Lecture (2):

Therapeutic Nurse-Client
Relationship
PSYCHIATRIC NURSING
OBJECTIVES

After completing this lecture, the students

will be able to:
 Identify Nature Of Nurse-client Relationship
 Define therapeutic nurse-patient relationship
 Distinguish among Therapeutic Relationship
And Social Relationship
 Recognize the Components Of The Nurse-
Client Relationship
 Explain Principles of nurse-client relationship
 Explain the phases of Therapeutic
Relationship
 Articulate the potential boundary violation
that may occur during the relationship
Answer these questions?
o Can you accept a gift from a client?
o When is it ok to hug a client? A staff member?
o Can you date a client? A client’s family
member?
o How should you act when you meet a client in
a social setting?
o Can you provide nursing care to your family
or friends? Paid? Unpaid?
o What can you tell clients about your personal
life?
Introduction

• The most important duty of a

psychiatric nurse is to maintain a
positive therapeutic relationship
with patients in a clinical setting.
Nature Of Nurse-client Relationship

• The nurse-client relationship is

professional and therapeutic relationship.
• It ensures the client’s needs are first and
foremost.
• It exists to meet the needs of the
client, not the needs of the nurse.
• It is always the nurse who is
responsible for establishing and
maintaining boundaries with clients,
regardless of how the patient
behaves.
 Definition of therapeutic nurse-
patient relationship
1) Is an interpersonal helping
process based on theory.
The relationship is helping because
it focus towards the client’s care,
well-being, learning , and growth.
2) It is a relation that involves two
persons, a professional one (nurse)
who has the ability to help and
relieve patient’s discomfort, and
the other person (patient) who is
seek relief of some existing
condition.
Characteristics Of Therapeutic And
Social Relationships
Characteristics Therapeutic Social
relationship relationship
Goal Client’s well- Mutual satisfaction .
being ,growth and
learning
Content Focus is on client Amount of self –
thoughts ,feelings and disclosure similar by
behaviors, nurse’s self both individuals.
disclosure based on
helping the client

length Time limited by the goal May last years,

achievement or patient ending of
discharge relationship often
gradual and planned
or unplanned
Characteristics Therapeutic Social
relationship relationship

Behavior Regulated by a code of Guided by personal

ethics and professional values and beliefs.
standards.

Remuneration Nurse is paid to provide No payment for

care to client. being in the
relationship.

Location of Place defined and Place unlimited;

relationship limited to where nursing often undefined.
care is provided.
Components of the nurse-client
relationship

There are five components:

Trust .
Respect .
Professional intimacy.
Empathy .
Power .
(1)Trust:

Trust is critical in the relationship

because:
• The client is in a vulnerable position.
• Initially, trust in a relationship is
fragile, so it’s important that a nurse
keep promises to a client.
• If trust is breached, it becomes
difficult to re-establish.
(2) Respect:

Respect is the recognition of the

inherent dignity, worth and
uniqueness of every individual,
regardless of socio-economic status,
personal attributes and the nature of
the health problem.
(3) Professional intimacy:

• Professional intimacy is present in

the type of care and services that
nurses provide.
• It may relate to the physical
activities, such as bathing, that
nurses perform for, and with the
client that creates closeness.
(4) Empathy:

• Is the expression of understanding,

awareness of the suffering of the
client coupled with the wish to
relieve it.
• In nursing, empathy includes
appropriate emotional distance from
the client to ensure an appropriate
professional response.
• Differentiate between sympathy and
empathy.

- Sympathy means that the nurse

feels sorry for the patient.
(5) Power:

 The nurse-client relationship is one

of unequal power
 The nurse has more power than the
client, because:
She/ he has specialized knowledge.
The nurse has more authority and
influence in the health care system.
 Access to privileged information.
 The appropriate use of power, in a
caring manner, enables the nurse to
partner with the client to meet the
client’s needs.
 A misuse of power is considered abuse.
Principles of nurse-client relationship

