1. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. Chapter 9 Therapeutic Relationships

2. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 2 Concepts of the Nurse-Patient Relationship Basis of all psychiatric nursing treatment approachesBasis of all psychiatric nursing treatment approaches To establish that the nurse isTo establish that the nurse is –Safe –Confidential –Reliable –Consistent Relationship with clear boundariesRelationship with clear boundaries

3. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 3 Goals and Functions Facilitate communication of distressing thoughts and feelingsFacilitate communication of distressing thoughts and feelings Assist patient with problem solvingAssist patient with problem solving Help patient examine self-defeating behaviors and test alternativesHelp patient examine self-defeating behaviors and test alternatives Promote self-care and independencePromote self-care and independence

4. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 4 Social Relationships Initiated for the purpose of friendship or meeting a goalInitiated for the purpose of friendship or meeting a goal Mutual needs are metMutual needs are met Communication to give advice, give or ask for helpCommunication to give advice, give or ask for help Content of communication superficialContent of communication superficial

5. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 5 Therapeutic Relationships Needs of patient identified and exploredNeeds of patient identified and explored Clear boundaries establishedClear boundaries established Problem-solving approaches takenProblem-solving approaches taken New coping skills developedNew coping skills developed Behavioral change encouragedBehavioral change encouraged

6. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 6 Necessary Behaviors for Nurses AccountabilityAccountability Focus on patient’s needsFocus on patient’s needs Clinical competenceClinical competence Delaying judgmentDelaying judgment SupervisionSupervision

7. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 7 Establishing Boundaries Physical boundariesPhysical boundaries The contractThe contract Personal spacePersonal space

8. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 8 Blurring of Boundaries When relationship slips into social contextWhen relationship slips into social context When nurse’s needs are met at expense of patient’s needsWhen nurse’s needs are met at expense of patient’s needs

9. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 9 Blurring of Roles Transference – patient unconsciously displaces onto individual in current life emotions and behaviors from childhood that originated in relationships with significant othersTransference – 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

10. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 10 Blurring of Roles Continued Countertransference – nurse displaces feelings related to people in nurse’s past onto patientCountertransference – nurse displaces feelings related to people in nurse’s past onto patient –Patient’s transference to nurse often results in countertransference in nurse –Common sign of countertransference in nurse is overidentification with the patient

11. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 11 Values, Beliefs, and Self-Awareness Nurse’s values and beliefsNurse’s 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

12. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 12 Peplau’s Model of Nurse-Patient Relationship Orientation phaseOrientation phase Working phaseWorking phase Termination phaseTermination phase

13. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 13 Orientation Phase Establishing rapportEstablishing rapport Parameters of the relationshipParameters of the relationship Formal or informal contractFormal or informal contract ConfidentialityConfidentiality Terms of terminationTerms of termination

14. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 14 Working Phase Maintain relationshipMaintain relationship Gather further dataGather further data Promote patient’sPromote patient’s –problem-solving skills –self-esteem –use of language

15. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 15 Working Phase Continued Facilitate behavioral changeFacilitate behavioral change Overcome resistant behaviorsOvercome resistant behaviors Evaluate problems and goalsEvaluate problems and goals –Redefine them as necessary Promote practice and expression of alternative adaptive behaviorsPromote practice and expression of alternative adaptive behaviors

16. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 16 Termination Phase Summarize goals and objectives achievedSummarize goals and objectives achieved Discuss ways for patient to incorporate new coping strategies learnedDiscuss ways for patient to incorporate new coping strategies learned Review situations of relationshipReview situations of relationship Exchange memoriesExchange memories

17. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 17 Factors That Help Nurse-Patient Relationship ConsistencyConsistency PacingPacing ListeningListening Initial impressionsInitial impressions

18. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 18 Factors That Help Nurse-Patient Relationship Continued Promoting patient comfort and balancing controlPromoting patient comfort and balancing control Patient factors includePatient factors include –trust and –active participation

19. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 19 Factors That Encourage and Promote Patient Growth GenuinenessGenuineness Empathy (not sympathy)Empathy (not sympathy) Positive RegardPositive Regard –attitudes and –actions

20. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 20 Factors That Encourage and Promote Patient Growth Continued AttendingAttending Suspending value judgmentsSuspending value judgments Helping patients develop resourcesHelping patients develop resources

21. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 21 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?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?

22. Elsevier items and derived items © 2010, 2006 by Saunders, an imprint of Elsevier Inc. 22 a.“Weren’t 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.”