MENTAL HEALTH: CHAPTER 5: THERAPEUTIC RELATIONSHIPS:

Types Of Relationships: Intimate Relationship:

- A healthy intimate relationship involves two people who are emotionally committed to each other. - Both parties are concerned about having their individual needs met and helping each other meet the needs as well. - The relationship may include sexual or emotional intimacy as well as sharing of mutual goals. - Evaluation of the interaction may be ongoing or not. - The intimate relationship has no place in the nurse-client interaction.

Avoiding Behaviors That Diminish Therapeutic Relationships: Inappropriate Behavior:

- All staff members, both new and veteran, are at risk for allowing a therapeutic relationship to expand into an inappropriate relationship. - Self-awareness is extremely important; the nurse who is in touch with his or her feelings and aware of his or her influence over others can help maintain the boundaries of the professional relationship. - The nurse must maintain professional boundaries to ensure the best therapeutic outcomes. - It is the nurse's responsibility to define the boundaries of the relationship clearly in the orientation phase and to ensure those boundaries are maintained throughout the relationship. - The nurse must act warmly and empathetically but must not try to be friends with the client. - Social interactions that continue beyond the first few minutes of a meeting contribute to the conversation staying on the surface. - This lack of focus on the problems that have been agreed on for discussion erodes the professional relationship. - One of the biggest risks for boundary violations is when the nurse believes "there is no way I would ever do anything nontherapeutic." - Boundary violations often begin unintentionally, or may even be well-intentioned, such as the nurse sharing personal relationship problems, thinking it might help the client. - Once personal information has been shared, it cannot be retracted. The harm to the therapeutic relationship cannot be undone. - If a client is attracted to a nurse or vice versa, it is up to the nurse to maintain professional boundaries. - Accepting gifts or giving a client one's home address or phone number would be considered a breach of ethical conduct. - Nurses must continually assess themselves and ensure they keep their feelings in check and focus on the clients' interests and needs

Orientation Phase: Nurse-Client Contracts:

- Although many clients have had prior experiences in the mental health system, the nurse must once again outline the responsibilities of the nurse and the client. - At the outset, both the nurse and the client should agree on these responsibilities in an informal or a verbal contract. - In some instances, a formal or written contract may be appropriate; examples include if a written contract has been necessary in the past with the client or if the client "forgets" the agreed-on verbal contract. The contract should state the following: •Time, place, and length of sessions •When sessions will terminate •Who will be involved in the treatment plan (family members or health team members) •Client responsibilities (arrive on time and end on time) •Nurse's responsibilities (arrive on time, end on time, maintain confidentiality at all times, evaluate progress with client, and document sessions)

Carper's Patterns of Nursing Knowledge: Aesthetic knowing (obtained from the art of nursing):

- Although the client shows outward signals now, the nurse has sensed previously the client's jumpiness and subtle differences in the client's demeanor and behavior.

Carper's Patterns of Nursing Knowledge: Ethical knowing (obtained from the moral knowledge of nursing):

- Although the nurse's shift has ended, he or she remains with the client.

Self-Awareness and Therapeutic Use of Self: Values:

- Are abstract standards that give a person a sense of right and wrong and establish a code of conduct for living. - Sample values include hard work, honesty, sincerity, cleanliness, and orderliness. - To gain insight into oneself and personal values, the values clarification process is helpful. - The values clarification process has three steps: choosing, prizing, and acting. - Choosing is when the person considers a range of possibilities and freely chooses the value that feels right. - Prizing is when the person considers the value, cherishes it, and publicly attaches it to him or herself. - Acting is when the person puts the value into action. - For example, a clean and orderly student has been assigned to live with another student who leaves clothes and food all over the room. - At first, the orderly student is unsure why she hesitates to return to the room and feels tense around her roommate. - As she examines the situation, she realizes that they view the use of personal space differently (choosing). - Next, she discusses her conflict and choices with her adviser and friends (prizing). - Finally, she decides to negotiate with her roommate for a compromise (acting).

Self-Awareness and Therapeutic Use of Self: Attitudes:

- Are general feelings or a frame of reference around which a person organizes knowledge about the world. - Attitudes, such as hopeful, optimistic, pessimistic, positive, and negative, color how we look at the world and people. - A positive mental attitude occurs when a person chooses to put a positive spin on an experience, a comment, or a judgment. - For example, in a crowded grocery line, the person at the front pays with change, slowly counting it out. - The person waiting in line who has a positive attitude would be thankful for the extra minutes and would begin to use them to do deep breathing exercises and to relax. - A negative attitude also colors how one views the world and other people. - For example, a person who has had an unpleasant experience with a rude waiter may develop a negative attitude toward all waiters. - Such a negative attitude might cause the person to behave impolitely and unpleasantly with every waiter he or she encounters. - The nurse should reevaluate and readjust beliefs and attitudes periodically as he or she gains experience and wisdom. - Ongoing self-awareness allows the nurse to accept values, attitudes, and beliefs of others that may differ from his or her own. - A person who does not assess personal attitudes and beliefs may hold a prejudice or bias toward a group of people because of preconceived ideas or stereotypical images of that group. - It is not uncommon for a person to be ethnocentric about his or her own culture (believing one's own culture other to be superior to others), particularly when the person has no experience with any culture than his or her own.

