Chapter 8

Therapeutic Relationships

Patient-Centered Care

• Gold standard

• Consists of dignity & respect, information sharing, patient & family participation, and collaboration in policy & program development

• Basis of psychiatric-mental health nursing

• Many components of many disorder can be improved by therapeutic relationships

Therapeutic Use of Self

• Use of our distinct gifts — personality traits and talents — that we can learn to use creatively to form positive bonds with others

• Using these gifts to promote healing

Psychotherapy

• A formalized approach to talk therapy that is based on therapeutic models

• Have to be licensed to practice

• Psychotherapy within a therapeutic partnership actually can change brain chemistry

• Best treatment with most psychiatric problems (except psychotic disorders) is combo of meds and psychotherapy

Counseling

• Supportive face-to-face process that helps individuals problem solve, resolve personal conflicts, and feel supported

• Basic and advanced level practitioners use counseling techniques

Recovery

• Process that begins with diagnosis and the eventual management of the psychiatric condition

• Goal of nurse-patient relationship

• Empowering individual to be key player in partnerships with healthcare providers to make decisions about personal care and treatment

• increase family and social support

Intimate Relationships

• Occur between people who have an emotional commitment to each other

• Mutual needs are met and intimate desires and hopes or shared

• moral and ethical concerns with patients, legal and professional restrictions

Personal Relationships

• Primarily initiated for the purpose of friendship, socialization, enjoyment, or accomplishment of a task

• Mutual needs met during social interaction

• Communication skills

Therapeutic Relationship

• Nurse maximizes communication skills, understanding of human behaviors and personal strenghts to enhace patient growth

• Interactions are focused on patient’s ideas, experiences, and feelings

• Address issues introduced by the patient

• Nurse may assume a variety of roles

• Nurse will: ID needs of pt and explore them, establish clear boundaries, encourage alternate problem-solving, help the pt develop new coping skills, and support behavioral change

Clinical Supervision

• A mentoring relationship characterized by feedback and evaluation

• Communication skills and knowledge of therapeutic relationships developed

• Support from clinical faculty and nursing staff

Therapeutic Encounter

• Relationship is limited but can still be substantial, useful and important for the patient

• Relationship my be informal and not extensive and pt and nurse may only meet a few times

Boundaries

• Expected and accepted legal, ethical, and professional standards that separate nurses from patients

• Separation is essential

• Nurse in position of some authority

• Boundaries provide a safe space in which the pt can explore feelings and treatment concerns, limit over & under involvment of the nurse

• Boundary Crossings: less serious for of over-involvement. Impression of something is not right but do not actually violate ethical standards — relationship slips into personal context and when nurse’s needs are met at expense of patient’s

• Boundary Violations: take advantage of the patient’s vulnerability and are ethically wrong, reversal of roles

• Professional Sexual Misconduct

• Blurring of Roles: transference & countertransference

Transference

Occurs when the patient unconsciously and inappropriately displaces (transfers) onto the nurse feelings and behaviors related to significant figures in the patient’s past

• Can be positive or negative

• Desire for affection, respect, gratification, hostility, jealousy, competitiveness, and love

Countertransference

Occurs when the nurse unconsciouly displaes feelings related to significant figures in the nurse's past onto the patient

• again can be positive or negative

• can affect nurses quality of care — over or under involved

Values

• Abstract standards and respresent an ideal, either positive or negative

• Your judgment about what is important in life

Beliefs

• another area of self-awareness

• An opinion or conviction, something that you hold to be true

• Confidentce, trust or faith

• Religious tenents, creed or faith

Peplau’s Model of the Nurse-Patient Relationship

• Professional nurse-patient relationship consists of a nurse who has skills and expertise and a patient who wants to feel better, find solutions to problems, explore different methods to improve qualtiy of life, or find an advocate.

• Facilitates forward movement for both nurse and pt

• Phases:

  • Preorientation: preparing for your assisgnment — reading a chart, staff reports, recognize own thoughts and feelings

  • Orientation: first time nurse and pt meet and is when nurse conducts initial interview, pt may begin to express thoughts and feelings, ID problems, and discuss realistic goals — introduction, establish rapport, specify a contract, and explain confidentiality

  • Working: gather further data, ID problem-solving skills and self-esteem, providing education about the disorder, promoting symptom management, providing medication education, evaluating progress

  • Termination: final, integral, phase. discuss during first meeting and again during working phase when appropriate. Tasks include summarize goals and objectives achieved, review pt education, provide handouts, discuss ways for patient to incorporate learned coping strategies, review situations that occurred and exchange memories
    
    

Rapport

A relationship characterized by understanding and harmony, which is facilitated by genuineness, empathy, and unconditional positive regard

Contract

• emphasizes the pt’s participation and responsibility because it shows that the nurse does something with the patient rather than for the patient

• either stated or written

• contains the place, time, date and duration of meetings

• discuss termination of the relationship

Confidentiality

• Information being held in confidence unless an authorization is made to share this information

• Pt has right to know who else will be given the information shared with the nurse and the information may be shared with specific people such as other staff

• Nurse cannot share info the patient doesn’t want shared except in extreme situations — child or elder abuse, threats of self-harm or harm to others

Genuiness

• Refers to the nurse’s ability to be open, honest and authentic in interactions with patients

• builds trust

• outside is congruent with inside

• convey it by listenting and communicating clearly

Empathy

• Occurs when the helping person attempts to understnad the world from the patient’s perspective

• Attempting to put oneself in the other’s position

• Consistent with improved patient outcomes and increased pt satisfaction

Sympathy

Instead of focusing on understanding the feelings of others, we feel pity or sorrow for others.

Positive Regard

• Respecting a person and viewing another person as being worthy of caring about and as someone who has strengths and achievement potential.

• Usually communicated indirectly by attitudes and actions rather than directly by words

• Attitudes, actions, attending behavior, suspending value judgments & helping pts to develop resources help establish this