1

The Nurse-Patient

Relationship:

Developing the Therapeutic

Relationship

2

Developing Therapeutic Relationships

At the completion of this session students will:

Formulate a list of therapeutic techniques

Have reviewed the phases of a therapeutic one-to-one relationship

Compare and contrast social and therapeutic relationships

Be aware of the potential boundary violations that may occur during a therapeutic relationship

Define self-awareness and describe a strategy for developing self-awareness

3

Exercise

Discuss within groups these following

questions:

What is a relationship?

What does it mean to be therapeutic?

How does the therapeutic relationship differ

from other relationships?

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The Therapeutic relationship is a

concept that is fundamental to the

identity of mental health nurses

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Characteristics of a therapeutic

relationship

Nurse takes responsibility for the conduct of the relationship

Relationship has a specific purpose and a health related goal

Relationship terminates when the identified goal is met

Focus of the relationship is on the client

Relationship is entered through necessity

Choice of whom to be in the relationship is not available to either the nurse or the client

Self-disclosure is limited for the nurse but encouraged for the client

Understanding should always be put into words

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The Mental Health Nurse role within

the relationship

Route to understanding

Finding meaning to the experience

Creating opportunities for change to occur

Problem solving

Health promotion

Being a resource for clients

education

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Peplau’s six nursing roles

Stranger role

Resource role

Teaching role

Counselling role

Surrogate role

Active leadership role

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Enhancing growth in others

Genuineness– Congruence

Empathy– Understanding ideas expressed and feelings present in

the other

Positive regard– Some actions manifest an attitude of respect

(attending, suspending value judgments)

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Enhancing growth in others

Helping Clients Develop Resources

– Awareness, encouragement

Self disclosure

– Appropriate (feelings, attitudes and beliefs)

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Exercise: Recognising role

limitations in self-disclosure

1. Make a list of phrases that describe your

own personality, such as: I am shy

I get angry when criticised

I find conflicts hard to handle

I am sexy

2. Mark each descriptive phase with one of

the following:A. Too embarrassing or intimate to discuss in a group

B. Could discuss in a group of peers

C. This behaviour characteristic might affect my ability to

function in a therapeutic manner if disclosed

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Exercise cont’dDiscuss in groups:

1. What criteria were used to determine the

appropriateness of self-disclosure?

2. How much variation is there in what each of you

would share with others in a group or clinical

setting?

3. Were there any behaviours commonly agreed on

that would never be shared with a client?

4. What interpersonal factors about the client would

facilitate or impede self-disclosure by the nurse?

5. What have you learnt from this exercise that

could be useful in future encounters with clients?

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Phases of the Nurse-Client

relationship

Preorientation

– Planning for the first interaction with client

– Identifying nurse concerns

Orientation

– Compressed due to short hospitalisations;

longer in community-based care

– Issues: trust, parameters of relationship,

contract, confidentiality, termination

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Phases of the Nurse-Client

relationship Working – Tasks:

– Maintain relationship

– Gather further information

– Promote client problem-solving skills, self-esteem and

communication

– Facilitate behavioural change

– Overcome resistance behaviours

– Evaluate problems and goals and redefine them as

necessary

– Practice and express alternative adaptive behaviours

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Phases of the Nurse-Client

relationship

Termination

– Deal with intense feelings regarding the

experience

– Summarise goals and objectives

– Review client plans for the future

– Finalise termination

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Boundary Blurring

Relationship slips into a social context

Nurse behaviour meets personal needs at expense of client

Under helping

Over helping

Controlling

Narcissism

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Boundary Blurring

Transference

– the unconscious emotional reaction patients have in a current situation that is really based on previous relationships and experiences

– Main Issue – the wish to be taken care of and to have needs met

– Forms may be severe or subtle

– Can be positive and negative

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Boundary Blurring

Counter- Transference

– Reactions based on the nurses past experience

– May lead the nurse to have inappropriate

responses to a patients action

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Boundary Blurring

Transference – Interventions

– Recognise the transference or counter-

transference

– Examine gently but directly

– Limit setting

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Factors beneficial to relationships

Consistent regular and private interactions with client– Consistency in assigned nurse

– Regular routine of activities

Being honest and congruent

Letting client set the pace

Listening to client concerns

Positive initial attitudes and preconceptions

Promoting client comfort and balancing control

Client demonstrating trust and actively participating in relationship

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Factors hampering relationship

Lack of nurse availability

Lack of nurse self-awareness

Nurse negative feelings about client

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Self-awareness

Recognising the nature of ones own

attitude, emotions and behaviour

a keen sense of self awareness acts as a

barometer of the relationship process

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Exercise – Developing self-

awareness

An effective way of raising self-awareness is

the use of questioning.

In order to raise your awareness of some

important issues ask yourself the following

questions then discuss your responses in

small groups

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1. What kinds of values do I hold as a important framework for living?

2. Where do these values come from?

3. How do they inform my understanding of what it is to be a person in this world?

4. How has my family of origin influenced how I view the world?

5. What values did my family hold as important?

6. What do I see as important in family life?

7. What do I know about why I choose to be a nurse?

8. What are the pervading social attitudes towards people in mental distress?

9. What are my beliefs about people in mental distress or with mental illness?

10. What experiences have I had that influence how I feel about people with mental illness?