This document discusses building nurse-client relationships and therapeutic communication. It outlines three types of relationships - social, intimate, and therapeutic - and emphasizes that the nurse-client relationship should be therapeutic. It describes components of a therapeutic relationship including trust, genuine interest, empathy, acceptance, and positive regard. It also discusses establishing the relationship, phases of the relationship, and methods to avoid inappropriate relationships. Finally, it covers therapeutic communication goals, privacy and boundaries, and appropriate types of touch. The overall focus is on ensuring the nurse-client relationship remains focused on the client's needs and is therapeutic in nature.

1. Building Nurse- Client
Relationship
Presented by: ERIC F. PAZZIUAGAN, RN, MAN

2. Types of Relationships:

3. Social Relationship
 Primarily initiated for the purpose of
friendship, socialization, companionship, or
accomplishment of task.
 Communication (may be superficial):
usually focuses on sharing ideas, feelings,
and experiences and meets the basic need
for people to interact.
 Advise if often given.
 Roles may shift.

4.  Acceptable in nursing, but must be limited.
 If relationship becomes more social than
therapeutic, serious work that moves the
client forward will not be done.

5. Intimate Relationship
 Involves two people who are emotionally
committed to each other.
 Both parties are concerned about having
their individual needs met and helping each
other to meet needs as well.
 May include sexual or emotional intimacy as
well as sharing of mutual goals.
 NO PLACE in the nurse-client interaction.

6. Therapeutic Relationship
 Differs from the social or intimate
relationship in many ways because it
focuses on the needs, experiences, feelings,
and ideas of the clients only.
 Nurse and client agree about the areas to
communicate to work on and evaluate the
outcomes.

7.  Nurse uses communication skills, personal
strengths, and understanding of human
behavior to interact with the client.
 Parameters are clear: the focus is the client’s
needs, not the nurse’s.
 The nurse must guard against allowing the
therapeutic relationship to slip into a more
social relationship and must constantly
focus on the client’s needs, not on his or her
own.

8. Establishing the Therapeutic
Relationship
 The nurse who has self-confidence rooted in
self-awareness is ready to establish
appropriate therapeutic relationships with
clients.
 Awareness of his or her strengths at any
particular moment is a good start.

9. Components of a
Therapeutic
Relationship

10. Trust
 Trust builds when the client is confident in
the nurse and when the nurse’s presence
conveys integrity and reliability.
 Trust develops when the client believes that
the nurse will be consistent in his or her
own words and actions and can be relied on
to do what he or she says.
 Congruence occurs when words and actions
match.

11.  Trust erodes when a client sees
inconsistency between what the nurse says
and does.
 Trust is difficult to establish in the
following:
 Paranoia
 Low self-esteem
 Anxiety

12. Trusting Behaviors (Nurse)
 Caring  Treating the client as
 Openness a human being
 Objectivity  Suggesting without
 Respect telling
 Interest  Approachability
 Understanding  Listening
 Consistency  Keeping promises
 Honesty

13. Genuine Interest
 When the nurse is comfortable with himself
or herself, aware of his or her strengths and
limitations, and clearly focused, the client
perceives a genuine person showing
genuine interest.
 The nurse should be open and honest and
display congruent behavior.

14.  Sometimes, responding with truth and
honesty alone does not provide the best
professional response.
 The nurse may choose to disclose to the
client a personal experience related to the
client’s current concerns.
 Be selective about personal examples.
 Maybe from the nurse’s past experience, not a
current problem that is still being resolved, or a
recent, still painful experience.
 Day-to-day experiences, not value-laden.

15. Empathy
 The ability to perceive the meanings and
feelings of the client and to communicate
that understanding to the client.
 One of the essential skills a nurse must
develop.
 Both the client and the nurse give a “gift of
self” when empathy occurs.

16.  Understand the difference between
empathy and sympathy (feelings of concern
or compassion one shows for another).
 By expressing sympathy, the nurse may
project his or her personal concerns onto
the client, thus inhibiting the client’s
expression of feelings.

17. Acceptance
 Avoiding judgments of the person, no
matter what the behavior is.
 E.g., The nurse does not become upset or
respond negatively to a client’s outbursts, anger
or acting out.
 Does not mean acceptance of inappropriate
behaviors but acceptance of the person as
worthy.

18.  The nurse must set boundaries for behavior
in the nurse-client relationship.
 By being clear and firm without anger or
judgment, the nurse allows the client to feel
intact while still conveying that certain
behavior is unacceptable.

19. Positive Regard
 The nurse who appreciates the client as a
unique worthwhile human being can respect
the client regardless of his or her behavior,
background or style.
 Measures to convey respect and positive
regard:
 Calling client by name
 Spending time with client
 Listening and responding openly
 Considering client’s ideas and preferences when
planning care.

