Concepts of the nurse-patient relationship

The health care community has increasingly grown to accept the concept of patient-centered care as the gold standard. The core concepts of patient- and family-centered care consist of (1) dignity and respect, (2) information sharing, (3) patient and family participation, and (4) collaboration in policy and program development (Institute for Patient- and Family-Centered Care, 2010). These tenets are familiar to members of the nursing profession as the nurse-patient relationship.

The nurse-patient relationship is the basis of all psychiatric mental health nursing treatment approaches, regardless of the specific goals. The very first connections between nurse and patient are to establish an understanding that the nurse is safe, confidential, reliable, and consistent, and that the relationship will be conducted within appropriate and clear boundaries.

It is true that many psychiatric disorders, such as schizophrenia, bipolar disorder, and major depression, have strong biochemical and genetic components; however, many accompanying emotional problems such as poor self-image, low self-esteem, and difficulties with adherence to a treatment regimen can be significantly improved through a therapeutic nurse-patient relationship. All too often, patients entering treatment have taxed or exhausted their familial and social resources and find themselves isolated and in need of emotional support.

The nurse-patient relationship is a creative process and unique to each nurse. Each of us has distinct gifts that we can learn to use creatively to form positive bonds with others, historically referred to as the therapeutic use of self. Travelbee (1971) defined therapeutic use of self as “the ability to use one’s personality consciously and in full awareness in an attempt to establish relatedness and to structure nursing interventions” (p. 19). The efficacy of this therapeutic use of self has been scientifically substantiated as an evidence-based intervention. Randomized clinical trials have repeatedly found that development of a positive alliance (therapeutic relationship) is one of the best predictors of positive outcomes in therapy (Gordon et al., 2010; Kopta et al., 1999). On the other hand, nonadherence with treatment and poor outcomes in therapy are related to a patient feeling unheard, disrespected, or otherwise unconnected with the clinician/health care worker (Gordon et al., 2010).

A successful therapeutic alliance is greatly influenced by the personal characteristics of the clinician and the patient, not necessarily the particular process employed. Furthermore, evidence suggests that psychotherapy (talk therapy) within a therapeutic partnership actually changes brain chemistry in much the same way as medication (Hollon & Ponniah, 2010; Serfaty et al., 2009). Thus the best treatment for most psychiatric problems (less so with psychotic disorders) is a combination of medication and psychotherapy. Cognitive-behavioral therapy, in particular, has met with great success in the treatment of depression, phobias, obsessive-compulsive disorders, and others.

Establishing a therapeutic relationship with a patient takes time. Skills in this area gradually improve with guidance from those with more skill and experience.

Relationship boundaries and roles

Establishing boundaries

According to Fox (2008), boundaries can be thought of in terms of the following:

• Physical boundaries: General environment, office space, treatment room, conference room, corner of the day room, and other such places

• The contract: Set time, confidentiality, agreement between nurse and patient as to roles, money, if involved with a licensed therapist

• Personal space: Physical space, emotional space, space set by roles, and so forth

Blurring of boundaries

A well-defined therapeutic nurse-patient relationship allows the establishment of clear boundaries that provide a safe space in which the patient can explore feelings and treatment issues. Theoretically, the nurse’s role in the therapeutic relationship can be stated rather simply as follows: The patient’s needs are separated from the nurse’s needs, and the patient’s role is different from that of the nurse; therefore, the boundaries of the relationship are well defined. Boundaries are constantly at risk of blurring, and a shift in the nurse-patient relationship may lead to nontherapeutic dynamics. Two common circumstances in which boundaries are blurred are (1) when the relationship is allowed to slip into a social context and (2) when the nurse’s needs (for attention, affection, and emotional support) are met at the expense of the patient’s needs.

Boundaries are primarily necessary to protect the patient. The most egregious boundary violations are those of a sexual nature (Wheeler, 2008). This type of violation results in high levels of malpractice actions and the loss of professional licensure on the part of the nurse. Other boundary issues are not as obvious. Table 8-1 illustrates some examples of patient and nurse behaviors that reflect blurred boundaries.

