Phases Of Therapeutic Nurse - Patient Relationship
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PHASES OF THERAPEUTIC NURSE - PATIENT RELATIONSHIP
DEFINITION
The nurse patient relationship is an end result of series of interaction between the nurse and patient over a period of time with the nurse focusing on need and problem of patient and his family while using the scientific knowledge and specific skills of nursing profession. Renjulal y 090504009
2
PHASES OF THERAPEUTIC NURSE- PATIENT RELATIONSHIP Pre interaction phase Introductory / orientation phase Working phase Termination phase
Renjulal y 090504009
3
Pre-interaction phase
Pre interaction is a phase which a nurse goes through before actual interaction with the patient. This phase begins when the nurse is assigned a patient to develop therapeutic relationship with him till she goes to him for interaction Renjulal y 090504009
4
Pre-Interaction Phase…..
The pre interaction phase begins before the nurses first contact with the patient. This involves preparation for first encounter with the client. This phase begins when the nurse is assigned a patient to develop therapeutic relationship with him or her till she goes him or her for interaction.
Renjulal y 090504009
5
Task of pre-interaction phase Obtaining available information
about the client from his or her charts, significant others or other health team members. From this information the initial assessment are begun. This initial information may also allow the nurse to become aware of personal response to the knowledge about the client. Renjulal y 090504009
6
Task of pre-interaction phase… Examining ones feelings, fears
and anxieties about working with a particular patient. Set objective for the interaction phase. Take help of the clinical supervisor or co-workers to overcome fears.
Renjulal y 090504009
7
Reactions of Nurse in Pre-Interaction Phase The nurse thinks and feels about
the patient before interacting according to her knowledge, fears and miss concepts. She tries to collect information from secondary sources like the patient’s records, a resource person and other nurses working in the ward.
Renjulal y 090504009
8
Pre Interaction Phase ……. The nurse plans how she is going
to interact with the patient, what she is going to achieve from this interaction and how she is going to help the patient. She plans her objective for interaction phase. Renjulal y 090504009
9
Pre Interaction Phase …….
The nurse may experience anxiety.
Anxiety may be manifested by standing in duty room and going through the records, talking with the clinical instructor.
Anxieties maybe,
Ø“will the patient talk to me? ØHe may not accept me or like me? ØHe may beat me?” Once she goes to the patient the anxiety reduces.
Renjulal y 090504009
10
How to overcome anxieties She can go through their record. Talk to the clinical supervisor or
other nurses about her fears. Can set her goals very clearly. Plan a brief interaction with the patient.
Renjulal y 090504009
11
INTRODUCTORY / ORIENTATION PHASE
Begins when the nurse goes to the patient, introduces herself and gets introduction about him. The nurse and client get acquainted. The orientation phase ends when the nurse and he patient begin to accept each other as a unique human being. Renjulal y 090504009
12
Task of introductory or orientation phase a) Establishment of Contact Nurse introduce herself to the
patient Build trust and rapport by demonstrating acceptance. Establishing a therapeutic environment ensuring safety and privacy
Renjulal y 090504009
13
Task of introductory or orientation phase.. b) Making Agreement or Pact Initiating a therapeutic contract
by establishing a time, place and duration of each meeting as well as the length of time the relationship will be in effect.
Renjulal y 090504009
14
Task of introductory or orientation phase.. c) Talking with the Patient While talking with the patient, shows trust in her behaviour. The patient may present a prepared ‘spiel’ to the nurse when she asks, “what is your problem?” during this task the nurse should establish a mode of communication which is acceptable to both the client and the Renjulal y 090504009
15
Task of introductory or orientation phase.. d) Assess the Clients Need,
Coping Strategies, Defense Mechanisms, Strengths and Weakness
Renjulal y 090504009
16
BARRIERS TO ORIENTATION PHASE 1) Establishing an agreement or
pact. 2) Social class of the patient or the
nurse. 3) Status of the patient. Renjulal y 090504009
17
5) Transference
When the patient perceive the nurse as a significant individual from the past: for example the perceives the nurse as his daughter and starts behaving with her like a father 6) Counter transference When the nurse perceives a male patient like her father and gives him the same care that she would have given to her father
Renjulal y 090504009
18
WORKING PHASE
Working Phase starts when the nurse and the patient are able to overcome the barriers of orientation and introductory phase. During this phase the nurse and the patient actively work on meeting the goals which they had establish during the orientation phase.
