Received: 6 June 2019 Revised: 15 August 2020
DOI: 10.1111/ijn.12938
LITERATURE REVIEW
Therapeutic communication within the nurse–patient
relationship: A concept analysis
Wantong Xue Master Degree Candidate, Senior Nurse1,2
Catrina Heffernan Miller Felllow, DN, MSc, BSc, RNT, RGN, Lecturer1
1
Department of Nursing and Healthcare
Sciences, Munster Technological University,
Ireland
2
Munster Technological University, Changsha
Central Hospital, Changsha, China
Correspondence
Catrina Heffernan, Department of Nursing and
Healthcare Science, Institute of Technology
Tralee, Co. Kerry, Ireland.
Email: Catrina.heffernan@staff.ittralee.ie
Int J Nurs Pract. 2021;e12938.
https://doi.org/10.1111/ijn.12938
Accepted: 17 March 2021
|
Abstract
Aims: To explore the concept of therapeutic communication within the nurse–patient
relationship, using concept analysis.
Background: Therapeutic communication is a term that is often used in the nursing
and related sciences literature, and yet it is still an ambiguous concept. Concept clari-
fication is required to support other healthcare professionals' understanding and to
guide theory development and practice.
Design: A concept analysis methodology was used, as proposed by Walker and
Avant.
Data Sources: A systematic literature search was performed using the Cochrane
database, Science Direct, Health Source: Nursing/Academic Edition,
Academic Search Complete, MEDLINE and PsycARTICLES with studies published
within the last 20 years.
Review Methods: The framework by Walker and Avant was adopted. The attributes,
antecedents, consequences and uses of the concept were identified.
Results: The attributes were information exchange, mutual respect, engagement and
managing health issues of concern to the patient. The antecedents were those
related to the nurse and those related to the patient. The consequences included
patient satisfaction, quicker recovery time, high-quality health care outcomes and
positive nurse–patient relationship outcomes.
Conclusions: A theoretical definition of the concept was developed. The attributes,
antecedents and consequences identified in this paper can be used in nursing educa-
tion, research and managerial and organizational planning.
KEYWORDS
concept analysis, nurse–patient relationship, nursing practice, therapeutic communication
Summary Statement
What is already known about this topic?
• Therapeutic communication is a term that is often used in the nursing and related
sciences literature, and yet it is still an ambiguous concept.
• Therapeutic communication is the core of patient-centred care.
wileyonlinelibrary.com/journal/ijn © 2021 John Wiley & Sons Australia, Ltd 1 of 8
2 of 8 XUE AND HEFFERNAN

• Most of the literature refers to therapeutic communication as a strategy to

improve the therapeutic relationship in the area of psychiatric nursing.
What this paper adds?
• Therapeutic communication within the nurse–patient relationship is a process of
information exchange between a nurse and patient, based on mutual respect and
engagement in managing health issues of concern to the patient.
• Nurse-related factors which can influence the quality of therapeutic communica-
tion including interpersonal competencies, academic readiness and motivation to
care.
• The generation of the concept has theoretical basis and provides a practical solu-
tion for managing patients' health problems and complaints.
The implications of this paper:
• This paper highlights the need for wider understanding of the concept for promot-
ing patient-centred care and addressing patients' needs in general nursing.
• Clarification of the concept of therapeutic communication within the nurse–
patient relationship provides a foundation for nurses to understand it.
• These findings may lead to improved human-to-human contact for patients within
the nurse–patient relationship and may enhance satisfaction and recovery rates
for patients.

1 | I N T RO DU CT I O N et al., 2019; Wilkie et al., 2014). TC leads to a reduction in the

The American Nurses Association (2020) recommends that nurses
must maintain a therapeutic nurse–patient relationship within the
boundaries of their profession. ‘Therapeutic communication’ (TC) is
not a new term. Nowadays, ‘therapeutic’ and ‘communication’ are
terms that are referred to frequently within the nursing literature. TC
appears to be used interchangeably with ‘therapeutic relationship’
and ‘communication’ in the nursing literature. Therapeutic
relationship refers to the relationship between a counsellor and a
client (Luedke et al., 2017). Communication is considered as an
essential element of quality care (Kluge et al., 2007) and is defined by
the Collins Dictionary (2020) as the imparting or exchange of
information, ideas or feelings. Both therapeutic relationship and
communication are at the core of patient-centred care and recovery-
orientated care for improving health (Kleier, 2013; Marshall &
Adams, 2018). Most of the literature refers to TC as a strategy to
improve the therapeutic relationship within the nurse–patient
relationship specifically applied in psychotherapy, ignoring application
within general nursing where it may benefit more patients. This is the
gap that this research sought to fill.
