Chapter 6

Question 1

The stranger

Answer 1

A nurse is at first a stranger to the patient. The patient is also a stranger to the nurse. Peplau (1991) stated:

Respect and positive interest accorded a stranger is at first nonpersonal and includes the same ordinary courtesies that are accorded to a new guest who has been brought into any situation. This principle implies: (1) accepting the patient as he is; (2) treating the patient as an emotionally able stranger and relating to him on this basis until evidence shows him to be otherwise. (p. 44)

Question 2

The resource person

Answer 2

According to Peplau, “A resource person provides specific answers to questions usually formulated with relation to a larger problem” (p. 47). In the role of resource person, the nurse explains, in language that the patient can understand, information related to the patient’s health care.

Question 3

The Teacher

Answer 3

In this role, the nurse identifies learning needs and provides information required by the patient or family to improve the health situation.

Question 4

The leader

Answer 4

According to Peplau, “Democratic leadership in nursing situations implies that the patient will be permitted to be an active participant in designing nursing plans for him” (p. 49). Autocratic leadership promotes overvaluation of the nurse and patients’ substitution of the nurse’s goals for their own. Laissez-faire leaders convey a lack of personal interest in the patient.

Question 5

The surrogate

Answer 5

Outside of their awareness, patients often perceive nurses as symbols of other individuals. They may view the nurse as a mother figure, a sibling, a former teacher, or another nurse who has provided care in the past. This perception occurs when a patient is placed in a situation that generates feelings similar to ones he or she has experienced previously. Peplau (1991) explained that the nurse-patient relationship progresses along a continuum. When a patient is acutely ill, he or she may incur the role of infant or child, while the nurse is perceived as the mother surrogate. Peplau (1991) stated, “Each nurse has the responsibility for exercising her professional skill in aiding the relationship to move forward on the continuum, so that person to person relations compatible with chronological age levels can develop” (p. 55).

Question 6

The technical expert

Answer 6

The nurse understands various professional devices and possesses the clinical skills necessary to perform interventions that are in the best interest of the patient.

Question 7

The counselor

Answer 7

The nurse uses “interpersonal techniques” to assist patients in adapting to difficulties or changes in life experiences. Peplau (1991) stated, “Counseling in nursing has to do with helping the patient to remember and to understand fully what is happening to him in the present situation, so that the experience can be integrated with, rather than dissociated from, other experiences in life” (p. 64).

Question 8

Rapport

Answer 8

Getting acquainted and establishing rapport is the primary task in relationship development. Rapport implies special feelings on the part of both the patient and the nurse based on acceptance, warmth, friendliness, common interest, a sense of trust, and a nonjudgmental attitude. Establishing rapport may be accomplished by discussing non–health-related topics. Travelbee (1971) states:

[To establish rapport] is to create a sense of harmony based on knowledge and appreciation of each individual’s uniqueness. It is the ability to be still and experience the other as a human being—to appreciate the unfolding of each personality one to the other. The ability to truly care for and about others is the core of rapport. (pp. 152, 155)

Question 9

Trust

Answer 9

Trust cannot be presumed; it must be earned. Trustworthiness is demonstrated through nursing interventions that convey a sense of warmth and caring to the patient. These interventions are initiated simply and concretely and directed toward activities that address the patient’s basic needs for physiological and psychological safety and security. Many psychiatric patients experience concrete thinking, which focuses their thought processes on specifics rather than generalities and on immediate issues rather than eventual outcomes. Examples of nursing interventions that promote trust in an individual who is thinking concretely include the following:

■ Providing a blanket when the patient is cold

■ Providing food when the patient is hungry

■ Keeping promises

■ Being honest (e.g., saying “I don’t know the answer to your question, but I’ll try to find out”) and then following through

■ Simply and clearly providing reasons for certain policies, procedures, and rules

■ Providing a written, structured schedule of activities

■ Attending activities with the patient if he or she is reluctant to go alone

■ Being consistent in adhering to unit guidelines

■ Listening to the patient’s preferences, requests, and opinions and making collaborative decisions concerning his or her care whenever possible

■ Ensuring confidentiality; providing reassurance that what is discussed will not be repeated outside the boundaries of the health-care team

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-patient relationship to progress beyond the superficial level of tending to the patient’s immediate needs.