Renjulal y 090504009
19
WORKING PHASE…. The characteristic feature of this
phase is that the nurse is able to overcome anxiety and the patient’s fear of un known is also decreased.
Renjulal y 090504009
20
Task of working phase The nurse collects the data in detail
from primary and secondary sources and identifies the needs of the patent. The nurse assists the patient to identify his or her problem. She helps the patient to communicate. She encourages the patient to Renjulal y 090504009
21
Task of working phase… The nurse helps the patient o find
an alternative solution to his or her problems She encourage the patients to use new patterns of behaviour. Helps the client to develop positive coping behaviors. Identifying available support system. Renjulal y 090504009
22
Task of working phase… The nurse helps the patient to
understand that he has a significant role in his treatment. Exploring the clients perception of reality and provide constructive feed back. Developing and implementing plan of action with a realistic goals. Evaluating the results of plan of Renjulal y 090504009
23
Task of working phase… The nurse prepares the patient
for termination of relationship by reminding him during the interviews
Renjulal y 090504009
24
Working phase… The working phase helps the nurse
to develop knowledge and skill in psychiatric nursing. She identifies her strengths and weakness as a nurse while interacting with patient. It enables the nurse to achieve the goals which they have plan for this phase. The end results lead the patient to verbalize, socialize, identify and faces the problems realistically Renjulal y 090504009
25
BARRIERS OF WORKING PHASE Testing of the nurse
The patient tests the nurse for the ability and competence. Example: Patient: “please continue talking I am very upset today…….” If the nurse gives in to his demand, it indicates manipulation. He may deliberately be aggressive to test whether he is able
Renjulal y 090504009
26
BARRIERS OF WORKING PHASE… Progress of the patient
A mentally ill patient may not show a quick progress. He may progress then regress and remains stagnant before making further progress. In therapeutic relationship the nurse must understand the realistic progress in the client Renjulal y 090504009
27
BARRIERS OF WORKING PHASE… Difficulty in collecting and
interpreting the data The nurse is unwilling to engage in TDS task in collecting and interpreting the data, applying the knowledge and skills in helping the patient, she finds too hard to do this acts as a barrier in completing the task of working phase.
Renjulal y 090504009
28
BARRIERS OF WORKING PHASE… Fear of closeness
The nurse feels that she is working closely with the patient she may find difficult to terminate the relationship. The patient may not like to discontinue the relationship. To avoid closeness she doesn’t communicate freely and makes deliberate attempts to avoid going to the patient. Renjulal y 090504009
29
STRATEGIES TO OVERCOME BARRIERS Learn the subject in depth Taking help from supervisors and
experts Discussions with peer group
Renjulal y 090504009
30
TERMINATION PHASE
The final step of the therapeutic relationship is the termination phase. The nurse terminates the relationship when they mutually agreed: on goals are reached.
Renjulal y 090504009
31
TERMINATION PHASE…. The nurse discusses the termination
phase with the client encourages to identify the progress that the client has made and explores the necessity of any referral that may be beneficial to the patient. As separations occurs clients commonly exhibit regressive behaviour demonstrates hostility or experience sadness. Renjulal y 090504009
32
TERMINATION PHASE…. The client may attempt to prolong
the relationship as clinical symptoms of separation anxiety are experienced however; termination needs to occur if a therapeutic relationship to be a complete process. Preparation for termination actually begins during the initiation phase Renjulal y 090504009
33
CAUSES
The
client is transferred or discharge. The nurse is finished clinical rotation. The patient may go on parole and doesn’t come back to hospital. The client has improved and no longer needs to have one to one Renjulal y 090504009
34
TASK OF TERMINATION Bring a therapeutic end to the
relationship. Review feelings about relationship. Evaluate progress towards goal. Establish mechanisms for meeting future therapy needs. Summarize entire communication and follow up treatments.
