1. Presented by Jasleen Kaur Brar Nurse-Patient
Relationship
2. INTRODUCTION The nurse-client relationship is the foundation
on which psychiatric nursing is established. The therapeutic
interpersonal relationship is the process by which nurses provide
care for clients in need of psychosocial intervention.
3. Mental health providers need to know how to gain trust and
gather information from the patient, the patient's family, friends
and relevant social relations, and to involve them in an effective
treatment plan. Therapeutic use of self is the instrument for
delivery of care to clients in need of psychosocial intervention.
Interpersonal communication techniques are the tools of
psychosocial intervention.
4. DYNAMICS OF A THERAPEUTIC NURSE-CLIENT RELATIONSHIP
Travelbee (1971), who expanded on Peplaus theory of interpersonal
relations in nursing, has stated that is is only when each
individual in the interaction perceives the other as a unique human
being that a relationship is possible. Therapeutic relationships
are goal oriented. The nurse and client decide together what the
goal of the relationship will be. Most often, the goal is directed
at learning and growth promotion, in an effort to bring about some
type of change in the clients life.
5. 1. Therapeutic Use of Self Travelbee described as ability to
use ones personality consciously and in full awareness in an
attempt to establish relatedness and to structure nursing
interventions. Nurses must possess self-awareness, self-
understanding, and a philosophical belief about life, death, and
the overall human condition for effective therapeutic use of
self.
6. 2. Gaining Self- Awareness Values clarification Knowing and
understanding oneself enhances the ability to form satisfactory
interpersonal relationships. Self awareness requires that an
individual recognize and accept what he or she values and learn to
accept the uniqueness and differences in others. An individuals
value system is established very early in life and has its
foundation in the value system held by primary caregivers. It is
culturally oriented; it may change many times over the course of a
lifetime; and it consists of beliefs, attitudes and values. Value
clarification is one process by which an individual may gain
self-
7. Beliefs A belief is and idea that one holds to be true, and
it can take any of several forms: Rational beliefs: Ideas for which
objective evidence to substantiate their truth. Irrational beliefs:
Ideas that an individual holds as true despite the existence of
objective contradictory evidence. Faith (sometimes called blind
beliefs): An ideal that an individual holds as true for which no
objective evidence exists. Stenotype: A socially shared belief that
describes a concept in an oversimplified or undifferentiated
matter.
8. Attitudes An attitude is a frame of reference around which
an individual organizes knowledge about his or her world. An
attitude also has an emotional component. Attitudes fulfil the need
to find meaning in life and to provide clarity and consistency for
the individual. The prevailing stigma attached to mental illness is
an example of negative attitude. An associated belief might be that
all people with mental illness are dangerous.
9. Values Values are abstract standards, positive or negative,
that represent an individuals ideal mode of conduct and ideal
goals. Examples of ideal mode of conduct include seeking truth and
beauty; being clean and orderly; and behaving with sincerity;
justice, reason, compassion, humility, respect, honour and loyalty.
Examples of ideal goals are security, happiness, freedom, equality,
ecstasy, fame and power.
10. Values differ from attitudes and beliefs in that they are
action oriented or action producing. One may hold many attitudes
and beliefs without behaving in a way that shows one holds those
attitudes and beliefs. Attitudes and beliefs flow out of ones set
of values. An individual may have thousands of beliefs and hundreds
of attitudes but his/ her values probably only number in the
dozens. Values may be viewed as a kind of core concept or basic
standards that determine ones attitudes and beliefs, and ultimately
ones behaviour. Raths, Merril, and Simon (1966) identified a seven
step process of valuing that can be used to help clarify personal
values. The process can be used by applying these seven steps to an
attitude or belief that one holds. When an attitude or belief has
met each of the seven
11. Level of operations Category Criteria Explanation Cognitive
Choosing 1. Freely 2. From alternatives 3. After careful
consideration of the consequences This value is mine. No one forced
me to choose it. I understand and accept the consequences of
holding this value. Emotional Prizing 1. Satisfied; pleased with
the choice 2. Making public affirmation of the choice, if necessary
I am proud that I hold this value, and I am willing to tell others
about it. Behavioural Acting 1. Taking action to demonstrate the
value behaviourally 2. Demonstrating this pattern of behaviour
consistently and repeatedly The value is reflected in the
individuals behaviour for as long as he or she holds it.