Research demonstrates that TC has an important role within the
education curriculum of nursing students (Abdolrahimi et al., 2017a)
and of physicians (Mottram, 2009; Popa-Velea & Purcarea, 2014). In
clinical nursing, the significance of TC is gradually unfolding as well:
recent studies found that sufficient TC leads to a reduction in the
numbers of patients absconding from hospitals and suicide (El-Refaay
numbers of patients absconding from hospitals (Wilkie et al., 2014),
whereas some studies demonstrate that nurses tend to keep
communication with patients and families at a superficial,
non-therapeutic level (Baer & Weinstein, 2013). In addition, Adistie
et al. (2018) undertook a quantitative study in a paediatric ward and
53.5% of parents (n = 101) reported that TC by nurses was poor.
Similarly, a study by Kwame and Petrucka (2020) reported poor
nurse–patient relationships within nursing. Despite TC been used
liberally in the literature, there are no concrete definitions agreed
amongst the authors.
Therefore, a concept analysis was undertaken in order to under-
stand and clearly define TC within the nurse–patient relationship. As
Walker and Avant (2011) argue that it is important to precisely define
the concepts that are important for understanding and interventions
and concept analysis provides the methodology to fill in the gap in
knowledge. This study adopts the Walker and Avant's conceptual
analysis method which is the most widely used approach in nursing
(Fitzpatrick & McCarthy, 2016).
2 | RE VIE W ME TH O DS
2.1 | Aims
The aim of this study is to explore the concept of TC within the
nurse–patient relationship, using concept analysis.
XUE AND HEFFERNAN
2.2 | Design
This paper details the Walker and Avant concept analysis methodol-
ogy. Walker and Avant (2011) were the first to develop an eight-step
model for nursing based on Wilson's work. They suggest that con-
cepts are categories of information that contain defining attributes
and concept analysis is the formal, linguistic exercise that enables
delineation of these defining characteristics or attributes. It included
the following steps: (1) selecting a concept; (2) determining the aim of
analysis; (3) identifying all possible uses of the concept in nursing;
(4) determining defining attributes; (5) identifying a model case;
(6) identifying a borderline case; (7) identifying antecedents and con-
sequences of the concept and (8) defining empirical referents of the
concept.
2.3 | Search methods
To garner an understanding of the concept, a search of
online databases was undertaken, including Cochrane Library,
Science Direct, Health Source: Nursing/Academic Edition, Academic
Search Complete, MEDLINE and PsycARTICLES. The search strategy
included keywords: ‘therapeutic communication OR therapeutic rela-
tionship’ AND ‘nurs*’. Limiters applied included a 20-year period and
articles published in the English language only.
FIGURE 1 PRISMA flow diagram (PRISMA, 2009)
3 of 8
2.4 | Search outcome
The articles were then scanned for their relevance to TC within the
nurse–patient relationship. Studies that referred to the definition or
application of TC were included. Additionally, reviews and reports
were treated as reference materials and hence were excluded.
Finally, 35 articles were included in the paper. This is presented in
Figure 1.
2.5 | Data abstraction and synthesis
Most of the articles were duplications and discussion papers which
did not have any content related to the concept. Following the
removal of duplications and articles that were not related to the con-
cept, all the peer-reviewed articles were assessed for eligibility.
Finally, 35 articles were used in the concept analysis paper.
2.6 | Quality appraisal
Articles were reviewed according to guidance, worksheets and tools
adapted from the Centre for Evidence-Based Medicine (CEBM, 2020).
