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Define three areas in which nurses are required to develop effective relationships.
List seven issues that either strengthen or interfere with relationships.
Identify ways in which selected nursing theorists inform therapeutic relationships.
Identify ways that the humanistic psychologies of Rogers and Maslow, as well as the positive psychology of Seligman, expand holistic thinking.
Identify four archetypes of human relationships that address physical, emotional, mental, and spiritual domains, using Jung and Arrien.
Identify core elements that lead to establishing and maintaining effective relationships.
Implement and evaluate effective negotiating styles that address issues while maintaining a sense of relatedness.
Gain insight into problematic aspects of relationships and how to manage them more effectively.
Increase your use of key effective personal relationship characteristics.
Develop strategies to incorporate effective boundaries in relationships.
Strengthen your concepts of spiritual relationship.
with others, rather than seeking power and control or becoming overly passive.
Connection means there is active involvement with another, associated with enhanced comfort and wellness.
Disconnection involves lack of involvement and is associated with lack of wellness and distress.
Parallelism implies disengagement, or the lack of involvement with others. This can have a positive effect of creating solitude with associated physical and psychological replenishment.
Enmeshment often describes negative, overinvolved relationships, fraught with anxiety, distress, and functional disability.
Sense of belonging means there is an appropriate “fit” with the environment, group, or individual. There is a sense of being valued and needed in the relationship.
Reciprocity is a positive aspect of relationship in which there is a perceived equal exchange between parties.
Mutuality represents how people tend to join with those they believe share similarities to them, or with whom they share an acceptance of differences.
Synchrony is a person’s perception of congruent feelings or behaviors with another with whom the individual shares a relationship.
The meaning and essence of care are experienced in the moment when one human being connects with another.
Feeling connected to one another creates harmony and healing; feeling isolated destroys spirit.
The relationship between patients and their families and members of the clinical team belongs at the heart of care delivery.
Care providers’ knowledge of self and self-care are fundamental requirements for high-quality care and healthy interpersonal relationships.
Healthy relationships among members of the healthcare team lead to the delivery of high-quality care and result in high patient, physician, and staff satisfaction.
The value of relationship in patient care must be understood, valued, and agreed to by all members of the healthcare organization.
A therapeutic relationship between a patient/family and a professional nurse is essential to high-quality patient care.
concept of the therapeutic relationship, which promotes a healing relationship. Being therapeutic implies using oneself as an agent of healing in the dynamic relationship between provider and patient or client. Although holistic nurses may not have expertise in a variety of psychological approaches, it is meaningful for them to have a basic understanding of selected psychological modalities that have influenced models of therapeutic relationship, counseling, and therapy. For human beings to relate well to one another, it is vital to comprehend some of the primary psychological theories that influence understanding of human behaviors and relationships. To understand others, it is first necessary to understand ourselves and why we do the things we do. Because human lives are built on interrelationships, it is understandable that the sources of our conflicts and troubles are associated with unhealthy relationships to a Higher Power, to other human beings, to the environment, and to one’s self.
Provide dignity and respect; honor patient and family choices. Incorporate the cultural background, values, and beliefs of the patient/family into health care.
Encourage patients and families to participate in decision making about their healthcare needs.
TABLE 20-1 Relationship Theorists
Psychologists
Theory and Applications
Eric Berne
Transactional Analysis (TA).
Concept: Three ego states, people move among states; unconscious games played between people may be a substitute for true intimacy. Three ego states are Adult (rational, objective), Parent (authoritative figure), and Child (playful, curious, stubborn). All human beings need social interaction, even if it is negative interaction.
Book: Games People Play: The Psychology of Human Relationships (1964)
Erik Erikson
Eight psychosocial stages of life; psychoanalytic approach:
1.
Trust vs. mistrust (infancy)
2.
Autonomy vs. shame (early childhood)
3.
Initiative vs. doubt (preschool)
4.
Competence vs. incompetence (elementary school)
5.
Identity vs. role confusion (middle/high school)
6.
Intimacy vs. isolation (college)
7.
Generativity vs. stagnation (adult)
8.