Self-Awareness and Therapeutic Use of Self: Beliefs:

- Are ideas that one holds to be true, for example, "All old people are hard of hearing," "If the sun is shining, it will be a good day," or "Peas should be planted on St. Patrick's Day." - Some beliefs have objective evidence to substantiate them. - For example, people who believe in evolution have accepted the evidence that supports this explanation for the origins of life. - Other beliefs are irrational and may persist, despite these beliefs having no supportive evidence or the existence of contradictory empirical evidence. - For example, many people harbor irrational beliefs about cultures different from their own that they developed simply from others' comments or fear of the unknown, not from any evidence to support such beliefs.

Self-Awareness and Therapeutic Use of Self:

- Before he or she can begin to understand clients, the nurse must first know him or herself. - Self-awareness is the process of developing an understanding of one's own values, beliefs, thoughts, feelings, attitudes, motivations, prejudices, strengths, and limitations and how these qualities affect others. - It allows the nurse to observe, pay attention to, and understand the subtle responses and reactions of clients when interacting with them.

Orientation Phase:

- Begins when the nurse and client meet and ends when the client begins to identify problems to examine. - - During the orientation phase, the nurse establishes roles, the purpose of meeting, and the parameters of subsequent meetings; identifies the client's problems; and clarifies expectations. - Before meeting the client, the nurse has important work to do. - The nurse reads background materials available on the client, becomes familiar with any medications the client is taking, gathers necessary paperwork, and arranges for a quiet, private, and comfortable setting. - This is the time for self-assessment. - The nurse should consider his or her personal strengths and limitations in working with this client. - Are there any areas that might signal difficulty because of past experiences? - For example, if this client is a spouse batterer and the nurse's father was also one, the nurse needs to consider the situation. How does it make him or her feel? What memories does it prompt, and can he or she work with the client without these memories interfering? - The nurse must examine preconceptions about the client and ensure that he or she can put them aside and get to know the person. - The nurse must come to each client without preconceptions or prejudices. - It may be useful for the nurse to discuss all potential problem areas with a mentor. - During the orientation phase, the nurse begins to build trust with the client. - It is the nurse's responsibility to establish a therapeutic environment that fosters trust and understanding - The nurse should share appropriate information about him or herself at this time, including name, reason for being on the unit, and level of schooling. - For example, "Hello, James. My name is Ms. Ames, and I will be your nurse for the next six Tuesdays. I am a senior nursing student at the University of Mississippi." - The nurse needs to listen closely to the client's history, perceptions, and misconceptions. - He or she needs to convey empathy and understanding. - If the relationship gets off to a positive start, it is more likely to succeed and to meet established goals. - At the first meeting, the client may be distrustful if previous relationships with nurses have been unsatisfactory. -The client may use rambling speech, act out, or exaggerate episodes as ploys to avoid discussing the real problems. - It may take several sessions until the client believes that he or she can trust the nurse.

Therapeutic Use Of Self:

- By developing self-awareness and beginning to understand his or her attitudes, the nurse can begin to use aspects of his or her personality, experiences, values, feelings, intelligence, needs, coping skills, and perceptions to establish relationships with clients. - This is called therapeutic use of self. - Nurses use themselves as a therapeutic tool to establish therapeutic relationships with clients and help clients grow, change, and heal. Peplau (1952), who described this therapeutic use of self in the nurse-client relationship, believed that nurses must clearly understand themselves to promote their clients' growth and to avoid limiting clients' choices to those that nurses value. - The nurse's personal actions arise from conscious and unconscious responses that are formed by life experiences and educational, spiritual, and cultural values. - Nurses (and all people) tend to use many automatic responses or behaviors just because they are familiar. - They need to examine such accepted ways of responding or behaving and evaluate how they help or hinder the therapeutic relationship.

Patterns Of Knowing:

- Carper (1978) identified four patterns of knowing in nursing: empirical knowing (derived from the science of nursing), personal knowing (derived from life experiences), ethical knowing (derived from moral knowledge of nursing), and aesthetic knowing (derived from the art of nursing). - These patterns provide the nurse with a clear method of observing and understanding every client interaction. - Understanding where knowledge comes from and how it affects behavior helps the nurse become more self-aware

Types Of Relationships: Therapeutic Relationship:

- Differs from the social or intimate relationship in many ways because it focuses on the needs, experiences, feelings, and ideas of the client only. - The nurse and client agree about the areas to work on and evaluate the outcomes. - The nurse uses communication skills, personal strengths, and understanding of human behavior to interact with the client. - In the therapeutic relationship, the parameters are clear; the focus is the client's needs, not the nurse's. - The nurse should not be concerned about whether or not the client likes him or her or is grateful. - Such concern is a signal that the nurse is focusing on a personal need to be liked or needed. - The nurse must guard against allowing the therapeutic relationship to slip into a more social relationship and must constantly focus on the client's needs, not his or her own. - The nurse's level of self-awareness can either benefit or hamper the therapeutic relationship. - For example, if the nurse is nervous around the client, the relationship is more apt to stay social because superficiality is safer. - If the nurse is aware of his or her fears, he or she can discuss them with the instructor, paving the way for a more therapeutic relationship to develop.

