The client in the termination phase of the nurse-client relationship is being very confrontational. How should the nurse interpret this behavior?
Possible Answers:
The treatment should revisit the working phase
The patient should be admitted to the hospital
This behavior is common for a client in the termination phase
The nurse has done something to offend the client
Correct answer: This behavior is common for a client in the termination phase
Explanation: Confrontational behavior is very common for a client in the termination phase. The nurse should not assume that she offended the client, and further action in terms of therapy should not be addressed until completing the termination phase.
The nurse is in the orientation phase of the nurse-client relationship where the client has been sexually assaulted. During this phase, the nurse should:
Possible Answers:
Identify themes of patterns of patient behavior and possible coping mechanisms
Actively listen to the client express his thoughts and feelings
Establish acceptance, trust, and boundaries
Explore personal ideas, stereotypes, and biases that my affect the nurse-client relationship
Correct answer: Establish acceptance, trust, and boundaries
Explanation: During the orientation phase the nurse should establish acceptance, trust, and boundaries with the client, which will be built upon in later phases.
Acceptance, trust and boundaries are established during which phase of the therapeutic nurse-client relationship?
Possible Answers:
Working
Preinteraction
Termination
Orientation
Correct answer: Orientation
Explanation: Acceptance, trust, and boundaries are established in the orientation phase of therapy.
Craig
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The foundation of nursing practice is the ability of the nurse to engage in interpersonal interactions in a goal-directed manner for the purpose of assisting patients with their emotional or physical health needs. The relationship between nurse and patient is a professional relationship and as such implies certain responsibilities. Responsibilities inherent in the nurse-patient relationship for all levels of nursing include:
• Accountability—The nurse assumes responsibility for the conduct and consequences of the assignment and for the nurse’s actions.
• Focus on the patient’s needs—The interest of the patient, not of other health care workers or the institution, is given first consideration. The nurse’s role is that of patient advocate.
• Clinical competence—The nurse bases his or her conduct on the principles of knowledge of and appropriateness to the specific situation. This involves awareness and incorporation of the latest knowledge made available from research.
• Delaying judgment—Ideally, nurses refrain from judging patients and avoid imposing their own values and beliefs on others.
• Supervision—Validation of performance quality is through regularly scheduled supervisory sessions. Supervision is conducted either by a more experienced clinician or through discussion with the nurse’s peers in professionally conducted supervisory sessions.
RESPONSIBILITIES OF THE NURSE DURING THE PHASES OF A THERAPEUTIC RELATIONSHIP
Many disciplines describe the phases of a therapeutic relationship during counseling. These phases are the same for all disciplines, although different disciplines might have their own names for them. We will use the names that are generally recognized in the practice of nursing: (1) the orientation phase, (2) the working phase, and (3) the termination phase.
In some situations, the nurse might only meet with the patient once or for only a few sessions. The time spent together might be brief, but the relationship or encounters can be substantial, useful, and important to the patient. This limited relationship is often referred to as a therapeutic encounter. Many of the following principles and practices apply to even a limited encounter (e.g., issues of confidentiality, goals, tasks) although the working phase is brief and adapted to the brief encounter. Termination per se might not apply; however, the nurse might want to find out what the patient thought was helpful or whether there is an issue the patient wishes to pursue that was discussed during the encounter. This might warrant referring the patient to appropriate staff or members of the treatment team.
Certain tasks and phenomena are specific to each phase, although they might overlap. For example, the issue of confidentiality, first addressed in the orientation phase, can be discussed and reiterated throughout all phases of the nurse-patient relationship. The following discussion highlights important aspects and responsibilities of the nurse during each phase.
Orientation Phase
The orientation phase can last for a few meetings or can extend for a longer period of time. The first time the nurse and patient meet, they are strangers to each other. When strangers meet for the first time, they interact according to their own backgrounds, standards, values, and experiences. This fact underlies the need for self-assessment and self-awareness on the part of the nurse.
Goals of the Orientation Phase
1. To establish trust. Establishing trust is essentially establishing a sound engagement with the patient in a therapeutic alliance. Trust is something that will or will not develop between the two parties. Establishing an atmosphere in which trust can grow is the responsibility of the nurse. Trust is nurtured by demonstrating genuineness (congruence) and empathy, developing a positive regard for the patient, demonstrating consistency, and offering assistance in alleviating the patient’s emotional pain or problems.