Renjulal y 090504009
35
PREPARATION OF PATIENT Explain
whatever goals of therapeutic relationship where plans have been met. Allow the patient to talk about his or her fear and an individualistic approach has to be used. A psychiatric social worker can be contacted to meet to visit the office and family of the patient.
Renjulal y 090504009
36
PREPARATION OF PATIENT… The patient may sent on parole
before discharge, so that he gradually goes through the weaning of the phase. The patient may be sent through a half way home. The patient may be asked to attend the day care center for few days.
Renjulal y 090504009
37
BARRIERS OF TERMINATION PHASE The patient may ask the nurse to
write to him or come back from duty and see him. The patient may ask the address and telephone number of nurse and ask permission to visit her in hospital Gift giving Renjulal y 090504009
38
BARRIERS OF TERMINATION PHASE…. The nurse may withdraw earlier
from the patient due to her own anxiety she may not interact with the patient The nurse may not assess the patient which she could otherwise do
Renjulal y 090504009
39
STRATEGIES TO OVERCOME Nurse needs to explore her own
feelings and thoughts about separation from the patient which will help her to accomplish the task of termination phase The patient should be explained that ‘every relationship terminates’ Getting help from supervisors
Renjulal y 090504009
40
STRATEGIES TO OVERCOME…. After discharge the patient comes
for intervention he or she should be referred to a second in charge. If the patient is giving some gifts: the patient need to be explained about the professional ethics, if he wants to give a gift he may be encourage to gift out something for the utilization of other patients.
Renjulal y 090504009
41
Thank you Presented by : Renjulal y M.Sc nursing Mental Health Nursing MCON
Renjulal y 090504009
42
DEFINITION
The nurse patient relationship is an end result of series of interaction between the nurse and patient over a period of time with the nurse focusing on need and problem of patient and his family while using the scientific knowledge and specific skills of nursing profession. Renjulal y 090504009
2
PHASES OF THERAPEUTIC NURSE- PATIENT RELATIONSHIP Pre interaction phase Introductory / orientation phase Working phase Termination phase
Renjulal y 090504009
3
Pre-interaction phase
Pre interaction is a phase which a nurse goes through before actual interaction with the patient. This phase begins when the nurse is assigned a patient to develop therapeutic relationship with him till she goes to him for interaction Renjulal y 090504009
4
Pre-Interaction Phase…..
The pre interaction phase begins before the nurses first contact with the patient. This involves preparation for first encounter with the client. This phase begins when the nurse is assigned a patient to develop therapeutic relationship with him or her till she goes him or her for interaction.
Renjulal y 090504009
5
Task of pre-interaction phase Obtaining available information
about the client from his or her charts, significant others or other health team members. From this information the initial assessment are begun. This initial information may also allow the nurse to become aware of personal response to the knowledge about the client. Renjulal y 090504009
6
Task of pre-interaction phase… Examining ones feelings, fears
and anxieties about working with a particular patient. Set objective for the interaction phase. Take help of the clinical supervisor or co-workers to overcome fears.
Renjulal y 090504009
7
Reactions of Nurse in Pre-Interaction Phase The nurse thinks and feels about
the patient before interacting according to her knowledge, fears and miss concepts. She tries to collect information from secondary sources like the patient’s records, a resource person and other nurses working in the ward.
Renjulal y 090504009
8
Pre Interaction Phase ……. The nurse plans how she is going
to interact with the patient, what she is going to achieve from this interaction and how she is going to help the patient. She plans her objective for interaction phase. Renjulal y 090504009
9
Pre Interaction Phase …….
