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PSYCHOTHERAPEUTIC MANAGEMENT IN THE CONTINUUM OF CARE-building the

nurse client relationship
(3 INTERVENTIONS 1. TNPR; 2. PSYCHOPHARMACOLOGY; 3. MILIEU THERAPY)

 THERAPEUTIC NURSE-PATIENT RELATIONSHIP- focuses on the needs, experiences,

feelings, and ideas of the client only
 the nurse uses communication skills, personal strengths and understanding of human
behavior to interact with the client
 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 own or her.
SOCIAL RELATIONSHIP
 communication focuses on sharing ideas, feelings and experiences
 primarily initiated for the purpose of friendship, socialization,
companionship or accomplishment of a task

Characteristics: Purpose=goal oriented

Patient centered
Process based
a) Therapeutic relationship
 a relationship that is established between a health care professional and a client for the
purpose of assisting the client to solve his problems
 a nurse-client interaction that is directed toward enhancing the client’s well being
 the client may be an individual, family, group, or a community

GOAL: The ability to establish their relationship with the client is one of the most
important skill a nurse can develop

b) Nurse-Patient Relationship
 it is a series of planned purposeful interaction between the nurse and the patient which
consists of a series of goal-directed interactions
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 the nurse and the client work together to assist the client to grow and solve his problems
with the therapeutic use of self that is achieved by maintaining the nurse’s self-
awareness

c) Self-awareness
understanding of one’s personality emotion, sensitivity, ethics, philosophy of
life, physical and social image and capacities.
 the greater the nurse’s understanding of his own feelings and responses, the
better he/she can communicate with and understand others.

Phases of a Therapeutic Nurse-Patient Relationship:

1) Orientation
 begins when the nurse and client meet and ends when the client begins to identify
problems to examine
 nurse establishes roles, the purpose of meeting and the parameters of subsequent
meetings
 identifies client’s problems and clarifies expectations
o Before meeting the client
 nurse reads background materials available on the client
 becomes familiar with medications the client is taking
 gathers necessary paperwork
 arranges for a quiet, private, and comfortable setting
 self-awareness/assessment
 nurse should consider his or her personal strengths and limitations in working with
the client
 are there any areas that might signal difficulty because of past experiences?

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
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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 real person

 the nurse begins to build trust with the client

 nurse’s responsibility is to establish a therapeutic environment that fosters trust and
understanding
 the nurse should share appropriate information about himself or herself this time,
including name, reason for being on the unit and level of schooling

EXAMPLE: “Hello, James. My name is Ms Grcae and I will be your nurse for the
next 6 Tuesdays. I am a junior nursing student at NWU.”

 Contract should the state the following:

o Time place and length of sessions
o When sessions will terminate
o Who will be involved in the treatment plan (family members or health care
team members)
o Client responsibilities (arrive on time and end on time)
o Nurse’s responsibilities (arrive on time, end on time maintain confidentiality
at all times, evaluate progress with client and document sessions)

2) Working
 client identifies the issues or concerns causing problems
 nurse guides the client to examine feelings and responses and to develop better coping
skills and a more positive self-image –this encourages behavior change and develops
independence
 the trust established between nurse and 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
o often when the client becomes uncomfortable because he or she is getting to
close to the truth, he or she will use testing behaviors to avoid the subject
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 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 not be nonjudgmental and refrain from giving advice
 the nurse should allow the client to analyze situations
 the nurse can guide the client to observe patterns of behavior and whether or not the
expected response occurs

EXAMPLE: A client who suffers from depression complains to the nurse about
the lack of concern her children shows her
o 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
o the nurse can then help the client explore more effective ways of
communicating in the future

 Specific tasks of the working phase:

o Exploring perceptions of reality
o Developing positive coping mechanisms
o Promoting a positive self-concept
o Encouraging verbalization of feelings
o Promoting independence
3) Termination
 final stage
 it begins when the problems are resolved and it ends when the relationship is ended
 both nurse and 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
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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.

THERAPEUTIC COMMUNICATION TECHNIQUES

ACCEPTING “Yes, I believe that’s right”

“I understand why you did that”

ASKING QUESTIONS “How was your sleep?”

“did you have a good day?”

BROAD OPENING what would you like to talk about today?”

“would you like to tell me about your feelings?”