Components Of Therapeutic Relationship: Empathy:

- Empathy is the ability of the nurse to perceive the meanings and feelings of the client and to communicate that understanding to the client. - It is considered one of the essential skills a nurse must develop to provide high-quality, compassionate care. - Being able to put him or herself in the client's shoes does not mean that the nurse has had the exact experiences as that of the client. - Nevertheless, by listening and sensing the importance of the situation to the client, the nurse can imagine the client's feelings about the experience. - Both the client and the nurse give a "gift of self" when empathy occurs—the client by feeling safe enough to share feelings and the nurse by listening closely enough to understand. - Empathy has been shown to positively influence client outcomes. - Clients tend to feel better about themselves and more understood when the nurse is empathetic. - The nurse must understand the difference between empathy and sympathy (feelings of concern or compassion one shows for another). - By expressing sympathy, the nurse may project his or her personal concerns onto the client, thus inhibiting the client's expression of feelings.

ROLES OF THE NURSE IN A THERAPEUTIC RELATIONSHIP: Advocate:

- In the advocate role, the nurse informs the client and then supports him or her in whatever decision he or she makes. - In psychiatric-mental health nursing, advocacy is a bit different from medical-surgical settings because of the nature of the client's illness. - For example, the nurse cannot support a client's decision to hurt him or herself or another person. - Advocacy is the process of acting on the client's behalf when he or she cannot do so. - This includes ensuring privacy and dignity, promoting informed consent, preventing unnecessary examinations and procedures, accessing needed services and benefits, and ensuring safety from abuse and exploitation by a health professional or authority figure. - For example, if a physician begins to examine a client without closing the curtains and the nurse steps in and properly drapes the client and closes the curtains, the nurse has just acted as the client's advocate. - Being an advocate has risks. In the previous example, the physician may be embarrassed and angry and make a comment to the nurse. - The nurse needs to stay focused on the appropriateness of his or her behavior and not be intimidated. - The role of advocate also requires the nurse to be observant of other health care professionals. - At times, staff members may be reluctant to see what is happening or become involved when a colleague violates the boundaries of a professional relationship. - Nurses must take action by talking to the colleague or a supervisor when they observe boundary violations. - State nurse practice acts include the nurse's legal responsibility to report boundary violations and unethical conduct on the part of other health care providers. - There is debate about the role of nurse as advocate. - There are times when the nurse does not advocate for the client's autonomy or right to self-determination, such as by supporting involuntary hospitalization for a suicidal client. - At these times, acting in the client's best interest (keeping the client safe) is in direct opposition to the client's wishes. - Some critics view this as paternalism and interference with the true role of advocacy. - In addition, they do not only see advocacy as a role exclusive to nursing but also relevant to the domains of physicians, social workers, and other health care professionals.

Types Of Relationships: Social Relationship:

- Is primarily initiated for the purpose of friendship, socialization, companionship, or accomplishment of a task. - Communication, which may be superficial, usually focuses on sharing ideas, feelings, and experiences and meets the basic need for people to interact. - Advice is often given. - Roles may shift during social interactions. - Outcomes of this kind of relationship are rarely assessed. - When a nurse greets a client and chats about the weather or a sports event or engages in small talk or socializing, this is a social interaction. - This is acceptable in nursing, but for the nurse-client relationship to accomplish the goals that have been decided on, social interaction must be limited. - If the relationship becomes more social than therapeutic, serious work that moves the client forward will not be done.

Orientation Phase: Confidentiality:

- Means respecting the client's right to keep private any information about his or her mental and physical health and related care. - It means allowing only those dealing with the client's care to have access to the information that the client divulges. - Only under precisely defined conditions can third parties have access to this information; for example, in many states, the law requires that staff report suspected child and elder abuse. - Adult clients can decide which family members, if any, may be involved in treatment and may have access to clinical information. - Ideally, the people close to the client and responsible for his or her care are involved. - The client must decide, however, who will be included. For the client to feel safe, boundaries must be clear. - The nurse must clearly state information about who will have access to client assessment data and progress evaluations. - He or she should tell the client that members of the mental health team share appropriate information among themselves to provide consistent care and that only with the client's permission will they include a family member. - If the client has an appointed guardian, that person can review client information and make treatment decisions that are in the client's best interest. - For a child, the parent or appointed guardian is allowed access to information and can make treatment decisions as outlined by the health care team. - The nurse must be alert if a client asks him or her to keep a secret because this information may relate to the client's harming him or herself or others. - The nurse must avoid any promises to keep secrets. - If the nurse has promised not to tell before hearing the message, he or she could be jeopardizing the client's trust. - In most cases, even when the nurse refuses to agree to keep information secret, the client continues to relate issues anyway.

