Psych Ch. 8 Therapeutic relationships
You are working with Allison on the inpatient psychiatric unit. Which of the following statements reflect an accurate understanding during which phase of the nurse-patient relationship the issue of termination should first be discussed? "Allison, you are being discharged today, so I'd like to bring up the subject of termination—discussing your time here and summarizing what coping skills you have attained." (to fellow nurse): "I haven't met my new patient Allison yet, but I am working through my feelings of anxiety in dealing with a patient who wanted to kill herself." "Allison, now that we are working on your problem-solving skills and behaviors you'd like to change, I'd like to bring up the issue of termination." "Allison, now that we've discussed your reasons for being here and how often we will meet, I'd like to talk about what we will do at the time of your discharge."
"Allison, now that we've discussed your reasons for being here and how often we will meet, I'd like to talk about what we will do at the time of your discharge." The issue of termination is brought up first in the orientation phase. All the other options describe other phases of the nurse-patient relationship—the termination phase, the preorientation phase, and the working phase.
Your patient, Emma, is crying in your one-to-one session while telling you of her father's recent death from a car accident. Which of the following responses illustrates empathy? "Emma, I'm so sorry. My father died two years ago, so I know how you are feeling." "Emma, you need to focus on yourself right now. You deserve to take time just for you." "Emma, that must have been such a hard situation to deal with." "Emma, I know that you will get over this. It just takes time."
"Emma, that must have been such a hard situation to deal with." This response reflects understanding of the patient's feelings, which is empathy. Feeling sorry for the client represents sympathy, whereas not addressing the patient's concern belittles the patient's feelings of grief she is expressing by changing the subject. Telling the patient she will get over it does not reflect empathy and is closed-ended.
Bethany, a nurse on the psychiatric unit, has a past history of alcoholism. She has weekly clinical supervision meetings with her mentor, the director of the unit. Which statement by Bethany to her mentor would indicate the presence of countertransference? "My patient, Miranda, is being discharged tomorrow. I provided discharge teaching and stressed the importance of calling the help line number should she become suicidal again." "My patient, Laney, has been abusing alcohol. I told her that the only way to recover was to go 'cold turkey' and to get away from her dysfunctional family and to do it now!" "My patient, Jack, started drinking after 14 years of sobriety. We are focusing on his treatment plan of attending AA meetings five times a week after discharge." "My patient, Gayle, is an elderly woman with depression. She calls me by her daughter's name because she says I remind her of her daughter."
"My patient, Laney, has been abusing alcohol. I told her that the only way to recover was to go 'cold turkey' and to get away from her dysfunctional family and to do it now!" This statement indicates countertransference; Bethany may be overidentifying with the patient because of her own past history of alcoholism. She is providing adamant advice to the patient that, besides being nontherapeutic, may be more relevant to her own past than to the patient's. The discharge teaching for a patient being discharged and focusing on the treatment plan for the alcoholic patient are appropriate and show no signs of countertransference. The patient calling the nurse by her daughter's name is transference rather than countertransference.
Willis has been admitted to your inpatient psychiatric unit with suicidal ideation. He resides in a halfway house after being released from prison, where he was sent for sexually abusing his teenage stepdaughter. In your one-to-one session he tells you of his terrible guilt over the situation and wanting to die because of it. Which of the following responses you could make reflects a helpful trait in a therapeutic relationship? "It's good that you feel guilty. That means you still have a chance of being helped." "Of course you feel guilty. You did a horrendous thing. You shouldn't even be out of prison." "The biggest question is, will you do it again? You will end up right back in prison, and have even worse guilt feelings because you hurt someone again." "You are suffering with guilt over what you did. Let's talk about some goals we could work on that may make you want to keep living."
"You are suffering with guilt over what you did. Let's talk about some goals we could work on that may make you want to keep living." This response demonstrates suspending value judgment, a helpful trait in establishing and maintaining a therapeutic relationship. Although it is difficult, nurses are more effective when they don't use their own value systems to judge patients' thoughts, feelings, or behaviors. The other options are all judgmental responses. Judgment on the part of the nurse will most likely interfere with further explorations of feelings and hinder the therapeutic relationship.
Rogers and Truax (1967) identified three personal characteristics of the nurse that help promote change and growth in patients—factors still valued today as vital components for establishing a therapeutic relationship:
(1) genuineness, (2) empathy, and (3) positive regard.
Two common circumstances in which boundaries are blurred are:
(1) when the relationship is allowed to slip into a social context and (2) when the nurse's needs (for attention, affection, and emotional support) are met at the expense of the patient's needs.
Peplau (1952, 1999) described the nurse-patient relationship as evolving through three distinct interlocking and overlapping phases. An additional preorientation phase, during which the nurse prepares for the orientation phase, has been identified. The four phases are as follows:
1.Preorientation phase 2.Orientation phase 3.Working phase 4.Termination phase
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 self-disclosure in an appropriate way. to the client permission to continue. countertransference. empathy to establish trust.
countertransference. Countertransference refers to the stirring up of feelings in the nurse by the client.
