THERAPEUTIC NURSE-CLIENT RELATIONSHIP
TYPES OF RELATIONSHIPS
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All relationships may be categorized into three major types:
1. Social
2. Intimate
3. Therapeutic
Social Relationship
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Is primarily initiated for the purpose of friendship, socialization, companionship, or
accomplishment of a task

Communication, which may be superficial, usually focuses on sharing ideas, feelings,
and experiences and meets the basic need for people to interact

Advice is often given. Roles may shift during interaction

Outcomes of this kind of relationship are rarely assessed

For the nurse–client relationship to accomplish the goals that have been decided on,
social interaction must be limited

If the relationship becomes more social than therapeutic, goals will not be achieved,
and the relationship will fail
Intimate Relationship

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

The relationship may include emotional intimacy as well as sharing of mutual goals

Evaluation of the interaction may be ongoing or not

The intimate relationship has no place in the nurse–client interaction
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DEFINITION
It is a clearly defined interpersonal process that involves two or more people and
incorporates principles of mental health nursing for the purposes of understanding
human behavior and maximizing personal strengths and potentials to enhance the
client’s growth, recovery and wellbeing.
GOALS OF NURSE-CLIENT THERAPEUTIC RELATIONSHIP
1. The nurse helps the patient to cope with the present problems.
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The reasons for patient's hospitalization
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Identify patient's perception of present problems
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Collection of information from the patient himself.
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Nurse does not try to go back to the past history from secondary sources.
2. The nurse helps the patient to understand the problems: Nurse keeps this goal
throughout the relationship
3. The nurse helps the patient to understand his active participation in an experience.
4. The nurse assists the patient to identify emerging problems realistically.
5. The nurse helps the patient to find out a new alternative for his or her problem.
6. The nurse helps the patient to try out new patterns of behavior.
7. The nurse helps the patient to communicate.
8. The nurse helps the patient to find meaning in his illness.
TYPES OF THERAPEUTIC RELATIONSHIP
1. Immediate: The nurse & client don’t know each other & the client is in immediate
severe difficulty that requires the nurse to interact or intervene.
2. Short-term: The nurse and the patient have an association with each other. Even if
the nurse knows the patient, she has no responsibilities for the patient.
3. Long-term: Nurse interacts with the patient in an effort to provide a corrective
emotional experience. The nurse will be supporting the patient and giving care to
the patient.
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COMPONENTS OF NURSE-PATIENT RELATIONSHIP
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The components of the nurse-client relationship, rapport, power, trust, respect, and
intimacy, are present whenever the nurse is providing nursing services.
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The nurse-client relationship is therapeutic; it is based on trust, respect and
intimacy with the client and requires the appropriate use of power.
1. Rapport
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Getting acquainted and establishing rapport are the primary tasks in relationship
development.
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It implies special feelings on the part of both the client and nurse based on
acceptance, warmth, friendliness, common interest, a sense of trust and a nonjudgmental attitude.
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Establishing rapport may be accomplished by discussing non-health related topics.
2. Power
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The therapeutic nurse-client relationship is one of unequal power.
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Although nurses may not perceive themselves as having power in the relationship,
nurses have more power than the client.
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The power of the nurse comes from the authority of own position in the health care
system, specialized knowledge, influence with other health care providers and the
client's significant others, and access to privileged information.
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In any professional-client relationship, there is an imbalance of power in favor of the
professional, and is reinforced in health care services by the inherent vulnerability
of a client needing care.
3. Trust
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To trust another, one must feel confidence in that person's experience, reliability,
integrity, reality and sincere desire to provide assistance when requested.
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It is the basis of therapeutic relationship.
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The nurse must have perfect skills that foster the development of trust-worthiness.
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Clients expect the nurse to have the necessary knowledge and skills and to
demonstrate caring attitudes and behaviors, and so entrust their care to the nurse.
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Trust is critical, as the client is in a vulnerable position in the relationship.
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Part of trust is keeping promises to clients. If trust is breached, then it becomes very
difficult to re-establish it.
4. Respect
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To show respect is to believe in the dignity and worth of an individual regardless of
his or her unacceptable behaviour.
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Respect for the dignity and worth of the client is fundamental to the relationship.
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The nurse needs to know and understand the culture and other aspects of the
client's individuality and to take these into account when providing care.
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Part of respect is being non-judgmental of the client, and seeking to discover the
meaning behind certain of the client's behaviors.
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The nurse can convey an attitude of respect through the following interactions:
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Calling the person by name
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Spending time with the individual
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Allowing for sufficient time to answer the client questions and concerns
5. Genuineness
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The concept of genuineness refers to the nurses' ability to be open, honest and real
in interactions with the client.
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To be 'real' is to be aware of what one is experiencing internally and express this