12. The Johari Window Also referred to as a
'disclosure/feedback model of self awareness. It was developed by
American psychologists Joseph Luft and Harry Ingham in the 1950's,
calling it 'Johari' after combining their first names, Joe and
Harry. Terminology: Refers to 'self' and 'others Self' - oneself,
i.e., the person subject to the Johari Window analysis 'Others' -
other people in the team
13. The four Johari Window perspectives: Called 'regions' or
'areas' or 'quadrants'. Each contains and represents the
information - feelings, motivation, etc in terms of whether the
information is known or unknown by the person, and whether the
information is known or unknown by others in the team The four
regions, areas, quadrants, or perspectives are as follows, showing
the quadrant numbers and commonly used names.
14. Johari window four regions 1. Open area, open self, free
area, free self, or 'the arena: what is known by the person about
him/herself and is also known by others. 2. Blind area, blind self,
or 'blindspot: what is unknown by the person about him/herself but
which others know 3.Hidden area, hidden self, avoided area, avoided
self or 'faade: what the person knows about him/herself that others
do not know 4.Unknown area or unknown self: what is unknown by the
person about him/herself and is also unknown by others
15. Johari quadrant 1 Open self/area, 'free area, 'public
area', 'arena Also known as the 'area of free activity Information
about the person - behaviour, attitude, feelings, emotion,
knowledge, experience, skills, views, etc known by the person ('the
self') and known by the team ('others').
16. The aim in any team is to develop the 'open area' for every
person, because when we work in this area with others we are at our
most effective and productive, and the team is at its most
productive too The open free area, or 'the arena - the space where
good communications and cooperation occur, free from distractions,
mistrust, confusion, conflict and misunderstanding
17. Johari quadrant 2 Blind self' or 'blind area' or
'blindspot: what is known about a person by others in the group,
but is unknown by the person him/herself Could also be referred to
as ignorance about oneself, or issues in which one is deluded Not
an effective or productive space for individuals or groups Also
include issues that others are deliberately withholding from a
person
18. The aim is to reduce this area by seeking or soliciting
feedback from others and thereby to increase the open area, i.e.,
to increase self- awareness Team members and managers take
responsibility for reducing the blind area - in turn increasing the
open area - by giving sensitive feedback and encouraging disclosure
Managers promote a climate of non-judgemental feedback, and group
response to individual disclosure, and reduce fear
19. Johari quadrant 3 Hidden self' or 'hidden area' or 'avoided
self/area' or 'facade' What is known to ourselves but kept hidden
from, and therefore unknown, to others Represents information,
feelings, etc, anything that a person knows about him/self, but
which is not revealed or is kept hidden from others Also include
sensitivities, fears, hidden agendas, manipulative intentions,
secrets - anything that a person knows but does not reveal
20. Relevant hidden information and feelings, etc, should be
moved into the open area through the process of 'self-disclosure'
and'exposure process' Organizational culture and working atmosphere
have a major influence on team members' preparedness to disclose
their hidden selves The extent to which an individual discloses
personal feelings and information, and the issues which are
disclosed, and to whom, must always be at the individual's own
discretion
21. Johari quadrant 4 Unknown self, 'area of unknown activity,
'unknown area' Information, feelings, latent abilities, aptitudes,
experiences etc, that are unknown to the person him/herself and
unknown to others in the group Can be prompted through
self-discovery or observation by others, or through collective or
mutual discovery Counselling can also uncover unknown issues Again
as with disclosure and soliciting feedback, the process of self
discovery is a sensitive one
22. Uncovering 'hidden talents' - that is unknown aptitudes and
skills, not to be confused with developing the Johari 'hidden area'
- is another aspect of developing the unknown area, and is not so
sensitive as unknown feelings Managers and leaders can create an
environment that encourages self discovery, and to promote the
processes of self discovery, constructive observation and feedback
among team members The unknown area could also include repressed or
subconscious feelings rooted in formative events and traumatic past
experiences, which can stay unknown for a lifetime
23. THERAPEUTIC NURSE-CLIENT RELATIONSHIP Therapeutic
relationships are goal- oriented and directed at learning and
growth promotion.
