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the therapeutic nurse-patient relationship is a mutual learning experience and a corrective emotional experience for the patient. It is based on the underlying humanity of nurse and patient, with mutual respect and acceptance of sociocultural differences. In this relationship the nurse uses personal attributes and clinical techniques in working with the patient to bring about insight and behavioral change.
Characteristics of the relationship:
The goals of a therapeutic relationship are directed toward achieving the patient's optimal growth and include the following dimensions:
Self-realization, self –acceptance, and an increased genuine self-respect.
A clear sense of personal identity and an improved level of personal integration.
An ability to form intimate, interdependent, interpersonal relationships with a capacity to give and receive love.
Improved functioning and increased ability to satisfy needs and achieve realistic personal goals.
This chapter examines the personal qualities of the nurse as helper, the phases of the relationship, facilitative communication, responsive and action dimensions, therapeutic impasses, and the therapeutic outcome (Figure).
Each of these factors influences the nurse's effectiveness.
I. Personal Qualities of the Nurse:
The therapeutic tool of the psychiatric nurse is the use of oneself. Thus self-analysis is the first building block in providing quality nursing care.
Research suggests that some essential qualities are needed if one is to help others.
1. Awareness of Self
The nurse must be able to examine personal feelings, actions, and reactions. A good understanding and acceptance of self allow the nurse to acknowledge a patient's differences and uniqueness.
Campbell (1980) has identified a holistic nursing model of self-awareness that consists of four interconnected components:
The psychological component includes knowledge of emotions, motivations, self-concept, and personality. Being psychologically self-aware means being sensitive to feelings and outside events that affect those feelings.
The physical component is the knowledge of personal and general physiology, as well as of body sensations, body image, and physical potential.
The environmental component consists of the sociocultural environment, relationship with others, and knowledge of the relationship between humans and nature.
The philosophical component is the sense of life having meaning. A personal philosophy of life and death may or may not include a spiritual being, but it does take into account responsibility to the world and the ethics of behavior.
Together these components provide a model that can be used to promote the self-awareness and self-growth of nurses and the patients for whom they care.
2. Clarification of Values:
Nurses should be able to answer the question, What is important to me? Awareness of one's own values helps the nurse to be honest, to better accept differences in others, and to avoid the unethical use of patients to meet personal needs.
One of the many challenges facing psychiatric nurses today is the need to provide care for patients from diverse backgrounds.
3. Exploration of Feelings:
It is often assumed that helping others requires complete objectivity and detachment. This is definitely not true. Complete objectivity and detachment describe someone who is unresponsive, false, unapproachable, impersonal, and self-alienated-qualities that block the
establishment of a therapeutic relationship.
Rather, nurses should be open to, aware of, and In control of their feelings so that they can be used to help patients.
For example, despite the patient's statement that "things are going real well", the nurse might perceive a strong sense of despair or anger.
4. Serving as Role Model:
Research has shown the power of role models in molding socially adaptive, as well as maladaptive, thus a nurse has an obligation to model adaptive and growth-producing behavior.
Altruism is concern for the welfare of others. It does not mean that an altruistic person should not expect adequate compensation and recognition or must practice denial or self-sacrifice. Only if personal needs have been appropriately met can the nurse expect to be maximally therapeutic.
6. Ethics and Responsibility:
The Code for Nurses reflects common values regarding nurse-patient relationships and responsibilities and serves as a frame of reference for all nurses in their judgments about patient welfare and social responsibility. Responsible ethical choice involves accountability, risk, commitment, and justice.
Phases of the Relationship:
It is important to distinguish between social support and professional support.
The support requested and ultimately provided should be within the domain of the nurse's role as a professional caregiver.
Four phases of the nurse-patient relationship have been identified: preinteraction, introductory, or orientation, phase; working phase; and termination phase.
1. Preinteraction Phase:
The preinteraction phase begins before the nurse's first contact with the patients. The nurse's initial task is one of self-exploration.
The self-analysis of the preinteraction phase is a necessary task.
To be effective, nurses should have a reasonably stable self-concept and an adequate amount of self-esteem. They should engage in positive relationships with others and face reality to help patients do the same.
Other tasks of this phase include gathering data about the interaction with the patients.
2. Introductory, or Orientation, Phase:
It is during the introductory phase that the nurse and patient first meet. One of the nurse's primary concerns is to find out why the patient sought help
An additional task is to establish goal consensus and collaboration.
