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Therapeutic
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The therapeutic relationship between nurse and client
is the hallmark of psychiatric nursing. In 1952, the publication
of Interpersonal Relations in Nursing,
by Hildegard E. Peplau, essentially revolutionized the teaching and practice of psychiatric nursing in the
United States. At a time
when the introduction of
psychotropic medications was changing the treatment
of psychiatric illness, Peplau
emphasized the interpersonal relationship
of the nurse and client.
The Nurse–Client
Relationship
The nurse–client relationship is the
context in which the nursing process occurs and is the primary means of
providing nursing care. This is true for all nursing practice, not just
psychiatric nursing. Ac- cording to Peplau, nursing’s unique focus is the reactions
of clients to the circumstances of their illness or health situation. Illness
provides an opportunity for learning and growth. The nurse, through careful
observation and thoughtfully guided communication, assists the client to
identify needs and develop new intellectual and interpersonal skills. The competency
of the nurse will substantially affect the quality of the client’s experience
and the outcome of care. Nursing competence goes beyond the mastery and
application of scientific knowledge and technical skills. The vehicle for all
nursing action is the nurse–client relationship, and it is the basis for a
successful and fulfilling nursing practice as well as for all nursing actions.
Characteristics of the Therapeutic
Nurse–Client Relationship
All intentional interactions with clients that are helpful are considered therapeutic. However, not all nurse–client interactions constitute a relationship. A relationship exists between the client and the nurse only when they become significant to each other. If it is achieved, the relationship becomes therapeutic. There are several characteristics that define the therapeutic nurse–client relationship. They include the following:
◆ To be therapeutic, the nurse–client relationship must be based on mutual respect.
◆ The relationship is client focused and designed to meet the client’s needs. The emotional needs of the nurse cannot interfere with this process. The interactions are goal oriented.
◆ Goals are mutually established by both the client and the nurse.
◆ The relationship is collaborative, with both the client and the nurse contributing to the healing, growth, and problem solving.
◆ The client and nurse engage in shared decision making.
◆ The relationship promotes the client’s independence to the maximum extent possible. The nurse works with the client and does not do for the client.
◆ The relationship promotes the expression of the client’s feelings.
Essential
Characteristics of the Nurse in a Therapeutic Relationship
Respect
Psychologist Carl Rogers (1951) referred to respect as
unconditional positive regard or the ability to accept another’s beliefs even
if they differ from one’s own feelings and beliefs. This concept is the foundation
for an accepting and nonjudgmental attitude. It communicates to clients that
their personal beliefs and values are important. The nurse does not need to
agree, but, at the same time, does not impose personal values on the client.
Rather, the nurse attempts to understand the client’s perspective. When the client
feels understood, a rapport or affinity develops between the client and the
nurse. An accepting and respectful attitude is likely to promote client comfort
and facilitate the client’s honest expression of symptoms, beliefs, thoughts,
feelings, and concerns.
Ways to foster respect include asking clients how they prefer to
be addressed, spending time with the client, being honest in all
communications, providing for privacy, maintaining confidentiality,
collaborating with clients on treatment planning, providing information, and
answering questions.
Trust
Trust is the foundation of all interpersonal relation- ships and
the first task in Erikson’s developmental hierarchy. The client’s ability to
trust will be influenced by how well this developmental task was accomplished
during early interactions with parents and caregivers. In describing trust,
Erikson (1963) used the terms consistent,
familiar, and predictable. The client needs to know that the nurse is reliable,
honest, and dependable. Trust is particularly important, given the vulnerable
position of clients with health- care needs. Trust does not happen immediately
but evolves or, more correctly, is earned over the course of the relationship.
Every interaction with the nurse will either support or shake the development
of trust on the part of the client. Nurse actions that promote trust include
following through on promises, showing kindness, treating the client fairly,
and presenting a confident manner.
Genuineness
The nurse’s ability to be oneself, or to be real, when
interacting with clients is referred to as genuine-
ness. By acting in a genuine way, the nurse helps the client to see the
shared humanity between client and nurse. Genuineness implies congruence
between what the nurse is feeling and the expression of that feeling. The nurse
must learn appropriate use of self- disclosure. The nurse would not share all
personal experiences, even if relevant, nor would the nurse express judgments
that are critical of the client or the client’s values. Still, there are many
ways that the nurse can show his or her humanity when interacting with the
client. The nurse may laugh at a funny joke told by the client or express
understanding about a difficulty the client is having, or share that the nurse
finds meditation to be a helpful form of relaxation. A novice nurse may try to
disguise his or her inexperience from the client out of concern that the client
will think less of the nurse. In fact, clients can easily detect a lack of
genuineness and are more likely to respect the nurse for honestly acknowledging
limitations. The quality of genuineness, or the authentic representation of the
self, will greatly enrich the nurse–client experience.
Empathy
Empathy
is the ability to put oneself in another’s place and see the
world as the other person does. This objective understanding of the client’s emotions allows the nurse to be sensitive to the client’s feelings without experiencing the
emotions. This is in contrast to sympathy, a
subjective experience, in which there is an actual sharing of experienced
emotions. Sympathy can interfere with the nurse–client relationship in a couple
of ways: the nurse can become overwhelmed by the emotions and be unable
to help the client; the nurse
who shares an experience with the client as a way of saying “I know how you
feel” risks shifting the focus of the interaction away from the client. The nurse’s
intention may be to support the client, but the action is not effective.
