NURSE CLIENT RELATIONSHIP

NURSE CLIENT INTERACTION

MODULE 4

NURSE CLIENT INTERACTION

(COMMUNICATION)
COMMUNICATION : is the process that people use to
exchange information.
Is an interaction between two or more people that
involves the exchange of information between a sender
and a receiver
Messages are simultaneously sent and received on two
levels:

Verbally through the use of words

Non- verbally by behaviors that accompany the words.

THERAPEUTIC COMMUNICATION

Is an interpersonal interaction between the nurse and

client during which the nurse focuses on the clients
specific needs to promote an effective exchange of
information.
therapeutic communication techniques helps the
nurse understand and empathize with the clients
experience.
All nurses need skills in therapeutic communication to
effectively apply the nursing process and to meet
standards of care for their client.

THERAPEUTIC COMMUNICATION CAN

HELP NURSES TO ACCOMPLISH GOALS:
1. Establish a therapeutic nurse- client
relationship
2. Identify the most important client concern at
that moment (client centered goal).
3. Assess the clients perception of the problem
as it unfolds. (the clients thoughts and feelings
about the situation, others and self).

4. Facilitate the clients expression of emotions.

5. Teach the client and family necessary self-care
skills.
6. Recognize the clients needs.
7. Implement intervention designed to address
the clients needs.
8. Guide the client toward identifying a plan of
action to a satisfying and socially acceptable
resolution.

TO HAVE EFFECTIVE THERAPEUTIC

COMMUNICATION THE NURSE MUST
CONSIDER:
Privacy and Respect of Boundaries
Use of Touch
Active listening and observation

1. PRIVACY AND RESPECT

BOUNDARIES
Privacy is desirable but not always possible in
Therapeutic Communication. ( delicate information
the nurse should know or the patient would revealed)
An interview or conference room is optimal, if the
nurse believes this setting is not isolative for
interaction.
The nurse needs to evaluate whether interacting in the
clients room is therapeutic.
Ex. If the client has difficulty maintaining
boundaries or has been making sexual
comments, then the clients room is not the best
setting.

BOUNDARIES

PROXEMICS: is the study of distance

zones between people during communication.

People feel more comfortable with smaller distance
when communicating with someone they know rather
than strangers.

1.
2.
3.
4.

4 Distance Zones:
Intimate
Personal
Social
Intimate

4 Distance Zones:
1. Intimate zone ( 0 to 18 inches between people) : this
amount of space is comfortable for parents with
young children, people who mutually desire
personal contact, or people whispering.

invasion of this intimate zone by anyone else

is threatening and produces anxiety.
2. Personal zone (18 to 36 inches) : this distance is
comfortable between family and friends who are
talking.

3. Social zone (4 to 12 feet): this distance is

acceptable for communication in social, work, and
business settings.
4. Public zone (12 to 25 feet): this is acceptable
distance between a speaker and an audience, small
groups, and other informal functions.
Both the client and the nurse can feel
threatened, if one invades the others personal
or intimate zone, which can result tension,
irritability, fidgeting (uneasy, nervous) , or even
flight.
When the nurse must invade the intimate or
personal zone, the nurse should ask the clients
permission.

2. TOUCH

AS INTIMACY INCREASES, THE NEED FOR DISTANCE

DECREASES.

5 TYPES OF TOUCH:
1.
Functional- Professional touch: is used in examination
or procedure.
2.
Social- Polite touch: is used in greetings, such as hand
shake
3.
Friendship- Warmth touch: hug in greeting, back
slapping
4.
Love- intimacy touch: tight hugs and kisses between
lovers or close relatives.
5.
Sexual- Arousal touch: used by lovers, specially the
married couple.

3. ACTIVE LISTENING AND

OBSERVATION
To receive the senders simultaneous messages, the
nurse must use active listening and active
observation.
Active listening : means refraining from other
internal mental activities and concentrating
exclusively on what the client says.
Active observation : means watching the speakers
nonverbal action as he/ she communicates.

COMMON MISCONCEPTION OF STUDENTS

learning the art of THERAPEUTIC
COMMUNICATION = is that they always must be
ready with questions the instant the client has
finished speaking.
They are constantly thinking ahead regarding the
next question rather than actively listening to
what the client is saying. The result can be that
the nurse does not understand the clients
concerns, and the conversation is vague,
superficial, and frustrating to both participants.

ACTIVE LISTENING AND

OBSERVATION
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 /her
perceptions fully.
Understand the clients perceptions of the issue
instead of jumping to conclusions.
Interpret and respond to the message objectively.