Formulating a contract. The tasks in this phase of the relationship are to establish a climate of trust, understanding, acceptance, and open communication and formulate a contract with the patient. Box 2-4 lists the elements of a nurse-patient contract.
The issue of confidentiality is an important one to discuss with the patient at this time. Confidentiality involves the disclosure of certain information only to another specifically authorized person.
Other tasks of the nurse in the orientation phase of the relationship are as follows:
To explore the patient's perceptions. Thoughts, feelings, and actions.
To identify pertinent patient problems
To define mutual, specific goals with the patient.
3. Working phase:
Most of therapeutic work is carried out during the working phase. The nurse and the patient explore stressors and promote the development of insight in the patient by linking perceptions, thoughts, feelings, and actions.
These insights should be translated into action and a change in behavior. They can then be integrated into the individual's life experiences.
Patients often display resistance behaviors during this phase because it involves the greater part of the problem-solving process.
As the relationship develops, the patient begins to feel close to the nurse and respond by clinging to old defenses and resisting the nurse's attempts to move forward.
4. Termination phase:
Termination is one of the most difficult but most important phases of the therapeutic nurse-patient relationship.
Termination is a time to exchange feelings and memories and to evaluate mutually the patient's progress and goal attainment.
Levels of trust and intimacy are heightened, reflecting the quality of the relationship and the sense of loss experienced by both nurse and patient
II. Facilitative Communication:
Communication, which takes place on two levels (verbal and nonverbal), can either facilitate the development of a therapeutic relationship or serve as a barrier to it.
Verbal communication occurs through words, spoken written.
Nonverbal communication includes all relayed information that does not involve the spoken or written word, including cues from all five senses. It has been estimated that about 7% of meaning is transmitted by words, 38% is transmitted by paralinguistic cues such as voice, and 55% is transmitted by body cues.
Types of Nonverbal Behaviors
Verbal cues: include all the nonverbal qualities of speech. Some examples include pitch; tone of voice; quality of voice; loudness or intensity; rate and rhythm of talking; and unrelated nonverbal sounds, such as laughing, groaning.
Action cues: are body movements, sometimes referred to as kinetics. Reflexes, posture, facial expression, gestures.
Object cues: are the speaker's international and unintentional use of all objects. Dress, furnishings, and possessions
Space: provides another clued to the nature of the relationship between two people.
Touch: involves both personal space and action. Therapeutic touch or the nurse's laying hands on or close to the body of an ill person for the purpose of helping or healing.
Therapeutic Communication Techniques:
There are two requirements for therapeutic communication:
All communication must preserve the self-respect of both individuals.
One should communicate understanding before giving any suggestions or advice.
Activities are carried out with the patient, not for the patient.
1. Listening: listening is essential to understanding the patient. Therefore the first rule of a therapeutic relationship is to lists to the patient.
Real listening is difficult. It is an active, not a passive, process.
2. Broad Openings: Broad openings, such as "What are you thinking about?" "Can you tell me more about that?" and "What shall we discuss today?" encourage the patient to select topics to discuss.
3. Restating: Restating is the nurse's repeating of the main thought the patient has expressed.
4. Clarification: Clarification occurs when the nurse attempts to put into words vague ideas or thoughts that are implicit or explicit in the patient's talking. Such as "I'm not sure what you mean. Are you saying that …?"
5. Reflection: Reflection of content is also called Validation, which lets the patient know that the nurse has heard what was said and understands the content. It consists of repeating in fewer or different words the essential ideas of the patient and resembles paraphrasing. Sometimes it helps to repeat a patient's statement, emphasizing a key word.
Reflection of feelings consists of responses to the patient's feelings about the content.
6. Focusing: Focusing helps the patient expand on a topic of importance.
7. Sharing Perceptions: Sharing perceptions involves asking the patient to verify the nurse's understanding of what the patient is thinking or feeling.
Perception checking is a way to explore incongruent or double-blind communication. "You're smiling, but I sense that you're really angry what happened."
8. Theme Identification: themes are underlying issues or problems experienced by the patient that emerge repeatedly during the course of the nurse-patient relationship.
They can relate to feelings (depression or anxiety), behavior (rebelling against authority or withdrawal), experiences (being loved or hurt), or combinations of all three.
9. Silence: Silence on the part of the nurse has varying effects depending on how the patient perceives it. To a vocal patient, silence on the part of the nurse may be welcome, as long as the patient knows the nurse is listening.
