Phases of nurse patient relationship – This book covers the entire syllabus of “Psychiatric Nursing” prescribed by the Universities of Bangladesh- for Basic and diploma nursing students. We tried to accommodate the latest information and topics. This book is an examination-friendly setup according to the teachers’ lectures and examination questions.
At the end of the book previous university questions are given. We hope in touch with the book students’ knowledge will be upgraded and flourish. The unique way of presentation may make your reading of the book a pleasurable experience.
Phases of nurse patient relationship
Therapeutic communication
‘A process by which two or more people exchange ideas, facts, feelings ‘common understanding’ of meaning, intent and use of a message’
Communication:
Or
[Ref: KP Neeraja/1/Vol-1/2021
A process by which information is exchanged between individuals through a common system of symbols, signs, or behavior.
Or
A system for transmitting or exchanging information. “The nurse directs the communication towards the patient to identify his current health problems, plans, implements and evaluates the action taken”.
[Ref: KP Neeraja/P/Vol-1/206)
Or
Therapeutic communication is an interpersonal interaction between the nurse and the client during which the nurse focuses on the client’s specific needs to promote an effective exchange of information.
[Ref: Psychiatric-Mental Health Nursing-Sheila, 1/5/991
Or
Therapeutic communication is an interpersonal interaction between the nurse and client (patient) during which the nurse focuses on the patient’s specific needs to promote an effective exchange of information between the nurse and the client. Skilled used of therapeutic communication techniques helps the nurse understand and empathize with the patient’s experience. All nurses need skills in therapeutic communication to effectively apply the nursing process and to meet standards of care for their patients.
[Ref-Maya George/2/136/
Purpose of therapeutic communication:
1. To achieve self-realization, self-acceptance, self-respect, personal identity, personal integration
2. To formulate good interpersonal therapeutic relationship
3. Satisfy needs and to achieve realistic personal goals
4. Permits the client to express their thoughts truly, openly
5. Aids in clarification of internal conflicts and frustrations of the client
6. Improves client’s ego strengths
7. Encourages socialization and family interaction process
8. Treats communication problems
9. Modifies maladaptive behaviour into adaptive behavior
10. Motivates the client to utilize new coping strategies
11. Helps the nurse to identify and intervene appropriate nursing approaches
12. Assists the client to develop self-control and utilizes problem solving skills in attacking the problems
13. Implements nursing process effectively.
(Ref: KP Neeraja/I/Vol-1/207]
Essential components of therapeutic communication:
Establishing a therapeutic relationship is one of the most important responsibilities of the nurse when working with clients. Communication is the means by which a therapeutic relationship is initiated, maintained, and terminated.
The components are –
1. Privacy
2. Confidentiality
3. Facial expression
4. Body language
5. Touch
6. Active listening and observing
[Ref: Psychiatric-Mental Health Nursing-Sheila. L/S/99/
Principles of therapeutic communication:
1. Establish a therapeutic nurse-client relationship.
2. Identify the most important client concern at that moment (the client-centered goal).
3. Assess the client’s perception of the problem as it unfolds.
4. This includes detailed actions (behaviors and messages) of the people involved and the client’s thoughts and feelings about the situation, others, and self.
5. Facilitate the client’s expression of emotions.
6. Teach the client and family necessary self-care skills.
7. Recognize the client’s needs.
8. Implement interventions designed to address the client’s needs.
9. Guide the client toward identifying a plan of action to a satisfying and socially acceptable resolution.
(Ref: Psychiatric-Mental Health Nursing-Sheila. L/S/99)
Functions of therapeutic communication:
1. Establish rapport with the client by being empathetic, genuine, caring, and unconditionally accepting of the client regardless of his or her behavior or beliefs.
2. Actively listen to the client to identify the issues of concern and to formulate a client-centered goal for the interaction.
3. Gain an in-depth understanding of the client’s perception of the issue, and foster empathy in the nurse-client relationship.
4. Explore the client’s thoughts and feelings.
5. Facilitate the client’s expression of thoughts and feelings.
6. Guide the client to develop new skills in problem solving.
7. Promote the client’s evaluation of solutions.
[Ref: Psychiatric-Mental Health Nursing-Shella. L/S/11
Phases of therapeutic relationship:
A. Pre-orientation phase:
1. The nurse collects data/information about the client and family members, from client charts OPD reports, assesses the total needs and demands of the client.
