What is the most important characteristic needed to establishing a therapeutic nurse patient relationship?

Preinteraction Phase

Concerns of New Nurses

The preinteraction phase begins before the nurse’s first contact with the patient. The nurse’s initial task is one of self-exploration. This is no small task because psychiatric nursing clinical experience can bring both stress and challenge to the student (Happell and Gough, 2009). In the first experience of working with psychiatric patients, the nurse brings the misconceptions and prejudices of the general public, in addition to feelings and fears common to all novices (Halter, 2008; Webster, 2009) (Box 2-2). A major one is anxiety or nervousness, which is common to new experiences of any kind. Another feeling is ambivalence or uncertainty because nurses may see the need for working with these patients but feel uncertain about their ability to do so.

The informal nature of psychiatric settings may threaten the nurse’s role identity. A common first reaction among students is a feeling of panic when they realize that they “can’t tell the patients from the staff.” It is unsettling for some students to give up their uniforms, stethoscopes, and scissors, which emphasizes that, in this nursing setting, the most important tools are the ability to communicate, empathize, and solve problems. Without a physical illness to manage, new students may feel self-conscious and hesitant about introducing themselves to a patient and starting a conversation.

Some nurses express feelings of inadequacy and fears of hurting or exploiting the patient. They worry about saying the wrong thing, which might drive the patient “over the brink.” With their limited knowledge and experience, they doubt that they will be of any value. They wonder how they can help or whether they can really make a difference. Some nurses perceive the plight of psychiatric patients as hopeful; others perceive it as hopeless. A common fear of nurses is related to the stereotype of psychiatric patients being violent. Because this is the picture portrayed by the media, many nurses are afraid of being physically hurt by a patient. Other nurses fear being psychologically hurt by a patient through rejection or silence. A final fear is related to nurses’ questioning their own mental health. Nurses may worry about how working with psychiatric patients might affect their own psychological struggles.

The following clinical example contains many of the feelings and fears expressed by one nursing student in the preinteraction phase of self-analysis, as reported in the notes from her journal of her psychiatric rotation.

Clinical Example

When first told that I would have a clinical psychiatric nursing experience, I received this information with a blank mind. Mental overload, denial, repression, or whatever it was made me hear the words but put off dealing with it. Then, when given a chance to sort through my thoughts and feelings, I thought more about what this experience would be like. Having never been personally involved with anyone who was hospitalized for a psychiatric illness, I was unable to rely on past personal experiences. I did, however, have quite a number of impressions from novels, television, and the movies.

As I thought more about it, I realized that three things scared me the most about this experience. First, I felt that the behavior of psychiatric patients is quite unpredictable. Would they get violent or aggressive without any warning? Would this aggression be directed toward me? If so, would I be hurt? Second, related to the first, is my feeling of inadequacy. I’ve been exposed to physically ill people and have learned how to respond to them. But not the psychiatrically ill. How can I help? What if I do or say something that offends them? Will I have the patience to persevere? I just don’t know, and my not knowing makes me even more nervous. My third fear is how seeing and being in contact with the psychiatrically ill will affect me. Although I know it’s not contagious, will I begin to doubt my own stability and sanity? I mean, adolescence hasn’t been easy for me, and I feel like I’m just now beginning to see things more clearly and feel better about myself. Will this experience stir up my fears and doubts, and, if so, how will I handle it? I am beginning to realize that there is a fine line between health and illness and that the psychiatric patients we’ll meet have been unable to gather enough resources from within to cope with their problems. Help, reassurance, and understanding are their needs. I’m hoping I can help them… but, honestly, I’m just not sure.

Introductory, or Orientation, Phase

It is during the introductory phase that the nurse and patient first meet. One of the nurse’s primary concerns is to find out why the patient sought help (Table 2-2). The reason for seeking help forms the basis of the nursing assessment, helps the nurse focus on the patient’s problem, and determines the patient’s motivation for treatment. It is important for the nurse to realize that help-seeking varies among different cultures, social, and ethnic groups. Another task is for the patient and nurse to establish their partnership and agree on the nature of the problem and the patient’s treatment goals. The focus is on the patient’s goals and not what the nurse believes should be done. Both the nurse and the patient may experience some degree of discomfort and nervousness in the introductory phase. Reasons that patients may have difficulty receiving help are listed in Box 2-3.

BOX 2-3   REASONS PATIENTS HAVE DIFFICULTY SEEKING HELP

• It may be hard to see or admit one’s difficulties, first to oneself and then to another.

• It is not easy to trust or be open with strangers.

• Sometimes problems seem too large, too overwhelming, or too unique to share them easily.

• Sharing personal problems with another person can threaten one’s sense of independence, autonomy, and self-esteem.

• Solving a problem involves thinking about some things that may be unpleasant, viewing life realistically, deciding on a plan of action, and then, most importantly, following through with whatever it takes to bring about a change. These activities place great demands on the patient’s energy and commitment.

TABLE 2-2

ANALYSIS OF WHY PATIENTS SEEK PSYCHIATRIC HELP

Modified from Burgess A, Burns J: Am J Nurs 73:314, 1973.

Termination Phase

Termination is one of the most difficult but most important phases of the therapeutic nurse-patient relationship. It is a time to exchange feelings and memories and to evaluate mutually the patient’s progress and goal attainment. Levels of trust and intimacy are heightened, reflecting the quality of the relationship and the sense of loss experienced by both nurse and patient. Box 2-5 lists criteria that can be used to determine whether the patient is ready to terminate.

Together the nurse and the patient review the progress made in treatment and the attainment of specified goals. It is appropriate to make referrals at this time for continued care or treatment. Successful termination requires that the patient work through feelings related to separation from emotionally significant people. The nurse can help by allowing the patient to experience and feel the effects of the anticipated loss, to express the feelings generated by the impending separation, and to relate those feelings to former symbolic or real losses. Helping the patient work and grow through the termination process is an essential goal of each relationship.

Learning to bear the sorrow of the loss while integrating positive aspects of the relationship into one’s life is the goal of termination for both the nurse and the patient. The patient’s response will be affected by the nurse’s ability to remain open, sensitive, empathic, and responsive to the patient’s changing needs. The impending termination can be as difficult for the nurse as for the patient. Nurses who can begin this process by reviewing their thoughts, feelings, and experiences will be more aware of personal motivation and more responsive to patients’ needs. The major tasks of the nurse during each phase of the nurse-patient relationship are summarized in Table 2-3.

TABLE 2-3

NURSE’S TASKS IN EACH PHASE OF THE RELATIONSHIP PROCESS