dynamics of nurse patient relationship, johari window, phases of nurse patient relationship, boundaries, role of nurse

1. Presented by
Jasleen Kaur Brar
Nurse-Patient
Relationship

2. INTRODUCTION
 The nurse-client relationship is the foundation on
which psychiatric nursing is established.
 The therapeutic interpersonal relationship is the
process by which nurses provide care for clients
in need of psychosocial intervention.

3.  Mental health providers need to know how to gain
trust and gather information from the patient, the
patient's family, friends and relevant social
relations, and to involve them in an effective
treatment plan.
 Therapeutic use of self is the instrument for
delivery of care to clients in need of psychosocial
intervention.
 Interpersonal communication techniques are the
“tools” of psychosocial intervention.

4. DYNAMICS OF A THERAPEUTIC
NURSE-CLIENT RELATIONSHIP
 Travelbee (1971), who expanded on Peplau’s
theory of interpersonal relations in nursing, has
stated that is is only when each individual in the
interaction perceives the other as a unique
human being that a relationship is possible.
 Therapeutic relationships are goal oriented. The
nurse and client decide together what the goal of
the relationship will be. Most often, the goal is
directed at learning and growth promotion, in an
effort to bring about some type of change in the
client’s life.

5. 1. Therapeutic Use of Self
 Travelbee described as ‘ability to use one’s
personality consciously and in full awareness in
an attempt to establish relatedness and to
structure nursing interventions.’
 Nurses must possess self-awareness, self-
understanding, and a philosophical belief about
life, death, and the overall human condition for
effective therapeutic use of self.

6. 2. Gaining Self- Awareness
Values clarification
 Knowing and understanding oneself enhances
the ability to form satisfactory interpersonal
relationships. Self awareness requires that an
individual recognize and accept what he or she
values and learn to accept the uniqueness and
differences in others.
 An individual’s value system is established very
early in life and has its foundation in the value
system held by primary caregivers. It is culturally
oriented; it may change many times over the
course of a lifetime; and it consists of beliefs,
attitudes and values. Value clarification is one
process by which an individual may gain self-

7. Beliefs
 A belief is and idea that one holds to be true, and
it can take any of several forms:
 Rational beliefs: Ideas for which objective
evidence to substantiate their truth.
 Irrational beliefs: Ideas that an individual holds as
true despite the existence of objective
contradictory evidence.
 Faith (sometimes called blind beliefs): An ideal
that an individual holds as true for which no
objective evidence exists.
 Stenotype: A socially shared belief that describes
a concept in an oversimplified or undifferentiated
matter.

8. Attitudes
 An attitude is a frame of reference around which
an individual organizes knowledge about his or
her world.
 An attitude also has an emotional component.
Attitudes fulfil the need to find meaning in life and
to provide clarity and consistency for the
individual.
 The prevailing stigma attached to mental illness is
an example of negative attitude.
 An associated belief might be that “all people
with mental illness are dangerous.”

9. Values
 Values are abstract standards, positive or
negative, that represent an individual’s ideal
mode of conduct and ideal goals.
 Examples of ideal mode of conduct include
seeking truth and beauty; being clean and
orderly; and behaving with sincerity; justice,
reason, compassion, humility, respect, honour
and loyalty.
 Examples of ideal goals are security, happiness,
freedom, equality, ecstasy, fame and power.

10.  Values differ from attitudes and beliefs in that they are
action oriented or action producing.
 One may hold many attitudes and beliefs without
behaving in a way that shows one holds those attitudes
and beliefs.
 Attitudes and beliefs flow out of one’s set of values. An
individual may have thousands of beliefs and hundreds of
attitudes but his/ her values probably only number in the
dozens.
 Values may be viewed as a kind of core concept or basic
standards that determine one’s attitudes and beliefs, and
ultimately one’s behaviour.
 Raths, Merril, and Simon (1966) identified a seven step
process of valuing that can be used to help clarify
personal values. The process can be used by applying
these seven steps to an attitude or belief that one holds.
 When an attitude or belief has met each of the seven

11. Level of
operations
Category Criteria Explanation
Cognitive Choosing 1. Freely
2. From alternatives
3. After careful consideration of
the consequences
“ This value is mine.
No one forced me to
choose it. I
understand and accept
the consequences of
holding this value.”
Emotional Prizing 1. Satisfied; pleased with the
choice
2. Making public affirmation of
the choice, if necessary
“ I am proud that I
hold this value, and I
am willing to tell
others about it.”
Behavioural Acting 1. Taking action to demonstrate
the value behaviourally
2. Demonstrating this pattern of
behaviour consistently and
repeatedly
The value is reflected
in the individual’s
behaviour for as long
as he or she holds it.