Orientation Phase: Self-Disclosure:

- Means revealing personal information such as biographical information and personal ideas, thoughts, and feelings about oneself to clients. - Traditionally, conventional wisdom held that nurses should share only their name and give a general idea about their residence, such as "I live in Ocean County." - Now, however, it is believed that some purposeful, well-planned self-disclosure can improve rapport between the nurse and the client. - The nurse can use self-disclosure to convey support, educate clients, and demonstrate that a client's anxiety is normal and that many people deal with stress and problems in their lives. - Self-disclosure may help the client feel more comfortable and more willing to share thoughts and feelings, or help the client gain insight into his or her situation. - When using self-disclosure, the nurse must also consider cultural factors. - Some clients may deem self-disclosure inappropriate or too personal, causing the client discomfort. - Disclosing personal information to a client can be harmful and inappropriate, so it must be planned and considered thoughtfully in advance. - Spontaneously self-disclosing personal information can have negative results. - For example, when working with a client whose parents are getting a divorce, the nurse says, "My parents got a divorce when I was 12, and it was a horrible time for me." The nurse has shifted the focus away from the client and has given the client the idea that this experience will be horrible for him or her. Although the nurse may have meant to communicate empathy, the result can be quite the opposite.

Patterns Of Knowing: Unknowing:

- Munhall (1993) added another pattern that she called unknowing—for the nurse to admit he or she does not know the client or the client's subjective world, opening the way for a truly authentic encounter. - The nurse in a state of unknowing is open to seeing and hearing the client's views without imposing any of his or her values or viewpoints. - In psychiatric nursing, negative preconceptions on the nurse's part can adversely affect the therapeutic relationship; thus, it is especially important for the nurse to work on developing this openness and acceptance toward the client.

Patterns Of Knowing: Preconceptions:

- Nurse theorist Hildegard Peplau (1952) identified preconceptions, or ways one person expects another to behave or speak, as a roadblock to the formation of an authentic relationship. Preconceptions often prevent people from getting to know one another. - Preconceptions and different or conflicting personal beliefs and values may prevent the nurse from developing a therapeutic relationship with a client. - Here is an example of preconceptions that interfere with a therapeutic relationship: Mr. Lopez, a client, has the preconceived stereotypical idea that all male nurses are homosexual and refuses to have Samuel, a male nurse, take care of him. Samuel has a preconceived stereotypical notion that all Hispanic men are violent, so he is relieved that Mr. Lopez has refused to work with him. - Both men are missing the opportunity to do some important work together because of incorrect preconceptions.

Therapeutic Relationship:

- One of the most important skills a nurse can develop - Crucial to success of interventions with clients requiring psychiatric care

Therapeutic Use Of Self: Johari Window "Word Portrait":

- One tool that is useful in learning more about oneself is the Johari window (Luft, 1970), which creates a "word portrait" of a person in four areas and indicates how well that person knows him or herself and communicates with others. The four areas evaluated are as follows: •Quadrant 1: Open/public—self-qualities one knows about oneself and others also know •Quadrant 2: Blind/unaware—self-qualities known only to others •Quadrant 3: Hidden/private—self-qualities known only to oneself •Quadrant 4: Unknown—an empty quadrant to symbolize qualities as yet undiscovered by oneself or others - In creating a Johari window, the first step is for the nurse to appraise his or her own qualities by creating a list of them: values, attitudes, feelings, strengths, behaviors, accomplishments, needs, desires, and thoughts. - The second step is to find out others' perceptions by interviewing them and asking them to identify qualities, both positive and negative, they see in the nurse. - To learn from this exercise, the opinions given must be honest; there must be no sanctions taken against those who list negative qualities. - The third step is to compare lists and assign qualities to the appropriate quadrant. - If quadrant 1 is the longest list, this indicates that the nurse is open to others; a smaller quadrant 1 means that the nurse shares little about him or herself with others. - If quadrants 1 and 3 are both small, the person demonstrates little insight. - Any change in one quadrant is reflected by changes in other quadrants. - The goal is to work toward moving qualities from quadrants 2, 3, and 4 into quadrant 1 (qualities known to self and others). - Doing so indicates that the nurse is gaining self-knowledge and awareness.

Self-Awareness Issues:

- Self-awareness is crucial in establishing therapeutic nurse-client relationships. - For example, a nurse who is prejudiced against people from a certain culture or religion but is not consciously aware of it may have difficulty relating to a client from that culture or religion. - If the nurse is aware of, acknowledges, and is open to reassessing the prejudice, the relationship has a better chance of being authentic. - If the nurse has certain beliefs and attitudes that he or she will not change, it may be best for another nurse to care for the client. - Examining personal strengths and weaknesses helps one gain a strong sense of self. - Seeking feedback from colleagues and others is another essential component of developing self-awareness. - How one is perceived by others may be different from oneself-perception or intentions. - Understanding oneself helps one understand and accept others who may have different ideas and values. - The nurse must continue on a path of self-discovery to become more self-aware and more effective in caring for clients. - Nurses, like others in helping professions, may experience compassion fatigue, a type of secondary traumatic stress or burnout that comes from working through traumatic experiences with clients. - The nurse "takes on" the burden of those experiences and may be unable to "leave work" at the end of the day. - Time outside work can be consumed by worries and concerns about clients and their situations. - Cetrano and colleagues (2017) found that several factors could have a positive impact on mental health workers and thus decrease compassion fatigue and burnout. - These factors included ergonomic work conditions, relief from undue time pressures, trusting relationships with management, and training and education. - Nurses also need to learn to "care for themselves." - This means balancing work with leisure time, building satisfying personal relationships with friends, and taking time to relax and pamper oneself. - Nurses who are overly committed to work become burned out, never find time to relax or see friends, and sacrifice their personal lives in the process. - When this happens, the nurse is more prone to boundary violations with clients (e.g., sharing frustrations or responding to the client's personal interest in the nurse). - In addition, the nurse who is stressed or overwhelmed tends to lose the objectivity that comes with self-awareness and personal growth activities. - In the end, nurses who fail to take good care of themselves also cannot take good care of clients and families.