VERBAL COMMUNICATION
SKILLS
1.
2.

USING CONCRETE
MESSAGES
USING THERAPEUTIC
COMMUNICATION
TECHNIQUES

1. USING CONCRETE MESSAGE

nurse should use words that are clear as

possible when speaking to the client so that the
client can understand the message.
In concrete message , the words are explicit
and need no interpretation.
Concrete questions, are clear, direct, and
easy to understand.
Ex. "what health symptoms caused you to
come to the hospital today? or when
was the last time you took your
antidepressant medications?

2. USING THERAPEUTIC COMMUNICATION

TECHNIQUES:

The choice of technique depends on the intent of

the interaction and the clients ability to
communicate verbally. Overall , the nurse
selects techniques that facilitate the
interaction and enhance communication
between client and nurse.
Techniques such as exploring, focusing,
restating, and reflecting encourage the client
to discuss his/her feelings or concerns in more
depth.

THERAPEUTIC
COMMUNICATION TECHNIQUES:

1.

Accepting

: indicating reception

Ex. yes I follow what you said. Nodding

2. Broad opening: allowing the client to take the

initiative in introducing the topic.
Ex. Is there something youd like to talk about?
Where would you like to begin?

3. Consensual validation: searching to mutual

understanding, for accord in the meaning of the words.
Ex. Tell me whether my understanding of it agrees
with yours.

4. Encouraging comparison: asking that

similarities and differences be noted.
Ex. Was it something like...? Have you had similar
experiences?

5. Encouraging

description of

perceptions: asking the client to verbalize what

he/ she perceives.

Ex. Tell me when you feel anxious What is
happening? What does the voice seem to be saying?

6. Encouraging expression: asking the

client to appraise the quality of his/her experiences.
Ex. What are your feelings in regard to....? Does
this contribute to your distress?

7. Exploring: delving further into a subject or

idea.
Ex. Tell me more about that. Would you describe it
more fully?

8. Focusing: concentrating on a single point.

Ex. This point seems worth looking at more closely.

9. Formulating a plan of action: asking

the client to consider kinds of behavior likely to be
appropriate in future situations.
Ex. What could you do to let your anger out
harmlessly?

10. General leads: giving encouragement to

continue.
Ex. Go on and then? Tell me about it.

11. Giving information: making available the

facts that the client needs.
Ex. My name is.... Visiting hours are... My purpose
in being here is.....

12. Giving recognition: acknowledging,

indicating awareness: Good morning, Mr. S....... I
notice that youve combed your hair.

13. Making observations: verbalizing what

the nurse perceives.
Ex. You appear tense. I notice youre biting your
lip.

14. Offering

self: making oneself available.

Ex. Ill sit with you awhile.

15. Presenting reality: offering for

consideration that which is real.
Ex. Ill see no one else in the room.

16. Reflecting: directing client actions. Thoughts,

and feelings back to client.
Ex. Client: do you think I should tell the doctor....?
Nurse: do you think you should?

17. Restating: repeating the main idea expressed.

Ex. Client: I cant sleep. I stay awake all the night.
Nurse: you have difficulty sleeping.

18. Seeking information: seeking to make

clear that which is not meaningful or that which is
vague.
Ex. Im not sure that I follow. Have I heard you
correctly?

AVOIDING NONTHERAPEUTIC
COMMUNICATION
In contrast, there are many therapeutic
techniques that nurses should avoid. These
responses cut off communication and make
it more difficult for the interaction to
continue.
Responses such as Everything will work out
or May be tomorrow will be a better day
may be intended to comfort the client, but
instead may impede the communication process.

NONTHERAPEUTIC
COMMUNICATION TECHNIQUES:
1. Advising: telling the client what to do.
Ex. I think you should...
2. Agreeing: indicating accord with the client.
Ex. Thats right.
3. Belittling feelings expressed: misjudging the
degree of the clients discomfort.
Ex. Client: I have nothing to live for... I wish I
was dead. Nurse: Everybody gets down in the
dumps. or Ive felt that way myself.

4. Challenging: demanding proof from client.

Ex. But how can you be president of the United
State? If youre dead, why is you heart beating?
5. Defending: attempting to protect someone or
something from verbal attack.
Ex. This hospital has a fine reputation. Im sure
your doctor has your best interests in mind.

