Nurse-Patient Relationship

Stages of Nurse-Patient Relationship

PURPOSE:
Ruesch (1961), the originator of the term “therapeutic communication”, notes that “the aim of therapeutic communication is to improve the patient’s ability to function alone, with one other persons and in groups”.

Main Goal: To nourish and expand the healthy part of the individual or patient so that his emotional difficulties will be lessened.

Specific Objectives:
 Establish rapport with the patient by being empathetic, genuine, caring and unconditionally accepting of the patient regardless of his or her behaviors and beliefs.
 A critical factor in helping patient to reassess priorities, and identify the issues of concern.
 Gain an in-depth understanding of the patient’s perception of the concern and empathy in the nurse-patient interaction.
 An opportunity to patient and to his family to explore new information about themselves, their thoughts and feelings.
 An interpersonal experience of discovering meaning in current life circumstances.
 Guide the patient to develop new skills in problem solving
 An avenue for the discovery of new possibilities to achieve well-being.
 Promote the patient’s evaluation of solutions.

1. Pre-orientation Phase
The nurse-patient relationship is therapeutic, not social in nature. It is always patient-centered and goal directed. It is objective rather than subjective. The intent of a professional relationship is for the patient behavior to change. It is a limited relationship, with the goal of helping the patient find more satisfying behavior.

 Start with yourself
Self is a concept central to understanding the person in the nurse-patient relationship. Coombs, Avila and Purkey (1980) have argued that self-concept is the most important single factor affecting behavior. Thus, knowledge of the human beings behind the diagnosis, the meaning behind the behavior, is the key to effective nurse-patient relationship. Self-concept is the way to understand the uniqueness of the nurse and the patient, as the basic units of NPR.

Self-Concept
Self-concept is an abstract structural construct used to describe the different images making up the self in each person’s mind (Westen, 1991). Self-concept reflects a person’s overall personality structure. At the heart of the self-concept lies a person’s essential human nature, forming the foundation for all roles, motivations, behaviors, feelings, thoughts, and physical and psychosocial make-up. Self concept is the underlying core construct that first introduces a person to the meaning of life. It represents a self knowledge of one’s coherence and authenticity.

Self-concept biases what a person focuses on in communication. What a person expects from others and what a person remembers of a conversation. How open and honest a person is able to be in a relationship with another person correlated with the self-concept. It accounts for differences in people’s definition of personally meaningful behavior and those life events that affect them very little. It affects treatment outcome.

Caring human connection often are as healing as medication and specific treatments in influencing human responses to an illness, because they touch and confirm self-concept. Even when the nurse is unable to promote healing through physical measures, the interpersonal process of understanding the meaning of the illness provides a different type of healing. Through the nurse-patient relationship the nurse helps the patient lessens the impact of confusion, social alienation and emptiness on the self-concept, which is activated by most illnesses.

The characteristics of Self-concept are dynamic, holistic, and unique mental construct reflecting a person’s interaction. It is a dynamic process which allows roles to change and enlarge as a person matures. Self-concept is a holistic construct which represents the unified whole of a person with each functional aspect of self-concept fitting together and each single element affecting all other parts. Self-concept is unique to each person (Travelbee,1971). Indiviidual physiological features and inborn personality traits differ, as does ethnic and cultural heritage. Life experiences are both quantitatively and qualitatively different.

Essential Qualities for a Therapeutic Relationship
 Sincerity, Genuineness and authenticity – put in your heart what ever purpose of having interaction to patient. Being true to yourself and to your patient is needed.
 Respect unconditional positive regards – active listening to what your patient said is very much important. It conveys respect. Nurse doesn’t argue with the patient and do not disapprove or opposing the client’s idea. Disagreeing implies the patient is wrong.
 Empathy – it is important to view the world through the patient’s eyes yet remaining objective. It doesn’t mean to accord or agree with the client but able to zero in on his or her feelings.

2. Orientation Phase
The nurse-patient relationship formally begins with orientation phase. When nurse and patient first meet in a therapeutic relationship, the patient often comes with dual behavioral responses: hope that the treatment process will be successful and the anguished doubt that anything can be changed or that life will ever be the same. The nurse enters the relationship in the stranger role.

The purpose of the orientation phase is to become acquainted, gain rapport, demonstrate genuine caring and understanding and establish trust for an effective working phase. Also to start with the assessment of patient’s need and concern, coping strategies, defense mechanism and adaptation style; To inform patient regarding contract related to working and termination phase and the general purpose of having interaction with the nurse. It usually from 2-5sessions but with some patients can take many months.