Carper's Patterns of Nursing Knowledge: Empirical knowing (obtained from the science of nursing):

- The client with panic disorder begins to have an attack. Panic attacks will raise pulse rate.

Carper's Patterns of Nursing Knowledge: Personal knowing (obtained from life experience):

- The client's face shows the panic.

Avoiding Behaviors That Diminish Therapeutic Relationships: Feelings of Sympathy and Encouraging Client Dependency:

- The nurse must not let feelings of empathy turn into sympathy for the client. - Unlike the therapeutic use of empathy, the nurse who feels sorry for the client often tries to compensate by trying to please him or her. - When the nurse's behavior is rooted in sympathy, the client finds it easier to manipulate the nurse's feelings. - This discourages the client from exploring his or her problems, thoughts, and feelings; discourages client growth; and often leads to client dependency. - The client may make increased requests of the nurse for help and assistance or may regress and act as if he or she cannot carry out tasks previously done. - These can be signals that the nurse has been "overdoing" for the client and may be contributing to the client's dependency. - Clients often test the nurse to see how much the nurse is willing to do. - If the client cooperates only when the nurse is in attendance and does not carry out agreed-on behavior in the nurse's absence, the client has become too dependent. In any of these instances, the nurse needs to reassess his or her professional behavior and refocus on the client's needs and therapeutic goals.

Components Of Therapeutic Relationship: Positive Regard:

- The nurse who appreciates the client as a unique worthwhile human being can respect the client regardless of his or her behavior, background, or lifestyle. - This unconditional nonjudgmental attitude is known as positive regard and implies respect. - Calling the client by name, spending time with the client, and listening and responding openly are measures by which the nurse conveys respect and positive regard to the client. - The nurse also conveys positive regard by considering the client's ideas and preferences when planning care. - Doing so shows that the nurse believes the client has the ability to make positive and meaningful contributions to his or her own plan of care. - The nurse relies on presence, or attending, which is using nonverbal and verbal communication techniques to make the client aware that he or she is receiving full attention. - Nonverbal techniques that create an atmosphere of presence include leaning toward the client, maintaining eye contact, being relaxed, having arms resting at the sides, and having an interested but neutral attitude. - Verbally attending means that the nurse avoids communicating value judgments about the client's behavior. - For example, the client may say, "I was so mad, I yelled and screamed at my mother for an hour." If the nurse responds with, "Well, that didn't help, did it?" or "I can't believe you did that," the nurse is communicating a value judgment that the client was "wrong" or "bad." A better response would be "What happened then?" or "You must have been really upset." - The nurse maintains attention on the client and avoids communicating negative opinions or value judgments about the client's behavior.

Components Of Therapeutic Relationship: Acceptance:

- The nurse who does not become upset or responds negatively to a client's outbursts, anger, or acting out conveys acceptance to the client. - Avoiding judgments of the person, no matter what the behavior, is acceptance. - This does not mean acceptance of inappropriate behavior but acceptance of the person as worthy. - The nurse must set boundaries for behavior in the nurse-client relationship. - By being clear and firm without anger or judgment, the nurse allows the client to feel intact while still conveying that certain behavior is unacceptable. - For example, a client puts his arm around the nurse's waist

ESTABLISHING THE THERAPEUTIC RELATIONSHIP:

- The nurse who has self-confidence rooted in self-awareness is ready to establish appropriate therapeutic relationships with clients. - Because personal growth is ongoing over one's lifetime, the nurse cannot expect to have complete self-knowledge. - Awareness of his or her strengths and limitations at any particular moment, however, is a good start.

Avoiding Behaviors That Diminish Therapeutic Relationships: Nonacceptance and Avoidance:

- The nurse-client relationship can be jeopardized if the nurse finds the client's behavior unacceptable or distasteful and allows those feelings to show by avoiding the client or making verbal responses or facial expressions of annoyance or turning away from the client. - The nurse should be aware of the client's behavior and background before beginning the relationship; if the nurse believes there may be conflict, he or she must explore this possibility with a colleague. - If the nurse is aware of a prejudice that would place the client in an unfavorable light, he or she must explore this issue as well. - Sometimes, by talking about and confronting these feelings, the nurse can accept the client and not let a prejudice hinder the relationship. - If the nurse cannot resolve such negative feelings, however, he or she should consider requesting another assignment. - It is the nurse's responsibility to treat each client with acceptance and positive regard, regardless of the client's history. - Part of the nurse's responsibility is to continue to become more self-aware and to confront and resolve any prejudices that threaten to hinder the nurse-client relationship