The tools guided the process of appraising qualitative and quantitative
studies.
4 of 8 XUE AND HEFFERNAN

3 | RESULTS 3.3 | Identifying all uses of the concept

3.1 | Selecting a concept
According to Walker and Avant (2011), the first step is to select a con-
cept. The concept should make some contribution to acknowledge
the development of the discipline, and there should be some lack of
clarity or consensus as to its meaning or use within the context in
which it is to be explored. TC within the nurse–patient relationship is
not just about the exchange of information for better care outcomes,
but a tactic to explore the emotional well-being for facilitating a
patients' recovery (Rice, 2018) and constructing realistic and positive
goals (Rosenberg & Gallo-Silver, 2011).
3.2 | Determining the aims of analysis
Once the concept is identified, the second step is to determine the
aim of the analysis. The aim of this analysis was to explore the con-
cept of TC within the nurse–patient relationship.
The third step involves a review of the recent literature to determine
all of the uses of the concept. This involves defining the concept.
Table 1 presents some definitions of TC reported in the literature. The
Oxford English Dictionary (2020) and the Collins Dictionary (2020),
refer to the word ‘therapeutic’ as helping one to feel better, treating
illness, healing or preserving health, and ‘communication’ refers to the
activity or process of expressing ideas and feelings or of giving people
information by various ways. Szirony and Kushner (2018) refer to TC
as a catalyst within the counselling process of assisting the clients in
transcending beyond mental dilemma while establishing effective
nurse–patient communication, and it is considered as one of the best
approaches to provide quality health care outcomes and patient satis-
faction (Norouzinia et al., 2016). In addition, Sherko et al. (2013)
believes that TC supports nurses to positively influence clients to
come to a better understanding of his/her issue through verbal or
nonverbal communication. And Kourkouta and Papathanasiou (2014)
state that good communication between the nurse and patient is a

TABLE 1 Uses of therapeutic communication

Kluge et al. (2007)
Rice et al. (2018)
Rosenberg and
Gallo-Silver (2011)
Fleischer et al. (2009)
Kushner (2018)
Norouzinia et al. (2016)
Sherko et al. (2013)
de Souza (2017)
Scott (2004)
Engard (2017)
Kleier (2013)
Mottram (2009)
Kornhaber et al. (2016)
Step et al. (2009)
Popa-Velea and Purcarea
(2014)
Therapeutic communication focuses on the affective or socioemotional aspects of ‘doing care’ and is distinct from other
forms of communication.
Therapeutic communication is commonly viewed as face to face interaction(s) with patients with a goal to promote
patient physical and mental well-being.
Therapeutic communication is a professional technique founded on empathy, and boundary maintenance for the
purposes of increasing understanding and stress reduction in both the cared-for and the caregiver.
Therapeutic communication refers to the face-to-face process of interacting that focuses on advancing the physical and
emotional well-being of a patient. Interpersonal or therapeutic relationships are continuous processes of
communication.
Therapeutic communication is acting as a catalyst in the process of assisting the client in transcending beyond
psychological and psychosocial blocks and issues in the process of therapeutic change.
TC is establishing effective nurse–patient communication is one of the best approaches to provide high-quality health
care services and gain satisfaction from patients.
In the process of therapeutic communication, nurses consciously influence a client or help the client to come to a better
understanding of his/her issue through verbal or nonverbal communication.
Therapeutic communication encourages both confrontational and supportive periods during hospitalization.
By therapeutic communication, nurses gain access into a world of intimate relationship—Both personal and medical.
Therapeutic communication can empower patients to learn or cope more effectively with their environment; support
during hospitalization (including physical and emotional support) should be required from nurses after it; it is to initiate
supportive interpersonal communication in order to understand the perceptions and needs of the other person.
When nurses spend time with patients, communicating, and developing relationships, then the result is usually a positive
therapeutic outcome.
Therapeutic communication is a collection of techniques that prioritize the physical, mental, and emotional well-being of
patients.
Therapeutic communication has the goal of establishing a nurse–patient relationship based on mutual trust and respect.
It is patient-centred as opposed to provider-centred.