12. The Johari Window
 Also referred to as a 'disclosure/feedback model
of self awareness. It was developed by American
psychologists Joseph Luft and Harry Ingham in
the 1950's, calling it 'Johari' after combining their
first names, Joe and Harry.
 Terminology: Refers to 'self' and 'others‘
 ‘Self' - oneself, i.e., the person subject to the
Johari Window analysis
 'Others' - other people in the team

13.  The four Johari Window perspectives:
 Called 'regions' or 'areas' or 'quadrants'.
 Each contains and represents the information -
feelings, motivation, etc – in terms of whether the
information is known or unknown by the person,
and whether the information is known or unknown
by others in the team
 The four regions, areas, quadrants, or
perspectives are as follows, showing the
quadrant numbers and commonly used names.

14. Johari window four regions
1. Open area, open self, free area, free self, or 'the
arena‘: what is known by the person about
him/herself and is also known by others.
2. Blind area, blind self, or 'blindspot‘: what is
unknown by the person about him/herself but
which others know
3.Hidden area, hidden self, avoided area, avoided
self or 'façade’: what the person knows
about him/herself that others do not know
4.Unknown area or unknown self: what is unknown
by the person about him/herself and is also
unknown by others

15. Johari quadrant 1
 ‘Open self/area‘, 'free area‘, 'public area', 'arena‘
 Also known as the 'area of free activity‘
 Information about the person - behaviour,
attitude, feelings, emotion, knowledge,
experience, skills, views, etc – known by the
person ('the self') and known by the team
('others').

16.  The aim in any team is to develop the 'open area'
for every person, because when we work in this
area with others we are at our most effective and
productive, and the team is at its most productive
too
 The open free area, or 'the arena‘ - the space
where good communications and cooperation
occur, free from distractions, mistrust, confusion,
conflict and misunderstanding

17. Johari quadrant 2
 ‘Blind self' or 'blind area' or 'blindspot‘: what is
known about a person by others in the group, but
is unknown by the person him/herself
 Could also be referred to as ignorance about
oneself, or issues in which one is deluded
 Not an effective or productive space for
individuals or groups
 Also include issues that others are deliberately
withholding from a person

18.  The aim is to reduce this area by seeking or
soliciting feedback from others and thereby to
increase the open area, i.e., to increase self-
awareness
 Team members and managers take responsibility
for reducing the blind area - in turn increasing the
open area - by giving sensitive feedback and
encouraging disclosure
 Managers promote a climate of non-judgemental
feedback, and group response to individual
disclosure, and reduce fear

19. Johari quadrant 3
 ‘Hidden self' or 'hidden area' or 'avoided self/area'
or 'facade'
 What is known to ourselves but kept hidden
from, and therefore unknown, to others
 Represents information, feelings, etc, anything
that a person knows about him/self, but which is
not revealed or is kept hidden from others
 Also include sensitivities, fears, hidden agendas,
manipulative intentions, secrets - anything that a
person knows but does not reveal

20.  Relevant hidden information and feelings, etc,
should be moved into the open area through the
process of 'self-disclosure' and'exposure process'
 Organizational culture and working atmosphere
have a major influence on team members'
preparedness to disclose their hidden selves
 The extent to which an individual discloses
personal feelings and information, and the issues
which are disclosed, and to whom, must always
be at the individual's own discretion

21. Johari quadrant 4
 ‘Unknown self‘, 'area of unknown activity‘,
'unknown area'
 Information, feelings, latent abilities, aptitudes,
experiences etc, that are unknown to the person
him/herself and unknown to others in the group
 Can be prompted through self-discovery or
observation by others, or through collective or
mutual discovery
 Counselling can also uncover unknown issues
 Again as with disclosure and soliciting feedback,
the process of self discovery is a sensitive one