The nurse may experience anxiety.
Anxiety may be manifested by standing in duty room and going through the records, talking with the clinical instructor.
Anxieties maybe,
Ø“will the patient talk to me? ØHe may not accept me or like me? ØHe may beat me?” Once she goes to the patient the anxiety reduces.
Renjulal y 090504009
10
How to overcome anxieties She can go through their record. Talk to the clinical supervisor or
other nurses about her fears. Can set her goals very clearly. Plan a brief interaction with the patient.
Renjulal y 090504009
11
INTRODUCTORY / ORIENTATION PHASE
Begins when the nurse goes to the patient, introduces herself and gets introduction about him. The nurse and client get acquainted. The orientation phase ends when the nurse and he patient begin to accept each other as a unique human being. Renjulal y 090504009
12
Task of introductory or orientation phase a) Establishment of Contact Nurse introduce herself to the
patient Build trust and rapport by demonstrating acceptance. Establishing a therapeutic environment ensuring safety and privacy
Renjulal y 090504009
13
Task of introductory or orientation phase.. b) Making Agreement or Pact Initiating a therapeutic contract
by establishing a time, place and duration of each meeting as well as the length of time the relationship will be in effect.
Renjulal y 090504009
14
Task of introductory or orientation phase.. c) Talking with the Patient While talking with the patient, shows trust in her behaviour. The patient may present a prepared ‘spiel’ to the nurse when she asks, “what is your problem?” during this task the nurse should establish a mode of communication which is acceptable to both the client and the Renjulal y 090504009
15
Task of introductory or orientation phase.. d) Assess the Clients Need,
Coping Strategies, Defense Mechanisms, Strengths and Weakness
Renjulal y 090504009
16
BARRIERS TO ORIENTATION PHASE 1) Establishing an agreement or
pact. 2) Social class of the patient or the
nurse. 3) Status of the patient. Renjulal y 090504009
17
5) Transference
When the patient perceive the nurse as a significant individual from the past: for example the perceives the nurse as his daughter and starts behaving with her like a father 6) Counter transference When the nurse perceives a male patient like her father and gives him the same care that she would have given to her father
Renjulal y 090504009
18
WORKING PHASE
Working Phase starts when the nurse and the patient are able to overcome the barriers of orientation and introductory phase. During this phase the nurse and the patient actively work on meeting the goals which they had establish during the orientation phase.
Renjulal y 090504009
19
WORKING PHASE…. The characteristic feature of this
phase is that the nurse is able to overcome anxiety and the patient’s fear of un known is also decreased.
Renjulal y 090504009
20
Task of working phase The nurse collects the data in detail
from primary and secondary sources and identifies the needs of the patent. The nurse assists the patient to identify his or her problem. She helps the patient to communicate. She encourages the patient to Renjulal y 090504009
21
Task of working phase… The nurse helps the patient o find
an alternative solution to his or her problems She encourage the patients to use new patterns of behaviour. Helps the client to develop positive coping behaviors. Identifying available support system. Renjulal y 090504009
22
Task of working phase… The nurse helps the patient to
understand that he has a significant role in his treatment. Exploring the clients perception of reality and provide constructive feed back. Developing and implementing plan of action with a realistic goals. Evaluating the results of plan of Renjulal y 090504009
23
Task of working phase… The nurse prepares the patient
for termination of relationship by reminding him during the interviews
Renjulal y 090504009
24
Working phase… The working phase helps the nurse
to develop knowledge and skill in psychiatric nursing. She identifies her strengths and weakness as a nurse while interacting with patient. It enables the nurse to achieve the goals which they have plan for this phase. The end results lead the patient to verbalize, socialize, identify and faces the problems realistically Renjulal y 090504009
25
BARRIERS OF WORKING PHASE Testing of the nurse
The patient tests the nurse for the ability and competence. Example: Patient: “please continue talking I am very upset today…….” If the nurse gives in to his demand, it indicates manipulation. He may deliberately be aggressive to test whether he is able
Renjulal y 090504009
26
BARRIERS OF WORKING PHASE… Progress of the patient
A mentally ill patient may not show a quick progress. He may progress then regress and remains stagnant before making further progress. In therapeutic relationship the nurse must understand the realistic progress in the client Renjulal y 090504009
27
BARRIERS OF WORKING PHASE… Difficulty in collecting and
interpreting the data The nurse is unwilling to engage in TDS task in collecting and interpreting the data, applying the knowledge and skills in helping the patient, she finds too hard to do this acts as a barrier in completing the task of working phase.