Components Of Therapeutic Relationship: Trust:

- The nurse-client relationship requires trust. - Trust builds when the client is confident in the nurse and when the nurse's presence conveys integrity and reliability. - Trust develops when the client believes that the nurse will be consistent in his or her words and actions and can be relied on to do what he or she says. - Some behaviors the nurse can exhibit to help build the client's trust include caring, interest, understanding, consistency, honesty, keeping promises, and listening to the client - A caring therapeutic nurse-client relationship enables trust to develop, so the client can accept the assistance being offered. - Congruence occurs when words and actions match. - For example, the nurse says to the client, "I have to leave now to go to a clinical conference, but I will be back at 2 PM," and indeed returns at 2 PM to see the client. - The nurse needs to exhibit congruent behaviors to build trust with the client. - Trust erodes when a client sees inconsistency between what the nurse says and does. - Inconsistent or incongruent behaviors include making verbal commitments and not following through on them. - For example, the nurse tells the client he or she will work with the client every Tuesday at 10 AM, but the next week, the nurse has a conflict with the conference schedule and does not show up. - Another example of incongruent behavior is when the nurse's voice or body language is inconsistent with the words he or she speaks. - For example, an angry client confronts a nurse and accuses her of not liking her. - The nurse responds by saying, "Of course I like you, Nancy! I am here to help you." But as she says these words, the nurse backs away from Nancy and looks over her shoulder; the verbal and nonverbal components of the message do not match.

ROLES OF THE NURSE IN A THERAPEUTIC RELATIONSHIP: Caregiver:

- The primary caregiving role in mental health settings is the implementation of the therapeutic relationship to build trust, explore feelings, assist the client in problem-solving, and help the client meet psychosocial needs - If the client also requires physical nursing care, the nurse may need to explain to the client the need for touch while performing physical care. - Some clients may confuse physical care with intimacy and sexual interest, which can erode the therapeutic relationship. - The nurse must consider the relationship boundaries and parameters that have been established and must repeat the goals that were established together at the beginning of the relationship.

ROLES OF THE NURSE IN A THERAPEUTIC RELATIONSHIP: Teacher:

- The teacher role is inherent in most aspects of client care. - During the working phase of the nurse-client relationship, the nurse may teach the client new methods of coping and solving problems. - He or she may instruct the client about the medication regimen and available community resources. - To be a good teacher, the nurse must feel confident about the knowledge he or she has and must know the limitations of that knowledge base. - The nurse should be familiar with the resources in the health care setting and community and on the internet, which can provide needed information for clients. - The nurse must be honest about what information he or she can provide and when and where to refer clients for further information. - This behavior and honesty build trust in clients.

Termination:

- The termination or resolution phase is the final stage in the nurse-client relationship. - It begins when the problems are resolved and ends when the relationship is ended. - Both the nurse and the client usually have feelings about ending the relationship; the client especially may feel the termination as an impending loss. - Often, clients try to avoid termination by acting angry or as if the problem has not been resolved. - The nurse can acknowledge the client's angry feelings and assure the client that this response is normal to ending a relationship. - If the client tries to reopen and discuss old resolved issues, the nurse must avoid feeling as if the sessions were unsuccessful; instead, he or she should identify the client's stalling maneuvers and refocus the client on newly learned behaviors and skills to handle the problem. - It is appropriate to tell the client that the nurse enjoyed the time spent with the client and will remember him or her, but it is inappropriate for the nurse to agree to see the client outside the therapeutic relationship.

Working Phase:

- The working phase of the nurse-client relationship is usually divided into two subphases. - During problem identification, the client identifies the issues or concerns causing problems. - During exploitation, the nurse guides the client to examine feelings and responses and develop better coping skills and a more positive self-image; this encourages behavior change and develops independence. - (Note that Peplau's use of the word exploitation had a very different meaning than current usage, which involves unfairly using or taking advantage of a person or situation. For that reason, this phase is better conceptualized as intense exploration and elaboration on earlier themes that the client discussed.) - The trust established between the nurse and the client at this point allows them to examine the problems and to work on them within the security of the relationship. - The client must believe that the nurse will not turn away or be upset when the client reveals experiences, issues, behaviors, and problems. Sometimes, the client will use outrageous stories or acting-out behaviors to test the nurse. - Testing behavior challenges the nurse to stay focused and not to react or to be distracted. - Often, when the client becomes uncomfortable because he or she is getting too close to the truth, he or she will use testing behaviors to avoid the subject. - The nurse may respond by saying, "It seems as if we have hit an uncomfortable spot for you. - Would you like to let it go for now?" This statement focuses on the issue at hand and diverts attention from the testing behavior. - The nurse must remember that it is the client who examines and explores problem situations and relationships. - The nurse must be nonjudgmental and refrain from giving advice; the nurse should allow the client to analyze situations. - The nurse can guide the client in observing patterns of behavior and whether or not the expected response occurs. - For example, a client who suffers from depression complains to the nurse about the lack of concern her children show her. - With the assistance and guidance of the nurse, the client can explore how she communicates with her children and may discover that her communication involves complaining and criticizing. - The nurse can then help the client