20.  The nurse relies on presence, or attending,
which is using nonverbal and verbal
communication techniques to make the
client aware that he is receiving full
attention.
 Nonverbal techniques: leaning toward the
client, eye contact, being relaxed, having the
arms rested at the side, and interested but
neutral attitude.
 Verbally attending: nurse avoids value
judgment about the client’s behavior.

21. Phases of the Nurse-
Client Relationship

22. Orientation Phase
 Begins when the nurse and client meet and
ends when the client begins to identify
problems to examine.
 Activities:
 Establish roles
 Establish the purpose of the meeting and the
parameters of the subsequent meeting
 Identify client’s problems
 Clarify expectations

23.  Before the meeting:
 Read background materials available on the
client
 Become familiar with the medications the client
is taking
 Gather necessary paper work
 Arrange for a quiet, private and comfortable
setting
 Self-assessment
 Examine preconceptions about the client and
ensure to put them aside and get to know the
real person.

24.  The nurse begins to build trust with the
client.
 Share appropriate information about
oneself: name, reason for being in the unit,
and level of schooling
 Listen closely to the client’s history,
perceptions and misconceptions.
 Be very empathetic and understanding.
 It may take several sessions before a client
trust the nurse.

25.  Nurse-client Contracts
 Agree responsibilities in an informal or verbal
contract
 A formal or written contract may be appropriate
at times.
 State the following:
 Time, place, and length of sessions
 When session will terminate
 Who will be involved in the treatment plan
 Client responsibilities (arrive on time, end on time)
 Nurse’s responsibilities (arrive on time, end on time,
evaluate progress with client, document sessions)

26.  Confidentiality:
 Respecting the client’s right to keep private
information about his or her mental and
physical care and related care.
 Allowing only those dealing with 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.
 Adult clients can decide which family members,
if any, may be involved in treatment and may
have access to clinical information.
 The nurse must avoid any promises to keep
secret.

27.  Tarasoff vs. University of California (1976):
releases professionals from previleged
communication with their clients should the
client make a homicidal threat (duty to
warn).
 Document client problems with planned
interventions.
 The client needs to know the limits of
confidentiality in the nurse-client
interactions and how the nurse will use and
share this information with professionals
involved in the care.

28.  Self-disclosure:
 Revealing personal information such as
biographical information and personal ideas,
thoughts, and feelings about oneself to others.
 Some purposeful, well-planned, self-disclosure
can improve rapport between the nurse and the
client.
 May be use to convey support, educate clients,
and demonstrate that anxiety is normal and that
many people deal with stress and problems in
their lives.

29.  Self- disclosure may help the client feel
more comfortable and more willing to share
thoughts and feelings, or help the client gain
insight into the situation.
 Consider cultural factors.
 Disclosing personal information to the
patient can be harmful and inappropriate,
so it must be planned and considered
thoughtfully in advance.
 Spontaneously self-disclosing personal
information can have negative results.

30. Working Phase
 Two sub-phases:
 Problem identification: client identifies the
issues or concerns causing the problems.
 Exploitation: the nurse guide the client to
examine feelings and responses and to develop
better coping skills and a more positive self-
image.
 Encourages behavior change and develops
independence.

31.  The client must believe that the nurse will
not turn away or be upset when the client
reveals experiences, issues and behaviors,
and problems.
 The client will sometimes use outrageous
stories or acting-out behaviors to test the
nurse.
 The nurse must remember that it is the
client who examines and explores problem
situations and relationships.

32.  Specific tasks:
 Maintaining the relationship
 Gathering the data
 Exploring perceptions of reality
 Developing positive coping mechanisms
 Promoting a positive self-concept
 Encourage verbalization of feelings
 Facilitating behavior change
 Working through resistance
 Evaluating progress and redefining goals as
appropriate
 Providing opportunities for the client to practice new
behaviors
 Promoting independence

33.  Transference: the client unconsciously
transfer to the nurse feelings he or she has
for significant others.
 Countertransference: the nurse responds to
the client based on personal unconscious
needs and conflicts.
 SELF-AWARENESS is important so that the
nurse can identify when transference and
countertransference might occur.

34. Termination
 Final stage of the in the nurse-client
relationship.
 Begins when the problems are resolved, and
it ends when the relationship is ended.
 Nurse and client usually have feelings about
ending the relationship.
 Clients may feel the termination as an
impending loss.

35.  Clients may avoid termination by acting
angry or as if the problem is not resolved.
 Acknowledge the client’s angry feelings and
assure that this response is normal to
ending a relationship.
 If the client tries to reopen and discuss old
resolved issues, the nurse must avoid feeling
as if the sessions were unsuccessful; instead
he or she should identify the client’s stalling
maneuvers and refocus the client on newly
learned behaviors and skills to handle the
problem.