22.  Uncovering 'hidden talents' - that is unknown
aptitudes and skills, not to be confused with
developing the Johari 'hidden area' - is another
aspect of developing the unknown area, and is
not so sensitive as unknown feelings
 Managers and leaders can create an
environment that encourages self discovery, and
to promote the processes of self discovery,
constructive observation and feedback among
team members
 The unknown area could also include repressed
or subconscious feelings rooted in formative
events and traumatic past experiences, which
can stay unknown for a lifetime

23. THERAPEUTIC NURSE-CLIENT
RELATIONSHIP
 Therapeutic relationships are goal- oriented and
directed at learning and growth promotion.

24. Requirements for Therapeutic
Relationship
 Rapport: getting acquainted and establishing
rapport is the primary task in relationship
development. Rapport implies special feeling on
the part of both the client and the nurse based on
acceptance, warmth, friendliness, common
interest, a sense of trust and nonjudgemental
attitude.

25.  Trust: to trust another, one must feel confidence
in that person’s presence, reliability, integrity and
sincere desire to provide assistance when
requested. Trust is the basis of a therapeutic
relationship. The nurse working in psychiatry
must perfect the skills that foster the development
of trust. Trust must be established in order for the
nurse-client relationship to progress.

26.  Respect: To show respect is to believe in the
dignity and worth of an individual regardless of
his or her unacceptable behaviour. The
psychologist Carl Rogers called this
unconditional positive regard. The client is
accepted and respected for no other reason than
that he or she is considered to be a worthwhile
and unique human being.

27.  Genuineness: it refers to the nurse’s ability to be
open, honest and “real” in interactions with the
client. To be “real” is to be aware of what one is
experiencing internally and to allow the quality of
inner experiencing to be apparent in the
therapeutic relationship. The nurse who
possesses the quality of genuineness responds
to the client with trust and honesty, rather than
with responses he or she may consider more
professional or ones that merely reflect the
nursing role.

28.  Empathy: empathy is the ability to see beyond
outward behaviour and to understand the
situation from the client’s point of view. With
empathy the nurse can accurately perceive and
comprehend the meaning and relevance of the
client’s thoughts and feelings. Empathy is
considered to be one of the most important
characteristics of a therapeutic relationship.
Accurate empathetic perceptions on the part of
the nurse assist the client to identify feelings that
may have been suppressed or denied.

29. Phases of a Therapeutic Nurse-
Client Relationship
Pre-interaction
phase
Orientation/Introdu
ctory Period
Working Termination

30.  1.Preinteraction Phase – it involves
preparation for the first encounter with the
client. Tasks include-
 Obtaining available information about the
client from his or her chart, significant others,
or other health team members. From this
information, the initial assessment is begun.
This initial information may also allow the
nurse to become aware of personal
responses to knowledge about the client.
 Examining one’s feelings, fears, and anxieties
about working with a particular client.

31.  2.Orientation Phase
 Establishing therapeutic environment.
 The roles, goals, rules and limitations of the
relationship are defined, nurse gains trust of
the client, and the mode of communication are
acceptable for both nurse and patient is set.
 Acceptance is the foundation of all therapeutic
relationship
 Acceptance of others requires acceptance of self
first.

32.  Rapport is built by demonstrating acceptance
and non-judgmental attitude.
 Acceptance of patient means encouraging
the patient verbally and non-verbally to
express both positive and negative feelings
even if these are divergent from accepted
norms and general viewpoint.
 The nurse can encourage the client to share his/her
feelings by making the client understand that no
feeling is wrong.
 Trust of patient is gained by being consistent.

33.  Assessment of the client is made by obtaining
data from primary and secondary sources.
 The patient set the pace of the relationship.
 During this phase, the problems are not yet
been resolved but the client’s feelings
especially anxietyis reduced, by using
palliative measures, to enable the client to
relax enough to talk about his distressing
feelings and thoughts.

