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Schnique Grant

NUR 132
Case Study
Orientation: Therapeutic relationship are not instantaneous; they take time.
The goal of the introductory phase is to establish rapport and build a
foundation for further work. Nurses focus on the following.

The parameters of the relationship are established (e.g., place of

meeting, length, frequency, role or service offered, confidentiality,
duration of relationship).

Trust, respect, honesty and effective communication are key principles

in establishing a relationship.

The expectations the nurse and the client have of each other and of
their relationship are discussed and clarified (Peplau, 1952).

The nurse gathers information and ensures that priority issues are
appropriately addressed.

Consistency and listening are considered by clients to be critical at the

beginning of the relationship (Forchuk et al., 1998abcd; Sundeen et al.,

The nurse assists in promoting client comfort that may include

reducing anxiety or tension.

Working Phase: clients are involved actively in achieving goals set during the
initial phase. They make progress by testing new behaviors, identifying
resources, and discovering avenues for change.

The working or middle phase of the relationship is where nursing

interventions frequently take place.

Problems and issues are identified and plans to address these are put
into action.

Positive changes may alternate with resistance and/or lack of change

(Sundeen et al., 1989).

The nurse assists the client to explore thoughts (e.g. views of self,
others, environment, and problem solving), feelings (e.g. grief, anger,
mistrust, sadness), and behaviors (e.g. promiscuity, aggression,
withdrawal, hyperactivity).

The content to be explored is chosen by the client (Parse, 1981;

Peplau, 1989) although the nurse facilitates the process.

The nurse continues his/her assessment throughout all phases of the


New problems and needs may emerge as the nurse-client relationship

develops and as earlier identified issues are addressed.

The nurse advocates for the client to ensure that the clients
perspectives and priorities are reflected in the plan of care.

Resolution phase: Whether a therapeutic relationship is brief or long term,

nurses must pay attention to the termination phase. They must mention the
date of conclusion well in advance (Carson, 2003). Termination always
involves loss. If substantial work has been done, both nurse and client may
feel the loss of the helping relationship. If goals have not been realized
because of time constraints or limitations in the relationships, termination
may seem less significant.

The resolution or ending phase is the final stage of the nurse-client


After the clients problems or issues are addressed, the relationship

needs to be completed before it can be terminated.

The ending of the nurse-client relationship is based on mutual

understanding and a celebration of goals that have been met (Hall,
1993; Hall, 1997).

Termination may be met with ambivalence.

Both should share feelings related to the ending of the therapeutic


Validating plans for the future may be a useful strategy (Hall, 1997;
Sundeen et al., 1989).

Increased autonomy of both the client and the nurse is observed in this
phase (Sundeen et al., 1989).
Wanda K. Mohr, Psychiatric-Mental Health Nursing, Evidence-Based
Concepts, Skills and Practices (2013). 8th Edition
B. How can the student nurse convey the essential elements of a
therapeutic relationship in talking to clients? Therapeutic

communication occurs when the nurse demonstrates empathy, uses effective

communication skills, and responds to the clients thoughts, needs, and
concerns. This planned process allows nurse and client to build a trusting
relationship in which the client is free to express thoughts, feelings, and
options without fear of judgment.
Therapeutic Communication Techniques
Exploring delving further into a subject
Tell me more about that
Focusing concentrating on a single point
This point seem worth looking at more closely
Restating clarification, repeating the main idea the client has stated to you
Pt says I cant take this med nurse says you cant take this med?
Reflecting directing client actions, thoughts and feelings back to the client
Pt do you think I should tell the dr., nurse do you think you should?
Make observations verbalizing what the nurse perceives
Have a client who is just sitting there and not interacting with anyone, ask
them what is wrong with them
you appear tense, are you uncomfortable when?,

Privacy and respect for boundaries

Therapeutic communication is most comfortable at 3 to 6 feet;
should not be less than 18 inches
Privacy is desirable but not always possible in therapeutic
An interview or conference room is optimal if the nurse believes
this setting is not too isolative for the interaction
Intimate zone 0-18 inches, this space is comfortable with
parents with young children, intimate couples, whispering,
invasion is threatening and produces anxiety
Personal zone 18-36 inches, comfortable between friends and
Social zone 4-12 feet, communication in social, work and
business settings
Public zone 12-25 feet, between speaker and audience, small
groups, other informal functions
Touch may be comforting and supportive
Touch also is an invasion of intimate and personal space
Nurse must evaluate whether the patient perceives touch as
positive or threatening and unwanted; never assume that
touching a patient is acceptable
Need to let them know when you are going to touch them: I am
going to take your dressing off now, I am going to touch you
Professional-functional used when doing procedures
Social-polite greeting, hand shake
Friendship-warmth hug, arm around shoulder
Love-intimacy tight hugs and kisses b/w lovers or close family
Sexual-arousal touch used by lovers

