Therapeutic N-Pt Relationship
Communication
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Therapeutic N-P Relationship
• Def: a series of goal-directed interactions
• Peplau: nursing as a significant, therapeutic,
interpersonal process
• Characteristics - goals, stages, specific time
and place. It is different from a social
relationship
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N-Pt Relationship
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Communication skills
Respect and a desire to help
Trust is based on confidentiality
Understanding
mental mechanisms
adaptation styles
coping strategies
therapeutic intervention skills
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Communication
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In-born nature
Happened at anytime, anyplace,
Multi-level
Verbal & Nonverbal
Proxemics - environmental, social, and
personal space
Kinesics - body movement
• Can be learned
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Therapeutic Communication
• Def: It is an interpersonal interaction in
which the nurse used the self to focus on the
client’s emotional issues, establish a
therapeutic relationships, identify client’
issues, discern the most important topic at
that time, and guide the client toward
identifying his/her own solutions to
problems
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Therapeutic Communication
Techniques (I)
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Broad opening - start the conversation
Offering self - available, concern, interest
Active listening - content, emotion
Using silence - respect, anxiety
Asking questions - what, when, who…
General leads - go on, Mm...
Restating - repeating
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Thera. Commu. Tech (II)
• Making observation - comment on what
have been seen
• reflecting
• Clarification - restate
• Focusing - single, important topic
• Exploring - getting more information
• Interpreting -
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Thera. Commu. Tech (III)
• Giving information - decision making
• Presenting reality - but no argument
• Voicing doubt - uncertainty about pt’s
interpretation/conclusion
• Placing an event in time or sequence - R
among events
• Encouraging comparison - similarity &
difference
• Summarizing - review the main points
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Nontherapeutic communication
techniques
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Advising vs. information giving
Agreeing/approval vs. giving recognition
Disagreeing vs. information seeking
Challenging/arguing vs. information seeking
Defending vs empathy
Introducing unrelated topic vs. focusing
Judging vs. voicing doubt
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Nontherapeutic communication
techniques (cont’d)
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Literal response
Probing Reassuring - false promising
Rejecting - no more sharing
Testing - level of insight/knowledge
Close-ended question - yes/no
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Phases of N-Pt Relationship
• Preinteraction phase
self-awareness, self-exploration
• Introductory or orientation phase
making a contract, building trust, setting goals
• Working phase
explore stressors, promoting insight, reality testing,
problem-solving, coping, identifying past
ineffective behavior
• Termination phase
goals, evaluation, referrals, separation, loss,
emotional responses
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Orientation Stage
• Building trust - honest, consistent, warmth
• Basic assessment - coping styles, needs,
tentative goals, awareness of the problems
• Management of emotions- fear of losing
control, anxiety, guilt, confusion,
• Providing support - non-judgmental,
recognize the healthy actions & feelings
• Providing structure - limit setting
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Assessment
• Mental status examination - orientation,
memory, calculation, attention, judgment…
• Fifth vital signs - Pain
• Violence , history of physical/sexual abuse
• Substance abuse
• Withdrawal symptoms, differential Dx, dual
Dx.
• Holistic/ interdisciplinary team- realistic goals
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Working Stage
• The process of learning - observation,
analysis, interpretation,
• In-depth data collection,
• Reality testing & cognitive restructuring
• Supportive confrontation
• Promoting change,
• Teaching new skills – social skills, problem
solving skills…
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Termination Stage
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Evaluation;
summarize the objectives achieved
Referrals
Discussion of termination - emotional
responses; acceptance, denial, anger,
regression.