Ego integrity vs. ego despair (older age)
Concept: Tasks of each age group must be completed; youth often develop identity crisis in their 20s after completing higher education.
Book: Identity, Youth, and Crisis (1968)
Carl Jung
Freudian psychoanalytic psychology.
Concepts: Collective unconscious as the inherited human unconscious composed of universal mental images and thoughts, which are archetypes.
Archetypes: Concepts of personality expressed in myths and fairy tales; people fit into these roles interchangeably.
Mother archetype: Most important, role of nurse, Mother of God, grandmothers, church, Earth, and Nature.
Crone archetype: The wise old woman who is a visionary, who at the crossroads of life chooses the path of the soul rather than the ego, and she speaks the truth always.
Book: Development of Personality (1981)
Angeles Arrien
Transpersonal psychology; views life holistically.
Concepts: Evolved Jungian archetypes, four primary archetypes identified.
Healer archetype: Holistic nursing professionals manifest this archetype by relating to others compassionately and with love. Other essential characteristics of the Healer include bringing caring to human relationships, viewing others in a positive light, and bringing emotional comfort.
Teacher archetype: The Teacher represents the mental quality in relationships, helping learners to achieve new knowledge, wisdom, and insight. Teachers are also very open to learning. Holistic nurses often exhibit the teacher quality as well.
Warrior archetype: The Warrior symbolizes physical qualities of relationship building. This archetype uses courage to help improve behaviors of self and others, is firm, and uses knowledge, especially facts, effectively. Holistic nurses are very interested in helping patients improve their health and wellness behaviors and can use facts and their knowledge very effectively in this endeavor.
Visionary archetype: The Visionary archetype symbolizes the spiritual aspect of relationship. The Visionary is nonjudgmental and assists in conflict resolution. This personality model exemplifies sound intuitive knowing to assist others in achieving their highest good. Holistic nurses need to focus on the spiritual aspect of relationship, which, in itself, tends to move others toward their highest potential.15
Book: The Four-Fold Way (1993)
Isabel Briggs Myers
Concept: Jungian based. Myers-Briggs Type Indicator (MBTI) test widely used to identify personality types. Basis of much psychometric testing; often used to gauge appropriate career choices for individuals, to describe marriage compatibility, and for personal development
The MBTI results are expressed in four-letter codes representing how personalities fall into four different domains. Possible to have total of 16 combinations of domains. Manner in which a person perceives reality is described as either “sensing” type (relies on the five senses) or “intuiting” type (relies on the unconscious to confirm what is real and what is not). Second area of personality involves the way a person judges, either through “thinking” (using logic in interpersonal relationships) or “feeling” (interpreting what something means to themselves as individuals). The third domain involves being an “extravert” (outgoing, makes quick decisions, attempts to influence situations) or an “introvert” (more interested in the inner world of ideas, needs time to develop ideas and insights, quieter). The final domain involves deciding between dominant and auxiliary processes. Sensing (S), intuition (N), thinking (T), and feeling (F) are placed together in pairs. Of these pairs, one function is “dominant” and the other is “auxiliary” (additional), which helps in ordering the letters. Extraverts (E), introverts (I), judgment (J), and perception (P) round out the personality symbols.
Abraham Maslow
Father of human psychology.
Concept: Hierarchy of needs. People move from lowest physiologic needs (food, water, oxygen) to safety and security, to love and belonging, to esteem and respect, to the highest level, self-actualization (need to do and be the person one is meant to be).
Other significant concepts of humanistic psychology:
▪
Identifying one’s own voice as the self, rather than listening to society or the parental figure
▪
Realization that life is a series of choices, one leading to personal growth and the other to regression
▪
Being honest and taking responsibility for one’s feelings, even if not popular
▪
Being the best one can be in one’s work; think outside box, creative
▪
Seeing others at their best, finding the good in others
▪
Abandoning psychological defense mechanisms
Book: Toward a Psychology of Being (1968)
Carl Rogers
Humanistic psychologist.