6. Disagreeing: opposing the clients ideas.

Ex. thats wrong.
7. Disapproving: denouncing the clients behavior or
ideas.
Ex. Thats bad Id rather you wouldnt
8. Giving approval: sanctioning the clients behavior
or ideas.
Ex. Thats good. Im glad that...

9. Interpreting: asking to make conscious that which

is unconscious; telling the client the meaning of his or
her experience.
Ex. What you really mean is.... Unconsciously youre
saying....
10. Probing: persistent questioning of the client.
Ex. Now tell me about this problem. You know I have
to find out.

INTERPRETING SIGNALS OR
CUES
To understand what the client means, the nurse
watches and listens carefully for cues.
CUES: are verbal or nonverbal messages that
signal key words or issues for the client.
Cue words introduced by the client can help the
nurse to know what to ask next or how to
respond to the client.

INTERPRETING SIGNALS OR
CUES (1/2)

Ex. Client: I had a boyfriend when I was

younger. Nurse: You had a boyfriend?
(reflecting, direct the clients actions,
thoughts, and feelings back to client) Tell me
about you and your boyfriend. (encouraging
description) How old were you when you had
this boyfriend? (placing events in time or
sequences)

NONVERBAL COMMUNICATION
SKILLS
Is behavior that a person exhibits while
delivering verbal content.
It includes:
facial expression,
eye contact,
space ,
time,
boundaries, and
body movements.

NONVERBAL
COMMUNICATION
involves

the unconscious
mind acting out emotions
related to the verbal content,
the situation, the
environment, and the
relationship between the
speaker and the listener.

1. FACIAL EXPRESSION
The human face produces the most visible, complex,
and sometimes confusing nonverbal messages.
Facial movements connect with words to illustrate
meaning; this connection demonstrates the speakers
internal dialogue.

Facial

expression can be
categorized into:

Expressive
Impassive
Confusing

EXPRESSIVE:
face

portrays the persons

moment- by- moment
thoughts, feelings and needs.
These expression may be
evident even when the
person does not want to
reveal his/her emotions.

IMPASSIVE:
is

frozen into an emotionless

deadpan expression similar
to mask.

EX.

FLAT AFFECT

CONFUSING:
facial

expression is one that is the

opposite of what the person wants
to convey.
A person who is verbally
expressing sad or angry feelings
while smiling is exhibiting a
confusing expression.

FACIAL EXPRESSION
often

affect the listeners

response. The nurse should
identify the facial expression and
ask the client to validate nurses
interpretation of it.
Ex. youre smiling, but I
sense you are very angry.

2. BODY LANGUAGE
Gesture

, postures, movements,
and body positions.
Is a nonverbal form of
communication.
Closed Body Position
Accepting Body Position

CLOSED BODY POSITION

such as crossed legs or arms

folded across the chest,
indicate that interaction
might threaten the listener
who is defensive or not
accepting

ACCEPTING BODY
POSITION

is to sit facing the client with both feet on the floor,

knees parallel, hands at the sides of the body, and
legs uncrossed or crossed only at the ankle.
This open posture demonstrate unconditional
positive regard, trust, care and acceptance.
The nurse indicates interest in and acceptance of the
client by facing and slightly leaning toward him or
her while maintaining nonthreatening eye contact

VOCAL CUES

Are nonverbal sound signals transmitted

along with the content: voice volume, tone,
pitch, intensity, emphasis, speed, and
pauses augment the senders message.
Volume : the loudness of the voice, can indicate
anger, fear, happiness, or deafness.
Tone: can indicate whether someone is relaxed,
agitated or bored.
Pitch: varies from shrill and high to low and
threatening.

 Intensity:

is the power, severity, and

strength behind the words, indicating
the importance of the message.
Emphasis: refers to accents on words or
phrases that highlight the subject or give
insight on the topic.
Speed: is number of words spoken per
minute.

EYE CONTACT
The eyes have been called the mirror of the soul
because they often reflect our emotions.
Looking into the other persons eyes during
communication, is used to assess the other
person and the environment and to indicate
whose turn it is to speak
it increases during listening but decreases while
speaking.
Although maintaining good eye contact is usually
desirable, it is important that the nurse doesnt
STARE at the client.

SILENCE

Or long pauses in communication may indicate many

different things.
The client may be depressed and struggling to
find the energy to talk.
Sometimes pauses indicate the client is thoughtfully
considering the question before responding.
At times, the client may seem to be LOST IN
HIS/HER OWN THOUGHTS and not paying
attention to the nurse.
It is important to allow the client sufficient time
to respond, even if it seems like a long time.

TO BE
CONTINUE......

