Jhaella Marie Pague
BSN 4A
THERAPEUTIC NURSE CLIENT
RELATIONSHIP
- A mutual learning experience and a
corrective emotional experience for the
patient
- The nurse uses personal attributes and
clinical techniques to bring about insight and
behavioral change
Components of a Therapeutic Relationship
TRUST
- Nurse is consistent in his or her words and
action- There is congruence
- Can be relied on to do what he or she says
(keeping Promises)
- Demonstrated through nursing
interventions that convey a sense of warmth
and caring
GENUINE INTEREST
- Nurses response is sincere, that the nurse is
not thinking and feeling one thing and saying
something different
- The nurse should be honest, sincere and
displays congruent behavior
SELF-DISCLOSURE
- The nurse’s willingness to share her own
points of view in a Therapeutic manner can
be an indication of genuineness
- This encourages the patient to become more
open to the nurse in return.
EMPATHY
- Empathy: the ability to enter into -the life of
another person, to accurately perceive his or
her current feelings and their meanings, and
to communicate this understanding to the
patient
- The nurse puts aside personal views and
values to enter into another's world without
prejudice.
- Verbal and nonverbal behaviors that Convey
high levels of empathy to the patient
➔ Consistent eye contact and response to the
patient's nonverbal cues
➔ Conveyance of interest, concern, and
warmth by the nurse’s own facial
expressions
➔ A tone of voice consistent with facial
expression and verbal response
- Nurse's cultural sensitivity
- Not to be confused with sympathy (pity)
ACCEPTANCE/POSITIVE REGARD
- Unconditional nonjudgmental attitude
- Appreciation of the client as a unique,
Worthwhile human being
- Acceptance of the person as worthy - but not
accepting inappropriate behaviors - setting
boundaries - provides the client with a clear
understanding of what is and is not
acceptable behavior and what the
consequences of their actions will be.
- Shown when the nurse does not become
upset or respond negatively to the client’s
outburst, anger, or acting out.
- Considering client’s ideas and preferences
when planning care - active participant of
care
Therapeutic Use of Self
- The nurse uses aspects of his or her
personality, experiences, values, feelings and
intelligence, needs, coping skills, and
perceptions to establish relationships with
clients
- Must have “self-awareness”
- Gathering data about the patient: read the
background material about the client,
medications taken
- Planning for the first interaction: arranges
for a quiet, private, comfortable setting
Jhaella Marie Pague
BSN 4A
ORIENTATION PHASE
Task: to establish a climate of trust.
understanding. acceptance and open
communication and formulate a
contract with the patient
Build Trust
- The nurse is honest about his or her
intentions is consistent, and keeps promises
- Warmth, interest and concern are conveyed
with words and congruent body language
- The nurse shares appropriate information
about himself or herself (name, reason for
being on the unit)
Formulating a contract
- Begins with the introduction of the Nurse
and the client, exchange of Names and
explanation of roles
- The contract should state:
1. Time, place, length of sessions when the
sessions will terminate
2. Who will be involved in the treatment plar
(family members, health team members)
3. Client responsibilities (arrive on time, end
on Time, participate in activities)
Providing Structure
- Unit activities
- Limit setting: the nurse accepts the client as
a human being while decreasing
self-defeating behaviors
1. Take temporary control if patient loses
control of their thoughts, feelings or behavior
2. Pointing out behaviors and their negative
Effects
3. Kind but firm strategy
- For withdrawn and nonparticipating clients:
spending time with them, even in silence
- explore patients perceptions, thoughts,
feelings, actions
- Identify pertinent patient problems
- Define mutual specific goals with the patient
TEACH
T- Trust
E- Environment
A- Assess
C- Contract
H- Help communicating
WORKING PHASE
* When the strategies of the Orientation stage
are successful and patients are ready to work
toward behavioral change
* Problem Identification
- In-depth data collection
- Direct the data collection and focus on
manageable and Changeable issues
- Awareness of the problem - ANALYSIS
- The nurse guides the patient to examine
feelings and responses and to develop better
coping skills and more positive self-image
- Testing-out step involves trying out the new
behavior or solution in a safe environment -
Role-playing
- Evaluation step assess the success of the
New behaviors or solutions to problems
Reality testing and Cognitive restructuring
* Presenting a point of view so the patient can
consider another option
* "I know the voices seem real to you, but I
don't hear any."