ROLES OF THE NURSE IN A THERAPEUTIC RELATIONSHIP: Parent Surrogate:

- When a client exhibits childlike behavior or when a nurse is required to provide personal care such as feeding or bathing, the nurse may be tempted to assume the parental role as evidenced in choice of words and nonverbal communication. - The nurse may begin to sound authoritative with an attitude of "I know what's best for you." - Often, the client responds by acting more childlike and stubborn. - Neither party realizes they have fallen from adult-adult communication to parent-child communication. - It is easy for the client to view the nurse in such circumstances as a parent surrogate. In such situations, the nurse must be clear and firm and set limits or reiterate the previously set limits. - By retaining an open, easygoing, nonjudgmental attitude, the nurse can continue to nurture the client while establishing boundaries. - The nurse must ensure the relationship remains therapeutic and does not become social or intimate

Components Of Therapeutic Relationship: Genuine Interest:

- When the nurse is comfortable with him or herself, aware of his or her strengths and limitations, and clearly focused, the client perceives a genuine person showing genuine interest. - A client with mental illness can detect when someone is exhibiting dishonest or artificial behavior, such as asking a question and then not waiting for the answer, talking over him or her, or assuring him or her everything will be alright. - The nurse should be open and honest and display congruent behavior. - Sometimes, however, responding with truth and honesty alone does not provide the best professional response. - In such cases, the nurse may choose to disclose to the client a personal experience related to the client's current concerns. - It is essential, however, that the nurse is selective about personal examples. - These examples should be from the nurse's past experience, not a current problem the nurse is still trying to resolve, or a recent, still painful experience. - Self-disclosure examples are most helpful to the client when they represent common day-to-day experiences and do not involve value-laden topics. - For example, the nurse might share an experience of being frustrated with a coworker's tardiness or being worried when a child failed an exam at school. - It is rarely helpful to share personal experiences such as going through a divorce or the infidelity of a spouse or partner. - Self-disclosure can be helpful on occasion, but the nurse must not shift emphasis to his or her own problems rather than the client's.

Cultural Awareness Questions:

Acknowledging your Cultural Heritage •To what ethnic group, socioeconomic class, religion, age group, and community do you belong? •What experiences have you had with people from ethnic groups, socioeconomic classes, religions, age groups, or communities different from your own? •What were those experiences like? How did you feel about them? •When you were growing up, what did your parents and significant others say about people who were different from your family? •What about your ethnic group, socioeconomic class, religion, age, or community do you find embarrassing or wish you could change? Why? •What sociocultural factors in your background might contribute to being rejected by members of other cultures? •What personal qualities do you have that will help you establish interpersonal relationships with people from other cultural groups? What personal qualities may be detrimental?

Peplau: Phases Of Nurse-Client Relationship: Termination:

Client: •Abandons old needs •Aspires to new goals •Becomes independent of helping person •Applies new problem-solving skills •Maintains changes in style of communication and interaction •Shows positive changes in view of self •Integrates illness •Exhibits ability to stand alone Nurse: •Sustains relationship as long as client feels necessary •Promotes family interaction to assist with goal planning •Teaches preventive measures •Uses community agencies •Teaches self-care •Terminates nurse-client relationship

Peplau: Phases Of Nurse-Client Relationship: Exploitation (Working):

Client: •Makes full use of services •Identifies new goals •Attempts to attain new goals •Rapid shifts in behavior: dependent and independent •Exploitative behavior •Self-directing •Develops skill in interpersonal relationships and problem-solving •Displays changes in manner of communication (more open, flexible) Nurse: •Continues assessment •Meets needs as they emerge •Understands reason for shifts in behavior •Initiates rehabilitative plans •Reduces anxiety •Identifies positive factors •Helps plan for total needs •Facilitates forward movement of personality •Deals with therapeutic impasse

Peplau: Phases Of Nurse-Client Relationship: Identification (Working):

Client: •Participates in identifying problems •Begins to be aware of time •Responds to help •Identifies with nurse •Recognizes nurse as a person •Explores feelings •Fluctuates dependence, independence, and interdependence in relationship with nurse •Increases focal attention •Changes appearance (for better or worse) •Understands continuity between sessions (process and content) •Testing maneuvers decrease Nurse: •Maintains separate identity •Exhibits ability to edit speech or control focal attention •Shows unconditional acceptance •Helps express needs and feelings •Assesses and adjusts to needs •Provides information •Provides experiences that diminish feelings of helplessness •Does not allow anxiety to overwhelm client •Helps client focus on cues •Helps client develop responses to cues •Uses word stimuli

Peplau: Phases Of Nurse-Client Relationship: Orientation:

Client: •Seeks assistance •Conveys needs •Asks questions •Shares preconceptions and expectations of nurse based on past experience Nurse: •Responds to client •Gives parameters of meetings •Explains roles •Gathers data •Helps client identify problem •Helps client plan use of community resources and services •Reduces anxiety and tension •Practices active listening •Focuses client's energies •Clarifies preconceptions and expectations of nurse

During the working phase of a nurse-client relationship, which of the following would occur? A. Expectations are clarified. B. Nurse-client contracts are established. C. Feelings of loss are addressed. D. Client's feelings are examined.

