Unit 1 Therapeutic Relationships Chapter 8

Question 1

Nurse and Patient Relationship

Answer 1

*Patient Centered Care: dignity and respect, information sharing, patient and family participation and collaboration in policy and program development

• Nurse-Patient Relationship is the basis of all psychiatric mental health nursing
  treatment.

Question 2

Goals and Functions of the Nurse-
Patient relationship

Answer 2

• Facilitates communication of distressing thoughts and feelings
• Assists pt in problem solving
• Helps pt examine self-defeating behaviors
• Promotes self-care and independence
• Provides education about meds and sx management
• Promotes Recovery

Question 3

What does social relationship consist of.

Answer 3

• Purpose of friendship, socialization, enjoyment
• Giving advice, lending money, superficial
• Roles may shift
• Little emphasis on the evaluation of the interaction

Question 4

What does a therapeutic relationship consist of

Answer 4

• Focus of the relationship is on the patient’s ideas, experience and feelings.
• Consistently focused on the patient’s
  needs
• Clear boundaries are established
• Help the patient developing new coping
  mechanisms
• Supports behavioral change
• Roles do not shift

Question 5

Why are boundaries important in nursing?

Answer 5

Boundaries exist to protect the patient. Well established boundaries allow for a safe environment where the patient can explore feelings and treatment concerns.

Question 6

Under involved nurse VS Over involved nurse

Answer 6

• Under-involved nurse – lack of agreed upon goals, no progress toward
  goals, failure to follow through with interventions, avoiding spending
  time with patient
• Overly-involved nurse - More frequent request for help, not being able
  to complete tasks w/o assistance they formally could complete
  independently, angry co-workers r/t nurse behaviors

Question 7

Blurred Roles

Answer 7

Blurred Roles
*Transference – pt transfers feelings & behaviors onto the nurse related to significant figures in the patient’s past.

• Countertransference- Nurse transfers feelings and behaviors onto the patient related to significant figures in the nurse’s past.

Question 8

Transference

Answer 8

Transference occurs when the patient unconsciously and inappropriately displaces (transfers) onto the nurse feelings and behaviors related to significant figures in the patient’s past. The patient may even say, “You remind me of my [mother, sister, father, brother, etc.].”

Question 9

Countertransference

Answer 9

Countertransference is transference in reverse. It occurs when the nurse unconsciously displaces feelings related to significant figures in the nurse’s past onto the patient. Frequently, the intense emotions of transference on the part of the patient bring out countertransference in the nurse. For example, say you remind your patient of his much-loved older sister and he works very hard to please you.

Question 10

Peplau’s Model of the Nurse-Patient
Relationship

Answer 10

4 phases
* Preorientation Phase
* Orientation Phase
* Working Phase
* Termination Phase

Question 11

Preorientation phase

Answer 11

The preorientation phase begins with preparing for your assignment. T

The chart is a rich source of information, including mental and physical evaluation, progress notes, and patient orders. You will probably be required to research your patient’s condition, learn about prescribed medications, and understand laboratory results. Staff may be available to share more anecdotal information or provide you with tips on how to best interact with your patient.

Another task before meeting your patient is recognizing your own thoughts and feelings regarding this first meeting. Nursing students usually have many concerns and experience anxiety on their first clinical day. These universal concerns include being afraid of persons with psychiatric disorders, of saying “the wrong thing,” and of not knowing what to do in response to certain patient behaviors. Table 8.1 identifies patient behaviors and gives examples of possible reactions and suggested responses.

Gathering information about pt ,

Question 12

Orientation phase

Answer 12

The orientation phase can last for a few meetings or extend over a longer period.

It is the first time the nurse and the patient meet and is the phase in which the nurse conducts the initial interview (refer to Chapter 9). During the ori- entation phase, the patient may begin to express thoughts and feelings, identify problems, and discuss realistic goals. Specific tasks of the orientation phase are discussed in the following sections.

FIRST TIME MEETING PT

SETTING GOALS
BUILDING RAPPORT

The first task of the orientation phase is introductions. The patient needs to know about the nurse (who the nurse is and the nurse’s background) and the purpose of the meetings.

Question 13

Example of a Orientation scenario

Answer 13

: “Hello, Ms. Chang. I am Bob Jacobs, and I’m a regis- tered nursing student from Fairlawn University. I am in my psychiatric rotation. We will be coming here on Thursdays and Fridays until the end of the semester. I would like to spend time with you on these days until you are discharged.
I’m here to be a support person for you as you work on your treatment goals.”

Knowing what the patient would like to be called is also
essential, as names and titles are meaningful to most people. In the previous example, the student began by using a formal title

Question 14

At which phase pf the Peplaus model does the nurse get to know what the patient would like to be called?

A. Preorientation Phase
B. Orientation Phase
C. Working Phase
D. Termination Phase

Answer 14

B. Orientation Phase

Knowing what the patient would like to be called is also
essential, as names and titles are meaningful to most people. In the previous example, the student began by using a formal title
of Ms. Chang. After checking the patient’s identification band and reading it out loud, “Dorothy Chang,” ask, “What would you like to be called?”

Question 15

Orientation continued

Answer 15

Establishing rapport. A major emphasis during the initial encounter with the patient is on providing an atmosphere in which trust and understanding, or rapport, can grow. Rapport is a relationship characterized by understanding and harmony, which is facilitated by genuineness, empathy, and unconditional positive regard on the part of the nurse. Being consistent, aiding in problem solving, and providing support are also essential aspects of establishing and maintaining rapport.