TABLE 8-1   

PATIENT AND NURSE BEHAVIORS THAT REFLECT BLURRED BOUNDARIES

WHEN THE NURSE IS OVERLY INVOLVED	WHEN THE NURSE IS NOT INVOLVED
More frequent requests by the patient for assistance, which causes increased dependency on the nurse	Patient’s increased verbal or physical expression of isolation (depression)
Inability of the patient to perform tasks of which he or she is known to be capable prior to the nurse’s help, which causes regression	Lack of mutually agreed-upon goals
Unwillingness on the part of the patient to maintain performance or progress in the nurse’s absence	Lack of progress toward goals
Expressions of anger by other staff who do not agree with the nurse’s interventions or perceptions of the patient	Nurse’s avoidance of spending time with the patient
Nurse’s keeping of secrets about the nurse-patient relationship	Failure of the nurse to follow through on agreed-upon interventions

Data from Pilette, P. C., Berck, C. B., & Achber, L. C. (1995). Therapeutic management of helping boundaries. Journal of Psychosocial Nursing and Mental Health Services, 33(1), 40–47.

Blurring of roles

Blurring of roles in the nurse-patient relationship is often a result of unrecognized transference or countertransference.

Transference.

Transference is a phenomenon originally identified by Sigmund Freud when he used psychoanalysis to treat patients. Transference occurs when the patient unconsciously and inappropriately displaces (transfers) onto the nurse feelings and behaviors related to significant figures in the patient’s past. The patient may even say, “You remind me of my (mother, sister, father, brother, etc.).”

Patient: “Oh, you are so high and mighty. Did anyone ever tell you that you are a cold, unfeeling machine, just like others I know?”

Nurse: “Tell me about one person who is cold and unfeeling toward you.” (In this example, the patient is experiencing the nurse in the same way she experienced significant other[s] during her formative years. In this case, the patient’s mother was very aloof, leaving the patient with feelings of isolation, worthlessness, and anger.)

Although transference occurs in all relationships, it seems to be intensified in relationships of authority. This may occur because parental figures were the original figures of authority. Physicians, nurses, and social workers all are potential objects of transference. This transference may be positive or negative. If a patient is motivated to work with you, completes assignments between sessions, and shares feelings openly, it is likely the patient is experiencing positive transference (Wheeler, 2008).

Positive transference does not need to be addressed with the patient, whereas negative transference that threatens the nurse-patient relationship may need to be explored. Common forms of transference include the desire for affection or respect and the gratification of dependency needs. Other transferential feelings are hostility, jealousy, competitiveness, and love.

Sometimes patients experience positive or negative thoughts, feelings, and reactions that are realistic and appropriate and not a result of transference onto the health care worker. For example, if a nurse makes promises to the patient that are not kept, such as not showing up for a meeting, the patient may feel resentment and mistrust toward the nurse.

Countertransference.

Countertransference occurs when the nurse unconsciously and inappropriately displaces onto the patient feelings and behaviors related to significant figures in the nurse’s past. Frequently the patient’s transference evokes countertransference in the nurse. For example, it is normal to feel angry when attacked persistently, annoyed when frustrated unreasonably, or flattered when idealized. A nurse might feel extremely important when depended on exclusively by a patient. If the nurse does not recognize his or her own omnipotent feelings as countertransference, encouragement of independent growth in the patient might be minimized at best.

Recognizing countertransference maximizes our ability to empower our patients. When we fail to recognize countertransference, the therapeutic relationship stalls, and essentially we disempower our patients by experiencing them not as individuals but rather as extensions of ourselves. Example:

Patient: “Yeah, well I decided not to go to that dumb group. ‘Hi, I’m so-and-so, and I’m an alcoholic.’ Who cares?”(Patient sits slumped in a chair chewing gum, nonchalantly looking around.)

Nurse: (In an impassioned tone) ”You always sabotage your chances. You need AA to get in control of your life. Last week you were going to go, and now you’ve disappointed everyone.”(Here the nurse is reminded of her mother, who was an alcoholic. The nurse had tried everything to get her mother into treatment and took it as a personal failure and deep disappointment that her mother never sought recovery. After the nurse sorts out her thoughts and feelings and realizes the frustration and feelings of disappointment and failure belonged with her mother and not the patient, the nurse starts out the next session with the following approach.)

