Chapter 6 Relationship Development

Patient-centered care

Promoted as central to quality and safety, and the therapeutic relationship remains at the foundation of this tenet

Role of the psychiatric nurse (7):

Stranger

Resource person

Teacher

Leader

Surrogate

Technical expert

Counselor

Therapeutic relationship

An interaction between two people in which input from both participants contributes to a climate of healing, growth promotion, or illness prevention.

The problem solving model:

1. Identity problem

2. Encourage discussion

3. Discuss potential changes

4. Discuss alternative strategies

5. Weigh benefits and consequences

6. Help client select an alternative

7. Encourage

8. Provide positive feedback

9. Help client evaluate outcomes

Therapeutic use of self

The ability to use one’s personality consciously and in full awareness in an attempt to establish relatedness and to structure nursing intervention.

In regards to therapeutic use of self, what should nurses possess?

Self awareness, self understanding, and a philosophical belief about life, death, and the overall human condition.

Characteristics that enhance the achievement of a therapeutic relationship:

Rapport

Trust

Respect

Genuineness

Empathy

Empathy

Attempt to feel what they feel, different from sympathy (feeling sorry for someone)

Rapport

Implies special feelings on the part of both the client and the nurse

Trust

Feeling confidence in another person’s presence

Respect

To believe in the dignity and worth of an individual

How do nurses convey an attitude of respect?

Calling the client by name

Spending time with the client

Allowing sufficient time to answer the client’s questions

Genuineness

Refers to the nurse’s ability to be open, honest, and real in interactions with client (may call for a degree of self-disclosure)

Phases of relationship development:

1. Preinteraction

2. Orientation

3. Working

4. Termination

Preinteraction phase

Obtain information about the client from chart, significant other, or other health team members.

Orientation phase

Create an environment for trust and rapport

Establish contract for intervention

Gather assessment data

Identify client’s strengths and limitations

Formulate nursing diagnoses

Set mutually agreeable goals and develop a realistic plan of action

Explore feelings of both client and nurse

Working phase

Maintain trust and rapport

Promote client’s insight and perception of reality

Problem solve using the model

Overcome resistance behaviors

Continuously evaluate progress toward goal attainment

Transference

Countertransference

How can feelings interfere with the therapeutic relationship? (9)

1. If the nurse over identifies with pt’s feelings

2. If the nurse and pt develop a social/personal relationship

3. Nurse attempts to rescue the pt

4. Nurse encourages and promotes pt’s dependence

5. If the nurse’s anger engenders feelings of disgust

6. If the nurse displays anxiousness and unease in pt’s presence

7. If the nurse presents as bored or apathetic in sessions

8. If the nurse has difficulty setting limits on pt’s behavior

9. Nurses defending pt’s behavior to other staff

Termination phase

Progress has been made toward attainment of goals

A plan of action for more adaptive coping with future stressors has been established

Feelings about termination of the relationship are recognized and explored.

Boundaries in the nurse-pt relationship:

Material, social, personal, and professional boundaries

What are some concerns regarding professional boundaries?

Self disclosure (small bits), gift giving, touch, and friendship or romantic association

What are some warning signs that professional boundaries may be in jeopardy?

1. Favoring one pt’s care over another’s

2. Keeping secrets with a client

3. Changing dress style when working with a particular pt

4. Swapping pt assignments to care for a particular pt