Specifying a contract. A contract emphasizes the patient’s participation and responsibility because it shows that the nurse does something with the patient rather than for the patient. The contract, either stated or written, contains the place, time, date, and duration of the meetings. You should also discuss the termination of the relationship.
Student: “Ms. Chang, we will meet at 10:00 am on Thursdays and Fridays. We have 30 minutes to discuss how you are doing and any concerns you may have. We will also discuss your diagnosis, symptom management, and review your medications and blood work. Like I said earlier, we will be able to work together until you are discharged.”

Explaining confidentiality. Confidentiality is an integral part of caring for people in the mental health field. Confidentiality refers to information being held in confidence unless an authorization is made to share this information. The patient has a right to know (1) who else will be given the information shared with the nurse and (2) that the information may be shared with specific people such as a clinical supervisor, the physician, the staff, or other students in postconference.

Question 16

Working phase

Answer 16

you are working with the patient

• Gathering further data
• Identifying problem-solving skills and self-esteem * Providing education about the disorder
• Promoting symptom management
• Providing medication education
• Evaluating progress

During the working phase, the nurse and patient identify and explore areas that are causing problems in the patient’s life. Often, the patient’s coping methods were developed to survive in a chaotic and dysfunctional family environment. Although coping methods may have worked for the patient at an earlier age, they may now interfere with the patient’s functioning and interpersonal relationships.

Question 17

Termination Phase

Answer 17

The termination phase is the final, integral phase of the nurse- patient relationship. You discuss termination during the first meeting and again during the working stage at appropriate times.

• Summarizing the goals and objectives achieved
• Reviewing patient education and providing handouts
• Discussing ways for the patient to incorporate new coping
  strategies
• Reviewing situations that occurred during the nurse-patient
  relationship
• Exchanging memories, which can help validate the experi-
  ence for both nurse and patient and facilitate closure of that relationship

Question 18

Positive regard

Answer 18

Positive regard is respecting a person and viewing another per- son as being worthy of caring about and as someone who has strengths and achievement potential. Positive regard is usually communicated indirectly by attitudes and actions rather than directly by words. It is not necessary to like all people or approve of what they have done, especially if they have done terrible and hurtful things.

Question 19

Genuineness

Answer 19

Genuineness refers to the nurse’s ability to be open, honest, and authentic in interactions with patients. Being genuine is a key ingredient in building trust.

Question 20

Empathy

Answer 20

Empathy occurs when the helping person attempts to under- stand the world from the patient’s perspective. Simply put, it is attempting to put oneself in the other’s position.

Question 21

Empathy vs Sympathy

Answer 21

Sympathy
-sympathy, we feel pity or sorrow for others.

Empathy-we understand the feelings of others,

Question 22

Empathetic response

Answer 22

Empathetic response: “This must be devastating for you (silence). It must seem so unfair. What thoughts and feelings are you having?” (You stay with your patient and listen.)

ALWAYS DIRECTED TOWARDS PATIENT AND HOW THEY FEEL

Question 23

Sympathetic response

Answer 23

Sympathetic response: “I feel so bad for you (tearing up). I know how close you are to your mom. She is such an amazing person. Oh, I am so sorry.” (You hug your friend.)

Question 24

Nursing Behaviors exhibiting Boundary crossing with patient

Answer 24

• Spending long periods of time with the patient, more than is necessary or is comparable to time spent with other patients
• Doing tasks for the patient that could be done independently
• Sharing too much personal information with the patient
• Thinking about the patient outside of the care setting
• Being defensive when others comment on the special attention the patient
  is receiving
• Accepting personal comments and questions made by the patient

Question 25

Which of the following is referred to as boundary violation

A. Accepting gifts from a patient
B. Showing the patient more attention than other patients
C. The patient seeing you as sister
D. You exhibiting justice in your care plan for the patient.

Answer 25

A. Accepting gifts from a patient

Other examples of boundary violations include accepting gifts or cash, planning a business together, excessive touching of the patient, and trying to influence a patient’s political or religious beliefs. Boundaries may even be violated indirectly. For example, if a patient’s case is discussed on Facebook, it may breach confidentiality and the patient’s right to privacy, also vio- lating boundaries.

Question 26

Patient behavior and Nurse reaction
(If the Patient Asks the Nurse to Keep a Secret-

What is the nurse best response?

Answer 26

The nurse cannot make such a promise. The information may be important to the health or safety of the patient or others:

“I cannot make that promise. It might be important for me to share it with other staff.” The patient then decides whether to share the information.

Question 27

Patient behavior and Nurse reaction
(If the Patient Threatens Suicide

What is the best nurse response?

Answer 27

patient out of it.”
The nurse may pick up some of the patient’s feelings of hopelessness.
The nurse assesses whether the patient has a plan and the lethality of the plan. The nurse tells the patient that this is serious, that the nurse does not want harm to come to the patient, and that this information needs to be shared with other staff:

“This is serious, Mr. Lamb. I don’t want any harm to come to you. I need to share how you’re feeling with the other staff.”
The nurse can then discuss with the patient the feelings and circumstances that led up to this decision. (Refer to Chapter 25 for strategies in suicide intervention.)