Concept: Patient-centered or client-centered therapy; some people have experienced being in open, trusting dialogue with another, without being judged, and having felt a sense of healing from this relationship. Based on Buber’s I-Thou philosophy of treating the other as person, not object.
Preferable to listen to what clients were saying, rather than trying to “fix” them. Therapist did not need to remain detached and objective; could respond emotionally to the client.
Book: On Becoming a Person: A Therapist’s View of Psychotherapy (1995)
Daniel Goleman
Concept: Began new movement looking at significance of emotional vs. intellectual intelligence. Qualities such as optimism, empathy toward others, resilience (the ability to recover from adversity), and ability to adapt to change are considered part of emotional intelligence. Also conscientiousness, goal orientation with delayed gratification to achieve goals, awareness of one’s own shortcomings, confidence in being able to handle most problems, having ability to interact well with others, be cooperative, and manage close personal relationships.
Book: Emotional Intelligence (1995)
Martin Seligman
Father of Positive Psychology.
▪
The study of emotions that are positive
▪
The study of traits that are positive, including virtues, intelligence, strength, and athleticism
▪
The study of social institutions or concepts that possess positive qualities (e.g., functional family units, freedom of inquiry, and democracy) and support a virtuous life. Virtues include integrity, loyalty, valor, and equity.
Concepts: Positive emotions such as trust, hope, and confidence help us most in times of distress. Optimistic people interpret problems as controllable, transient, and limited to one situation. Pessimistic people believe troubles last forever, are uncontrollable, and undermine them.
Learned helplessness: Concept that studied human and animal responses to uncontrollable events. Learned Linked to passivity in emotionally stressed and traumatized human beings. Linked to depression and victim abuse because of learned helplessness.
Book: Authentic Happiness: Using the New Positive Psychology to Realize Your Potential for Lasting Fulfillment (2002)
Source: Adapted from T. Butler-Bowden, 50 Psychology Classics: Who We Are, How We Think, What We Do (Boston, MA: Nicholas Brealey, 2007).
TABLE 20-2 Case Studies Using Theoretical Models
Using the Rogerian model
The nurse provides client-centered care in her psychiatric setting. She listens to Shelly, a 16-year-old female who has just lost her mother, and she allows her to tell stories of how her mother was her best friend. The nurse nonjudgmentally allows Shelly to describe her guilt over having an argument with her mother the day before she died.
Using the Myers-Briggs Type Indicator
The nurse is providing care to 43-year-old JoEllen who talks excessively about her past. The nurse recognizes that JoEllen may have the Feeler personality type, and talking is her way of expression. Another patient, Ryan, is a 35-yearold executive who has a Thinker personality, consistent with his job as a manager. The nurse recognizes that Thinkers prefer direct information rather than excessive conversation.
Using Seligman’s Positive Psychology
The nurse assists 28-year-old Amy, a victim of physical abuse, to avoid the passivity and pessimism that often comes with being abused. The nurse points Amy in the direction of hope, positive change, lack of acceptance of this “learned helplessness,” and optimism about a new future.
Share complete and unbiased information with patients/families, and make certain the information in accurate, timely, and complete.
Healthcare leadership should collaborate with patients/families to develop and implement patient-centered policies, programs, education, and care delivery.
occurs through presence, inferring, being with, and doing with another. These theorists believe “through relating with other persons as presences, individuals become more and realize their uniqueness” and so that presence is a gift of self.16 This concept implies that people grow and improve through relationship. Learning to understand others gives each person the opportunity to appreciate the uniqueness of his or her self. Presence is characterized by spontaneity, availability, and reciprocity in a mutual nurse-patient relationship. Reciprocity is considered a flow between two people in a shared situation. The nurse’s goal is to nurture well-being. The nurse-patient relationship is a type of community, implying two or more people moving toward a common goal. Paterson and Zderad utilize Martin Buber’s concept of “I-Thou” as the ideal relationship, as compared with “I-It.” “I-Thou” refers to viewing the other as a valued, integral whole, while “I-It” refers to viewing others without relationship and caring. The theorists mold Buber’s work into a nursing framework emphasizing that a person comes to know himself or herself as a unique person primarily through relationship to others.
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