Chapter 8: Therapeutic Relationships

Question 1

Concepts of the Nurse-Patient Relationship

Answer 1

Basis of all psychiatric nursing treatment approaches
To establish that the nurse is: safe, confidential, reliable, consistent
Relationship with clear boundaries

Question 2

Use personality consciously and in full awareness.
Attempt to establish relatedness
Structure nursing interventions

Answer 2

Therapeutic use of self.

Be aware of yourself

Question 3

Goals and functions

Answer 3

Facilitate communication of distressing thoughts and feelings
Assist pt with problem solving
Help pt examine self-defeating behaviors and test alternatives
Promote self-care independence
Goal oriented and directed at learning and growth development

Question 4

Social relationships

Answer 4

Initiated for the purpose of friendship, socialization, enjoyment, or accomplishment of a task
Mutual needs are met
Communication to give advice, give or ask for help
Content of communication superficial

Question 5

Therapeutic relationships

Answer 5

Needs of pt identified and explored 
Clear boundaries established
Problem-solving approaches taken 
New coping skills developed 
Behavioral change encouraged

Question 6

Necessary Behaviors for Nurses

Answer 6

Accountability 
Focus on pt's needs 
Clinical competence 
Delaying judgement 
Supervision 
Refrain judgements, not just delay them 
Unconditional acceptance and positive regard 
Understand your values and beliefs but don't impose them

Question 7

Establishing boundaries

Answer 7

Physical boundaries: also emotional space.
The contact: caring touch can be therapeutic to the pt. NEVER okay to have sexual or friendly relationship with the pt
Personal space

Question 8

Blurring of Boundaries

Answer 8

When relationship slips into social context
When nurse’s needs are met at expense of pt’s needs
Separating nurse’s needs from pt’s needs are how roles are differentiated.
Don’t do for them what they can do for themselves (don’t overhelp. Put some responsibility on them).
You aren’t there to feel helpful, you are there to give them what they need (you are there to be helpful, not feel helpful)

Question 9

Pt unconsciously and inappropriately displaces onto nurse feelings and behaviors r/t significant figures in pt’s past. Intensified in relationships of authority. Pt projects onto nurse. Someone else they are “confusing” you with.

Answer 9

Transference

Question 10

Nurse displaces feelings r/t people in nurse’s past onto pt. Pt’s transference to nurse often results in ____ in nurse. Common sign of ___ in nurse is over overidentification with pt. When therapist or nurse displaces onto pt positive or negative feelings of person from their past.

Answer 10

Countertransference.

Question 11

Warning signs that could indicate that professional boundaries of the nurse-client relationship may be in jeopardy

Answer 11

Favoring a pt’s care over another’s (special attenuate or tx to one pt over another)
Keeping secrets with a pt
Changing dress style for working with a particular pt
Swapping pt assignments to care for a particular pt
Spending free time with pt.
Frequently thinking about pt while away from work.
Sharing personal info or work concerns with pt
Receiving gifts or continuing contact with pt after discharge

Question 12

Nurse’s values and beliefs

Answer 12

Reflect own culture/subculture
Derived from range of choices
Chosen from a variety of influences and role models

Question 13

People’s Model of Nurse-Pt relationship

Answer 13

Used with every pt in every relationship
Important tool in all nursing practices
Accountability, focus on pts needs, clinical competence, supervision of nurse to validate performance quality
Therapeutic encounter
Pre-orientation, orientation, working, termination

Question 14

Prior to first clinical session. Thoughts and feelings that nurse experiences prior. Planning for first interaction.

Answer 14

Pre-orientation phase

Question 15

Establishing rapport (providing an atmonphere in which trust and understanding can grow). Parameters of the relationship. Formal or informal contract (times, dates, goals). Confidentiality. Terms of termination.

Answer 15

Orientation phase.
Name, how long you will be their nurse.
Start planning for discharge/termination during orientation.
Nurse needs to be aware of transference/countertransference issues.
Promote atmosphere of trust, establish mutually agreed upon goals
Initial emphasis is on establishing trust and rapport

Question 16

Maintain relationship.
Gather further data.
Promote pt’s: problem-solving skills, self-esteem, use of language
Facilitate behavioral change
Overcome resistant behaviors
Evaluate problems and goals: redefine them as necessary
Promote practice and expression of alternative adaptive behaviors

Answer 16

Working phase

Question 17

Summarize goals and objectives achieved.
Discuss ways for pt to incorporate new coping strategies learned.
Review situations of relationship.
Exchange memories/evaluate process

Answer 17

Termination

Question 18

Factors that help nurse-patient relationship

Answer 18

Consistency- what to expect and when
Pacing care according to the pt’s needs
Listening- every pt has a need to be heard. Listen o them and really hear them. Not just what is said but what is not said.
Initial impressions- look at any prejudice you may have before you enter the room for the first time.
Promoting pt comfort and balancing control- make sure that the pt is an independent and as self-sufficient as possible
Pt factors include: trust, active participation

Question 19

Factors that promote pt growth

Answer 19

Genuineness
Empathy (not sympathy)- ability to see things from pt’s perspective. Denotes acceptances.
Positive regard- ability to view another as being worthy of being cared for. Attitudes, actions.
Attending- special kind of listening that conveys you are there with the pt in that moment
Suspending value judgements
Helping pts develop resources- be aware of their strengths and encourage them to use their own resources. Conveys respect.

Question 20

The primary difference between a social and a therapeutic relationship is the

a) type of information exchanged.
b) amount of satisfaction felt.
c) type of responsibility involved.
d) amount of emotion invested.

Answer 20

c) type of responsibility involved.

Question 21

The use of empathy and support begins in the stage of the nurse-client relationship termed the

a) orientation stage.
b) working stage.
c) identification stage.
d) resolution stage.

Answer 21

a) orientation stage.

Question 22

A client reports that her mother-in-law is very intrusive. The nurse responds, “I know how you feel. My mother-in-law is nosy, too.” The nurse is demonstrating

a) self-disclosure in an appropriate way.
b) to the client permission to continue.
c) countertransference.
d) empathy to establish trust.

Answer 22

c) countertransference.

Question 23

Which of the following statements are true regarding the differences between a social relationship and a therapeutic relationship? (select all that apply):

a) In a social relationship, both parties’ needs are met; in a therapeutic relationship only the patient’s needs are to be considered.
b) A social relationship is instituted for the main purpose of exploring one member’s feelings and issues; a therapeutic relationship is instituted for the purpose of friendship.
c) Giving advice is done in social relationships; in therapeutic relationships giving advice is not usually therapeutic.
d) In a social relationship, both parties come up with solutions to problems and solutions may be implemented by both (a friend may lend the other money, etc.); in a therapeutic relationship solutions are discussed but are only implemented by the patient.
e) In a social relationship, communication is usually deep and evaluated; in a therapeutic relationship communication remains on a more superficial level, allowing patients to feel comfortable.

Answer 23

a) In a social relationship, both parties’ needs are met; in a therapeutic relationship only the patient’s needs are to be considered.
c) Giving advice is done in social relationships; in therapeutic relationships giving advice is not usually therapeutic.
d) In a social relationship, both parties come up with solutions to problems and solutions may be implemented by both (a friend may lend the other money, etc.); in a therapeutic relationship solutions are discussed but are only implemented by the patient.