D. Client's feelings are examined. - Rationale: During the working phase, the client identifies issues or concerns and his or her feelings and responses are examined. o Expectations are clarified and contracts are established during the orientation phase. Feelings of loss are addressed during the termination phase.

Is the following statement true or false? A nurse displays empathy by showing feelings of concern and compassion.

False - Rationale: Empathy is perceiving the client's meanings and feelings and communicating that understanding. o Sympathy is showing feelings of concern and compassion.

Is the following statement true or false? A social relationship usually involves communication for the purposes of friendship or task accomplishment.

True - Rationale: A social relationship occurs for friendship, socialization, companionship, or task achievement. It involves communication that may be superficial and may have an effect on shifting roles.

Trusting Behaviors:

Trust is built in the nurse-client relationship when the nurse exhibits the following behaviors: •Caring •Openness •Objectivity •Respect •Interest •Understanding •Consistency •Treating the client as a human being •Suggesting without telling •Approachability •Listening •Keeping promises •Honesty

2. Abstract standards that provide a person with his or her code of conduct are a.values. b.attitudes. c.beliefs. d.personal philosophy.

a. Values

1. .Building trust is important in a.the orientation phase of the relationship. b.the problem identification subphase of the relationship. c.all phases of the relationship. d.the exploitation subphase of the relationship.

a.the orientation phase of the relationship.

4. The emotional frame of reference by which one sees the world is created by a.values. b.attitudes. c.beliefs. d.personal philosophy.

b.attitudes.

3. Ideas that one holds as true are a.values. b.attitudes. c.beliefs. d.personal philosophy.

c. Beliefs

5. The client tells the nurse, "My biggest problem right now is trying to deal with a divorce. I didn't want a divorce and I still don't. But it is happening anyway!" Which of the following responses by the nurse will convey empathy? a."Can you tell me about it?" b."I'm so sorry. No wonder you're upset." c."Sounds like it has been a difficult time." d."You must be devastated."

c."Sounds like it has been a difficult time."

The specific tasks of the working phase include the following:

•Maintaining the relationship •Gathering more data •Exploring perceptions of reality •Developing positive coping mechanisms •Promoting a positive self-concept •Encouraging verbalization of feelings •Facilitating behavior change •Working through resistance •Evaluating progress and redefining goals as appropriate •Providing opportunities for the client to practice new behaviors •Promoting independence - As the nurse and client work together, it is common for the client to unconsciously transfer to the nurse feelings he or she has for significant others. - This is called transference. - For example, if the client has had negative experiences with authority figures, such as a parent, teachers, or principals, he or she may display similar reactions of negativity and resistance to the nurse, who is also viewed as an authority. - A similar process can occur when the nurse responds to the client based on personal unconscious needs and conflicts; this is called countertransference. - For example, if the nurse is the youngest in her family and often felt as if no one listened to her when she was a child, she may respond with anger to a client who does not listen or resists her help. - Again, self-awareness is important so that the nurse can identify when transference and countertransference might occur. - By being aware of such "hot spots," the nurse has a better chance of responding appropriately rather than letting old unresolved conflicts interfere with the relationship.

Methods to Avoid Inappropriate Relationships between Nurses and Clients:

•Realize that all staff members, whether male or female, junior or senior, or from any discipline, are at risk for overinvolvement and loss of boundaries. •Assume that boundary violations will occur. Supervisors should recognize potential "problem" clients and regularly raise the issue of sexual feelings or boundary loss with staff members. •Provide opportunities for staff members to discuss their dilemmas and effective ways of dealing with them. •Develop orientation programs to include how to set limits, how to recognize clues that the relationship is losing boundaries, what the institution expects of the professional, clearly defined consequences, case studies, how to develop skills to maintain boundaries, and recommended reading. •Provide resources for confidential and nonjudgmental assistance. •Hold regular meetings to discuss inappropriate relationships and feelings toward clients. •Provide senior staff to lead groups and model effective therapeutic interventions with difficult clients. •Use clinical vignettes for training. •Use situations that reflect not only sexual dilemmas but also other boundary violations, including problems with abuse of authority and power.

Possible Warnings or Signals of Abuse of the Nurse-Client Relationship:

•Secrets; reluctance to talk to others about the work being done with clients •Sudden increase in phone calls between nurse and client or calls outside clinical hours •Nurse making more exceptions for client than normal •Inappropriate gift-giving between client and nurse •Loaning, trading, or selling goods or possessions •Nurse disclosure of personal issues or information •Inappropriate touching, comforting, or physical contact •Overdoing, overprotecting, or overidentifying with client •Change in nurse's body language, dress, or appearance (with no other satisfactory explanation) •Extended one-on-one sessions or home visits •Spending off-duty time with the client •Thinking about the client frequently when away from work •Becoming defensive if another person questions the nurse's care of the client •Ignoring agency policies