2. Plan the activities to reach the goals.
3. Orientation phase, initial or establishment phase:
4. This phase lasts for 2-10 sessions
5. Establish the contract, follow the contract and keep the appointments correctly
6. Allow the client to be responsible for this contract
7. Acquaint with the client
8. Establish boundaries of relationship and trust with client
9. Sincerity in formulating IPR
10. Identify the problems of client
B. Identification phase:
Provide opportunity to the client to respond to the nurse; encourage the client to express when he feels to reorient the feelings, strengths, positive forces. Nurses and the clients will understand each other. They will discuss with each other, the preconceptions and expectations.
C. Working phase or therapeutic phase:
1. This phase starts when the client takes the responsibility to focus on problems.
2. Focus on increasing the patient’s independence and decreasing patient’s reliance on the nurse.
3. Maintain the goal of client’s confronting and working through identified problems.
4. Motivate the client to set goals and change his behaviour and setting goals before him so that they will help him to grow and develop self-worthiness.
5. Maintenance phase: To maintain social and emotional well-being in chronically ill cases, where termination is not possible upto death, certain nursing interventions were planned and carried out.
D. Termination phase or resolution phase:
1. Nurse should not give her personal address and telephone number as the client will develop mood dependency.
2. Assist the client to become independent in the given society.
3. This stage starts from orientation phase.
4. Anticipate the problems of termination, e.g. patient may become too dependent on the nurse.
5. Termination may recall patient’s previous separation experiences causing feelings of abandonment, rejection and depression, negative self-concept
6. Discuss patient’s previous experiences and his feeling about termination
7. More dependent people will take longer time for adjustment to terminate
8. When client is improved, the nurse reduces the time of contract; decreases the meeting time
9. Prepare the client to accept the help from the nurse to terminate in a healthy way
10. Nurse must discuss about the feelings of the client
11. Discuss the gain, growth and changes made by the client in Therapeutic Nurse-Patient Relationship.
[Ref: KP Neeraja/1/Vol-1/199-200]
Criteria of therapeutic communication:
1. The nurse has to possess certain characteristics to develop and maintain therapeutic relationship.
2. Response Dimensions
3. Genuineness.
4. Openness, honesty, sincerity, active involvement, accepting the client as he is, personal freedom to the client.
5. Respect: Warmth, positive regard; self-respect, respecting others, caring, concern, liking, valuing, wrathfulness; non-judgmental, maintains confidentiality, active listening.
6. Empathetic understanding.
7. Nurse’s sensitivity to the client’s current feelings and responds to it; accurate empathy involves more than knowing what the patient means; confirms with the client, the accuracy of perceptions and guided responses among the client.
8. Action Dimension
9. Confrontation: Belittling, blaming and embarrassing assertive form. It is an expression by nurse of perceived discrepancies in the patient’s behaviour.
10. The nurse has to use an active role in modelling, insight and understanding to remove ambiguity and inconsistency, develops deeper insight into the client’s problems.
[Ref: KP Neeraja/1/Vol-1/207-210)
Therapeutic relationship:
Repeated human contacts are essential to develop trust, love, tenderness, concern and acceptable nature. The client need for protection, the nurse has to act as parental role, has to accept the client’s thoughts, feelings, interests and problems, hence the nurse’s acceptance is unconditional. Nurse has to provide encouragement and support, always expecting the patient’s capacity to improve and to excel, yet knowing and making allowances for the shortcomings.
Definition:
“Interaction occurs between two persons, the nurse who possesses the skills, abilities and resources to relieve the clients’ discomfort and assisting him to alleviate his existing problem’.
Or
“An interaction process in which the nurse fulfils her role by using professional knowledge and skills in such a way that she will help the client in all the aspects (physically, mentally, emotionally and socially).
[Ref: KP Neeraja/1″/Vol-1/196-197)
Factory determine nurse-patient relationships
The ability to establish therapeutic relationships with chents is one of the most important skills a nurse can develop. Although important in all nursing specialties, the therapeutic relationship is expecially crucial to the success of interventions with clients requiring paychiatric care because the therapeutic relationship and the communication within a serve as the underpinning for treatment and saccess.