Specifically, the study found evidence that the following factors enhanced the nurse-patient relationship, allowing it to progress in a mutually satisfying manner:
Consistency Patient set the pace Listening Initital impressions Promoting patient comfort
In the process of trying new values, which step shows the highest commitment to the value? Cherishing the value Publicly stating affirmation of the value Choosing a stand consistent with the value from among several alternatives Consistently acting in ways that repeatedly affirm the value
Consistently acting in ways that repeatedly affirm the value. Values clarification theory puts acting consistently on one's belief as the highest level of the process, following prizing and choosing.
Countertransference
Countertransference occurs when the nurse unconsciously and inappropriately displaces onto the patient feelings and behaviors related to significant figures in the nurse's past.
Discuss physical boundaries in the nurse-patient relationship
General environment, office space, treatment room, conference room, corner of the day room, and other such places
Which of the following statements are true regarding the differences between a social relationship and a therapeutic relationship? (select all that apply): In a social relationship, both parties' needs are met; in a therapeutic relationship only the patient's needs are to be considered. 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. Giving advice is done in social relationships; in therapeutic relationships giving advice is not usually therapeutic. 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. 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.
In a social relationship, both parties' needs are met; in a therapeutic relationship only the patient's needs are to be considered. Giving advice is done in social relationships; in therapeutic relationships giving advice is not usually therapeutic. 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.
It is important that the nurse be aware of the differences between a therapeutic relationship and a social or intimate relationship.
In a therapeutic nurse-patient relationship, the focus is on the patient's needs, thoughts, feelings, and goals. The nurse is expected to meet personal needs outside this relationship in other professional, social, or intimate arenas.
During what stage of the therapeutic nurse-client relationship is a formal or informal contract between the nurse and client established? Preorientation Orientation Working Termination
Orientation. Contracting is part of the orientation phase of the relationship. Establishing the operational "rules" provides a foundation for the relationship.
Discuss personal space in a nurse-patient relationship
Physical space, emotional space, space set by roles, and so forth
The nurse would NOT address which of the following goals in attempting to establish a therapeutic nurse-client relationship? Assisting the client with self-care needs when appropriate. Helping the client identify self-defeating behaviors. Providing the client with opportunities to socialize. Facilitating the client's communication of disturbing feelings or thoughts. Encouraging the client to make decisions when appropriate.
Providing the client with opportunities to socialize. Addressing the client's need to socialize is not one of the goals of establishing a therapeutic relationship. The other options are goals addressed in a therapeutic relationship.
Discuss the contract in a nurse-patient relationship
Set time, confidentiality, agreement between nurse and patient as to roles, money, if involved with a licensed therapist
Client reactions of intense hostility or feelings of strong affection toward the nurse are common forms of resistance. transference. countertransference. emotional abreaction.
The stirring up of feelings in the client by the nurse is referred to as transference.
Transference
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.)."
Amanda was raised by a rejecting and abusive father and had a difficult childhood. As an inpatient, she frequently comments on how hard her nurse, Jane, works and on how other staff members do not seem to care as much about their patients as Jane does. Jane finds herself agreeing with Amanda. Jane appreciates her insightfulness, and realizes that the other staff members do not appreciate how hard she works and take her for granted. Jane enjoys the time she spends with Amanda and seeks out opportunities to interact with her. What phenomenon is occurring here, and which response by Jane would most benefit her and the patient? a.Amanda is experiencing transference; Jane should help Amanda to understand that she is emphasizing in Jane those qualities that were missing in her father. b.Jane is idealizing Amanda, seeing in her strengths and abilities that Amanda does not possess; Jane should temporarily distance herself somewhat from Amanda. c.Amanda is overidentifying with Jane, seeing similarities that do not in reality exist; Jane should label and explore this phenomenon in her interactions with Amanda. d.Jane is experiencing countertransference in response to Amanda's meeting Jane's needs for greater appreciation; Jane should seek clinical supervision to explore these dynamics.
a.Amanda is experiencing transference; Jane should help Amanda to understand that she is emphasizing in Jane those qualities that were missing in her father.
A student nurse exhibits the following behaviors or actions while interacting with her patient. Which of these are appropriate as part of a therapeutic relationship? a.Sitting attentively in silence with a withdrawn patient until the patient chooses to speak. b.Offering the patient advice on how he could cope more effectively with stress. c.Controlling the pace of the relationship by selecting topics for each interaction. d.Limiting the discussion of termination issues so as not to sadden the patient unduly.
a.Sitting attentively in silence with a withdrawn patient until the patient chooses to speak.
Which of the following actions best represents the basis or foundation of all other psychiatric nursing care? a.The nurse assesses the patient at regular intervals. b.The nurse administers psychotropic medications. c.The nurse spends time sitting with a withdrawn patient. d.The nurse participates in team meetings with other professionals.
a.The nurse assesses the patient at regular intervals.
A male patient frequently inquires about the female student nurse's boyfriend, social activities, and school experiences. Which of the following initial responses by the student best addresses the issue raised by this behavior? a.The student requests assignment to a patient of the same gender as the student. b.She limits sharing personal information and stresses the patient-centered focus of the conversation. c.She tells him that she will not talk about her personal life. d.She explains that if he persists in focusing on her, she cannot work with him.
b.She limits sharing personal information and stresses the patient-centered focus of the conversation.
