TYPES OF RELATIONSHIPS
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Each relationship is unique because of the various combinations of traits and characteristics of and circumstances related to the people involved. Although every relationship is different, all relationships may be categorized into three major types: social, intimate, and therapeutic.
Social Relationship A social relationship is primarily initiated for the purpose of friendship, socialization, companionship, or accomplishment of a task. Communication, which may be superficial, usually focuses on sharing ideas, feelings, and experiences and meets the basic need for people to interact. Advice is often given. Roles may shift during social interactions.
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Outcomes of this kind of relationship are rarely assessed. When a nurse greets a client and chats about the weather or a sports event or engages in small talk or socializing, this is a social interaction. This is acceptable in nursing, but for the nurse–client relationship to accomplish the goals that have been decided on, social interaction must be limited. If the relationship becomes more social than therapeutic, serious work that moves the client forward will not be done.
Intimate Relationship A healthy intimate relationship involves two people who are emotionally committed to each other. Both parties are concerned about having their individual needs met and helping each other to meet needs as well. The relationship may include sexual or emotional intimacy as well as sharing of mutual goals. Evaluation of the interaction may be ongoing or not. The intimate relationship has no place in the nurse–client interaction.
Therapeutic Relationship The therapeutic relationship differs from the social or intimate relationship in many ways because it focuses on the needs, experiences, feelings, and ideas of the client only. The nurse and client agree about the areas to work on and evaluate the outcomes. The nurse uses communication skills, personal strengths, and understanding of human behavior to interact with the client. In the therapeutic relationship the parameters are clear: the focus is the client’s needs, not the nurse’s. 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 or her own.
The nurse’s level of self-awareness can either benefit or hamper the therapeutic relationship. For example, if the nurse is nervous around the client, the relationship is more apt to stay social because superficiality is safer. If the nurse is aware of his or her fears, he or she can discuss them with the instructor, paving the way for a more therapeutic relationship to develop.
ESTABLISHING THE THERAPEUTIC RELATIONSHIP The nurse who has self-confidence rooted in self-awareness is ready to
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establish appropriate therapeutic relationships with clients. Because personal growth is ongoing over one’s lifetime, the nurse cannot expect to have complete self-knowledge. Awareness of his or her strengths and limitations at any particular moment, however, is a good start.
Phases Peplau studied and wrote about the interpersonal processes and the phases of the nurse–client relationship for 35 years. Her work provides the nursing profession with a model that can be used to understand and document progress with interpersonal interactions. Peplau’s model (1952) has three phases: orientation, working, and resolution or termination (Table 5.2). In real life, these phases are not that clear-cut; they overlap and interlock.
Orientation The orientation phase begins when the nurse and client meet and ends when the client begins to identify problems to examine. During the orientation phase, the nurse establishes roles, the purpose of meeting, and the parameters of subsequent meetings; identifies the client’s problems; and clarifies expectations.
Before meeting the client, the nurse has important work to do. The nurse reads background materials available on the client, becomes familiar with any medications the client is taking, gathers necessary paperwork, and arranges for a quiet, private, and comfortable setting. This is the time for self-assessment. The nurse should consider his or her personal strengths and limitations in working with this client. Are there any areas that might signal difficulty because of past experiences? For 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 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 must come to each client without preconceptions or prejudices. It may be useful for the nurse to discuss all potential problem areas with the instructor.
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During the orientation phase, the nurse begins to build trust with the client. It is the nurse’s responsibility to establish a therapeutic environment that fosters trust and understanding (Table 5.3). The nurse should share appropriate information about himself or herself at this time, including name, reason for being on the unit, and level of schooling: For example, “Hello, James. My name is Miss Ames, and I will be your nurse for the next six Tuesdays. I am a senior nursing student at the University of Mississippi.”
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Phases of nurse–client relationship
The nurse needs to listen closely to the client’s history, perceptions, and misconceptions. He or she needs to convey empathy and understanding. If the relationship gets off to a positive start, it is more likely to succeed and to meet established goals.
At the first meeting, the client may be distrustful if previous relationships with nurses have been unsatisfactory. The client may use rambling speech, act out, or exaggerate episodes as ploys to avoid discussing the real problems. It may take several sessions until the client believes that he or she can trust the nurse.
Nurse–Client Contracts. Although many clients have had prior experiences in the mental health system, the nurse must once again outline the
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responsibilities of the nurse and the client. At the outset, both nurse and client should agree on these responsibilities in an informal or verbal contract. In some instances, a formal or written contract may be appropriate; examples include if a written contract has been necessary in the past with the client or if the client “forgets” the agreed-on verbal contract.
The contract should state the following:
• Time, place, and length of sessions • When sessions will terminate • Who will be involved in the treatment plan (family members or health
team members) • Client responsibilities (arrive on time and end on time) • Nurse’s responsibilities (arrive on time, end on time, maintain
confidentiality at all times, evaluate progress with client, and document sessions)
Confidentiality. Confidentiality means respecting the client’s right to keep private any information about his or her mental and physical health and related care. It means allowing only those dealing with the client’s care to have access to the information that the client divulges. Only under precisely defined conditions can third parties have access to this information; for example, in many states the law requires that staff report suspected child and elder abuse.