A therapeutic relationship has been defined as one which is perceived by patients to be caring, supportive, non-
judgemental and to offer a perception of safety from threatening events.
Therapeutic interpersonal relationships have the capacity to transform and enrich the patients' experiences.
It is imperative to find ways to better integrate the rich bank of available relational communication constructs into
observational studies of health communication.
Improving therapeutic communication is considered as a standard ingredient of the bio-psycho-social (BPS) model of
care.
XUE AND HEFFERNAN
crucial element in implementing individualized nursing care, coping
with prognosis and treatment plans. As it is said, TC encourages con-
frontational and supportive periods during hospitalization
(de Souza, 2017), by which nurses gain access into a world of intimate
relationships—both personal and medical (Plawecki & Amrhein, 2010).
3.4 | Determining the defining attributes
The fourth step involves determining the defining attributes of the con-
cept: those characteristics that are essential to the concept. The objec-
tive of this step is to identify the characteristics that appear repeatedly
with the intention of enabling differentiation of a concept from a
related or similar one (Walker & Avant, 2011). From reviewing the dic-
tionary, thesaurus and literature definitions of TC within the nurse–
patient relationship, the following three attributes emerged: (1) infor-
mation exchange between nurse and patient, (2) mutual respect and
engagement and (3) managing health issues of concern to the patient.
The first attribute is information exchange (Jasmine, 2009; Rice
et al., 2018; Scott, 2004). Information exchange involves the interac-
tion between at least two people but also infers the physical, mental
and emotional well-being of patients (Engard, 2017).
The second attribute of mutual respect and engagement are the
foundation for forming a nurse–patient relationship (Kluge
et al., 2007) and influencing the patients' health outcomes
(Jasmine, 2009; Rice, 2018; Scott, 2004). Mutual respect is the core
to the nurse/patient relationship with patients showing willingness to
collaborate (Hess et al., 2015; Williams, 2008).
The third attribute of dealing with health issues of concern to the
patient is instrumental in TC, and it is the attribute that differentiates
TC from communication. Dealing with health issues, nurses focus on
the emotional well-being of patients and develop nursing as a thera-
peutic practice by assisting the patient to talk about their feelings and
explore their anxieties, fears and vulnerabilities (Foster & second day, she communicated with Wang regarding his concerns
Hawkins, 2005). As non-professionals, patients lack knowledge
around issues such as disease; hence, nurses' education and training
play a significant role in health-focused behaviour and help further
patient self-management. Within the hospital setting, patients need a
supportive nurse to assist in eliciting emotional concerns (Kornhaber
et al., 2016). Dealing with health issues of concern during hospitaliza-
tion (including physical and emotional) is a necessity within TC
(Forchuk & Reynolds, 2001; Jasmine, 2009; Rice, 2018; Scott, 2004).
Thus, the attributes give rise to an operational definition: TC
within the nurse–patient relationship is a process of information
exchange between a nurse and patient, based on mutual respect and
engagement in managing health issues of concern to the patient.
3.5 | Identifying a model case
The fifth step involves constructing a model case. A model case is a
real-life example containing all the defining attributes in the clinical
scenario (Walker & Avant, 2011).
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Zhang, a 45 years old male, was admitted to hospital with acute
chest pain and was diagnosed with coronary heart disease (CHD). As
it was his first admission to hospital, Zhang felt strange about the ward
environment and also concerned about his new diagnosis. His primary
nurse, Lily introduced herself and the ward environment to Zhang. Lily
reassured him that she was available to discuss any anxieties or
worries that he may have about his new diagnosis. Zhang stated that
this was important to him and thanked nurse Lily (mutual respect and
engagement). On the second morning, as Lily was helping Zhang with
his activities of daily living, they started to chat (information exchange
between the nurse and patient), and Zhang stated that he felt anxious
about his new diagnosis and what his life would be like when he was
discharged. Lily explained the different types of treatment and the
importance of diet and exercise. She also stated that he would be able
to resume his normal routine, that is, return to work as he was the
main earner (managing health issues of concern of the patient).
This case identifies the three defining attributes of TC.