THERAPEUTIC
RELATIONSHIP

THERAPEUTIC RELATIONSHIP
The

nurses relationship with the

patient consists of a series of goaldirected interactions through which
the nurse assesses patients
problems, elicits patient input,
selects interventions, and evaluates
the effectiveness of care.

RELATIONSHIP:
3

Types :
Social
Intimate
Therapeutic

SOCIAL RELATIONSHIP

is primarily initiated for the purpose of

friendship, socialization, companionship, or
accomplishment of task.
Communication, w/c may be superficial,
Usually sharing of ideas, feelings and experiences
and meets basic need for people to interact.
Advise is often given.

INTIMATE RELATIONSHIP

healthy 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 sexual or emotional
intimacy as well as sharing of mutual goals.

THERAPEUTIC RELATIONSHIP
Differs

from the social and intimate

relationship in many ways because
it focuses on the needs, experiences,
feelings, and ideas of the client only.
The nurse and client agree about
the areas to work on and evaluate
the outcomes.

THERAPEUTIC RELATIONSHIP
The

nurse uses communication skills,

personal strengths, and
understanding of human behavior to
interact with the client.
The nurse should not be concerned
about whether or not the client likes
him/her or grateful.
The nurse must constantly focus on
the clients needs not his/her own.

COMPONENTS OF A
THERAPEUTIC RELATIONSHIP
Trust
Genuine interest
Empathy
Acceptance
Positive regard
Self-awareness
Therapeutic use of self

TRUST
Trust

develops when the

client believes that the
nurse will be consistent
in his/her words and
actions and can be relied
on to do what he or she
says.

GENUINE INTEREST
The

client perceives a
genuine person showing
genuine interest.

A client with mental illness can detect when

someone is exhibiting dishonest or artificial
behavior such as asking a question and then not
waiting for the answer, talking over him or her,
or assuring him/her everything will be all right.

EMPATHY
Is

the ability of the nurse to perceive

the meaning and feelings of the client
and to communicate that
understanding to the client.

It is considered one of the essential skills a nurse

must develop.
Being able to put himself/herself in the clients
shoes does not mean that the nurse has had the
same exact experiences as the client.
Ex. Empathy : I see you are sad.... How can I help
you?
Ex. Sympathy : I feel so sorry for you.

ACCEPTANCE
The

nurse who does not become

upset or respond negatively to a
clients outbursts, anger, or acting
out conveys acceptance to the client.

Avoiding judgment s of the person, no matter

what the behavior, is acceptance.
This does not mean acceptance of inappropriate
behavior but acceptance of the person as worthy.

The nurse must set boundaries in the nurseclient relationship.

Ex. A client puts his arm around the nurses
waist.

An appropriate response would be for the

nurse to remove his hand and say, john,
do not place your hand on me. We are
working in your relation with your
girlfriend and that does not require you
to touch me. Now, lets continue.

POSITIVE REGARD
The

nurse who appreciates the

client as a simple worth while
human being can respect the client
regardless of his or her behavior,
background, or lifestyle.

Calling the client by name, spending time with

the client, and listening and responding openly
are measures by which the nurse conveys
respect and positive regard to the client.

SELF- AWARENESS
Before the nurse can begin to understand
clients, the nurse must know himself /herself.
Self awareness: is the process of developing an
understanding of one owns values, beliefs, thoughts,
feelings, attitude, motivations, prejudices, strengths,
and limitations and how these qualities affect others.

VALUES:
are

abstract standards that give a

person a sense of right and wrong
and establish a code of conduct for
living.
Sample values: hard work, honesty,
sincerity, cleanliness,, and
orderliness.

BELIEFS
are ideas that one holds to be true,
Ex. if the sun is shining, it will be a
good day.
Some Beliefs have objective
evidence to substantiate them.
Ex. People who believe in evolution
have accepted the evidence that
supports this explanation for the
origin of life.

ATTITUDES:
are

general feelings or a frame of

reference around which a person
organizes knowledge about world.
Attitudes such as: hopeful,
optimistic, pessimistic, positive, and
negative, color how we look at the
world and people.

THERAPEUTIC USE OF SELF

By

developing self- awareness and

beginning to understand his/ her
attitudes, the nurse can begin to use
aspects of his/her personality,
experiences, values, feelings, intelligence,
needs, coping skills, and perceptions to
establish relationships with client.

Nurses use themselves as therapeutic tool to

establish therapeutic relationships with clients
and help clients grow, change, and heal.