CLEAR AND CONGRUENT if you say that you want to sit and talk, and you are sitting still
and actively listening
If you say you will give your client full, undivided attention, and refrain from
working on other tasks

CLARIFICATION “you said you feel sick inside, what do you mean by that?”
“I did not get well what you meant, would you say it again?”

ENCOURAGING ELABORATION “I think we were talking about…..”

FOCUSING
GENERAL LEAD “tell me what brought you to the hospital?

INFORMATION “Dr. Ruiz will meet with you today at 10am”

LISTENING Sensible receptiveness

LISTENING SKILLS : LENS; INCLINATION TOWARDS THE PATIENT; SENSIBLE

RECEPTIVENESS; TRAPS TO AVOID: drifting, concluding, jumping; EXPRESSION OF
CONCERN; NEED FOR REFLECTION AND FEEDBACK

OFFERING ONESELF “I will accompany you to the doctor’s clinic for your therapy”
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OBTAINING FEEDBACK “may I know how you felt about your visit with the doctor?”

OBSERVATION/S “your wound healed so quickly”

PRESENTING REALITY “you are presently being treated at mariveles mental hospital”

REFLECTING
RESTATING
RECOGNITION
SILENCE nodding
SUMMARIZING “let’s see, these are all we discussed about”

THERAPEUTIC TOUCH A pat on the shoulder for a good deed

Barriers to Therapeutic Communication

1. Highly judgmental responses “I don’t think that was a good idea”

2. Inattentive listening
3. No feedback
4. Defensive and demeaning response PT: “my doctor never seems to know whats going
on”
Nurse: “He is a good doctor, I can assure you that”
5. Reassurances that are false PT: “Im worried”
Nurse: “ everything will be ok”
6. Advise Nurse: “Do it this way”
7. Needless prying or probing questions Nurse: “ why is it that you were not visited by
your mother”
8. Clichés Nurse: “ don’t worry, it happens all the time”
9. Erratic responses PT: “ I’m worried about my daughter”
Nurse: “ it’s time to take a bath”
10.Solving the problem for the client and sympathizing

DOCUMENTATION OF Nurse-Patient Interaction (NPI) Documentation in Psychiatric Nursing

Practice
1. Problem oriented recording (POR)
 follows the subjective, objective, assessment, plan, implementation and evaluation
(SOAPIE) format
 it has as its basis a list of problems
 when it is used by nursing, the problems (nrsg.dx) are identified on a written plan of
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care with appropriate nursing interventions described for each.

S – subjective data (information gathered from what the patients, family or other
source has said or reported)
O – objective data (information gathered by direct observation of the person doing
the assessment. May include a physiologic measurement, such as BP or behavioral
response, such as affect)
A – assessment (the nurse’s interpretation of the subjective and objective data)
P – plan (the actions or treatments to be carried out)
*may be omitted in daily charting if the plan is clearly explained in the written
nursing care plan and no changes are expected.
I – intervention (those nursing actions that were actually carried out)
E – evaluation of the problem, following nursing intervention.
*some nursing interventions cannot be evaluated immediately, so this section
may be an optional entry.

Example:
DATE/TIME PROBLEM PROGRESS NOTES
2-12-22/10:00 AM Social Isolation S: states he doesn’t want to sit with or
talk to others; “they frighten me”
O: Stays in room alone unless strongly
encouraged to come out; no group
involvement at times listens to group
conversations from a distance but does
not
interact; some hyper vigilance and
scanning
noted
A: Inability to trust; panic level of
anxiety;
delusional thinking.
I: Initiated trusting relationship by
spending
time alone with patient. Discussed his
feeling in regards to interactions with
others.
Accompanied patient to group
appointment.
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Provide positive feedback for

voluntary
participating in assertiveness training.

2. Narrative Recording
 NARRATIVE REPORT
 is to describe something
 is told from a particular point of view
 is filled with precise detail
 chronological, baseline charted every shift
 lengthy and time consuming

3. Process recording
 a system used for teaching nursing students to understand and analyze verbal and
non-verbal interaction.
 the conversation between nurse and the patient is written on special forms or in a
special format.
 Things to be recorded:
 observations, perceptions, thoughts, feelings. and conversation
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students are asked to:

1. Analyze his or her communication
2. Determining and naming both therapeutic and
non-therapeutic techniques used within an
interaction.
3. The process recording is then studied by the
nursing instructor to discover patterns of
difficulty in communicating with the patients
and to help the student nurse identify them.