3.6 | Identifying a borderline and a contrary case
The sixth step involves constructing a number of other cases. These
cases are constructed to illustrate how the concept is used. The cases
constructed include a borderline case and a contrary case.
A borderline case is a real life example containing some of the
defining attributes (Walker & Avant, 2011). Wang, a 45 years old male,
was admitted to hospital with acute chest pain and was diagnosed
with CHD. After an initial assessment, he was transferred to Cardio-
vascular Department and was anxious about the unfamiliar ward envi-
ronment and also concerned about his new diagnosis. His primary
nurse, Ann briefly introduced herself and the ward environment. Ann
reassured Wang that she would provide more information if he
needed it and Wang agreed (mutual respect and engagement). On the
about his new diagnosis. Ann reassured him that this was a normal
reaction and started discussing the ward environment (information
exchange between nurses and inpatients). However, Ann did not fig-
ure out his concern of disease (not managing health issues of concern
with the patient). As a result, the conversation ended quickly.
This case identifies most of the defining attributes but fails to
address the final attribute which demonstrates inconsistency with the
model case. This attribute is the key difference between communica-
tion and TC.
A contrary case is a real-life example that does not include any of
the defining attributes (Walker & Avant, 2011). Li, a 45 years old male,
was hospitalized due to acute chest pain and was diagnosed with
CHD. After an initial assessment, he was transferred to the Cardiovas-
cular Department and was anxious about the unfamiliar ward environ-
ment and also concerned about his new diagnosis. His primary nurse,
Anna briefly introduced herself and the ward environment despite Li
stating that he wanted to have a rest (no mutual respect and engage-
ment). Li was upset and as there were other patients in the room, Li
remained quite (no information exchange between nurses and
6 of 8
inpatients). Anne stated that there was nothing to worry about and
that she would return later (no coping with health issues of concern
of the patient).
3.7 | Antecedents
Antecedents are those factors, derived from the literature, that pre-
cede the occurrence of the concept (Walker & Avant, 2011). It is
important to identify antecedents as antecedents and attributes can-
not be the same. The antecedents to TC from the nurses' perspective
are interpersonal competencies, academic readiness and a motivation
to care. Antecedents to TC from the patients' patients include physical
readiness, awareness of improvement and preconceptions.
Interpersonal competencies include characteristics such as self-
awareness, expression and culture diversity (Foster & Hawkins, 2005)
and communication skills such as the use of silence, acceptance,
understanding, observing and encouraging conversation
(Engard, 2017). Furthermore, academic readiness refers to nurses who
are equipped with professional knowledge (Engard, 2017;
Kleier, 2013) to gain patients' trust and confidence (Abdolrahimi
et al., 2017b). Since the late 1960s, an extensive body of literature
presents beneficial evidence advocating the patient-centred approach
towards more collaboration and better communication which requires
nurses have a motivation to care (Koubel & Bungay, 2008).
For patients, physical readiness includes the condition of his/her
illness and mood during the hospital stay which is linked with the
ability to communicate (Abdolrahimi et al., 2017b). In professional
practice, the ethical views and values of patients should be taken
into considerations (Koubel & Bungay, 2008). Before action, nurses
should evaluate patients' physical readiness and measure whether it
is appropriate to perform TC at that time. Additionally, the aware-
ness of improvement plays a significant role as well, and it can be
cultivated to enhance help-seeking behaviours in the adaptive
process which is identified by Roy as four modes, from physiologic-
physical mode to interdependence mode, whereas nurses play a
core role in motivating the awareness of improvement of patients
(Bittencourt et al., 2018; Roy & Andrews, 2001). In another aspect,
preconception is a preexisting cognitive model of disease and
influenced by patients' experiences, intuition and knowledge
(Nowicka-Sauer et al., 2018). Before TC, patients have their own
imagination or awareness about the coming process, which can
facilitate or impede the activity. Referring to environmental factors,
nurses should make sure it is as comfortable as possible, including
proper temperature, quiet atmosphere, avoiding publicity and
guaranteeing the confidentiality, which can influence how much the
patient is willing to talk (Williams, 2008).
