• 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.

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.

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.

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.

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.

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:

OR

For a psychiatric–mental health advanced-practice registered nurse (APRN-PMH) working in the clinical setting, the parameters might be altered.

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:

For an APRN-PMH, the contract might be:

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 threatens self-harm

• When the patient does not intend to follow through with the treatment plan