The factors determine nurse-patient relationship are-
1 Caring
2. Openness
3 Objectivity
4 Respect
5 Interest
6. Understanding
7. Consistency
8 Treating the client as a human being
9. Suggesting without telling
10. Approachability
11 Listening
12. Keeping promises
13 Honesty
Essential qualities of therapeutic relationshle
1 Genuineness
2 Sincerity
3.Respecting the client
4.Shows love and affection
5. Concem
6. Active latener
7. Empathy
8. Concreteness-speaking in a realistic wy
9. Self-ducipline
11. Rale-model
11 Condrontation-expressing the perceived problem of the sent in an accepting way
12. Communication skills in order to establish rapport with the client
13 Immediacy
14 Explorate of the problem (catharsis)
Types of relationship:
Every human relationship is unique. Individuals will bring their own backgrounds, beliefs and personalities working together to solve problems and to develop confidence and enjoys the life happily and satisfactorily.
1. Social relationship: Man is a social being and he cannot live alone; because of gregarious in nature. He will establish relationships with others to meet their individual needs. Both individuals are equally involved and are concerned with one to another. There is no predetermined goal or focus in the relationship. The continuation of relationship is not deter- mined at the onset, e.g. colleagues; neighbors.
2. Intimate relationship: A relationship between two individuals who committed to one another, caring and respect for each other, they love each other, e.g. relationship between couple/partners, etc.
3. Therapeutic relationship: The relationship between nurse and the client, where both of them are working together; client’s inner resources will be utilized that facilitates growth. Relationship is purposefully established, maintained and carried out to help the client to gain new adaptive skills. In Therapeutic nurse-patient relationship the previous difficulties may be solved and present difficulties are expressed and the nurse will assist the client to solve problems by adopting new coping strategies. The growth of client by developing personal integration. This relationship focuses on the energies of both nurse and the client: It emphasizes on mutual collaboration.
[Ref: KP Neeraja/1/Vol-1/1981
Nurse-patient relationship:
“A meaningful ongoing communication with the clients in an atmosphere of mutual respect and trust whereby close helping relationship will be established which allows the nurse and the client to work collaboratively”.
[Ref: KP Neeraja/1/Vol-1/196)
Elements of nurse patient relationship:
Many factors can enhance the nurse-client relationship, and it is the nurse’s responsibility to develop them. These factors promote communication and enhance relationships in all aspects of the nurse’s life.
The components that build therapeutic relationship are –
1. Trust
2. Professionalism
3. Mutual respect
4. Caring
5. Empathy
6. Genuineness
7. Unconditional positive regard
8. Partnership
A. Trust: It involves choosing to take the risk of sharing oneself with another, knowing that one is exposing himself or herself for the possibilities of emotional disturbances. Like hurt, disappointment, etc. The mentally ill clients will be reluctant to trust others as they have emotional disturbances.
Nurses have to understand clients’ feelings and sensitive reactions, with their caring process, they have to win the confidentiality of clients, through honest, thoughtful, consistent interactions with the clients. Nurses have to achieve the client’s trust and win the confidence.
B. Professionalism: Nurses are the professionals who apply a specific background of knowledge and skills to promote the client’s mental health. They will intervene effectively in care aspects; provide current information and insight into client’s problems systematically by using adequate coping strategies and guide the clients to appropriate community resources to fit each clients’ needs. Nurses must be competent to help their clients at all levels.
C. Mutual Respect: Nurses must respect client and his family background as it influences values and family functioning. Nurses have to interact with the clients effectively; give respect for religious beliefs as they understood their importance in relation to mental health. Nurses have to receive and give respect to maintain intact relationship, within limits they have to work.
D. Caring: Core values of nursing consists of 3 values giving of the self, meeting the client’s needs in a timely manner and providing comfort measures for both clients and family, ready to utilize any time and whatever the energy. Genuinely and willingness to do work are some of the essential features for a nurse to form therapeutic nurse-patient relationship.
E. Empathy: “Emotional knowing of another person”. It is a feeling what it must be like to be that person; empathy involves active listening with carefulness; being in time with what clients are seeing; having insight into the meaning of their thoughts, feelings and behaviours.
F. Genuineness: Truthfulness or involves being a real person. Work with the client in openness and exchange the ideas truly and freely. It arises out of deep concern.