Question 10

Respect

Answer 10

■ Calling the patient by name (and title, if he or she prefers).

■ Spending time with the patient.

■ Allowing sufficient time to answer the patient’s questions and concerns.

■ Promoting an atmosphere of privacy during therapeutic interactions with the patient and during physical examination or therapy.

■ Always being open and honest with the patient, even when the truth may be difficult to discuss.

■ Listening to the patient’s ideas, preferences, and opinions and making collaborative decisions concerning his or her care whenever possible.

■ Striving to understand the motivation behind the patient’s behavior regardless of how unacceptable it may seem.

Question 11

Genuineness

Answer 11

The concept of genuineness refers to the nurse’s ability to be open, honest, and “real” in interactions with the patient. To be real is to be aware of what one is experiencing internally and to allow the quality of this inner experience to be apparent in the therapeutic relationship. When one is genuine, there is congruence between what is felt and what is expressed

Question 12

Empathy

Answer 12

Empathy is the ability to see beyond outward behavior and understand the situation from the patient’s point of view. With empathy, the nurse can accurately perceive and comprehend the meaning and relevance of the patient’s thoughts and feelings. The nurse must also be able to communicate this perception to the patient by attempting to translate words and behaviors into feelings.

Question 13

The preinteraction phase

Answer 13

■ Obtaining available information about the patient from his or her chart, significant others, or other health-care team members. From this information, the initial assessment begins. The nurse may also become aware of personal responses to knowledge about the patient.

■ Examining one’s feelings, fears, and anxieties about working with a particular patient. For example, the nurse may have been reared in an alcoholic family and have ambivalent feelings about caring for a patient who is dependent on alcohol. All individuals bring attitudes and feelings from prior experiences to the clinical setting. The nurse needs to be aware of how these preconceptions may affect his or her ability to care for individual patients.

Question 14

The orientation (introductory) phase

Answer 14

■ Creating an environment for the establishment of trust and rapport.

■ Establishing a contract for intervention that details the expectations and responsibilities of both nurse and patient.

■ Gathering assessment information to build a strong patient database.

■ Identifying the patient’s strengths and limitations.

■ Formulating nursing diagnoses.

■ Setting goals that are mutually agreeable to the nurse and patient.

■ Developing a plan of action that is realistic for meeting the established goals.

■ Exploring feelings of both the patient and nurse in terms of the introductory phase.

Question 15

The working phase

Answer 15

■ Maintaining the trust and rapport established during the orientation phase.

■ Promoting the patient’s insight and perception of reality.

■ Problem-solving using the model presented earlier in this chapter.

■ Overcoming resistance behaviors on the part of the patient as the level of anxiety rises in response to discussion of painful issues.

■ Continuously evaluating progress toward goal attainment

Question 16

The termination phase

Answer 16

■ Progress has been made toward attainment of mutually set goals.

■ A plan for continuing care or for assistance during stressful life experiences is mutually established by the nurse and patient.

■ Feelings about termination of the relationship are recognized and explored. Both the nurse and patient may experience feelings of sadness and loss. The nurse should share his or her feelings with the patient. Through these interactions, the patient learns that it is acceptable to have these kinds of feelings at a time of separation. With this knowledge, the patient experiences growth during the process of termination. This is also a time when both nurse and patient may evaluate and summarize the learning that occurred as an outgrowth of their relationship.

Question 17

Transference

Answer 17

occurs when the patient unconsciously displaces (or “transfers”) to the nurse feelings formed toward a person from his or her past (Sadock, Sadock, & Ruiz, 2015). These feelings may be triggered by something about the nurse’s appearance or personality characteristics that remind the patient of another person. Transference can interfere with the therapeutic interaction when the feelings expressed include anger and hostility. Anger toward the nurse can be manifested by uncooperativeness and resistance to therapy.

Question 18

Countertransference

Answer 18

refers to the nurse’s behavioral and emotional responses to the patient in which the nurse transfers feelings (often unconscious) about past experiences or people onto the patient. These responses may be related to unresolved feelings toward significant others from the nurse’s past, or they may be generated in response to transference feelings on the part of the patient. It is not easy to refrain from becoming angry when the patient is consistently antagonistic, to feel flattered when showered with affection and attention by the patient, or even to feel quite powerful when the patient exhibits excessive dependency on the nurse. These feelings can interfere with the therapeutic relationship when they initiate the following types of behaviors:

■ The nurse overidentifies with the patient’s feelings, as they remind him or her of problems from the nurse’s past or present.

