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
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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.
Table 5.2 Phases of the Nurse–Client Relationship
Working
Orientation Identification Exploitation Termination
Client
Seeks assistance Conveys needs Asks questions
Shares preconceptions and expectations of nurse based on past experience
Participates in identifying problems
Begins to be aware of time Responds to help Identifies with nurse Recognizes nurse as a person Explores feelings
Fluctuates dependence, independence, and
interdependence in relationship with nurse
Increases focal attention Changes appearance (for better or worse)
Understands continuity between sessions (process and content) Testing maneuvers decrease
Makes full use of services Identifies new goals Attempts to attain new goals Rapid shifts in behavior:
dependent and independent Exploitative behavior Self-directing
Develops skill in interpersonal relationships and problem-solving
Displays changes in manner of communication (more open, flexible)
Abandons old needs Aspires to new goals
Becomes independent of helping person
Applies new problem-solving skills
Maintains changes in style of communication and interaction Shows positive changes in view of self
Integrates illness
Exhibits ability to stand alone
Nurse
Responds to client
Gives parameters of meetings Explains roles
Gathers data
Helps client identify problem Helps client plan use of community resources and services
Reduces anxiety and tension Practices active listening
Maintains separate identity Exhibits ability to edit speech or control focal attention Shows unconditional acceptance Helps express needs and feelings Assesses and adjusts to needs Provides information Provides experiences that diminish feelings of helplessness Does not allow anxiety to
Continues assessment Meets needs as they emerge Understands reason for shifts in behavior
Initiates rehabilitative plans Reduces anxiety
Identifies positive factors Helps plan for total needs Facilitates forward movement of personality
Sustains relationship as long as client feels necessary Promotes family interaction to assist with goal planning Teaches preventive measures Uses community agencies Teaches self-care Terminates nurse–client relationship
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• Focuses client’s energies
Clarifies preconceptions and expectations of nurse
overwhelm client Helps client focus on cues Helps client develop responses to cues
Uses word stimuli
Deals with therapeutic impasse
Adapted from Forchuck, C., & Brown, B. (1989). Establishing a nurse–client relationship. Journal of Psychosocial Nursing, 27(2), 30–34.
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.”
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 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:
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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 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.
Table 5.3 Communication during the Phases of the Nurse–Client Relationship
Phase of
Relationship Sample Conversation Communication Skill
Orientation Nurse: “Hello, Mr. O’Hare. I am Sally Fourth, a nursing student from Orange County Community College. I will be coming to the hospital for the next six Mondays. I would like to meet with you each time I am here to help support you as you work on your treatment goals.”
Establishing trust; placing boundaries on the relationship and first mention of termination in 6 weeks
Orientation Nurse: “Mr. O’Hare, we will meet every Monday from June 1 to July 15 at 11 AM in conference room 2. We can use that time to work on your feelings of loss since the death of your twin sister.”
Establishing specifics of the relationship time, date, place, and duration of meetings (can be written as a formal contract or stated as an informal contract)
Orientation Nurse: “Mr. O’Hare, it is important that I tell you I will be sharing some of what we talk about with my instructor, peers, and staff at clinical conference. I will not be sharing any information with your wife or children without your permission. If I feel a piece of information may be helpful, I will ask you first if I may share it with your wife.”
Establishing confidentiality
Working Client: “Nurse, I miss my sister Eileen so much.”
Nurse: “Mr. O’Hare, how long have you been without your sister?”
Gathering data
Working Client: “Without my twin, I am not half the person I was.”
Nurse: “Mr. O’Hare, let’s look at the strengths you have.”
Promoting self-esteem
Working Client: “Oh, why talk about me. I’m nothing without my twin.”
Nurse: “Mr. O’Hare, you are a person in your own right. I believe working together we can identify strengths you have. Will you try with me?”
Overcoming resistance
Termination Nurse: “Well, Mr. O’Hare, as you know I only have 1 week left to meet with you.”
Client: “I am going to miss you. I feel better when you are here.”
Nurse: “I will miss you also, Mr. O’Hare.”
Sharing of the termination experience with the client demonstrates the partnership and the caring of the relationship
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
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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 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
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Providing opportunities for the client to practice new behaviors Promoting independence
As the nurse and client work together, it is common for the client 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