1. The nurse functions within the standards

of practice.
2. The nurse needs to know the requirements
of, and recognize, her accountability for
maintaining professional behavior.
3. The relationship should developed for
the purpose of promoting the health and
well-being of the client and not to meet
the needs of the nurse.
4. The nurse needs to respect the
individual characteristics of the client,
such as:
- Cultural, social identity, appearance,
and religious affiliation.
5. The nurse needs to recognize when she/he
does not have the necessary knowledge or
skill, to seek information and assistance
from other members of the health team .
6. The nurse should recognized that some
clients’ behavior can appear to be abusive,
so the nurse may need to seek help and
guidance when dealing with challenging
clients.
Phases of therapeutic relationship

• Peplau (1952) described three phases, also

referred to as stages, of nurse– client
therapeutic relationships:
• Each phase is associated with specific
therapeutic tasks or goals to be
accomplished.
Phases of therapeutic relationship

1- initiating or
orientation

3-Termination 2- Working
phase. phase
1. Initiating or Orientation Phase

• The first step of the therapeutic

relationship.
• During this phase, the nurse become
acquainted with the client.
• The nurse also begins the assessment
process.
• The nurse and client may experience
anxiety with this first meeting.
Therapeutic tasks accomplished by the
psychiatric nurse during initiating phase:

1. Building trust and rapport by

demonstrating acceptance
2. Establishing a therapeutic
environment, ensuring safety and
privacy
3. Establishing a mode of communication
acceptable to both client and nurse
4. Initiating a therapeutic contract by
establishing a time, place, and
duration for each meeting, as well as
the length of the relationship.
5. assessing the client’s needs, coping
strategies, defense mechanisms,
strengths and weaknesses.
2. Working phase

• The second phase of the therapeutic

relationship.
• The client begins to relax, trusts the
nurse, and is able to discuss mutually
agreed-on goals with the nurse
• The client focuses on unpleasant,
painful aspects of life while the nurse
provides support.
Therapeutic tasks accomplished by the
psychiatric nurse during working phase:

1. Exploring client’s perception of reality

and providing constructive feedback;
2. Helping client develop positive coping
behaviors
3. Identifying available support systems
4. promoting a positive self-concept by
focusing on what the client can do and
what the client can’t do
5. Encouraging verbalization of feelings
6. Promoting client independence by
teaching new skills
7. Developing a plan of action with realistic
goals
8. Implementing the plan of action; and
9. Evaluating the results of the plan of
action.
3. Terminating Phase

• The final step of the therapeutic

relationship.
• The nurse terminates the relationship
when the mutually agreed-on goals are
reached, the client is transferred or
• discharged, or the nurse has finished
the clinical rotation.
• The nurse discusses the termination
phase with the client.
• As separation occurs, clients commonly
exhibit regressive behavior, demonstrate
hostility, or experience sadness.
• The client may attempt to prolong the
relationship.
• Preparation for termination actually
begins during the initiating phase.
Goals resulting in the termination of
a therapeutic relationship include
 The client’s ability to:
1. Provide self-care and maintain his or her
environment;
2. Demonstrate independence and work
interdependently with others;
3. Cope positively when experience feelings
such as anxiety, anger, or hostility;
4. Demonstrate emotional stability
Therapeutic impasses

Resistance.
Transference.
Counter transference.
Boundary violation (abuse).
Understanding Boundaries in the Nurse-Client
Relationship

Yellow Lights

“Warning Signals” of Nurse Behaviors:

Frequently thinking of the client when
away from work.
 Frequently planning other client’s care
around the client’s needs.
Seeking social contact or spending free time
with the client.
• Feeling unusual irritation if someone
or something in the system creates a
barrier or delay in the client’s
progress.
• Hiding aspects of the relationship with
the client from others.
• Having more physical touching than is
appropriate or required for the
situation.
• Introducing sexual content in
conversation with the client.
• Feeling a sense of excitement or desire
related to the client.
• Using the client to meet personal needs for
status, social support or financial gain.
• Having romantic or sexual thoughts about
the client.
Crossing boundaries

 Some behaviors are unacceptable in the

nurse-client relationship.
 Unacceptable behaviors include:
-Verbal, physical, sexual, emotional and
financial abuse and neglect.
Situations that may create problems
with boundaries
• Giving and Receiving Gifts
• Monetary Gain or Personal Benefit.
• Hugging or Touching.
• Self-disclosure:
disclosing personal information that is
extended, or intimate is never
acceptable.
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