■ The nurse and patient develop a social or personal relationship.

■ The nurse begins to give advice or attempts to “rescue” the patient.

■ The nurse encourages and promotes the patient’s dependence.

■ The nurse’s anger engenders feelings of disgust toward the patient.

■ The nurse feels anxious and uneasy in the presence of the patient.

■ The nurse is bored and apathetic in sessions with the patient.

■ The nurse has difficulty setting limits on the patient’s behavior.

■ The nurse defends the patient’s behavior to other staff members.

The nurse may be completely unaware or only minimally aware of the countertransference as it is occurring (Hilz, 2013).

Question 19

Material Boundaries

Answer 19

These boundaries can be seen, such as fences that border land.

Question 20

Social Boundaries

Answer 20

These are established within a culture and define how individuals are expected to behave in social situations.

Question 21

Personal Boundaries

Answer 21

These are boundaries that individuals define for themselves. They include physical distance boundaries, or how closely individuals will allow others to enter their physical space, and emotional boundaries, or how much individuals choose to disclose of their most private and intimate selves to others

Question 22

Professional Boundaries

Answer 22

These boundaries limit and outline expectations for appropriate professional relationships with patients. “Professional boundaries are the spaces between a nurse’s power and the patient’s vulnerability” (National Council of State Boards of Nursing [NCSBN], 2018). Nurses must recognize that they have an imbalance of power with their patients because of their role and the patient information to which they have access. They must be consistently conscientious in avoiding any circumstance in which they might achieve personal gain within that relationship.

Question 23

Self Disclosure

Answer 23

Self-disclosure on the part of the nurse may be appropriate when the information could therapeutically benefit the patient. It should never be undertaken to meet the nurse’s needs.

Question 24

Gift Giving

Answer 24

Individuals who are receiving care often feel indebted toward health-care providers. The British Columbia College of Professional Nurses (BCCPN, 2019) clarify in their practice standards that, although nurses do not generally exchange gifts with patients, when it is deemed to have therapeutic intent, groups of nurses may accept a token gift, but significant gifts should be returned or redirected. There is always a degree of clinical judgment necessary in deciding to accept or refuse a gift, including the appropriateness, the value, and the reason the gift is being offered. Cultural beliefs and values may also enter into the decision of whether to accept a gift from a patient. In some cultures, failure to do so would be interpreted as an insult (Pies, 2012). Accepting financial gifts is never appropriate, but in some instances, nurses may be permitted to instead suggest a donation to a charity of the patient’s choice. If acceptance of a small gift of gratitude is deemed appropriate, the nurse may choose to share it with other staff members who have been involved in the patient’s care. In all instances, nurses should exercise professional judgment when deciding whether to accept a gift from a patient, and refusal of a gift should be done with sensitivity for the patient’s feelings. Attention should be given to what the gift-giving means to the patient, as well as to institutional policy, the American Nurses Association (ANA) Code of Ethics for Nurses, and the ANA Scope and Standards of Practice.

Question 25

Touch

Answer 25

Nursing, by its very nature, involves touching patients. Touching is required to perform the therapeutic procedures involved in providing physical care. Caring touch is the touching of patients when there is no physical need to do so. Touching or hugging can be beneficial when it is implemented with therapeutic intent and patient consent. When using caring touch, make sure it is appropriate, supportive, and welcomed (BCCPN, 2019). Caring touch may provide comfort or encouragement, but some vulnerable patients may misinterpret its meaning. In some cultures, touch is not considered acceptable unless the parties know each other very well. The nurse must be sensitive to these cultural nuances and aware when touch is crossing a personal boundary. Additionally, patients who are experiencing high levels of anxiety, suspiciousness, or psychosis may interpret touch as aggressiveness. These are times when touch should be avoided or considered with extreme caution.

Question 26

Friendship or romantic association

Answer 26

When a nurse is already acquainted with a patient, the relationship must move from a personal nature to professional. If the nurse is unable to accomplish this separation, he or she should withdraw from the nurse-patient relationship. Likewise, nurses must guard against personal relationships developing as a result of the nurse-patient relationship. Romantic, sexual, or otherwise intimate personal relationships are never appropriate between nurse and patient.