36.  It is appropriate to tell the client that the
nurse enjoyed the time spent with the client
and will remember him or her, but it is
inappropriate for the nurse to agree to see
the client outside the therapeutic
relationship.

37. Possible Warnings or Signals of
Abuse of the Nurse-Client
Relationship
 Secrets; reluctance to talk to others about
the work being done with the client.
 Sudden increase in phone calls between the
nurse and client calls outside the clinical
hours.
 Nurse making exceptions for client than
normal.

38.  Inappropriate gift-giving between client and
the nurse.
 Loaning, trading, or selling goods or
possessions.
 Nurse disclosure of personal issues or
information.
 Inappropriate touching, comforting or
physical contact.
 Overdoing, overprotecting, or
overidentifying with the client.

39.  Change in the nurse’s body language, dress or
appearance (with no other satisfactory
explanation).
 Extended one-on-one sessions or home visits.
 Spending off-duty time with the client.
 Thinking about the client frequently when
away from work.
 Becoming defensive if another person
questions the nurse’s care of the client.
 Ignoring agency’s policies.

40. Methods to Avoid Inappropriate
Relationships Between Nurses
and Clients
 Realize that all staff members, whether male or
female, junior or senior, or from any discipline
are at risk for over-involvement or loss of
boundaries.
 Assume that boundary violations will occur.
Supervisors should recognize potential
“problem” clients and regularly raise the issue
of sexual feelings or boundary loss with staff
members.

41.  Provide opportunities for staff members to
discuss their dilemmas and effective ways of
dealing with them.

42. THERAPEUTIC
COMMUNICATION

43. Therapeutic Communication
 An interpersonal interaction between
the nurse and the client during which
the nurse focuses on the client’s
specific needs to promote an effective
exchange of information.
 Skilled use helps the nurse understand
and emphatize with the client’s
experience.

44. Goals of Therapeutic
Communication
 Establish a therapeutic nurse-client
relationship.
 Identify the most important client concern
at that moment (the client-centered goal).
 Assess the client’s perception of the problem
as it unfolds. This includes detailed actions
(behaviors and messages) of the people
involved and the client’s thoughts and
feelings about the situation, others, and self.

45.  Facilitate the client’s expression of
emotions.
 Teach the client and family necessary
self-care skills.
 Recognize the client’s needs.
 Guide the client toward identifying a
plan of action to a satisfying and
socially acceptable situation.

46. Privacy and Respecting
Boundaries
 Privacy is desirable but not always possible
in therapeutic communication.
 Possible venues:
 Interview/ conference room
 End of the hall
 Quiet corner of the day room or lobby
 Evaluate whether interacting in the client’s
room is therapeutic.

47.  Proxemics: study of distance zones between
people during communication.
 Intimate zone (0-18 inches between people):
parents with children, people who mutually
desire personal contact, or people whispering.
Invasion is threatening and produces anxiety.
 Personal zone (18-36 inches): family and friends
who are talking.
 Social zone (4-12 feet): communication in social,
work, and business settings.
 Public zone (12-25 feet): between speaker and
an audience, small groups, and other informal
functions.

48.  Consider the culture of the client.
 Hispanic, Mediterranean, East Indian, Asian, and
Middle Eastern: comfortable with less that 4-12
feet distance.
 When invading the personal zone, the nurse
should ask permission.
 Therapeutic communication interaction is
most comfortable when the client and the
nurse are 3-6 feet apart.
 If client invades the nurse’s personal space,
the nurse should set limits gradually.

50. Touch
 Five types:
 Functional-professional: touch is used in
examination or procedures.
 Social-polite: touch is used in greeting, such as hand-
shake and the “air kisses” some women use to greet
acquaintances, or when a gentle hand guides
someone for the correct direction.
 Friendship-warmth: touch involves a hug in greeting,
an arm thrown around the shoulder of a good friend,
or the backslapping some men used to greet friends
or relatives.
 Love-intimacy: touch involves tight hugs and kisses
between lovers and close relatives.
 Sexual arousal: touch used by lovers.

51.  Touching a client can be comforting and
supportive when it is welcomed and
permitted.
 Observe for cues that show whether touch is
desired or indicated.
 Although touch can be comforting and
therapeutic, it is an invasion of intimate
personal space.
 When performing a procedure, prepare the
client verbally before starting the procedure.

53. Active Listening and
Observation
 Active listening: refraining from other
internal mental activities and
concentrating exclusively on what the
client says.
 Active observation: watching the
speaker’s nonverbal actions as he or
she communicates.

54.  Active listening and observation help the
nurse to:
 Recognize the issue that is most important to
the client at this time.
 Know what further questions to ask the client.
 Use additional therapeutic communication
techniques to guide the client to describe his or
her perceptions fully.
 Understanding the client’s perceptions of the
issue instead of jumping to conclusions.
 Interpret and respond to the message
objectively.