Chapter 8: Therapeutic Relationships

What is considered the gold standard in psychiatric nursing care?

Patient-centered care.

What are key components of patient-centered care?

Dignity, respect, information sharing, patient and family participation, collaboration in policy/program development.

What is the foundation of all PMH nursing treatment approaches?

The nurse–patient relationship.

What qualities should the nurse demonstrate in the nurse–patient relationship?

Safe, confidential, reliable, consistent, with clear boundaries.

What is the therapeutic use of self?

Using personality traits, gifts, and talents to form a positive bond and promote healing.

Why is self-awareness important in PMH nursing?

It helps the nurse use their personality and skills effectively while maintaining professional boundaries.

How does counseling differ from psychotherapy?

Counseling is a supportive, face-to-face process that helps individuals problem-solve, resolve personal conflicts, and feel supported—it is not psychotherapy.

What is a primary goal of the nurse–patient relationship (not considered therapy)?

Facilitate communication of distressing thoughts and feelings.

How does the nurse help patients with problem solving?

Assists them in examining self-defeating behaviors and testing alternatives.

What role does the nurse play in promoting patient independence?

Encourages self-care and autonomy.

How does the nurse support patient education?

Provides information about disorders, symptom management, and treatments.

What is the overall goal of recovery in psychiatric nursing?

A process of change in which individuals improve health/wellness, live self-directed lives, and strive to reach full potential.

What are guiding principles of recovery?

Hope for recovery, person-driven care, holistic approach, culturally congruent, respect for patient autonomy and abilities.

What defines an intimate relationship?

Occurs between people with an emotional commitment to each other.

What is a key feature of intimate relationships regarding needs?

Mutual needs are met.

What is shared in an intimate relationship?

Intimate desires and hopes.

What is the purpose of personal/social relationships?

Friendship, socialization, enjoyment, or accomplishing a task.

How are mutual needs met in social relationships?

Through sharing feelings and experiences during interaction.

What types of communication occur in social relationships?

Giving advice, offering help, asking for help.

How do roles function in personal/social relationships?

Roles are switched—both talking and listening occur.

How deep is the content of communication in social relationships?

Superficial; little emphasis on evaluating the interaction.

What does a nurse use to enhance a patient’s growth in a therapeutic relationship?

Knowledge of communication skills, human behaviors, and personal strengths.

Who is the focus in a therapeutic relationship?

The patient—their ideas, feelings, and experiences.

How are patient needs addressed in a therapeutic relationship?

Needs are identified, explored, and progress is evaluated.

What is essential for maintaining a therapeutic relationship?

Clear boundaries.

How does a therapeutic relationship support the patient?

Supports behavioral change, encourages alternate problem-solving, and helps develop new coping skills.

What are boundaries in the nurse–patient relationship?

Legal, ethical, and professional standards that separate nurses from patients.

Who is responsible for setting boundaries?

The nurse (not the patient).

Why are boundaries necessary in nursing?

Because of the power differential between nurse/nursing student and patient.

How do boundaries help the nurse?

They help maintain a professional role.

How do boundaries help the patient?

They provide a safe space to explore feelings.

What does under-involvement in a therapeutic relationship look like?

Disinterest or neglect toward the patient.

What does over-involvement in a therapeutic relationship look like?

Boundary crossings, boundary violations, blurring of roles, or professional misconduct.

Why is understanding the continuum of therapeutic involvement important?

To maintain professional boundaries while providing effective patient care.

What are boundary crossings in nursing?

The least serious form of over-involvement where the relationship slips into a personal context without violating ethical standards.

Whose needs are at risk of being prioritized during a boundary crossing?

The nurse’s needs (for attention, affection, emotional support) may be met at the expense of the patient’s needs.

Give examples of boundary crossings.

Spending too much time with one patient, doing tasks the patient can do, sharing too much personal info, answering personal questions, thinking about the patient outside work.

Is sharing personal information always inappropriate in nursing?

A minimal amount is acceptable, but it must not interfere with patient care.

What are boundary violations in nursing?

Ethically wrong actions where the nurse takes advantage of the patient’s vulnerability, meeting the nurse’s needs instead of the patient’s.

How do boundary violations usually develop?

They often start small and become increasingly problematic.

Give examples of boundary violations.

Accepting gifts/cash, excessive touching, influencing political/religious beliefs, planning a business with a patient, asking for reduced fees, discussing patient’s case on social media.

Why are boundary violations dangerous?

They exploit patient vulnerability and breach ethical and professional standards.

What is professional sexual misconduct in nursing?

The most extreme form of boundary violation, which may be verbal or physical and involves expressions interpreted as sexual in nature.

Give an example of professional sexual misconduct.

A nurse having a personal or intimate relationship with a patient.

Why is professional sexual misconduct serious?

It violates ethical, legal, and professional standards and exploits the patient’s vulnerability.

What is transference in the nurse–patient relationship?

When the patient unconsciously transfers positive or negative feelings/behaviors from significant figures in their past onto the nurse.

What is countertransference?

When the nurse unconsciously transfers feelings/behaviors from significant figures in their past onto the patient.

How does transference or countertransference affect the therapeutic relationship?

It can result in over-involvement and negatively impact the therapeutic relationship.

What are signs of role blurring caused by transference or countertransference?

Strong positive or negative feelings toward the patient, power struggles, and overidentification.

