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Therapeutic Relationships

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Concepts of the Nurse-Patient Relationship Basis of all psychiatric nursing treatment approaches To establish that the nurse is Safe Confidential Reliable Consistent Relationship with clear boundaries

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Goals and Functions Facilitate communication of distressing thoughts and feelings Assist patient with problem solving Help patient examine self-defeating behaviors and test alternatives Promote self-care and independence

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Social Relationships Initiated for the purpose of friendship or meeting a goal Mutual needs are met Communication to give advice, give or ask for help Content of communication superficial

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Therapeutic Relationships Needs of patient identified and explored Clear boundaries established Problem-solving approaches taken New coping skills developed Behavioral change encouraged

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Necessary Behaviors for Nurses Accountability Focus on patients needs Clinical competence Delaying judgment Supervision

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Establishing Boundaries Physical boundaries The contract Personal space

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Blurring of Boundaries When relationship slips into social context When nurses needs are met at expense of patients needs

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Blurring of Roles Transference patient unconsciously displaces onto individual in current life emotions and behaviors from childhood that originated in relationships with significant others Transference intensified with person in authority in current life

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Blurring of Roles Continued Countertransference nurse displaces feelings related to people in nurses past onto patient Patients transference to nurse often results in countertransference in nurse Common sign of countertransference in nurse is overidentification with the patient

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Values, Beliefs, and Self-Awareness Nurses values and beliefs Not right for everyone Reflect own culture/subculture Derived from range of choices Chosen from a variety of influences and role models

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Peplaus Model of Nurse-Patient Relationship Orientation phase Working phase Termination phase

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Orientation Phase Establishing rapport Parameters of the relationship Formal or informal contract Confidentiality Assessing patient strengths and coping Identification of Nursing Diagnosis and NOC Terms of termination

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Working Phase Maintain relationship Gather further data Clarify expectations Develop plan of care Promote patients problem-solving skills self-esteem

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Working Phase Continued Facilitate behavioral change Overcome resistant behaviors Evaluate problems and goals Redefine them as necessary Promote practice and expression of alternative adaptive behaviors

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Termination Phase Summarize goals and objectives achieved Discuss ways for patient to incorporate new coping strategies learned Review situations of relationship Exploring the need for referrals post-discharge Establish plans for long-term post discharge functioning

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Factors That Help Nurse-Patient Relationship Consistency Pacing Listening Encouraging active patient collaboration Initial impressions

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Factors That Help Nurse-Patient Relationship Continued Promoting patient comfort and balancing control Patient factors include trust and active participation

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Factors That Encourage and Promote Patient Growth Genuineness Empathy (not sympathy) Positive Regard attitudes and actions

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Factors That Encourage and Promote Patient Growth Continued Attending Suspending value judgments Helping patients develop resources

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A nurse seeks to establish a relationship with a patient readmitted to the hospital. The patient has bipolar disorder, depressed type, and was hospitalized the preceding month. Which statement by the nurse would contribute to establishing trust?

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Answers a. Werent you complying with your medication regimen? b. It must be discouraging to be readmitted to the hospital so soon. c. Everyone with bipolar disorder ends up in the hospital occasionally. d. You must take your drugs as prescribed or you will be rehospitalized.

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Communication and the Clinical Interview

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The Communication Process Stimulus for information, comfort, or advice Sender initiates contact Message sent or expressed Variety of media hearing, visual, touch, smell Feedback received

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Factors That Affect Communication Personal factors Environmental factors Relationship factors

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Nonverbal Communication Tone of voice Emphasis on certain words Physical appearance Facial expressions Body posture Amount of eye contact Hand gestures

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Verbal Communication All words a person speaks Communicates Beliefs and values Perceptions and meaning Can convey Interest and understanding Insult and judgment Double or mixed messages

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Therapeutic Communication Techniques Tools for enhancing communication Using silence Active listening Listening with empathy

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Clarifying Techniques Paraphrasing Restating Reflecting Exploring

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Asking Questions and Eliciting Patient Responses Open-ended questions Closed-ended questions

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Nontherapeutic Communication Techniques Excessive questioning Giving approval or disapproval Giving advice Asking why questions

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Cultural Considerations Communication style Eye contact Touch Cultural filters form of bias or prejudice

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Preparing for the Interview Pace Setting Seating Introductions Initiating the interview

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Attending Behaviors Foundation of the interview Eye contact Body language Vocal quality Verbal tracking

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Process Recording Written record of a segment of the nurse-patient session that reflects as closely as possible the verbal and nonverbal behaviors of both patient and nurse Useful tool for identifying communication patterns