- Goal: help the patient cope with negative
thoughts and beliefs and see other viewpoints
that will help them come to more realistic
conclusions.
Testing behaviors
- Forgetting scheduled sessions or being late
- Expressing anger
- Transference and countertransference
become important issues
Jhaella Marie Pague
BSN 4A
PROVIDE * Bodily contact
- Promote positive self-concept * Direction of gaze
- Realistic goal setting * Emotive tone in speech
- Organize support system * Facial and gestural movements
- Verbalize feelings * Physical appearance
- Implement action plan * Posture
- Develop positive coping behaviors
- Evaluate results of plan of action

TERMINATION PHASE
* Begins the first day of the Relationship -
when the nurse Explains that the relationship
is time limited
* Actual problems are resolved and ends
when the relationship is ended
* Usually stressful for the clients

AVOIDING BEHAVIORS THAT DIMINISH

THE THERAPEUTIC RELATIONSHIP
* Inappropriate Boundaries
- The nurse must act warmly but must not
THERAPEUTIC COMMUNICATION
try
to be friends with the patient
- Interpersonal interaction between the nurse
- Giving one's phone number and address
and the client during which the nurse focuses
would be a beach of ethical conduct
on the client's specific needs to promote an
effective exchange of information.
* FEELINGS OF SYMPATHY AND
ENCOURAGING CLIENT DEPENDENCY
Purposes
- When the nurse sympathizes the patient,
* Establishing a therapeutic nurse-client
she/he can easily be manipulated
relationship.
* Identify client's concerns and problem.
COMMUNICATION
* Assess client's perception of the problem.
* Exchange of information
* Recognize client's needs.
* Messages are Simultaneously received on
* Guide client towards a satisfying and
two levels:
1. Verbally - use of words
2.
socially acceptable solution
Nonverbally - actions or behaviors that
accompany words
Attentive Listening
* Listening actively, using all the senses
Verbal
* It involves paying attention to the total
* Associated with spoken words
message, both verbal and non verbal, and
noting whether these communications are
Nonverbal (represents a more accurate
congruent.
message than does verbal content)
* Accent
Jhaella Marie Pague
BSN 4A
Physical Attending: The manner of being
present
5 specific ways to convey physical
attending: SOLER
* Face the other person SQUARELY
* Adopt an OPEN posture
* LEAN toward the person
* Maintain good EYE contact
* Try to be relatively RELAXED

* Misconception: must always be ready with

questions
- Superficiality - conversation is vague
- Nurse does not understand - may work from
assumptions
* Active Observation
- watching the client's nonverbal actions as he
or she communicates
- First step in the therapeutic interaction
* Using Concrete messages
- Words are explicit/clear - Interpretation is
not needed
- Concrete questions - direct, clear, and easy
to understand
* Abstract messages
- Contain figures of speech that are difficult to
interpret
Abstract (unclear) : "Your clinical
performance has to improve"
Concrete (clear): "To administer medications
tomorrow, you’ll have to be able to calculate
dosages correctly by the end of today’s class
Therapeutic Communication
- the nurse focuses on the client's specific
needs to promote an effective exchange of
information
Therapeutic Communication Techniques
1. Using silence
- Absence of verbal communication, which
provides time for the client to put thoughts or
feelings into words, regain composure and
continue talking.
- not a passive technique
2. Accepting
- Indicating that the nurse acknowledges that
she has understood and heard what you're
the client has said.