Why is awareness of transference and countertransference important for nurses?

To maintain professional boundaries and preserve the effectiveness of the therapeutic relationship.

Why is self-awareness important in a therapeutic relationship?

It is a key component that helps the nurse interact effectively and maintain professional boundaries.

What should nurses be aware of in themselves for self-awareness?

Their own values, beliefs, culture, and subculture.

How are a nurse’s values and beliefs formed?

Derived from a range of choices, influences, and role models.

Give examples of areas influencing a nurse’s values and beliefs.

Religion, politics, abortion, gender roles, sexuality, and family roles.

What mindset should nurses maintain to enhance self-awareness?

Be curious about themselves and reflect on their values and biases.

What does self-awareness require?

Understanding what we value and the beliefs that guide our behavior.

How do our values and beliefs affect us?

They guide behavior and give meaning to life.

How can differences in values and beliefs affect us?

We can feel threatened by others who have different values and beliefs.

What should we do when feelings or behaviors arise in response to others?

Notice them and be curious about them, without judgment.

How does self-awareness benefit our interactions with others?

Helps us accept uniqueness and differences in others.

Who established the foundation for psychiatric-mental health (PMH) nursing practice?

Hildegard Peplau.

Does the nurse–patient relationship only apply to mental health nursing?

No, it applies to all areas of nursing practice.

How does Peplau define the nurse–patient relationship?

An interactive process between a skilled nurse and a patient seeking to feel better, solve problems, explore ways to improve quality of life, or find an advocate.

What does the nurse–patient relationship facilitate according to Peplau?

Patient’s boundary management, independent problem solving, and decision-making that promotes autonomy.

What is the nurse’s role in Peplau’s model?

Use skills and expertise to support the patient’s growth, problem solving, and quality of life improvement.

What are the four phases in Peplau’s model of the nurse–patient relationship?

Preorientation phase, Orientation phase, Working phase, Termination phase.

What is the preorientation phase?

The phase before meeting the patient, where the nurse prepares by reviewing information and examining personal biases.

What is the orientation phase?

When the nurse and patient meet, establish rapport, identify patient problems, and set goals.

What is the working phase?

The phase where the nurse and patient actively work on problem-solving, coping strategies, and behavior change.

What is the termination phase?

The conclusion of the nurse–patient relationship, reviewing progress, and ensuring patient independence and closure.

What should a nurse do before beginning a patient assignment according to Peplau?

Research the patient’s history, be familiar with safety rules and unit routines, and engage in self-awareness.

What does self-awareness involve when preparing to meet a patient?

Recognizing your own thoughts, feelings, and possible reactions to the patient.

Give examples of self-awareness questions a nurse might ask before interacting with a patient.

• What if I say the wrong thing?

• What if the patient asks a personal question?

• What if a patient cries?

• What if a patient doesn’t want to talk?

Why is preparing through self-awareness important in the nurse–patient relationship?

It helps maintain professional boundaries, manage emotions, and provide effective therapeutic support.

• LOOK OVER TABLE 8.1

What occurs during the orientation phase of Peplau’s nurse–patient relationship?

Nurse and patient first meet, introductions are made, and the purpose of the meeting is explained.

What should the nurse clarify about the patient during the orientation phase?

How the patient would like to be addressed.

What is important for establishing rapport in the orientation phase?

Building trust, understanding, support, and consistency.

What parameters of the relationship are discussed during the orientation phase?

Place, time, date, and duration of meetings; may include a formal or informal contract.

How is confidentiality addressed in the orientation phase?

Nurse explains who patient information will be shared with and emphasizes ethical and legal responsibilities.

What important future aspect of the relationship is discussed during orientation?

Termination of the nurse–patient relationship.

What is the focus of the working phase in Peplau’s nurse–patient relationship?

Actively addressing patient problems and promoting growth through therapeutic interventions.

What types of activities occur during the working phase?

Gathering further data, exploring patient issues, patient teaching, promoting symptom management.

How does the nurse support the patient’s personal development in the working phase?

Promotes problem-solving skills, self-esteem, effective use of language, and coping skills.

What ongoing evaluation occurs during the working phase?

Evaluating patient progress and effectiveness of interventions.

What future-oriented discussion continues during the working phase?

Discussion about termination of the nurse–patient relationship.

What is the main goal of the termination phase?

Summarize goals and objectives achieved in the nurse–patient relationship.

What educational aspect is reviewed during termination?

Patient education and ways to incorporate new coping strategies learned.

What relational activities occur in the termination phase?

Review situations of the relationship, exchange memories, and acknowledge that separation may be difficult.

What future-oriented discussion takes place during termination?

Discuss plans for the patient’s future.

When is termination first introduced to the patient?

It is discussed during the first meeting (orientation) and revisited in the working phase.

What does genuineness mean in nursing?

Being open, honest, and authentic; key for building trust.

What is empathy in nursing?

Understanding the patient’s perspective and putting oneself in their position; produces an emotional response.

How is empathy different from sympathy?

Empathy is understanding and connecting emotionally; sympathy is feeling sorry for another.

What is positive regard in nursing?

Respecting the patient, viewing them as worthy of care, and recognizing their potential.

How is positive regard communicated?

Through attitudes (e.g., “this is just an assignment”), actions, attending behaviors (active listening, culturally congruent eye contact and body language), suspending value judgments, and helping patients develop autonomy.