 Built trust and security

Introduce yourself. Know your patient. It is important to know his or her complete name and also to include his nickname. Psychological attitudes implicitly recognizing the dignity of the patient from an important part of the interpersonal context. Human dignity and the patient’s personhood are acknowledged through simple nursing actions such as calling the patient by the correct title and name, providing the patient with as much freedom and decision making as the patient’s condition and developmental status allow, encouraging as much self-responsibility as possible given the patient’s level of self-care capacity. Show your sincerity in caring and interest which sometimes stimulates an atmosphere of hope. Convey honesty.

Ex: “ Magandang umaga sa iyo. Ako si Ms. Rubeth San Diego, nurse. Anong pangalan mo?” ……. “Anong gusto mong itawag ko sa iyo bilang palayaw mo?”

Nurse should set limit at the very beginning of the interaction. It must be clear to the patient your status to prevent from wrong expectations specially nurse and patient is opposite gender. Use your clinical eye and be observant of the patient’s behavior.

Ex. “ Ako ang magiging nurse mo at ikaw ang aking pasyente.”

 Introducing Purpose

The nurse needs to clarify the purpose of the relationship in the first session. Initial meetings should have two outcomes: First, the patient should emerge from the encounter with a better idea of some of the beginning health issues and possible goals. Second, the patient should feel that the nurse is interested in him or her as a person, not just a hospital number, because the nurse has taken the time to know more about the patient’s personal health care needs.

 Establish contract

Follow it and keep appointments. Inform the patient regarding the date, time, meetings, duration of each meeting, purpose, roles of both nurse and patient, use of information that will obtained.

Ex. “ Narito ako upang malaman ko ang mga concerns mo upang magtulungan tayong maiayos mo ang mga pangangailangan mo.

There must be arrangement for notifying patient or nurse if unable to keep appointment. It is important to allow patient to be responsible for the contract.

Ex. “Makakaasa ba ako sa iyong kooperasyon sa gagawin nating aktibidades na ito?”
 Developing a Therapeutic Contract

The final step in orientation phase of the relationship is a concise verbal expression of what both the nurse and patient can expect from the relationship (Arnold and Boggs, 1991). Referred to as a therapeutic contract, the verbal agreement supports the aims of the relationship and spells out role expectations and goals. At the outset, both nurse and client should agree on these responsibilities in an informal or verbal contract.

The contract should include:
 Time, place and length of sessions
 When sessions will start and be terminated
 Who will be involved in the treatment plan (family members, health team members, Professors, etc.)
 Client’s responsibilities
 Nurse’s responsibilities
 Observe and assess the patient’s strength and positive aspects of his or her own personality. Include the patient in identification of patient’s own attributes.

The nurse must read background materials available on the client, becomes familiar with the medication he is taking, gathers necessary paperwork and arranges for a quiet, private, comfortable setting.

Data collection is needed to know the concerns of your patient. It serves as a baseline of your interventions in working phase. The orientation phase begins when the nurse and client meet and ends when the client begins to identify the problem to examine.

3. Working Phase
This phase begins when the patient assumes responsibility to uphold the limits of the relationship. Focus is on the “here and now”. The purpose of the working phase is to do in-depth data collection, to develop supportive relationship with the patient, to help patient to reduce some of his symptoms by helping him modify some, to teach patient some of new skills like relaxation techniques and to assist patient during Psychotherapy. It is to bring about positive changes in the patient’s behavior.

 Involve Patient’s interest in the interaction:

To achieve maximum well-being, patient must be convinced that change is in their best interest. Only then will the necessary modification in attitude and active involvement in the treatment process occur. The treatment process can fail when a patient does not iunderstand a part of it or is indecisive, reluctant, anxious, doubtful or opposed to engaging fully with it. In this situatios, nurse can reperesent a decicive intervening variable.

 Formulate Nursing Care Plan.

Identify patient’s concerns, nursing diagnoses, outcome criteria and nursing interventions for preparation in the working phase. It is important to assess very well the patient’s response to this phase so you have the knowledge and data on how your nursing care plan will be.

 Facilitate the patient’s ability to verbalize his or her concern.
 Set priorities when determining patients need.

Observe safety: Assess if patient is suicidal, not eating, smoking in bed while medicated, and acting out behavior harmful to others.