24. Requirements for Therapeutic Relationship Rapport: getting
acquainted and establishing rapport is the primary task in
relationship development. Rapport implies special feeling on the
part of both the client and the nurse based on acceptance, warmth,
friendliness, common interest, a sense of trust and nonjudgemental
attitude.
25. Trust: to trust another, one must feel confidence in that
persons presence, reliability, integrity and sincere desire to
provide assistance when requested. Trust is the basis of a
therapeutic relationship. The nurse working in psychiatry must
perfect the skills that foster the development of trust. Trust must
be established in order for the nurse-client relationship to
progress.
26. Respect: To show respect is to believe in the dignity and
worth of an individual regardless of his or her unacceptable
behaviour. The psychologist Carl Rogers called this unconditional
positive regard. The client is accepted and respected for no other
reason than that he or she is considered to be a worthwhile and
unique human being.
27. Genuineness: it refers to the nurses ability to be open,
honest and real in interactions with the client. To be real is to
be aware of what one is experiencing internally and to allow the
quality of inner experiencing to be apparent in the therapeutic
relationship. The nurse who possesses the quality of genuineness
responds to the client with trust and honesty, rather than with
responses he or she may consider more professional or ones that
merely reflect the nursing role.
28. Empathy: empathy is the ability to see beyond outward
behaviour and to understand the situation from the clients point of
view. With empathy the nurse can accurately perceive and comprehend
the meaning and relevance of the clients thoughts and feelings.
Empathy is considered to be one of the most important
characteristics of a therapeutic relationship. Accurate empathetic
perceptions on the part of the nurse assist the client to identify
feelings that may have been suppressed or denied.
29. Phases of a Therapeutic Nurse- Client Relationship
Pre-interaction phase Orientation/Introdu ctory Period Working
Termination
30. 1.Preinteraction Phase it involves preparation for the
first encounter with the client. Tasks include- Obtaining available
information about the client from his or her chart, significant
others, or other health team members. From this information, the
initial assessment is begun. This initial information may also
allow the nurse to become aware of personal responses to knowledge
about the client. Examining ones feelings, fears, and anxieties
about working with a particular client.
31. 2.Orientation Phase Establishing therapeutic environment.
The roles, goals, rules and limitations of the relationship are
defined, nurse gains trust of the client, and the mode of
communication are acceptable for both nurse and patient is set.
Acceptance is the foundation of all therapeutic relationship
Acceptance of others requires acceptance of self first.
32. Rapport is built by demonstrating acceptance and
non-judgmental attitude. Acceptance of patient means encouraging
the patient verbally and non-verbally to express both positive and
negative feelings even if these are divergent from accepted norms
and general viewpoint. The nurse can encourage the client to share
his/her feelings by making the client understand that no feeling is
wrong. Trust of patient is gained by being consistent.
33. Assessment of the client is made by obtaining data from
primary and secondary sources. The patient set the pace of the
relationship. During this phase, the problems are not yet been
resolved but the clients feelings especially anxietyis reduced, by
using palliative measures, to enable the client to relax enough to
talk about his distressing feelings and thoughts.
34. This stage progresses well when the nurses show empathy
provide support to client and temporary structure until the client
can control his own feelings and behavior. Reality testing is
accepting the patients perceptions, feelings and thoughts as
neither right nor wrong, but at the same time offering other
options or points of view to the client in a non-argumentative
manner for the purpose of helping the client arrive at more
realistic conclusions. To provide structure is to intervene when
the client loses control of his own feelings and behaviors by
medications, offering self, restrain, seclusion and by assisting
client to observe a consistent daily schedule.
