Theory of interpersonal relationship In 1952, Hildegarde Peplau created the first psychiatric framework for the nurse–patient relationship (Boyd, 2017). The systematic organization of the professional relationship she created can be generalized to a wider spectrum for healthcare workers meeting mental health needs. The framework consists of three phases of the professional relationship. The first phase is the orientation phase: the introduction and initial exchange of acquaintance and building of trust that can happen in minutes or may take months (Boyd, 2017). The older adult is seeking help and has identified unmet mental health needs. The therapeutic relationship begins with the first interaction and changes with every subsequent interaction. The healthcare worker uses the orientation phase to listen, establish boundaries, manage expectations, and use self-awareness to check for countertransference (Boyd, 2017). The second phase is the working phase: the space for examining existing problems and finding acceptable solutions to overcome them (Boyd, 2017). This phase is where the majority of the interpersonal relationship for assessing, implementing, and evaluating take place. It typically happens over time. A sense of comfort is felt in this phase for the older adult and the healthcare worker. The older Communication is a vital key for the healthcare worker to properly meet mental health needs of older adult clients. A healthcare worker can provide dignity and respect when the older adult client feels heard (Jack et al., 2019). The National Institute on Aging (NIA) has recommendations for improving communication with the older adult. Communication with older adults is often hindered by declining sensory, cognitive, and physical abilities (NIA, 2021a). Therefore, a healthcare worker must utilize a variation in communication techniques— tailored to suit the needs/abilities of the client. These can aid the healthcare worker’s ability to elicit information for proper assessment and intervention. They also have recommendations for communicating with the older adult who has hearing, visual, or cognitive deficiencies. Hearing and vision are both normal biological processes that decline with age and need to be accommodated when assessing and intervening with the older adult to ease the information exchange. Recommendations for improving communication with the older adult include the following (NIA, 2017): ● Use an older client’s preference for being addressed and include their proper titles such as Mr., Mrs., Ms., Dr. ● Avoid endearing terms such as honey and dear . ● Ensure comfort for them and provide adequate chairs or adjust the setting as needed. ● Choose your words wisely and clarify when confusion seems apparent; some words are used flippantly, such as depression and crazy . ● Proceed with cultural competence. ● Encourage the client to write or take notes if desired. ● Suggest that a family member or caregiver be present during interactions and be involved in tasks to provide support. ● Include reassurance of understanding and use the teach-back method when applicable to the older adult and the family members or caregivers. Recommendations for accommodating hearing impairments include the following (NIA, 2017): ● Assess that the client can clearly hear you. If they cannot, ask if they use a hearing aid and make sure it is being used properly if needed. ● Use a regular pitch and volume. Raising your voice actually decreases understanding for those with hearing difficulties. ● Posture yourself directly in front of the client for face-to- face contact, which enhances their ability to read your lips if needed. ● Decrease background noise and close doors if they’re comfortable with it. ● Spell words out if confusion is present nonverbally.
adult has emotional safety in this phase and is able to address mental health struggles. The healthcare worker is cautioned that transference is common in this phase (Boyd, 2017). Goals toward recovery should be reached during this phase. The final stage of the framework is the resolution phase: the termination of the services and relationship take place in this stage (Boyd, 2017). Not all relationships will follow through to the resolution phase. But if they do, the healthcare worker can say “good-bye” and reflect on the progress made by the older adult as well as the social support put into place for continued success (Boyd, 2017). The components of trust that build rapport, culture consideration, empathy, and professional boundaries can be applied throughout Hildegarde Peplau’s framework. The healthcare worker can visualize the potential psychiatric therapeutic relationship with the older adult client prior to initiation with the goal of improved interactions. The healthcare worker can also have an awareness for the progression and evolution of the therapeutic relationship, including its termination. ● Have a piece of paper ready if you need to write or they want to write to you. ● When transitioning is going to take place in the interview, tell them verbally that you are changing the subject, for example, “I’m going to move on to the next part of this interview.” Recommendations for accommodating visual impairments include the following (NIA, 2017): ● Assess whether the client can clearly see. If they need eyeglasses, ask if they brought them. ● Proper lighting is necessary for the older adult. Reduce glare for screens. ● Ask for their preferred method of learning when providing instructions (verbal, written, visual, pictures, etc.) ● If writing, make sure they can read it. ● If using printed materials, 14-point font is suggested. Recommendations for accommodating cognitive impairments include the following (NIA, 2017): ● Be patient and allow for ample time to reduce feeling rushed. ● Ensure you have the client’s attention prior to starting. ● Orient and reorient the client as needed throughout the interaction. ● Use a familiar setting for the interview if possible. ● Include family, friends, or caregivers with client consent. ● Avoid medical jargon and rephrase to understandable wording. ● Present one question or direction at a time. ● Choose open-ended (e.g., “How does that make you feel?” or “What do you think might have contributed to this feeling?”) or closed-ended questions (e.g., “Did you get any sleep last night?” or “Have you been feeling sad and down lately?”) based on the client’s ability to answer (closed-ended questions are often easier if cognitive deficits are present). ● Consider following up with the client within the week to assess for understanding and allow for questions. ● Encourage cognitively stimulating activities, exercise, and a healthy diet. Hearing, visual, or cognitive impairments that are clinically prohibitive to communication will require the healthcare worker to utilize more extensive variations in technique, and possibly require professional assistance or assistive devices. If professional assistance and assistive devices are required, the healthcare worker can collaborate with experts, such as case management, to mitigate communication barriers for the older adult client.
COMMUNICATION AND LIMITATIONS WITH OLDER ADULTS
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