3.8 | Consequences
The consequences are those factors derived from the literature
that result from the concept (Walker & Avant, 2011). The
XUE AND HEFFERNAN
consequences of TC within the nurse–patient relationship include
patient satisfaction, quicker recovery, high-quality health care out-
comes and positive nurse–patient relationship outcomes (Maame
Kissiwaa Amoah et al., 2018; Norouzinia et al., 2016; Sethi &
Rani, 2017).
3.9 | Defining empirical referents
The eighth and final step in the process of concept analysis is
the identification of empirical referents, by which nurses can
measure the concept. Empirical referents are classes or categories
of actual phenomena that by their existence or presence
demonstrate the occurrence of the concept itself (Walker &
Avant, 2011).
There are various tools to measure TC which include the Clinical
Assessment of Modes (CAM; Fan & Taylor, 2016), The Intentional
Relationship Model (IRM; Smith & Taylor, 2011), the P'Com-5 scale
(Baumann et al., 2016) and the WHAT model (Szirony &
Kushner, 2018). Although the tools are applied within different con-
texts, nurses may extract part of the tool and apply to TC within the
nurse–patient relationship.
4 | DI SCU SSION
The concept analysis determined three attributes of TC within the
nurse–patient relationship. Alleviating patients' mental illnesses or
distressed states is no longer just in the area of psychiatric nursing.
When it comes to health issues, then it can goes into the scope of
clinical nurses as well. TC needs to be regarded as the core of pro-
fessional nursing practice in general nursing as it may benefit more
patients and lead to improved care outcomes and patient
satisfaction. Not only does it integrate relevant theories of nursing
care but also forms part of the other scientific disciplines like
sociology (Fleischer et al., 2009). Through this analysis, the
competency was found to be based on human to human connec-
tion including mutual respect and engagement. TC within the
nurse–patient relationship negates a greater likelihood in achieving
effectiveness in delivering nursing care, and furthermore, it can be
learnt. Furthermore, a number of studies proposed academic readi-
ness as a key antecedent. In other aspect, the concept analysis
also demonstrates that nurses with a body of professional knowl-
edge and a positive character can be educated to practice TC and
thus building on the nurse–patient relationship and promoting
improved quality of care.
In addition, a great number of articles reviewed proposed suitable
communication environments, which can make TC more formal and
effective (Gurková et al., 2015; Kourkouta & Papathanasiou, 2014).
As Kourkouta and Papathanasiou (2014) suggest that conversation
between a patient and a nurse should be held in appropriate environ-
ments such as a private environment time, rather than in the middle
of the corridor or the nursing department.
XUE AND HEFFERNAN
4.1 | Study Limitations
This concept analysis is limited as the search limits were limited to
electronic databases reported in the English language only.
5 | C O N CL U S I O N
This is the first paper to propose a concept analysis on TC within the
nurse–patient relationship. It addresses a theory-practice gap in the
literature. The concept analysis process allows the concept to be
defined and therefore understood from the perspective of the nurse.
This paper explored the attributes of TC within the nurse–patient
relationship by examining antecedents, consequences and empirical
referents. Over all, the concept analysis process assisted in providing
greater clarity to a concept that is often misinterpreted within the
literature.
ACKNOWLEDGEMEN TS
We thank all the professors in the Department of Nursing and
Healthcare Science in Tralee, for their help and guidance with the
Nursing Science Module. The first author also thanks Dr. Catrina
Heffernan, who is a professor in nursing theory, for her participation
and support of the project.
CONF LICT OF IN TE RE ST
All authors report no conflict of interest related to this manuscript.
AUTHORSHI P STATEMENT
Wantong Xue developed the topic, conducted the literature review,
analyse and summarize the results and wrote the first draft of the arti-
cle; Dr. Catrina Heffernan assisted in the synthesis and modified the
important content of the article. All authors approved the final version
for submission.
ORCID
Wantong Xue https://orcid.org/0000-0001-7144-7385
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How to cite this article: Xue, W., & Heffernan, C. (2021).
Therapeutic communication within the nurse–patient
relationship: A concept analysis. International Journal of
Nursing Practice, e12938. https://doi.org/10.1111/ijn.12938