The nurse is finding it difficult to provide structure and set limits for a client. The nurse should self-evaluate for boundary blurring. value dissonance. covert anger. empathy.
boundary blurring.
Emily is a 28-year-old nurse on the psychiatric unit. She has been working with Jenna, a 27-year-old who was admitted with depression. Emily and Jenna find they have much in common, including each having a 2-year-old daughter and each having graduated from the same high school. Emily and Jenna discuss getting together for lunch with their daughters after Jenna is discharged. This situation reflects: a.Successful termination b.Promoting interdependence c.Boundary blurring d.A strong therapeutic relationship
c.Boundary blurring
According to Rogers, a synonym for genuineness is respect. empathy. congruence. positive regard.
congruence. Genuineness refers to self-awareness of one's feelings as they arise within the relationship and the ability to communicate them when appropriate. It is the ability to meet others person-to-person without hiding behind roles. Rogers uses the word congruence to signify genuineness.
The outcome of the nurse's expressions of sympathy instead of empathy toward the client often leads to enhanced client coping. lessening of client emotional pain. increased hope for client improvement. decreased client communication.
decreased client communication. Sympathy and the resulting projection of the nurse's feelings limits the client's opportunity to further discuss the problem.
An action that is acceptable in a social relationship but not in a therapeutic relationship is giving advice. listening actively. clarifying feelings. giving positive regard.
giving advice. Giving and receiving advice is acceptable in a social relationship. In a therapeutic relationship, it is appropriate for the nurse to assist the client in exploring alternative solutions to problems and in making his or her own decisions.
One of the possible sources of boundary violations is placing the focus on meeting the nurse's needs. identifying client disturbances. assessing the client's ego strength. assessing the client's weaknesses.
meeting the nurse's needs. Boundary violations have two sources: (1) allowing the therapeutic relationship to slip into a social relationship, and (2) meeting the nurse's personal needs at the expense of the client's needs
A client states "That nurse nevers seems comfortable being with me." The nurse can be described as not seeming genuine to the client. transmitting fear of clients. unfriendly and aloof. controlling.
not seeming genuine to the client. Hiding behind a role, using stiff or formal interactions, and creating distance between self and client suggest a nurse is lacking in genuineness, or the ability to interact in a person-to-person fashion.
The use of empathy and support begins in the stage of the nurse-client relationship termed the orientation stage. working stage. identification stage. resolution stage.
orientation stage. The use of empathy and support should begin in the orientation stage. These tools are helpful in building trust and furthering the relationship.
A client tells the nurse "I really feel close to you. You are like the friend I never had." The nurse can assess this statement as indicating the client may be experiencing congruence. empathetic feelings. countertransference. positive transference
positive transference. Transference involves the client experiencing feelings toward a nurse that belong to a significant person in the client's past.
The pre-orientation phase of the nurse-client relationship is characterized by the nurse's focus on self-analysis of strengths, limitations, and feelings. clarification of the nursing role. changing the client's dysfunctional behavior. incorporating coping skills into client's routine.
self-analysis of strengths, limitations, and feelings. During the preorientation phase the nurse prepares for a relationship with a client by engaging in self-examination.
The phase of the nurse-client relationship that may cause anxieties to reappear and past losses to be reviewed is the preorientation phase. orientation phase. working phase. termination phase.
termination phase. Termination, a stage in which the client must face the loss or ending of the therapeutic relationship, often reawakens the pain of earlier losses.
To help a client develop his or her resources, the nurse must first be aware of the client's strengths. negative transferences. countertransferences. resistances.
the client's strengths. Nurses work to bolster a client's strengths, to identify areas of dysfunction, and to assist in the development of new coping strategies.
The orientation phase of the nurse-client relationship focuses on the nurse identifying personal biases. the nurse and client identifying client needs. overcoming resistance to changing behavior. reviewing situations that occurred in previous meetings.
the nurse and client identifying client needs. The orientation phase is the first stage of the nurse-client relationship and focuses on, among other things, the identification of client needs.
When a nurse and client meet informally or have an otherwise limited but helpful relationship, the relationship is referred to as a(n) crisis intervention. therapeutic encounter. autonomous interaction. preorientation phenomenon.
therapeutic encounter. A therapeutic encounter is a short but helpful interaction between the nurse and client.
The primary difference between a social and a therapeutic relationship is the type of information exchanged. amount of satisfaction felt. type of responsibility involved. amount of emotion invested.
type of responsibility involved. In a therapeutic relationship the nurse assumes responsibility for focusing the relationship on the client's needs, facilitating communication, assisting the client with problem- solving, and helping the client identify and test alternative coping strategies.
When a nurse is biased against a client, those feelings will likely make it difficult to assess the client's symptoms. assess boundary issues with the client. view the client with positive regard. engage in values clarification with the client.
view the client with positive regard. Whenever a nurse harbors negative feelings about a client, these feelings stand in the way of objectivity and reduce his or her ability to give the client positive regard.