34.  This stage progresses well when the nurses show
empathy provide support to client and temporary
structure until the client can control his own
feelings and behavior.
 Reality testing – is accepting the patient’s perceptions,
feelings and thoughts as neither right nor wrong, but at
the same time offering other options or points of view to
the client in a non-argumentative manner for the
purpose of helping the client arrive at more realistic
conclusions.
 To provide structure is to intervene when the client loses
control of his own feelings and behaviors by
medications, offering self, restrain, seclusion and by
assisting client to observe a consistent daily schedule.

35.  3. Working/ Exploration/ Identification
Stage – at this point, the client’s problems are
identified and solutions are explored, applied
and evaluated.
 The focus of the assessment and of the
relationship is the client’s behavior and the
focus of the interaction is the client’s feelings.
 The nurse should realize that the client’s
feelings of security are developed by being
consistent at all times.

36.  Perception of reality, coping mechanisms and
support systems are identified.
 The nurse assists the patient to develop
coping skills, positive self concept and
independence in order to change the behavior
of the client to one that is adaptive and
appropriate.
 The nurse uses the techniques of communication
and assumes different roles to help the client.

37.  4. Termination/ Resolution stage
 The nurse terminates the relationship when
the mutually agreed goals are met, the patient
is discharged or transferred or the rotation is
finished. The focus of this stage is the growth
that has occurred in the client and the nurse
helps the patient to become independent and
responsible in making his own decisions. The
relationship and the growth or change that
has occurred in both the nurse and the patient
is summarized.

38.  Client may become anxious and react with increased
dependence, hostility and withdrawal, these are
normal reactions and are signs of separation anxiety,
these feelings and behavior should be discussed with
the client.
 The nurse should be firm in maintaining
professionalism until the end of the relationship. She
should not promise the client that the relationship will
be continued.

39.  The time parameters should be made early in
the relationship and meetings are set further
and further apart near the end to foster
independence of the patient and prepare the
latter gradually for the separation.
 The nurse should not give her address or
telephone numbers to the patient.
 Referral for continuing health care and
support after discharge provides additional
resources for the client and the family.

40.  The goal of the therapeutic relationship have
been met when the patient has developed
emotional stability, cope positively, recognized
sources or causes of anxiety, demonstrates
ability to handle anxiety and independence,
and is able to perform self-care.
 Preparation of the termination phase begins at the
orientation phase, when the duration and length of
the nurse-client relationship was established.
 It is normal for the client to experience
separation anxiety such as sleeplessness, anorexia,
physical symptoms, withdrawal and hostility.

41. Boundaries in the Nurse-Client
Relationship
Material boundaries
Social boundaries
Personal boundaries
Professional boundaries
Self-disclosure
Gift-giving
Touch
Friendship or romantic association

42. Certain warning signs exist that indicate that
professional boundaries of the nurse-patient
relationship may be in jeopardy:
 Favouring one client’s care over that of another
 Keeping secrets with a client
 Changing dress style for working with a particular
client
 Swapping client assignments to care for a particular
client
 Giving special attention or treatment to one client over
others
 Spending free time with a client
 Frequently thinking about the client when away from
work
 Sharing personal information or work concerns with
the client

43. Role of the Psychiatric Nurse
The stranger
The resource person
The teacher
The leader
The surrogate
The counsellor

44. Research related to nurse patient
relationship
 Bonnie M. Hagerty, Kathleen L. Patusky
concluded human relatedness framework
provides new insights and oppurtunities for
assessment, intervention and research within the
context of nurse patient relationship.
 Wendy Moyle did phenomenological study of
individuals hospitalized with a depressive illness
found that a therapeutic relationship did not come
instinctively to the mental health nurses and that
there was a dichotomy between the close
relationship expected by patients and the distant
relationship provided by nurses.

45. Summarization
 Introduction
 Dynamics of therapeutic nurse client relationship
 The Johari Window
 Requirements for therapeutic relationship
 Phases of therapeutic nurse client relationship
 Boundaries in nurse client relationship
 Role of nurse

46. Bibliography
 Michael W. Eyesenck & cara
Flanagan.Psychology for A2 Level;[1];306-24
 Fernald/Fernald. Munn’s Introduction to
Psychology. [5];241-65
 Carole Wade, Carol Tavris. Psychology.[8];407-15
 Clifford T. Morgan, Richard A. King, John R.
Weisz, John Schopler. Introduction to
Psychology;[8]64-87