2. To effect some degree of anxiety reduction in the patient.
3. To instill hope and ensure that the patient will remain adherent to treatment.
4. To develop an assessment from which nursing diagnoses can be formulated, if a nursing assessment has not already been done.
5. To develop appropriate treatment goals (outcome criteria) and a plan of care.
Tasks of the Orientation Phase
During the orientation phase, the nurse addresses four specific issues: (1) the parameters of the relationship, (2) the formal or informal contract, (3) confidentiality, and (4) termination.
Parameters of the Relationship
Patients have the right to know about the nurse or counselor with whom they will be working. For example, who is this nurse and what is the nurse’s background? They also need to know the stated purpose of the meetings. For a student, this providing of information might be conveyed thus:
“Hello, Mrs. Gonzales, I am Sylvia Collins from Sullivan College. I am in my senior year, and I am doing my psychiatric rotation here at St. Michael’s clinic. I will be coming to St. Michaels for the next 8 Thursdays, and I would like to meet with you each Thursday, if you are still here. I am here to be a support person for you as you work on your treatment goals.”
OR
“Hello, Mrs. Gonzales. I am Jim Santos from Ohio State College. I am here only once this week, so we will have today to discuss your most important issues.”
For a psychiatric–mental health advanced-practice registered nurse (APRN-PMH) working in the clinical setting, the parameters might be altered.
“Hello, Mrs. Gonzales, I am John Horton. I am an advanced-practice psychiatric nurse, and I have been counseling patients for about 4 years now. Dr. Sharp referred you to me and stated that you wished to work out some issues in counseling/therapy.”
Formal or Informal Contract
A contract emphasizes the patient’s participation and responsibilities. It implies that the nurse does something with the patient, not just for the patient. The contract, either stated or written, includes the time, place, date, and duration of the meetings as well as mutual agreement as to goals. If a fee is to be paid, the patient is told how much it will be and when the fee is due.
For a student, the statement of the contract might sound something like this:
“Mr. Snyder, we will meet at 10:00 AM each Monday in the consultation room at the clinic for 45 minutes from September 15 to October 27. We can use that time to further discuss your feelings of loneliness and explore some things you could do to make things better for yourself.”
For an APRN-PMH, the contract might be:
“Mrs. Lang, we will meet on Thursdays at 10:00 AM in my office at the clinic. Our sliding-scale fee is $45 per session. Our policy states that if you can’t make a session, it is important to let us know 24 hours in advance; otherwise we will charge you for the session. We can use our time together to further explore your feelings of loneliness and anger with your husband and any other issues you wish to work on.”
Confidentiality
The patient has the right to know who else knows about the information being shared with the nurse. He or she needs to know that the information might be shared with specific people, such as a clinical supervisor, the physician, the treatment team, or other students in conference. The patient also needs to know that the information will not be shared with the patient’s family, friends, or others outside the treatment team, except in extreme situations. Extreme situations include:
• When the patient reveals information that might be harmful to the patient or others (child abuse, elder abuse)
• When the patient threatens self-harm
• When the patient does not intend to follow through with the treatment plan
When information must be given to others, it is usually done by the physician, according to legal guidelines. The nurse must be aware of the patient’s right to confidentiality and must not violate that right. Refer to Box 3-1 for ethical guidelines for confidentiality.
Box 3-1
Ethical Guidelines for Confidentiality
1. Keep all patient records secure.
2. Consider carefully the content to be entered into the record.
3. Release information only with written consent and full discussion of the information to be shared, except when release is required by law.
4. Use professional judgment deliberately regarding confidentiality when the patient is a danger to self or others.
5. Use professional judgment deliberately when deciding how to maintain the confidentiality of a minor. The rights of the parent/guardian must also be considered deliberately.
6. Disguise clinical material when used professionally for teaching and writing.
7. Maintain confidentiality in consultation and peer review situations.
8. Maintain anonymity of research subjects.
9. Safeguard the confidentiality of the student in teaching/learning situations.
From Colorado Society of Clinical Specialists in Psychiatric Nursing. (1990). Ethical guidelines for confidentiality. Journal of Psychosocial Nursing and Mental Health Services 28, 42-44.