G. Unconditional Positive Regard: It is the ability to give to the client without strings attached. Clients will be respected and focused attention regardless of their behaviour, despite their flows and setbacks.
H. Partnership: The client and family are active partners in care. Therapies are focussed on mutual problem solving. Joint approach in therapy planning; empowering clients to take care of themselves. Partnership involves power sharing and negotiation. Families and friends other situational support are viewed as an invaluable resource for client. Nurses have to consider them and involve them in their treatment.
[Ref: KP Neeraja/I/Vol-11
Problems in therapeutic relationship:
1. Resistance: Client is resistant to talk about self and doubt about self,
2. Transference: Client thinks that nurse is a significant person, hence transfers their emotions because of that, the nurse should clarify their relationship.
3. Counter transference: Nurse develops some emotional attachment on the client. At that time the nurse can take help from seniors or experienced people to adjust themselves with the client areas where therapeutic Nurse-Patient Relationship is difficult.
4. Person who is unable to communicate.
5. No emotional reaction where therapeutic relationships cannot be developed.
6. Avoiding the nurse by hiding and remaining in the group.
7. Superficially.
8. People who are having pseudo-communication.
➤ Very angry
➤Low self-esteem
➤ Suspiciousness.
[Ref: KP Neeraja/1/Vol-1/200-2011
Factors determine effective nurse patient relationship:
Self-awareness: It includes
1. Self-concept
2. Beliefs
3. Values and life experiences.
4. Nurse who has self-awareness will be able to assist the client in an effective manner.
Attitude towards the patient:
1. Attitude and acceptance of the client as he is
2. Treat the client as an individual and respect their status
3. Tolerates clients feelings; nurses have to be non-judgmental and keep limitation to client’s behaviour.
Rapport:
1. Mutual sympathy, respect and rapport have to be established.
2. Warmth, genuineness and empathy are required.
(Ref: KP Neeraja/1″/Vol-1/201]
Barriers of therapeutic relationship:
1. Not listening properly (actually in therapeutic nurse-patient relationship, nurse is active listener)
2. Maintaining dominance in therapeutic interaction will not benefit both (either to nurse or to the client)
3. Giving reassurance, false hopes will not contribute the therapeutic relationship
4. Too much probing into personal matters in the beginning usually goes wrong
5. Making stereotyped comments, shows that you are not interested towards the client
6. Without listening to the clients’ feelings and problems, if the nurse goes on changing the topic or bringing unrelated topics, the patient will be discouraged from discussing his problem.
7. If nurses offer challenges to the client, it will not work out
8. Too much advising the client is not good in TNPR Belittling the patient will reinforce withdrawal features of client.
10. Utilizing denial process in therapeutic nurse-patient relationship.
Reduction of barriers of nurse-client relationship:
1. Self-awareness is crucial in the therapeutic relationship. The nurse’s values, beliefs, and attitudes all come into play as he or she forms a relationship with a cient
2. Carper identified four patterns of knowing, empirical, aesthetic, personal, and ethical.
3. Munhall established the pattern of unknowing as an openness that the nurse brings to the relationship that prevents preconceptions from clouding his or her view of the client
4. The three types of relationships are social, intimate, and therapeutic. The nurse-client relationship should be therapeutic, not social or intimate.
5. Nurse theorst Hildegard Peplau developed the phases of the nurse-client relationship: orientation, working (with subphases of problem identification and exploitation), and termination or resolution. These phases are ongoing and overlapping.
6. The orientation phase begins when the nurse and client meet and ends when the client begins to identify problems to examine.
7. Tasks of the working phase include maintaining the relationship, gathering more data, exploring perceptions of reality, developing positive coping mechanisms, promoting a positive self-concept, encouraging verbalization of feelings that facilitate behavior change, working through resistance, evaluating progress and redefining goals as appropriate, providing opportunities for the client to practice new behaviors, and promoting independence.
8. Termination begins when the problems are resolved and ends when the relationship is ended
9. Factors that diminish the nurse-client relationship include loss of, or unclear, boundaries, intimacy, and abuse of power.
10. Therapeutic roles of the nurse in the nurse-client relationship include teacher, caregiver, advocate, and parent surrogate. [
Ref: Psychiatric-Mental Health Nursing Sheila L/S
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