PT20E Therapeutic Communications and
Relationships
PowerPoint #4

Course Objective #21 & 22
• List the stages of the therapeutic P.T.—patient relationships.
• Identify and describe the major tasks of each stage of the P.T.—patient relationship

Stages of TxNPR
• Orientation Stage
• Working Stage
• Termination Stage

Orientation stage
• Establishing trust and rapport
• Nurses learns
– Concerns
• Patient learns
– Role of the nurse

Orientation stage
• Create an environment
– Honest
– consistent,
– keeps promises
• Clear, specific communications
• Confidentiality explained

Orientation stage
• Initiating conversations
• Non-confrontational

Orientation stage
• Establish a contract
– Expectation
– responsibilities

Orientation stage
• Gather assessment information
– intake interview
• Needs
• coping strategies
• defense mech.
• recurring thoughts, feelings, behaviors
• awareness of problems
• ability and motivation to change

Orientation stage
• Gather assessment information
• Defining goals
• Needs
• Coping strategies
• Defense mech.
• Recurring T, F, B
• Motivate to change
– Prioritize

Orientation stage
• Management of emotions:
– Fear of losing control
– Feelings
– Anger

Orientation stage
• Feelings natural
– Expression
• Empathy
– Not alone
– Hope

Orientation stage
• Palliative coping mechanisms
– Rest
– Nutrition
– Exercise
– Meditation

Orientation Stage
• Teaching healthy ways to meet emotional needs
– Coping skills
– Challenging negative self-images

Orientation stage
• Providing support:
– Realistic hope
• Abilities
• Strengths
– Worth
– Non-judgmental
– Dependence  independent

Orientation stage
• Providing structure:
• If the pt loses control
– take temporary control
• If the patient is withdrawn
– Spending time
• The major task of providing structure is
– limit-setting

Orientation stage
Providing support
Managing emotions

Working Stage
• AKA:
– Learning Stage
– Change Stage
• Problem-solving
– Work toward change
– Stabilization

Objective #23
• Describe the following techniques that promote change in a patient in the working stage of the nurse-patient relationship.

Objective #24
• List the steps in problem identification

Working Stage
• Observation:
– Describe the problem

Working Stage
• Observation:
– Describe the problem
– “Participant Observer”
• Nurses relationship

Working Stage
• Analysis:
– Encourages accuracy in pts conclusions

Working Stage
• Interpretation:
– Change is necessary
– Explore solutions

Working Stage
• Planning:
– formulating a plan
– assists pts to solve their own problems
– Encourage short-term, realistic, achievable, daily goals

Working Stage
• Testing out:
– Trying out new behavior or solution in a safe environment first
– Rehearsal

Working Stage
• Role playing
– Practicing behaviors
– Nurse
• plays the role of persons with whom pts are difficulty
• assess communication & behavior

Working Stage
• Evaluation
– assess success

Working Stage
• Feedback
– Constructive

Working Stage
• In-depth data collection:
– Increased knowledge
– Priority issues

Working Stage
• Reality testing:
– Presenting another point of view

Working Stage
• Cognitive restructuring:
– Cope with negative thoughts 
– more realistic conclusions
• redefine
• reinterpret
• change perception

Working Stage
• Supportive confrontation:
– Challenging pt’s contradictions,
– It challenges pts to
• Meet their own needs
• Be accountable for their own
– Feelings
– Behaviors
– Decisions

Supportive Confrontation
• Example:
• Pt: “I went out drinking only once last week. At least I’m trying to change.”
• Nurse: “I can appreciate your effort, but you agreed to abstain from alcohol completely.”

Working Stage
• Writing/journaling:
– Tool
– Release emotions
– Objective
• Letters

Working Stage
• Promoting change:
– Pt. initiated change
– Support
• Family & friends
• Groups
– Motivated

Working Stage
• Teaching new skills:
– Desire + Know how
– Small steps
– Practice
– Feedback

Termination Stage
• Evaluation & summary of progress:
– ID changes
– Long-term goals
– Strengths & weaknesses

Termination Stage
• Synthesizing what has occurred:
– Progress
– Indirect outcomes of TxPNR
– Encouraged other relationships

Termination Stage
• Referrals:
– ID community resources
– Written d/c instructions

Termination Stage
• Discussion of termination:

Continuum of Care
• Definition:
– levels of care through which a pt can move depending on needs at the time

Course objective #26
• Compare and contrast transference and counter-transference

Transference (pt)
• Unconscious emotional reaction
• Patient  Nurse
• Based on past experiences

Transference (pt)
• Positive
– if pts view the nurses as helpful and caring
• Negative
– interfere with treatment

Countertransference (nurse)
• Unconscious emotional reactions
– Nurse  patient
– based on the nurse’s past experiences
– sympathetic
– unable to confront the pt appropriately

Interventions
• 1 st
– Recognize
• 2 nd
– Discuss
– Gently & directly

Course Objective #27
• Relate the nursing process to psychiatric nursing

• Assessment
• Diagnosis
• Planning
• Implementation
• Evaluation

Nursing process in psychiatric nursing…
• Patient centered
• Individualized

Course Objective #28
• List key members for a psychiatric treatment team.

Treatment Team
• Psychiatrist:
– MD
– Specializes in psychiatry
– Lead
– Writes medical orders

Treatment Team
• Psychologist:
– PhD in psychology
– psychological testing
– individual therapy

• RN+ Master ( ᴪ)
• I – G – F therapy
• Education

Treatment Team
• Clinical Social Worker:
– D/C planning/placement
– individual therapy
– licensed

Treatment Team
• MFT’s:
– Marriage and family therapists
– Run groups
– Individual therapy

Treatment Team
• Nursing Staff:
– RN’s, LVN’s, PT’s:
– manage the milieu
– administer meds

Treatment Team
• Activity Therapists:
– AKA: Recreational therapist
– Leisure skill
– Activity therapy groups

Treatment Team
• Occupational Therapists:
– Training for work skills
– ADL’s

Treatment Team
• Patient:
– Participate

Encouraging Description of Perceptions
• Perceptions are unique so it is important to learn how each person perceives a feeling or interprets situations and events.

Course objective #29 & 30
• Define and describe the following: Intake interview, Brief psychiatric rating scale,
Nursing care plan, Process recording
• Define and give examples SOAP and narrative progress notes

• Proof
• Law
Documentation

Types of Documentation
• Progress Notes:
– Assessing and analyzing communication skills, identifying pt themes, and evaluating the effectiveness of interventions

Types of Documentation
• S.O.A.P. Notes:
– General narrative of basic nursing care provided to the pt

SOAP Charting
S:
Subjective Data:
– What the pt says: “___”
– Reported

SOAP Charting
• O:
• Objective Data:
– Direct observation

SOAP Charting
• A:
• Assessment/Analysis:
– interpretation
– Conclusions
– responses

SOAP Charting
• P:
• Plan:
– Actions / treatments

Types of Documentation
• Problem-oriented Recording (POR)
– description of a specific intervention, used for a specific problem and evaluates the pts response

P.I.E.
Problem-oriented Charting
• P
– Problem
• I
– Intervention
• E
– Evaluation

Types of Documentation
• Pt Care Plan:
– Formal, written plan
– Guides pt care
• Diagnosis
• Goals
• Interventions

Types of Documentation
• Special Procedures Documentation:
– Interventions implemented
– Timely
– Expected level of care

Intake Interview
• Systematic
• Mental Status Exam (MSE)
• Assessments include:
– Motivation to change
– Coping strategies
– Defense mechanisms
– Recurring T, F, B’s