Chapter 8
Therapeutic Relationships
Copyright © 2018, Elsevier Inc. All rights reserved.
Concepts of the Nurse–Patient
Relationship
• Basis of all psychiatric nursing treatment approaches-patient
centered care
• To establish that the nurse is
• Safe
• Confidential
• Reliable
• Consistent
• Relationship with clear boundaries-protect patients, involvement
needs to be healthy
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Therapeutic Use of Self
Goals and Functions
Therapeutic Use of Self
˜ Be in full awareness
˜ Attempt to establish relatedness
˜ Structure nursing interventions
Goals and Functions
˜ Facilitate communication of distressing thoughts and feelings
˜ Assist patient with problem solving
˜ Help patient examine self-defeating behaviors and test alternatives
˜ Promote self-care and independence
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Therapeutic Relationships
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Maximize communication
Understand their personal strengths
Enhance patient’s growth
Needs of patient identified and explored
Clear boundaries established
Problem-solving approaches taken
New coping skills developed
Behavioral change encouraged
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Factors That Help
Nurse–Patient Relationship
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Consistency
Pacing
Listening
Initial impressions
Promoting patient comfort and balancing control
Patient factors include
• Trust
• Active participation
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Factors That Promote
Patient Growth-Empowerment
• Genuineness
• Empathy (not sympathy)
• Positive regard
• Attitudes
• Actions
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Attending
Suspending value judgments
Helping patients develop resources
Reality Orientation
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Establishing Boundaries
Blurring Boundaries
Establishing Boundaries
˜Physical boundaries
˜The contract
˜Personal space
Blurring Boundaries
˜When relationship slips into social context
˜When nurse’s needs are met at expense of patient’s needs
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Blurring of Roles
• Transference—patient unconsciously and inappropriately
displaces onto nurse feelings and behaviors related to significant
figures in patient’s past
• Transference intensified in relationships of authority
• Countertransference—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
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Peplau’s Model of Nurse–Patient
Relationship
Orientation Phase
• Establishing rapport
• Parameters of the
relationship
• Formal or informal
contract
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Working Phase
˜ Maintain relationship
˜ Gather further data
˜ Promote patient’s
• Problem-solving skills
• Self-esteem
• Use of language
• Confidentiality
˜ Facilitate behavioral change
• Terms of termination
˜ Overcome resistant behaviors
˜ Evaluate problems and goals
Copyright © 2014, 2010, 2006 by Saunders, an imprint of Elsevier Inc.
Termination Phase
˜Summarize goals and objectives achieved
˜Discuss ways for patient to incorporate new coping strategies
learned
˜Review situations of relationship
˜Exchange memories
Tell me more...
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Copyright © 2018, Elsevier Inc. All rights reserved.
Chapter 9
Therapeutic Communication
Copyright © 2018, Elsevier Inc. All rights reserved.
The Communication Process
˜Stimulus—need for information, comfort, or advice
˜Sender—initiates contact
˜Message—sent or expressed, verbal or nonverbal
˜Channel—variety of media (hearing, visual, touch, smell)
˜Receiver—interprets and responds through feedback
*Validation essential
*Empowerment essential
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*Goal directed
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Verbal Communication
• All words a person speaks
• Communicates
• Beliefs and values
• Perceptions and meaning
• Can convey
• Interest and understanding
• Insult and judgment
• Clear or conflicting messages
• Honest or distorted feelings
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Nonverbal Communication
• May be sending the real message
• Tone of voice-tone, pitch, level, intensity, pauses, silences,
fluency
• Emphasis on certain words
• Physical appearance-grooming, dress, hygiene, complexion,
physique
• Facial expressions-frown, smile, raised eyebrows, licking lips
• Body posture-body movements, gestures, gait
• Amount of eye contact and gaze behavior-intimidating gaze,
lowering brows
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Interaction of Verbal and Nonverbal
Communication
• Messages can appear to be one thing when in fact
they are another.
• People are often less aware of their nonverbal
messages and behaviors.
• Verbal message can be called the content, while the
nonverbal behavior is the process.
• Double-bind messages: Mutually contradictory messages,
usually given by a person in power.
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Therapeutic Communication
Techniques
˜Tools for enhancing communication
• Using silence-allows for reflection
• Active listening-providing undivided attention
• Clarifying techniques-paraphrase in fewer words, restating using key
words, exploring by “tell me more or give me an example,” reflection help
them understand their own thoughts and feelings
Asking Questions and Eliciting Patient Responses
Open-ended questions-what, how, when, avoid why
Closed-ended questions-need specific information
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Nontherapeutic Communication
Techniques
• Excessive questioning-not respectful or sensitive
• Giving approval or disapproval-when vulnerable value comment
could be misinterpreted
• Giving advice-empower them instead
• Asking “why” questions-implies wrongdoing and demands an
explanation
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Preparing for the Clinical Patient
Interview
˜ Pace-let patient set the pace
˜ Setting-where patient feels safe
˜ Seating-avoid face to face, 90-120 degree angle better, avoid barriers between, both sitting or standing
˜ Introductions-how would they like to be addressed, who you are, goal of meeting, timeframe
˜ Initiating the interview-where should we start? Apply therapeutic toolbox
Cultural Considerations
˜ Communication style
˜ Eye contact
˜ Touch
˜ Cultural filters—form of bias or prejudice
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Attending Behaviors
• Eye contact
• Body language
• Proxemics: The study of personal space
• Intimate distance (United States): 0 to 18 inches
• Personal distance: 18 to 40 inches
• Social distance: 4 to 12 feet
• Public distance: 12 feet or more
• Vocal quality
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Tactics to Avoid
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Arguing, minimizing, or challenging the patient
Giving false reassurance
Interpreting or speculating
Probing into sensitive areas the patient doesn’t want to discuss
Trying to “sell” the patient on accepting treatment
Joining in attacks patients launch on others
Participation in criticizing other staff members
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HESI pointers
• Therapeutic communications
• Purpose is to allow patients autonomy to make choices
when appropriate
• Keep statement value-free, advice-free and re-assurance
free
• Just facts, no opinions
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FORBIDDEN PHRASES
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“You should…”
“You’ll have to…”
“You can’t…”
“If it were me, I’d…”
“Why don’t you…”
“It’s the policy on the unit…”
“Don’t worry…”
“Everyone…”
“Why…”
“Just a second…”
“I know…”
Avoid social interaction, clichés, and saying too much
Avoid changing the subjects
Avoid words like good, bad, right, wrong, and nice
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Basic Communication applies to
ALL patients
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Establish trust
Demonstrate non-judgmental attitude
Offer self,; be empathetic, not sympathetic
Use active listening
Accept and support pt’s feelings
Clarify and validate pt’s statements
Use matter-of-fact approach
Nurses’ non-verbal communication may be more important than the verbal
communication
• The nurses can’t tell a pt they won’t tell anyone what the pt discloses, nurse
may NEED to tell others.
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