With a depressed or withdrawn patient, the nurse's silence may convey support, understanding, and acceptance.
10. Humor: Humor is a basic part of the personality and ahs a place within the therapeutic relationship. As a part of interpersonal relationships, it is a constructive coping behavior. By learning to express humor, a patient may be able to learn to express other feelings.
11. Informing: informing or information giving, is and essential nursing technique in which the nurse shares simple facts or information with the patient.
12. Suggesting: suggesting is the presentation of alternative ideas, and is exploring alternative coping mechanisms. Suggesting or advice, also can be no therapeutic, reinforces the patient's dependence.
The nurse's intent in using the suggesting technique should be to provide feasible alternatives and allow patients to explore their values in their unique life situation.
III. RESPONSIVE DIMENSIONS
The nurse must possess certain skills or qualities to establish and maintain a therapeutic relationship. Specific core conditions for facilitative interpersonal relationships can be divided into responsive dimensions and action dimensions
The responsive dimensions include genuineness, respect, empathic understanding, and concreteness. The helping process can impede the patient's growth rather than enhance it, depending on the level of the nurse's responsive and facilitative skills.
The responsive dimensions are crucial in a therapeutic relationship to establish trust and open communication. The nurse's goal is to understand the patient and to help the patient gain self understanding and insight. These responsive conditions then continue to be useful throughout the working and termination phases.
Genuineness means that the nurse is an open, honest, sincere person who is actively involved in the relationship. Genuineness is the opposite of self-alienation, which occurs when many of an individual's real, spontaneous reactions to life are suppressed.
Genuineness means that the nurse's response is sincere, the nurse is not thinking and feeling one thing and saying something different. It is an essential quality because nurses cannot expect openness, self-acceptance, and personal freedom in patients if they lack these qualities themselves
Whatever the nurse shows must be real and not merely a 'professional' response that has been learned and repeated. In focusing on the patient, many of the nurse's personal needs are put aside, as well as some of the usual ways of relating to others.
Respect is also called unconditional positive regard. It does not depend on the patient's behavior. Caring, liking, and valuing are other terms for respect. The patient is regarded as a person of worth and is respected as such.
Empathy is the ability to enter into the life of another person, to accurately perceive the person's current feelings and their meanings, and to communicate this understanding to the patient.
Accurate empathy involves more than knowing what the patient means. It also involves sensitivity to the patient's current feelings and the verbal ability to communicate this understanding in a language attuned to the patient.
Empathy can significantly promote constructive learning and change. First, it dissolves the patient's sense of isolation by connecting the patient to another person.
The patient can perceive that "I make sense to another human being. .. so I must not be so strange. … and if I am in touch with someone else, I am not so alone.
Concreteness involves using specific terminology rather than abstractions when discussing the patient's feelings, experiences, and behavior. It avoids vagueness and ambiguity and is the opposite of generalizing, labeling, and making assumptions about the patient's experiences.
IV. ACTION DIMENSION
The action-oriented conditions for facilitative interpersonal relationships are confrontation, immediacy, therapist self-disclosure, catharsis, and role playing.
With the action dimensions, the nurse moves the therapeutic relationship upward and outward by identifying obstacles to the patient's progress and the need for specific behavior change.
Confrontation often implies venting anger and engaging in aggressive behavior. However, confrontation as a therapeutic action dimension is an assertive rather than aggressive action.
Confrontation is an expression by the nurse of perceived
discrepancies in the patient's behavior. Three categories of
confrontation include the following:
discrepancies between the patient's expression of what he is (self-concept) and what he wants to be (self-ideal)
discrepancies between the patient's verbal self-expression and nonverbal behavior.
Discrepancies between the patient's expressed experience of himself and the nurse's experience of him
Confrontation is an attempt by the nurse to make the patient
ware of incongruence in feelings, attitudes, beliefs and
Confrontation also must be appropriately timed to be effective (figure). In the orientation phase of the relationship, the nurse should use confrontation infrequently and pose it as an observation of incongruent behavior.
A simple mirroring the discrepancy between a patient's actions and words is the most nonthreatening type of confrontation. The nurse might say, "you seem to be saying two different things. "this type of confrontation closely resembles clarification at this time.
Nurses also might identify discrepancies between how they and patients are experiencing their relationship, point out unnoticed patient strengths or untapped resources, or provide patients with objective but perhaps different information about their world.