JOHARI WINDOW
One

tool that useful in learning more

about oneself.
Which creates a word portrait of a
person in four areas and indicates
how well that person knows himself/
herself and communicates with
others.
The Four Areas evaluated are as
follows:
Quadrant 1: Open /Public self = qualities
one knows about oneself and others also
know.

Quadrant

2: Blind/ Unaware self

= qualities know only to others.
Quadrant 3: Hidden/Private self
= qualities known only to oneself.
Quadrant 4: Unknown = an empty
quadrant to symbolize qualities as
yet undiscovered by oneself or
others.

JOHARI WINDOW

3 PHASES/ STAGES OF NURSECLIENT RELATIONSHIP

1.
2.
3.

ORIENTATION STAGE
WORKING STAGE
TERMINAL STAGE

ORIENTATION PHASE
Begins

when the nurse and client

meet and ends when the client begins
to identify problems to examine.

Before meeting the client:

The nurse reads background materials
available on the client.
Becomes familiar with any medications the
client is taking
The nurse should consider his/her personal
strengths and limitations in working with
this client (self assessment).
Acceptance is the foundation of all
therapeutic relationship.

(ORIENTATION PHASE)
During

the Orientation Phase:

The nurse establishes roles
The purpose of meeting and parameters of
subsequent meetings
Identifies the clients problems, and
clarifies expectations.
Built trust: it is the nurse responsibility
to establish a therapeutic
environment that foster trust and
understanding.

 The

nurse should share appropriate

information about himself/herself at
this time, including name, reason
for being on the unit, and level of
schooling. (self- disclosure)
The nurse needs to listen closely to
the clients history, perceptions and
misconceptions.
The nurse needs to convey empathy
and understanding.

 Reality

testing : is accepting the patients

perception, feelings and thoughts as neither right

or wrong, but at the same time offering other
options or points of view to the client in a nonargumentative manner for the purpose of helping
the client arrive at more realistic conclusion.

To

provide structure: is to intervene

when client loses control of his feelings
and behaviors by medications, offering
self, restrain, seclusion and by assessing
client to observe a consistent daily
schedule.

ORIENTATION PHASE:
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
client.
Both nurse and client agree on these
responsibilities in an informal or
verbal contract.

ORIENTATION PHASE:
CONFIDENTIALITY, DUTY TO WARN
MEANS RESPECTING THE CLIENTS
RIGHT TO KEEP PRIVATE ANY
INFORMATION ABOUT HIS/HER MENTAL
AND PHYSICAL HEALTH AND RELATED
CASE.
DUTY TO WARN:
The decision requires the nurse to notify
intended victims and police of such threat.
Ex. Suicidal threats, threat from the client
to harm other person.

WORKING PHASE
The

phase where issues are

addressed,
Problems identified
Solutions explored
Nurse and client work to
accomplish goals

WORKING EXPLORATION
/IDENTIFICATION PHASE
At

this point the clients problem are

identified and solutions are explore,
applied and evaluated.
The focus of the assessment and of
the relationship is the clients
behavior and the focus of the
interaction is the clients feelings.
The nurse should realize that the
clients feelings of security are
developed by being consistent at all
times.

WORKING PHASE
Perception

of reality, coping
mechanisms and support system 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.

THE SPECIFIC TASKS OF WORKING

PHASE INCLUDE THE FF:

Maintain 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
Providing opportunities for the client to practice new
behaviors
Promoting independence

Transference : the client unconsciously to transfer to

the nurse feelings he or she has for significant others.

Countertransferrence: a similar process can occur

when the nurse responds to the client based on
personal unconscious needs and conflicts.
Ex. 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 resist her help.

TERMINATION PHASE
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 the clients try to avoid termination by
acting angry or as if the problem has not
been resolved.

 The

nurse can acknowledge the clients

angry feelings and assure the client that
this response is normal to ending a
relationship.
It is appropriate to tell the client that
the nurse enjoyed the time spent with
the client and will remember him/he, but
it is inappropriate for the nurse to
agree to see the client outside the
therapeutic relationship.

Ex. Nurse Jones comes to see Mrs. Cruz for the last
time.

Mrs.

Cruz: is weeping quietly, oh, Ms.

Jones, you have been so helpful to me. I
just know I will go back to my old self
without you here to help me.

Nurse Jones: Mrs. Cruz, I think weve had a

very productive time together. You have learned
so many new ways to have better relationships
with your children, and I know you will go home
and be able to use those skills. When you come
back for your follow-up visit, I will want to hear
about how things have changed at home.

END