Ex. "Yes" or "I follow what you said"
Nodding.. Then saying "I hear what they're
saying.'
3. Giving Recognition
- Acknowledging, indicating awareness of
change, or noting efforts the client has made
all show that the nurse recognizes the client
as a person.
Ex. “I noticed you combed your hair.”
4. Offering self
- Making oneself available
- To offer his /her presence,interest and
desire to understand
Ex. "I'II sit with you awhile."
“Let's walk to the cafeteria together."
Jhaella Marie Pague
BSN 4A
5. Using Broad Openings
- Allowing the patient to. take the Initiative in
introducing a topic
Ex. "What would you like to talk about?"
"Tell me what's bothering you."
"Tell me where you'd like to begin?"
6. Using General Leads
- This indicates that the nurse is listening and
following what the client is saying and letting
the client know that he or she is on the right
track and should continue
Ex. "Go on.” “Hmmm.. I am listening"
"Tell me about it" "Please go on."
7. Placing the event in time or sequence
- Putting events in proper sequence helps
both the nurse and the client to see them in
perspective - client may gain insight into
cause and effect behavior and consequences
Ex. "What seemed to lead up to...?" "Were you
frightened before or after the movie?”
8. Making Observations
- Verbalizing what the nurse perceives.
Ex. "You appear tense" "I notice you are biting
your lips.
9. Encouraging Description of Perceptions
- Asking the client to verbalize what he or she
perceives - to relieve the tension he/she is
feeling thus he/she is likely to. take action on
ideas that are harmful or frightening.
Ex. "What do you think is happening to you
right now..?" "What are these voices telling
you to do?"
10. Restating
- Repeating the main idea expressed- this lets
the client know that he/she communicated
the idea effectively and to let him/her know
that he/she is heard
Ex. Client: "I can't sleep. I stay awake all
night."
Nurse: "You have difficulty sleeping"
Client: "I'm down."
Nurse: "You feel depressed?"
11. Reflecting*
- Directing client's actions, thoughts and
feelings back to the client - encourages the
client to recognize and accept his or her own
feelings
Ex. Patient: "Do you think I should tell the
doctor?"
Nurse: "Do you think you should tell the
doctor?"
12. Focusing
- Concentrating on a single paint - prevents a
multitude of factors or problems from
overwhelming the client.
Ex. "This point seems worth looking at more
closely." "You said something earlier that I
want you to go back to.”
13. Exploring
- Delving further into a subject or idea - to
understand better the problem
Ex. "Would you describe that more fully."
"These dreams you mentioned, what are they
like?"
14. Giving Information
- Making available what the client needs.
Ex. "My name is...I am a student nurse..""My
purpose in being here is...”
15. Seeking Clarification
- Asking patients to elaborate, or give
examples of ideas or feelings to seek
clarification of what is unclear.
- restating, reflecting, exploring
Ex. "I am not familiar with your work, can you
describe it further for me" "When you say
Jhaella Marie Pague
BSN 4A
your brother is crazy, does the word crazy
mean "kind of wild?" "Tell me if we both
understand that word in the same way."
16. Presenting Reality
- Offering for consideration that which is
real.- to indicate an alternative line of thought
for the client and not belittling his her
experience. - do not argue
Ex. "I know you hear voices, but I do not hear
them." "This is a hospital, not a
hotel."
17. Voicing Doubt
- Expressing uncertainty about the reality of
the client's perception - to encourage the
client to reconsider or reevaluate what has
happened.
Ex. "I find it hard to believe.. “
18. Seeking Consensual Validation
- Searching for consensual understanding.
Ex. "Tell me whether my understanding of it
agrees with yours."
19. Verbalizing the Implied*
- An attempt to detect the true meaning of
verbal messages
Ex. Client: 'I won't be bothering you anymore
soon."
Nurse: "Are you thinking of killing
yourself?"
20. Encouraging decisions
- Asking the patient to make a choice among
options
Ex. "Given all these choices, what would you
prefer to do?"