Finally, to be effective, confrontation requires high levels of empathy and respect.
Immediacy involves focusing on the current interaction of the nurse and the patient in the relationship. It is a significant dimension because the patient's behavior and functioning in the relationship are indicative of functioning in other interpersonal relationships.
Immediacy involves sensitivity to the patient's feelings and a willingness to deal with these feelings rather than ignore them.
3. Nurse self-disclosure
Self-disclosures are subjectively true, personal statements about the self, intentionally revealed to another person. The nurse may share experiences or feelings that are similar to those of the patient and may emphasize both the similarities and differences.
This kind of self-disclosure is an index of the closeness of the relationship and involves a particular kind of respect for the patient. It is an expression of genuineness and honesty by the nurse and is an aspect of empathy.
The research literature provides significant evidence that therapist self-disclosure increases the likelihood of patient self-disclosure. Patient self-disclosure is necessary for a successful therapeutic outcome.
4. Emotional catharsis
Catharsis occurs when the patient is encouraged to talk about things that are most bothersome. Catharsis brings fears, feelings, and experiences out into the open so that they can be examined and discussed with the nurse.
The expression of feelings can be very therapeutic in itself; even if behavioral change does not result
5. Role playing
Role playing involves acting out a particular situation. It increases the patient's insight into human relations and can deepen the ability to see the situation from another person's point of view.
When role playing is used to facilitate attitude change, one key element of the exercise is role reversal. The patient may be asked to assume the role of a certain person in a specific situation or to play the role of someone with opposing beliefs.
After experiencing role reversal, patients may be more receptive to modifying their own attitudes.
Used as a method of promoting self-awareness and conflict resolution, role playing may help the patient "experience" a situation, which can be more helpful than just talking about it.
One of the ways in which role playing can be used to resolve conflicts and increase self-awareness is through a dialogue that requires the patient to take turns speaking for each person or each side of a problem. If the conflict is internal, the dialogue occurs in the present tense and alternates between the patient's conflicting selves until one part of the conflict outweighs the other. If the conflict involves a second person, the patient is instructed to "imagine that the other person is sitting in the chair across from you."
V. Therapeutic impasses
Therapeutic impasses are blocks in the progress of the nurse-patient relationship. They come about for a variety of reasons, but all impasses create stalls in the therapeutic relationship. Impasses provoke intense feelings in both the nurse and the patient, which may range from anxiety and apprehension to frustration, love, or intense anger. Four specific therapeutic impasses and ways to overcome them are discussed here: resistance, transference, counter-transference, and boundary violations.
Resistance is the patient's reluctance or avoidance of verbalizing or experiencing troubling aspects of oneself.
Resistance is often caused by the patient's unwillingness to change when the need for change is recognized.
Transference is an unconscious response in which patients experience feelings and attitudes toward the nurse that were originally associated with other significant figures in their life.
Transference reduces self-awareness by allowing the patient to maintain an inaccurate view of the world in which all people are seen in similar terms.
The first is the hostile transference. If the patient internalizes anger and hostility, this resistance may be expressed as depression and discouragement.
A second difficult type of transference is the dependent reaction transference. This resistance is characterized by patients who are submissive, subordinate, and ingratiating and who regard the nurse as a godlike figure.
3. Counter transference
Counter transference is a therapeutic impasse created by the nurse's specific emotional response to the qualities of the patient.
Counter transference reactions are usually of the following three types:
Reactions of intense love or caring
Reactions of intense disgust or hostility
Reactions of intense anxiety, often in response to resistance by the patient.
4. Boundary violations
Which occur when a nurse goes outside the boundaries of the therapeutic relationship and establishes a social, economic, or personal relationship with a patient.
Possible boundary violations related to psychiatric nurses
The patient takes the nurse out to lunch or dinner.
The professional relationship turns into a social relationship.
The nurse attends a party at a patient's invitation.
The nurse regularly reveals personal information to the patient.
The patient introduces the nurse to family members, such as a son or daughter, for the purpose of social relationship.
The nurse accepts free gifts from the patient's business.
The nurse agrees to meet the patient for treatment outside the usual setting without therapeutic justification.
The nurse attends social functions that include the patient
The patient gives the nurse an expensive gift.
The nurse routinely hugs or has physical contact with the patient
The nurse does business with or purchases services from the patient.