Renjulal y 090504009
28
BARRIERS OF WORKING PHASE… Fear of closeness
The nurse feels that she is working closely with the patient she may find difficult to terminate the relationship. The patient may not like to discontinue the relationship. To avoid closeness she doesn’t communicate freely and makes deliberate attempts to avoid going to the patient. Renjulal y 090504009
29
STRATEGIES TO OVERCOME BARRIERS Learn the subject in depth Taking help from supervisors and
experts Discussions with peer group
Renjulal y 090504009
30
TERMINATION PHASE
The final step of the therapeutic relationship is the termination phase. The nurse terminates the relationship when they mutually agreed: on goals are reached.
Renjulal y 090504009
31
TERMINATION PHASE…. The nurse discusses the termination
phase with the client encourages to identify the progress that the client has made and explores the necessity of any referral that may be beneficial to the patient. As separations occurs clients commonly exhibit regressive behaviour demonstrates hostility or experience sadness. Renjulal y 090504009
32
TERMINATION PHASE…. The client may attempt to prolong
the relationship as clinical symptoms of separation anxiety are experienced however; termination needs to occur if a therapeutic relationship to be a complete process. Preparation for termination actually begins during the initiation phase Renjulal y 090504009
33
CAUSES
The
client is transferred or discharge. The nurse is finished clinical rotation. The patient may go on parole and doesn’t come back to hospital. The client has improved and no longer needs to have one to one Renjulal y 090504009
34
TASK OF TERMINATION Bring a therapeutic end to the
relationship. Review feelings about relationship. Evaluate progress towards goal. Establish mechanisms for meeting future therapy needs. Summarize entire communication and follow up treatments.
Renjulal y 090504009
35
PREPARATION OF PATIENT Explain
whatever goals of therapeutic relationship where plans have been met. Allow the patient to talk about his or her fear and an individualistic approach has to be used. A psychiatric social worker can be contacted to meet to visit the office and family of the patient.
Renjulal y 090504009
36
PREPARATION OF PATIENT… The patient may sent on parole
before discharge, so that he gradually goes through the weaning of the phase. The patient may be sent through a half way home. The patient may be asked to attend the day care center for few days.
Renjulal y 090504009
37
BARRIERS OF TERMINATION PHASE The patient may ask the nurse to
write to him or come back from duty and see him. The patient may ask the address and telephone number of nurse and ask permission to visit her in hospital Gift giving Renjulal y 090504009
38
BARRIERS OF TERMINATION PHASE…. The nurse may withdraw earlier
from the patient due to her own anxiety she may not interact with the patient The nurse may not assess the patient which she could otherwise do
Renjulal y 090504009
39
STRATEGIES TO OVERCOME Nurse needs to explore her own
feelings and thoughts about separation from the patient which will help her to accomplish the task of termination phase The patient should be explained that ‘every relationship terminates’ Getting help from supervisors
Renjulal y 090504009
40
STRATEGIES TO OVERCOME…. After discharge the patient comes
for intervention he or she should be referred to a second in charge. If the patient is giving some gifts: the patient need to be explained about the professional ethics, if he wants to give a gift he may be encourage to gift out something for the utilization of other patients.
Renjulal y 090504009
41
Thank you Presented by : Renjulal y M.Sc nursing Mental Health Nursing MCON
Renjulal y 090504009
42
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