35. 3. Working/ Exploration/ Identification Stage at this
point, the clients problems are identified and solutions are
explored, applied and evaluated. The focus of the assessment and of
the relationship is the clients behavior and the focus of the
interaction is the clients feelings. The nurse should realize that
the clients feelings of security are developed by being consistent
at all times.
36. Perception of reality, coping mechanisms and support
systems are identified. The nurse assists the patient to develop
coping skills, positive self concept and independence in order to
change the behavior of the client to one that is adaptive and
appropriate. The nurse uses the techniques of communication and
assumes different roles to help the client.
37. 4. Termination/ Resolution stage The nurse terminates the
relationship when the mutually agreed goals are met, the patient is
discharged or transferred or the rotation is finished. The focus of
this stage is the growth that has occurred in the client and the
nurse helps the patient to become independent and responsible in
making his own decisions. The relationship and the growth or change
that has occurred in both the nurse and the patient is
summarized.
38. Client may become anxious and react with increased
dependence, hostility and withdrawal, these are normal reactions
and are signs of separation anxiety, these feelings and behavior
should be discussed with the client. The nurse should be firm in
maintaining professionalism until the end of the relationship. She
should not promise the client that the relationship will be
continued.
39. The time parameters should be made early in the
relationship and meetings are set further and further apart near
the end to foster independence of the patient and prepare the
latter gradually for the separation. The nurse should not give her
address or telephone numbers to the patient. Referral for
continuing health care and support after discharge provides
additional resources for the client and the family.
40. The goal of the therapeutic relationship have been met when
the patient has developed emotional stability, cope positively,
recognized sources or causes of anxiety, demonstrates ability to
handle anxiety and independence, and is able to perform self-care.
Preparation of the termination phase begins at the orientation
phase, when the duration and length of the nurse-client
relationship was established. It is normal for the client to
experience separation anxiety such as sleeplessness, anorexia,
physical symptoms, withdrawal and hostility.
41. Boundaries in the Nurse-Client Relationship Material
boundaries Social boundaries Personal boundaries Professional
boundaries Self-disclosure Gift-giving Touch Friendship or romantic
association
42. Certain warning signs exist that indicate that professional
boundaries of the nurse-patient relationship may be in jeopardy:
Favouring one clients care over that of another Keeping secrets
with a client Changing dress style for working with a particular
client Swapping client assignments to care for a particular client
Giving special attention or treatment to one client over others
Spending free time with a client Frequently thinking about the
client when away from work Sharing personal information or work
concerns with the client
43. Role of the Psychiatric Nurse The stranger The resource
person The teacher The leader The surrogate The counsellor
44. Research related to nurse patient relationship Bonnie M.
Hagerty, Kathleen L. Patusky concluded human relatedness framework
provides new insights and oppurtunities for assessment,
intervention and research within the context of nurse patient
relationship. Wendy Moyle did phenomenological study of individuals
hospitalized with a depressive illness found that a therapeutic
relationship did not come instinctively to the mental health nurses
and that there was a dichotomy between the close relationship
expected by patients and the distant relationship provided by
nurses.
45. Summarization Introduction Dynamics of therapeutic nurse
client relationship The Johari Window Requirements for therapeutic
relationship Phases of therapeutic nurse client relationship
Boundaries in nurse client relationship Role of nurse
46. Bibliography Michael W. Eyesenck & cara
Flanagan.Psychology for A2 Level;[1];306-24 Fernald/Fernald. Munns
Introduction to Psychology. [5];241-65 Carole Wade, Carol Tavris.
Psychology.[8];407-15 Clifford T. Morgan, Richard A. King, John R.
Weisz, John Schopler. Introduction to Psychology;[8]64-87