awareness in the therapeutic relationship.
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When one is genuine, there will be congruence between what is felt and what is
being expressed.
6. Intimacy
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Intimacy relates to the kinds of activities nurses perform for and with the client
which create personal and private closeness on many levels.
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This does not refer to sexual intimacy. This can involve physical, emotional and
spiritual elements.
PRINCIPLES OF NURSE-PATIENT RELATIONSHIP
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A nurse is expected to be competent and to have the professional attributes required
to manage a therapeutic relationship.
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The nurse-client relationship is established and maintained by the nurse through the
use of professional nursing knowledge and skill, and caring attitudes and behaviors.
Principles of professional practice
1. The nurse functions within the standards for nursing practice.
2. The nurse knows the requirements of and recognizes own accountability for
maintaining professional behavior.
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It is the responsibility of the nurse to set and maintain the appropriate
boundaries for the duration of the relationship regardless of the wishes of a
client or the setting in which the relationship occurs.
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Nurses are responsible for the outcomes of their actions in the nurse client
relationship, including outcomes that may have been unintended, but should
have been foreseen.
3. Although both the nurse and the client have needs, the therapeutic nurse-client
relationship is developed for the purpose of promoting client health and well-being
and not to meet the needs of the nurse.
4. The nurse respects the individual characteristics of the client such as cultural and
social identity, appearance, sexual orientation and religious affiliation, and
recognizes the impact that these have on both the nurse-client relationship and the
health of the client.
5. Nurses recognize when they do not possess the necessary knowledge or skills to
manage the therapeutic nurse-client relationship and seek information and
assistance from other members of the health team or elsewhere.
6. It is recognized that some client's behaviour can be abusive to nurses.
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It is the nurse's responsibility to understand the meaning behind the abusive
behavior and to work with the health team to develop strategies to meet the client's
needs.
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The nurse seeks help and guidance when dealing with challenging clients.
STRUCTURING THERAPEUTIC RELATIONSHIPS
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Central to the establishment of the therapeutic nurse-client relationship is the
nurse's ability to use a wide range of communication strategies and effective
interpersonal skills.
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Effective communication is an essential factor in creating and maintaining a
successful relationship.
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Regardless of the setting and the length of interaction, the nurse acts in therapeutic
ways to manage the boundaries of the relationship. This involves:
1. Introducing self to the client and addressing the client by preferred name and/or
title;
2. Listening to the client without immediately giving advice or diminishing the client's
feelings (The nurse listens to, understands and respects the client's values, opinions,
needs, and ethno-cultural beliefs. These latter elements are integrated into the care
plan, with the client's assistance. The nurse listens to the concerns of the family and
significant others about the client and acts on those concerns as appropriate.);
3. Identifying the goals and wishes of the client and incorporating them into the plan of
care;
4. Giving the client time and opportunity to explain self and to ask questions;
5. Exploring unusual comments, attitudes or behaviors of clients to discover the
underlying meaning;
6. Showing a genuine interest in, and compassion for, the client;
7. Providing information to promote client choice and to enable the client to make
informed decisions.
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8. Helping clients find the best possible solution for themselves, given their personal
values, beliefs, and different decision making styles (The nurse discusses the client's
beliefs and wishes with them and encourages them to advocate on their own behalf
or advocates for them.); and
9. Discussing the boundaries of confidentiality with the client including the nurse's
legal responsibilities.
STAGES OF NURSE-CLIENT RELATIONSHIP
Pre-interaction Phase
Pre-interaction phase begins before the nurse's first contact with the patient. Nurse's
initial task is one of self exploration. In the first experience working with psychiatric
patients, the nurse brings misconceptions and prejudices of the general public, in
addition to feelings and fear about new situations.
Tasks in Pre interaction phase
1. obtaining available information about the patient from medical records, significant
others or other health team members
2. initial assessment form the available information
3. explore own feelings, fantasies and feelings
4. analyze professional strengths and limitations
5. plan for first meeting with patient
Orientation phase
During this phase the nurse and patient fist meet. One of the first primary concerns of
the nurse at this phase is to find out why the patient sought help. The reasons for
seeking help and whether or not it was voluntary from the basis of assessment help the
nurse to focus on the patient's troubles and determine the patient's motivation for
treatment.
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Tasks in Orientation phase
1. Creating an environment for the establishment of trust and rapport
2. Determine why patient sought help
3. Determining a contract from interventions that has details of expectations and
responsibilities of both nurse and patient
4. Getting assessment information to build a strong patient database
5. formulating nursing diagnosis, setting goals that are mutually agreeable to the nurse
and patient
6. developing a plan of action that is realistic for meeting the established goals
7. explaining the feelings of both the patient and nurse in terms of the introductory
phase
Working Phase
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The focus of working phase is to achieve the goals that were worked out in the
nurse-patient contract.
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This is the time for working on solving the problems and trying out new behaviors.
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Most of the therapeutic work is carried out during this phase of relationship.
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The nurse and the patient explore stressors and promote the development of insight
in the patient by6 linking perceptions and thoughts feelings and actions.
Tasks in working phase
1. Maintaining the trust and support that was established during the orientation phase
