outcome (i.e. falls reduction) (Virani et al. 2002). These recommendations are sequentially provided in the attached appendix. These recommendations require encapsulated in the walls of the clinical setting in the context of motivating the nurse professionals, physicians, demented patients and their family members for practicing therapeutic communication and shared medical decision-making for systematic improvement in the psycho-socio-somatic outcomes. The configuration of interpersonal relationship with the demented patients through extended professional communication (while utilizing the practice recommendations will substantially reduce the risk of their prospective falls in the clinical as well as residential settings.

 


The practice implications of the recommended Top-14 recommendations include the substantial reduction in the length of stay of the demented patients in the clinical settings and reduction in the additional cost incurred in treating traumatic complications that emanate under the influence of frequent falling episodes. The empathic and person-centred healthcare approaches will improve the pattern of self-sufficiency of the demented patients and increase their partnership in the process of medical decision-making. The systematic deployment of goal oriented dementia care approaches in the clinical settings will eventually reduce the development of co-morbid states and physical challenges that could potentially elevate the scope of falls and associated trauma.

Conclusion

The BEET tool was categorically explored for evaluating the scope of establishing a systematic transformation in the conventional practice methodology for the demented patients in the context of reducing their frequency of falls and traumatic conditions. The subject of study was researched in evidence-based literature and the findings advocated the requirement of actively engaging the nurse professionals and patients in the process of medical decision-making with the utilization of therapeutic communication. The Top – 14 best practice recommendations require implementation in the dementia care settings for enhancing the pattern of person-centred approaches requiring administration with the objective of reducing the frequency of falling episodes and associated adverse clinical complications in the demented people.

 

References

Abdolrahimi, M, Ghiyasvandian, S, Zakerimoghadam, M & Ebadi, A 2017, 'Therapeutic communication in nursing students: A Walker & Avant concept analysis', Electronic Physician, vol 9, no. 8, pp. 4968-4977, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5614280/>.

Aizen , E 2015, 'FALLS IN PATIENTS WITH DEMENTIA', Harefuah, vol 154, no. 5, pp. 323-6, 338, <https://www.ncbi.nlm.nih.gov/pubmed/26168645>.

Alghamdi , MG 2016, 'Nursing workload: a concept analysis', Journal of Nursing Management, vol 24, no. 4, pp. 449-457, <https://www.ncbi.nlm.nih.gov/pubmed/26749124>.

Bunn, F, Dickinson, A, Simpson, C, Narayanan, V, Humphrey, D, Griffiths, C, Martin, W & Victor, C 2014, 'Preventing falls among older people with mental health problems: a systematic review', BMC Nursing, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3942767/>.

Campbell, BK, Guydish, J, Le, T, Wells, EA & MacCarty, D 2015, 'The Relationship of Therapeutic Alliance and Treatment Delivery Fidelity with Treatment Retention in a Multisite Trial of Twelve-Step Facilitation', Psychology of Addictive Behaviors, vol 29, no. 1, pp. 106-113, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4739723/>.

Detweiler, MB, Sharma, T, Detweiler, JG, Murphy, PF, Lane, S, Carman, J, Chudhary, AS, Halling, MH & Kim, KY 2012, 'What Is the Evidence to Support the Use of Therapeutic Gardens for the Elderly?', Psychiatry Investigation, vol 9, no. 2, pp. 100-110, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3372556/>.

Hammond, T & Wilson, A 2013, 'Polypharmacy and Falls in the Elderly: A Literature Review', Nursing and Midwifery Studies, vol 2, no. 2, pp. 171-175, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4228551/>.

IOM 2013, 'Engaging Patients, Families, and Communities', in Best Care at Lower Cost: The Path to Continuously Learning Health Care in America, National Academies Press, USA, <https://www.ncbi.nlm.nih.gov/books/NBK207234/>.

Jong, MRD, Elst, MVD & Hartholt, KA 2013, 'Drug-related falls in older patients: implicated drugs, consequences, and possible prevention strategies', Therapeutic Advances in Drug Safety, vol 4, no. 4, pp. 147-154, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4125318/>.

Jootun , D & McGhee , G 2011, 'Effective communication with people who have dementia', Nursing Standard, vol 25, no. 25, pp. 40-46, <https://www.ncbi.nlm.nih.gov/pubmed/21469475>.

Kim, DH, Brown , RT, Ding, EL, Kiel, DP & Berry, SD 2011, 'Dementia Medications and Risk of Falls, Syncope, and Related Adverse Events Meta-Analysis of Randomized Controlled Trials', Journal of the American Geriatrics Society, vol 59, no. 6, pp. 1019-1031, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3260523/>.

Negussie, N & Demissie, A 2013, 'Relationship Between Leadership Styles of Nurese Managers and Nurses' Job Satisfaction in Jimma University Specialized Hospital', Ethiopian Journal of Health Science, vol 23, no. 1, pp. 49-58, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3613815/>.

Phelan, EA, Mahoney, JE, Voit, JC & Stevens, JA 2015, 'Assessment and Management of Fall Risk in Primary Care Settings', Medical Clinics of North America, vol 99, no. 2, pp. 281-293, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4707663/>.

Segev-Jacubovski, O, Herman, T, Yogev-Seligmann, G, Mirelman, A, Giladi, N & Hausdorff, JM 2011, 'The interplay between gait, falls and cognition: can cognitive therapy reduce fall risk?', Expert Review of Neurotherapeutics, vol 11, no. 7, pp. 1057–1075, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3163836/>.

Smebye, KL, Kirkevold, M & Engedal, K 2012, 'How do persons with dementia participate in decision making related to health and daily care? A multi-case study', BMC Health Services Research, p. 241, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3475075/>.

Struksnes, S, Bachrach-Lindström, M, Hall-Lord, ML, Slaasletten, R & Johansson, I 2011, 'The nursing staff's opinion of falls among older persons with dementia. a cross-sectional study', BMC Nursing, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3142214/>.

Swaminathan, A & Jicha, GA 2014, 'Nutrition and prevention of Alzheimer’s dementia', Frontiers in Aging Neuroscience, p. 282, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4202787/>.

Velea, P & Purc?rea, VL 2014, 'Issues of therapeutic communication relevant for improving quality of care', Journal of Medicine and Life, vol 7, no. 4, pp. 39-45, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4813615/>.

Virani, T, Tait, A, McConnell, H, Scott, C & Gergolas, E 2002, Nursing Best Practice Guideline - Shaping the future of Nursing (Establishing Therapeutic Relationships), RNAO, Ontario, <https://rnao.ca/sites/rnao-ca/files/Establishing_Therapeutic_Relationships.pdf>.

Wen, J & Schulman, KA 2014, 'Can Team-Based Care Improve Patient Satisfaction? A Systematic Review of Randomized Controlled Trials', PLoS One, vol 9, no. 7, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4094385/>.

Westermann, S, Cavelti, M, Heibach, E & Caspar, F 2015, 'Motive-oriented therapeutic relationship building for patients diagnosed with schizophrenia', Frontiers in Psychology, p. 1294, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4557062/>.

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