Empathy promotes sensitivity to the client’s feelings
and needs. The nurse must
communicate this understanding to the client in a way that the client can
understand. This will contribute to the client’s experience of being understood,
thus building trust.
Conditions That Influence the Nurse– Client Relationship
Client Factors
Religion and Culture
Styles of communication vary
across cultures and religions. It is helpful for the nurse to be familiar with the beliefs, values, customs, and
preferences of the groups most often served in the community. Even with
knowledge of general beliefs and practices, the nurse should not assume that
the client fits that expectation. Therefore, the nurse should clarify personal
preferences with each client. Consideration should be given to the proper
pronunciation of the client’s name,
the need for an interpreter, the
role of the family, and preferences or religious requirements regarding interaction with persons of the opposite gender. Cultural variances may
include the use of eye contact, the acceptable distance
between persons while
communicating, posture, and other nonverbal
communication. The nurse needs to be sensitive to these differences and
respectful to the client.
Age or Developmental Level
The nurse must have knowledge of the client’s developmental level and be aware of the client’s ability to communicate. This understanding will shape the way the
nurse relates to the client. Communication must
be appropriate to the client’s level of comprehension. The nurse will need to be aware of the client’s nonverbal
communication and open to alternative ways of communicating, such as play. Children can express feelings,
fears, and concerns through play.
Nurse Factors
Self-Awareness
Self-awareness literally means understanding the
self. The nurse has a responsibility to examine personal feelings,
thoughts, behaviors, attitudes, and intentions. This ongoing monitoring
requires openness and an ability
to be self-critical. The nurse’s emotional
responses and actions have a significant impact on the client. The nurse
must be sensitive to this effect. Self-awareness allows the nurse to separate
personal feelings from the client’s responses.
This ability to control and manage personal emotions and respond appropriately to others is called emotional competency
or emotional intelligence. The
personal growth that comes through self-awareness will enrich the therapeutic relationship.
Boundaries
Boundaries are limits that help
establish and maintain the nurse and client roles in the relationship. To be truly helpful to clients, nurses
need to under- stand the difference between professional and social relationships. Social
relationships are interactions in
which the needs of both persons are of equal importance. In contrast, professional relationships are those in which the needs of the client are paramount. This principle
guides the nurse’s decisions on
handling difficult situations with clients.
Self-Disclosure.
One area of boundaries involves self-disclosure.
Self-disclosure refers to revealing personal information about oneself, with the goal of benefiting the client and the therapeutic process. It is not always easy to know if the information will help the client. Self-disclosure can reverse the nurse–client dynamic and sever the client from the role of information giver. The focus of the nurse–client relation- ship is always the client. With experience, the nurse is better able to determine what information may be shared without compromising the relationship. In the following example, the nurse balances genuineness with maintaining a professional relationship.Selfdisclosure is a controversial intervention that should only be used to benefit the client and the therapeutic process, never for selfish reasons.Example:
Client: “I think I have to place my mother in a nursing facility. She is becoming very forgetful and needs help with her personal care. What do you think I should do?”Nurse: “That is something you will have to decide. I have an elderly parent, and I can imagine how difficult this is for you.”
The nurse should never reveal intimate information or answer questions that raise feelings of discomfort.
Example: Client: “May I have your phone number so I can stay in touch after I leave the hospital?”Nurse: “I cannot give my phone number. Are you concerned about who to call if you have questions or concerns after you are discharged?”In this example, the nurse appropriately refuses to give personal information and counters the client’s possible feelings of rejection by showing concern and a willingness to help. Because decisions about what information is appropriate to share with the client are difficult, the nurse should seek guidance from an experienced nurse or colleague. One piece of information important to disclose to the client to protect the client’s rights is the nurse’s name, title, and position. As mentioned earlier, students and beginning practitioners may be reluctant to divulge their novice status. Clients, however, may pick up on an interviewer’s newness. Thus, denying that you are new in the field may cause a lack of trust. Clients who seem distressed by the nurse’s lack of experience should be encouraged to discuss this with the nurse and may be referred to the nurse’s supervisor for reassurance if necessary. Psychiatric clients who have had previous experience with new nurses and students often come to expect this as the norm; certain clients actually take pride in “training” new nurses.
Touch.
The use of touch is another area that is influenced by the importance of maintaining appropriate boundaries. Touch is commonly used to convey caring, provide comfort, or offer support. Touch is essential to carry out physical care or treatments. However, touch can be interpreted differently by clients, and at times may be misinterpreted. Touch may not be welcomed based on cultural or religious preferences. Clients who are experiencing paranoia or psychoses may be threatened by touch, and clients with sexual preoccupation may misinterpret the nurse’s touch as sexual. Inpatient settings often have a general rule of no touching as a way of reducing incidents related to such misinterpretations. This rule is helpful to students and novice practitioners, since it often takes experience to recognize when touch can present serious risks. In the absence of a rule,
Communication Techniques
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