21. Attempting to Translate Into Feelings
- Seeking to verbalize client's feelings that
helshe expresses indirectly.
Ex. Client: "I'm dead."
Nurse: "Are you suggesting that you feel
lifeless."
22. Suggesting Collaboration
- Offering to share, to strive, to work with the
client for his /her benefit - the nurse offers to
do things with, rather than for the client.
Ex. “Let's talk and see if we can work together
to understand this." "Perhaps we can discuss
this and see what offended you."
23. Summarizing
- Organizing and summing up what has gone
before. - ta bring out the important points of
the discussion, to provide sense of closure
Ex. "Let's see, so far you have said..” "During
this meeting, we discussed what you will do
when you feel the urge to hurt yourself again
and this includes.”
NON THERAPEUTIC COMMUNICATION
- may hinder nurse client relationship
1. Overloading
- talking rapidly, changing subjects too often,
and asking for more information than can be
absorbed at one time.
- "What's your name? I see you like sports.
Where do you live?"
2. Value Judgments
- giving one's own opinion, evaluating,
moralizing or implying one's values by using
words such as "nice", "bad", "right",
"wrong",
"should" and "ought''.
"You shouldn't do that,
its wrong".
3. Incongruence
- sending verbal and non-verbal messages
that contradict one another.
Jhaella Marie Pague
BSN 4A
- The nurse tells the patient "I'd like to spend
time with you" and then walks away.
4. Underloading
- remaining silent and unresponsive, not
picking up cues, and failing to give feedback.
- The patient asks the nurse, the nurse simply
walks away.
5. False reassurance
- Using cliché to reassure clients.
- "It's going to be alright".
6. Focusing on self
- responding in a way that focuses attention
on the nurse instead of the client.
- "This sunshine is good for my roses. I have
beautiful rose garden"
7. Changing the subject
- introducing new topic inappropriately, a
pattern that may indicate anxiety.
- The client is crying, when the nurse asks
"How many children do you have?"
8. Giving advice
- telling the client what to do, giving opinions
or making decisions for the client, implies the
client cannot handle his or her own life
decisions and that the nurse is accepting
responsibility.
- "If I were you... Or it would be better if you
do it this way..
9. Internal validation
- making an assumption about the meaning of
someone else's behavior that is not validated
by the other person (jumping into
conclusion).
- The nurse sees a suicidal client smiling and
tells another nurse the patient is in good
mood.
10. Rejecting
- Refusing to discuss certain topics with the
client. These responses often make clients feel
that the nurse is rejecting not only their
communication but also the client
themselves.
- " I don't want to discuss that. Let's talk
about..” “Let's discuss other areas of interest
to you rather than the two problems you keep
mentioning." " I can't talk now. I'm on my way
for a coffee break."
11. Defending
- attempting to protect someone or something
from verbal attack. (may imply that the client
has no right to express opinions, impressions
and feelings.)
- "This hospital has a fine reputation.""I'm
sure your doctor has your best interest in
mind.”
12. Interpreting
- telling the client the meaning of his or her
experience. (The client's thoughts and
feelings are his or her own, not to be
interpreted by the nurse for hidden meaning.)
- "Whât you really mean..." "Unconsciously
you're saying..."
13. Requesting an explanation
- asking the client to provide reasons for
thoughts, feelings, behaviors, events.
- "Why do you think that?" "Why do you feel
that way?"
Other ineffective behaviors and responses:
* Literal responses - "If you feel empty then
you should eat more".
* Looking too busy.
Jhaella Marie Pague
BSN 4A
* Appearing uncomfortable in silence.
* Being opinionated.
* Avoiding sensitive topics
* Arguing and telling the client is wrong
* Making false promises - "I'lI make sure to
call you when you get home"
* Making sarcastic remarks
* Laughing nervously
* Showing disapproval - "You should not do
those things.'