Nurse: “Look, I was thinking about last week, and I realize the decision to go to AA or find other help is solely up to you. It’s true that I would like you to live a fuller and more satisfying life, but it’s your decision. I’m wondering, however, what happened to change your mind about going to AA.”

If the nurse feels either a strongly positive or a strongly negative reaction to a patient, the feeling most often signals countertransference. One common sign of countertransference is overidentification with the patient. In this situation, the nurse may have difficulty recognizing or objectively seeing patient problems that are similar to the nurse’s own. For example, a nurse who is struggling with an alcoholic family member may feel disinterested, cold, or disgusted toward an alcoholic patient. Other indicators of countertransference are when the nurse gets involved in power struggles, competition, or arguments with the patient. Table 8-2 lists some common countertransference reactions.

TABLE 8-2   

COMMON COUNTERTRANSFERENCE REACTIONS

As a nurse, you will sometimes experience countertransference feelings. Once you are aware of them, use them for self-analysis to understand those feelings that may inhibit productive nurse-patient communication.
REACTION TO PATIENT	BEHAVIORS CHARACTERISTIC OF THE REACTION	SELF-ANALYSIS	SOLUTION
Boredom (indifference)	Showing inattention. Frequently asking the patient to repeat statements. Making inappropriate responses.	Is the content of what the patient presents uninteresting? Or is it the style of communication? Does the patient exhibit an offensive style of communication? Have you anything else on your mind that may be distracting you from the patient’s needs? Is the patient discussing an issue that makes you anxious?	Redirect the patient if he or she provides more information than you need or goes “off track.” Clarify information with the patient. Confront ineffective modes of communication.
Rescue	Reaching for unattainable goals. Resisting peer feedback and supervisory recommendations. Giving advice.	What behavior stimulates your perceived need to rescue the patient? Has anyone evoked such feelings in you in the past? What are your fears or fantasies about failing to meet the patient’s needs? Why do you want to rescue this patient?	Avoid secret alliances. Develop realistic goals. Do not alter meeting schedule. Let the patient guide interaction. Facilitate patient problem solving.
Overinvolvement	Coming to work early, leaving late. Ignoring peer suggestions, resisting assistance. Buying the patient clothes or other gifts. Accepting the patient’s gifts. Behaving judgmentally at family interventions. Keeping secrets. Calling the patient when off duty.	What particular patient characteristics are attractive? Does the patient remind you of someone? Who? Does your current behavior differ from your treatment of similar patients in the past? What are you getting out of this situation? What needs of yours are being met?	Establish firm treatment boundaries, goals, and nursing expectations. Avoid self-disclosure. Avoid calling the patient when off duty.
Overidentification	Having special agenda, keeping secrets. Increasing self-disclosure. Feeling omnipotent. Experiencing physical attraction.	With which of the patient’s physical, emotional, cognitive, or situational characteristics do you identify? Recall similar circumstances in your own life. How did you deal with the issues now being created by the patient?	Allow the patient to direct issues. Encourage a problem-solving approach from the patient’s perspective. Avoid self-disclosure.
Misuse of honesty	Withholding information. Lying.	Why are you protecting the patient? What are your fears about the patient’s learning the truth?	Be clear in your responses and aware of your hesitation; do not hedge. If you can provide information, tell the patient and give your rationale. Avoid keeping secrets. Reinforce the patient with regard to the multidisciplinary nature of treatment.
Anger	Withdrawing. Speaking loudly. Using profanity. Asking to be taken off the case.	What patient behaviors are offensive to you? What dynamic from your past may this patient be re-creating?	Determine the origin of the anger (nurse, patient, or both). Explore the roots of patient anger. Avoid contact with the patient if the anger is not understood.
Helplessness or hopelessness	Feeling sadness.	Which patient behaviors evoke these feelings in you? Has anyone evoked similar feelings in the past? Who? What past expectations were placed on you (verbally and nonverbally) by this patient?	Maintain therapeutic involvement. Explore and focus on the patient’s experience rather than on your own.

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