Adult clients can decide which family members, if any, may be involved in treatment and may have access to clinical information. Ideally, the people close to the client and responsible for his or her care are involved. The client must decide, however, who will be included. For the client to feel safe, boundaries must be clear. The nurse must clearly state information about who will have access to client assessment data and progress evaluations. He or she should tell the client that members of the mental health team share appropriate information among themselves to provide consistent care and that only with the client’s permission will they include a family member. If the client has an appointed guardian, that person can review client information and make treatment decisions that are in the client’s best interest. For a child, the parent or appointed guardian is allowed access to information and can make treatment decisions as outlined by the health-care team.
The nurse must be alert if a client asks him or her to keep a secret because this information may relate to the client’s harming himself or
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herself or others. The nurse must avoid any promises to keep secrets. If the nurse has promised not to tell before hearing the message, he or she could be jeopardizing the client’s trust. In most cases, even when the nurse refuses to agree to keep information secret, the client continues to relate issues anyway. The following is an example of a good response to a client who is suicidal but requests secrecy:
Client: “I am going to jump off the 14th floor of my apartment building tonight, but please don’t tell anyone.”
Nurse: “I cannot keep such a promise, especially if it involves your safety. I sense you are feeling frightened. The staff and I will help you stay safe.”
The Tarasoff vs. Regents of the University of California decision in 1976, releases professionals from privileged communication with their clients should a client make a homicidal threat. The decision requires the nurse to notify intended victims and police of such a threat. In this circumstance, the nurse must report the homicidal threat to the nursing supervisor and attending physician so that both the police and the intended victim can be notified. This is called a duty to warn and is discussed more fully in Chapter 9.
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The nurse documents the client’s problems with planned interventions. The client must understand that the nurse will collect data about him or her that helps in making a diagnosis, planning health care (including medications), and protecting the client’s civil rights. The client needs to know the limits of confidentiality in nurse–client interactions and how the nurse will use and share this information with professionals involved in client care.
Self-Disclosure. Self-disclosure means revealing personal information such as biographical information and personal ideas, thoughts, and feelings about oneself to clients. Traditionally, conventional wisdom held that nurses should share only their name and give a general idea about their residence, such as “I live in Ocean County.” Now, however, it is believed that some purposeful, well-planned, self-disclosure can improve rapport between the nurse and the client. The nurse can use self-disclosure to convey support, educate clients, and demonstrate that a client’s anxiety is normal and that many people deal with stress and problems in their lives.
Self-disclosure may help the client feel more comfortable and more willing to share thoughts and feelings, or help the client gain insight into his or her situation. When using self-disclosure, the nurse must also consider cultural factors. Some clients may deem self-disclosure inappropriate or too personal, causing the client discomfort. Disclosing personal information to a client can be harmful and inappropriate, so it must be planned and considered thoughtfully in advance. Spontaneously self-disclosing personal information can have negative results. For example, when working with a client whose parents are getting a divorce, the nurse says, “My parents got a divorce when I was 12, and it was a horrible time for me.” The nurse has shifted the focus away from the client and has given the client the idea that this experience will be horrible for the client. Although the nurse may have meant to communicate empathy, the result can be quite the opposite.
Working The working phase of the nurse–client relationship is usually divided into two subphases: During problem identification, the client identifies the issues or concerns causing problems. During exploitation, the 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. (Note that Peplau’s use of the word exploitation had a very different meaning than current usage, which involves unfairly using or taking advantage of a person or situation. For
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that reason, this phase is better conceptualized as intense exploration and elaboration on earlier themes that the client discussed.) 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. Often, when the client becomes uncomfortable because he or she is getting too close to the truth, he or she will use testing behaviors to avoid the subject. 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 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. For example, a client who suffers from depression complains to the nurse about the lack of concern her children show her. 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. The nurse can then help the client explore more effective ways of communicating in the future. The specific tasks of the working phase include the following:
• Maintaining the relationship • Gathering more data • Exploring perceptions of reality • Developing positive coping mechanisms • Promoting a positive self-concept • Encouraging verbalization of feelings • Facilitating behavior change • Working through resistance • Evaluating progress and redefining goals as appropriate • Providing opportunities for the client to practice new behaviors • Promoting independence
As the nurse and client work together, it is common for the client
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unconsciously to transfer to the nurse feelings he or she has for significant others. This is called transference. For example, if the client has had negative experiences with authority figures, such as a parent or teachers or principals, he or she may display similar reactions of negativity and resistance to the nurse, who also is viewed as an authority. A similar process can occur when the nurse responds to the client based on personal unconscious needs and conflicts; this is called countertransference. For example, if the nurse is the youngest in her family and often felt as if no one listened to her when she was a child, she may respond with anger to a client who does not listen or resists her help. Again, self-awareness is important so that the nurse can identify when transference and countertransference might occur. By being aware of such “hot spots,” the nurse has a better chance of responding appropriately rather than letting old unresolved conflicts interfere with the relationship.
Termination The termination or resolution phase is the final stage in the nurse–client relationship. 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 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.
Nurse Jones comes to see Mrs. O’Shea for the last time. Mrs. O’Shea is weeping quietly.
Mrs. O’Shea: “Oh, Ms. Jones, you have been so helpful to me. I just know I will go back to my old self without you here to help me.”
Nurse Jones: “Mrs. O’Shea, I think we’ve had a very productive time together. You have learned so many new ways to have better relationships with your children, and I know you will go home and be able to use those skills. When you come back for your follow-up visit, I will want to hear all about how things have changed at home.”