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Use of Self - Self is the “Tool”
• Want to help
• Open to learn about self and others Process recording
• Respect & privacy
• Communication - verbal/nonverbal
• Insight - defense mechanisms, adaptation,
and coping
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Process Recording
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The tool with which the nurse
assesses pt’s problems,
elicits pt’s input,
selects interventions
evaluates the effectiveness of care
learns about self
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Process Recording (cont’d)
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Verbal interaction & nonverbal behaviors
Analysis of content, mood, and interaction
Share with colleagues
Learning tool / professional growth
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Nursing Challenges
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Silence - being quiet, listening, respect,
“Doing nothing” - lack of structure
Fear of aggression
What to say - saying wrong thing
Being there vs. being therapeutic - no one is
100% therapeutic
• Touch
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More Nursing Challenges
• Self-disclosure - guidelines & cautions
• Keep self disclosure effective
Not to meet your own needs
Monitor your comfort level
Respect pt privacy/ comfort level
Never agree to secrecy
Cultural variations
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Clinical Wisdom
• Remain true to nursing role and avoid the
seductions of institutionalization
• Nurses must constantly monitor and
understand boundary management,
transference and countertransference issues
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Empathy
Putting yourself in the other’s shoes
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Being there
Listening
Assumption - as if
Interpretation and validation
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Barriers in Expressing Empathy
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Stress
Lack of time
High acuity, high workload
New employee
Caring for difficult patients
Limited opportunities to spend time with
patients
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English as a Second Language
• Diversity trend of the society.
• Process information in another language &
articulate a culturally sensitive patient
response.
• Mentor & support the ESL psychiatric
worker in linguistic competence &
therapeutic communication techniques.
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Demographics in the U.S.
• 1998 - U.S. Bureau of Census
• White, 72%;
Black, 13%
• Hispanic, 11%; Asian and Pacific Islanders 4%.
• 2050: Euro-Americans will be the slight majority
and the combination of other cultural groups will
make up the remaining 48% of the people in the
United States
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Shrink the Earth’s Population to
100
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57 Asians
21 Europeans
14 North, Central and South Americans
8 Africans
70 would be non-white, 30 white
70 would be non-Christian, 30 Christian
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Cultural Issues
• Ethnocentrism – only acknowledging and
valuing one’s own culture
• Cultural competent nursing
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Sensitivity
Awareness
Knowledge
Encounter
Desire
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Nursing Diagnosis & Nursing Goals
Nursing Dx. - be specific and point to a
desired outcome
Goals 1. adaptive behavior vs. dysfunctional one
2. measurable and achievable in time frame
3. Short- term vs. long-term goals
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Behavioral Assessment
• Context, thought, and feeling associated
with the behavior,
• Congruence of the behavior to the context
• Adapativeness of the behavior
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Planning
• Behavior-oriented problems - suicide,
aggression, escape, withdrawal, delusion,
compulsive acts,
• Update with treatment team
• Patient’s strength and weakness
• Continuum of care - education, referral, ...
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Anxiety, Coping & Crisis
Stressor
Anxiety
Coping behaviors
Neurochemical/
physiological
reactions
Adaptive
Maladaptive
Dysfunctional
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Defense Mechanisms
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Compensation
Conversion
Denial
Displacement
Dissociation
Identification
Intellectualization
Projection
• Rationalization
• Reaction
formation
• Regression
• Repression
• Sublimation
• Suppression
• Undoing
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Defense Mechanisms (II)
• Primary gain – relief or expression of
anxiety through symptoms of disorder.
• Secondary gain – attention and support
received from others while ill.
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Theory and model
• Theory – beliefs about how things happen
and work
• Theory lead to the expansion of knowledge
• Theories & models:
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Psychoanalytic theory
Behavior theory
Cognitive-behavior theory
Ecologic-developmental model
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Family Adaptation Model
• Dealing with the catastrophic event
– Crisis, chaos, shock
– Denial
– Hoping against hope
• Learning to cope
– Anger, gild, resentment
– recognition
– grief
• Moving into the advocacy
– Understanding, acceptance, advocacy and action
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Evidence based practice
• Nursing practice based on the scientific
method and empirical evidence
• Def: Care that integrates the best available
evidence from research with clinical
expertise
• Barrier –
– some clients are disenchanted with the
outcomes of professionally approved treatments
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– Pseudoscientific information from internet
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