Active listening means refraining from other internal mental

activities and concentrating exclusively on what the patient says
Active observation means watching the speakers nonverbal actions
as he or she communicates
These are used to help the nurse to:
Recognize the issue that is most important to the client at this
Know what further questions to ask the client
Use additional therapeutic communication techniques to guide
the client to describe his perceptions fully
Understand the clients perceptions of the issue instead of
jumping to conclusions
Interpret and respond to the message objectively

C. How can the student nurses maintain a professional relationship

and avoid a social one for clients in psychiatric settings?
Use self disclosure to help clients open up to you- not to meet your
own needs
Keep disclosures brief
Be careful not to imply that your experience is exactly the same as the
Disclose only those situations that you have mastered.
So not use self-disclosure to discuss painful situations from which you
have not recovered because this reverses the nurse- client roles.
D. Identify essential elements and potential obstacles to this
Some behaviors are unacceptable in the nurse-client relationship and clearly
violate professional standards. Unacceptable behaviors include verbal,
physical, sexual, emotional and financial abuse and neglect. Abuse is a
betrayal of trust or the misuse of the power imbalance between the nurse
and the client. It is unacceptable for nurses to engage in behaviors, or make
remarks, toward clients that are perceived to be demeaning, seductive,
insulting, exploitive, disrespectful or humiliating. Taking actions that result in
monetary or personal benefit to the nurse or monetary or personal loss to the
client are also unacceptable. Other behaviors by the nurse toward clients,
while unacceptable in most contexts, may be acceptable and appropriate in
special circumstances. For example, while generally nurses should not
disclose information about themselves to clients, there may be times when
select and limited disclosure may be judged helpful in meeting the
therapeutic needs of the client. While some boundaries are absolute and
must never be violated (e.g., any form of abuse of clients), there may be
shades of gray around other boundaries that require the use of good

judgment and careful consideration of the context (e.g., when, if ever, is it

appropriate to hug a client?). While each separate situation may appear
harmless, when put together they may form a pattern indicating a boundary
has been crossed. Inappropriate relationships with clients may start with
something very benign then gradually progress until the nurse has clearly
violated a boundary in the nurse-client relationship and failed to meet the
CRNBC Standards for Registered Nursing Practice in British Columbia, and the
CNA Code of Ethics for Registered Nurses. For example, having a casual and
coincidental coffee with a clients significant other in the hospital cafeteria
can become a friendship and then turn into a romantic relationship.
The nature of nursing involves touching clients. Nurses use both task touch
and supportive touch. Task touch is used to perform procedures or to assist
clients with an activity. Supportive touch is touching the client when there is
no physical need. It is used to provide comfort or encouragement and when
used effectively it has a calming and therapeutic effect on the client. There
are also formal touch therapies that have distinct techniques and therapeutic
goals. Nurses may touch or hug children, adult clients or their clients
significant others in some situations to be supportive. While it is a
therapeutic, human and caring response to a number of situations, such
contact has the potential to be misinterpreted by vulnerable clients. The
type, location and amount of touch will vary with the nurses and the clients
age, gender and culture. Nurses need to carefully assess each situation and
determine that supportive touch would be appropriate and welcome. They
need to be aware of the clients perception of the meaning of the touch. The
perception and response of the clients family is also important.
Nurses usually have both casual and close relationships with people in their
communities. A dual role exists when someone a nurse has a personal
relationship with becomes a client and a professional relationship is
established. The nurse must clarify this new professional relationship with the
client in order to provide appropriate nursing care. If unable to clarify the
relationship is professional, the nurse should assign the client to another
nurse and withdraw because a dual role can be problematic, having the
potential to create conflict, a loss of objectivity and harm clients. For these
same reasons, when a professional nurse-client relationship exists it is
unacceptable for a nurse to enter into a friendship or engage in a romantic,
dating or sexual relationship with a client or a clients significant others.
Furthermore, nurses need to be cautious about entering into personal
relationships with former clients or their significant others, particularly those
clients who are vulnerable or who have the potential to become clients again.
Wanda K. Mohr, Psychiatric-Mental Health Nursing, Evidence-Based
Concepts, Skills and Practices (2013). 8th Edition