of relationship
2. Promoting the patient's insight and perceptions of reality
3. Problem solving using the model presented earlier
4. Overcoming resistant behaviour on the part of the patient as the level of anxiety
rises in response to discussion of painful incidents.
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Working phase consists of periods of growth and resistance.
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As the relationship moving towards its goals, the client's behaviour changes.
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At this time, it is important to explore the meaning of the change in the client.
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Patients often display resistance during this phase, because it involves greater part
of the problem-solving process.
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As the relationship develops, the patient begins to feel close to the nurse and
responds by changing the old defenses and resisting the nurses attempt to move
forward.
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This result in impasse or plateau in the relationship.
BLOCKS OF THE RELATIONSHIPS
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For variety of reasons therapeutic communication can be hindered.
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Therapeutic blocks are blocks in the progress of nurse-patient relationship.
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They arise for variety of reasons, but they all creates stall in the process of nursepatient relationship.
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Blocks provoke variety of emotions in both the patient and nurse ranging from
anxiety and apprehension to frustration, love, or intense anger.
The commonest four blocks are:
1. Resistance
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Resistance is the patent's reluctance or avoidance of verbalizing or experiencing
troubling aspects of oneself.
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The term was first coined by Freud.
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Resistance is often caused by patient's unwillingness to change when the need for
change is recognized.
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Patient usually displays resistance during the working phase of nurse-patient
relationship, because greater part of problem-solving occurs during this phase.
2. Transference
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Transference is an unconscious response in which the patient experiences feelings
and attitudes toward the nurse that were originally associated with other significant
figures I his or her life.
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They may be triggered by superficial similarity, such as facial features or speech, or
by personality style or trait.
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These reactions are the patient's attempt to reduce anxiety.
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The nurse may be viewed as an authority figure from the past such as parent figure,
or lost loved object, such as former spouse
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Transference reactions are harmful to the therapeutic relationship only if they are
ignored and unexplained.
3. Countertransference
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It is a therapeutic block created by the nurse's specific emotional response to the
qualities of the patient.
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This is inappropriate to the content and context of therapeutic nurse-patient
relationship.
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It is transference applied to the nurse.
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It is natural that nurse feels warmth toward or liking for some patients more than
others.
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The nurse also will be genuinely angry about the actions of some patient.
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But in countertransfernce, the nurse's responses are not justified by reality.
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Here nurse identify the patient with individuals from their past, and personal needs
interfere with their therapeutic relationship.
4. Boundary Violations
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Here the nurse goes beyond the boundaries of therapeutic relationship and
establishes a social, economic, or personal relationship with a patient.
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Boundary violation is involved whenever a nurse is doing or thinking of doing
something special, different or unusual for a patient.
Signs of Boundaries Violation
1. Frequently thinking of the client when away from work.
2. Frequently planning other clients’ care around the client’s needs.
3. Spending free time with the client.
4. Sharing personal information or work concerns with the client.
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5. Feeling responsible if the client’s progress is limited.
6. Noticing more physical touching than is appropriate or sexual content in
interactions with the client.
7. Favoring one client’s care at the expense of another client.
8. Keeping secrets with the client.
9. Selective reporting of client’s behavior (i.e., negative or positive client behavior).
10. Swapping patient assignments.
11. Communicating in a guarded and defensive manner when questioned regarding
interactions/relationships with the client.
12. Changing dress style for work when working with the client.
13. Giving and/or receiving gifts or continued contact/communication with the client
after discharge from your assignment/caseload.
14. Denying the fact that the client is a patient.
15. Acting and/or feeling possessive about the client.
16. Giving special attention/treatment to this client which differs from that given to
other clients.
Termination Phase
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At the beginning of the relationship, the nurse establishes with the client, family and
health team an estimated period of time that the relationship will last.
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The health-related goals and needs of the client determine when the relationship
will end.
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The nurse indicate the necessity of providing care for one shift in a hospital setting
or until the ulcer heals or until the client has no further need for nursing services.
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As the time for terminating the relationship approaches, the nurse needs to discuss
ongoing plans for meeting the client's care needs.
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The nurse and client may identify other necessary resources with other team
members helping the client identify what would work best for him/her.
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In some settings, this may include discharge planning with a referral to community
organizations.
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It may also involve a transfer to another health care provider in the same
organization or from one shift to another.
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