therapeutic nurse – patient relationship (2)

by Dr/ Wafaa Osman
head of mental health department
Faculty of nursing - Helwan University

1. By:
Dr. Wafaa Osman

2. Learning Objectives
After this lecture student should be able to
Building and enhancing the nurse–client relationship (trust,
genuine interest, empathy, acceptance, and positive regard).
2. Explain the importance of values, beliefs, and attitudes in the
development of the nurse–client relationship.
3. Describe the importance of self-awareness and therapeutic
use of self in the nurse–client relationship.
4. Identify self-awareness issues that can enhance or hinder the
nurse–client relationship.
5.Describe the differences between social, intimate, and
therapeutic relationships

3. Therapeutic Nurse –Patient Relationship
Definition of Therapeutic Relationship:
the therapeutic nurse-patient relationship is a mutual learning
experience and a corrective emotional experience for the patient. It is
based on the underlying humanity of nurse and patient, with mutual
respect and acceptance of sociocultural differences. In this
relationship the nurse uses personal attributes and clinical
techniques in working with the patient to bring about insight and
behavioral change
It is the relation between a trained person who sees the patient in a series of
interviews among to bring about a favorable effect on him in an attempt to
modify or change his behavior.

4. Importance of therapeutic relationship
1 -It is one of the tools of psycho therapy.
2 –Helps the nurse to assess patient needs & meeting needs.
3 –Provides opportunities for growth for both nurse & patient .
4 -The patient learns how to accept & to relate to others.
5 –The patient returns to the community depend on the
therapeutic relationship.
6 –Increase self realization, self acceptance, and self respect.
7 –To clear sense of personal identity.

5. Elements or component of therapeutic
relationship
1-Acceptance
2-Successful communication
3-Trust
4-Empathy
5-Rapport
6-Respect
7-Genuineness
Many factors can enhance the nurse–client relationship, and it is the
nurse’s responsibility to develop them. These factors promote
communication and enhance relationships in all aspects of the nurse’s
life.

6. 1-Acceptance
acceptance to the client. Avoiding judgments 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 for behavior in
the nurse–client relationship. By being clear and firm without
anger or judgment, the nurse allows the client to feel intact
while still conveying that certain behavior is unacceptable.

7. 2-Successful communication
Communication is the process of exchanging
ideas, feeling, attitude, believe and meaning
between two or more individuals. It is a two way
process is an ongoing, dynamic & ever changing
series of events. It is the mechanisms, by which
people establish, maintain & improve their human
contacts

8. Improving Body Language -Tips
•Keep appropriate distance
•Touch only when appropriate
•Take care of your appearance
•Be aware -people may give false cues
•Maintain eye contact
•Smile genuinely

9. 3-Trust
The nurse–client relationship requires trust.
Trust is built in the nurse–client relationship when the nurse
exhibits the following behaviors:
• Caring • Suggesting without telling
• Openness • Consistency
• Objectivity • Respect
• Interest • Understanding
• Approachability • Listening
• Keeping promises • Honesty
• Treating the client as a human being

10. When working with a client with psychiatric problems,
some of the symptoms of the disorder, such as
paranoia, low self-esteem, and anxiety, may make trust
difficult to establish. For example, a client with
depression has little psychic energy to listen to or
comprehend what the nurse is saying. Likewise, a
client with panic disorder may be too anxious to focus
on the nurse’s communication. Although clients with
mental disorders frequently give incongruent
messages because of their illness, the nurse must
continue to provide consistent congruent messages.
Examining one’s own behavior and doing one’s best to
make messages clear, simple, and congruent help to
facilitate trust between the nurse and the client.

11. 4-Empathy
Empathy vs. sympathy

12. Empathy is the ability of the nurse to perceive the meanings
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 or herself in the client’s
shoes does not mean that the nurse has had the exact
experiences as the client. Nevertheless, by listening and sensing
the importance of the situation to the client, the nurse can
imagine the client’s feelings about the experience.

13. Both the client and the nurse give a “gift of self” when empathy
occurs—the client by feeling safe enough to share feelings and
the nurse by listening closely enough to understand. Empathy
has been shown to positively influence client outcomes. Clients
tend to feel better about themselves and more understood
when the nurse is empathetic
Several therapeutic communication techniques, such as
reflection, restatement, and clarification, help the nurse to
send empathetic messages to the client.

14. 5-Rapport
Rapport, interpersonal harmony characterized by understanding
and respect, is important in developing a trusting, therapeutic
relationship. Nurses establish rapport through interpersonal
warmth, a nonjudgmental attitude, and a demonstration of
understanding. A skilled nurse will establish rapport that will
alleviate the patient’s anxiety in discussing personal problems.
People with psychiatric problems often feel alone and isolated.
Establishing rapport helps lessen feelings of being alone. When
rapport develops, a patient feels comfortable with the nurse and
finds self-disclosure easier. The nurse also feels comfortable and
recognizes that an interpersonal bond or alliance is developing. All
these factors—comfort, sense of sharing, and decreased anxiety—
are important in establishing and building the nurse–patient
relationship.

15. 6-Genuine Interest
When the nurse is comfortable with himself or herself,
aware of his or her strengths and limitations, and clearly
focused, the client perceives a genuine person showing
genuine interest.
The nurse should be open and honest and display
congruent behavior. Sometimes, however, responding with
truth and honesty alone does not provide the best
professional response. In such cases, the nurse may choose
to disclose to the client a personal experience related to the
client’s current concerns. It is essential, however, that the
nurse is very selective about personal examples.

16. 7-Respect
respect or Positive Regard the client regardless of his or her
behavior, background, or lifestyle. This unconditional
nonjudgmental attitude is known as positive regard and
implies respect. 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. The nurse also conveys positive regard by considering
the client’s ideas and preferences when planning care. Doing
so shows that the nurse believes the client has the ability to
make positive and meaningful contributions to his or her own
plan of care.

17. TYPES OF RELATIONSHIPS
Each relationship is unique because of the various
combinations of traits and characteristics of and
circumstances related to the people involved. Although
every relationship is different, all relationships may be
categorized into three major types: social, intimate, and
therapeutic.

18. Intimate Relationship
A 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. Evaluation
of the interaction may be ongoing or not. The intimate
relationship has no place in the nurse–client interaction.

19. Differences between Social &
Therapeutic relationship
Therapeutic Social
1 –Goal directed & purposeful. -Definite goals not usually establish.
2 –Focus on patient needs not
nurse's need.
-Set up for mutual need satisfaction
for both participate.
3 –The nurse must develop
specific skills, which are used to
help pt work through his
problem.
-There is no need for such skills.
4 –There is a commitment to work
with the pt until the problem has
been worked through.
-No commitment to remain with the
individual. There is freedom to
leave uncomfortable situation.
5 –Time Limit. -No time limit.

20. Phases of Therapeutic Relationship
A-The pre-interaction phase
B-Initiating phase
C-Working phase
D-Termination phase
Phases of nurse–client relationship

21. A -The pre-interaction phase
Before the nurse contact with patient, the main tasks:
1. Nurse self exploration, fears, fantasies, self esteem, and self
concept.
2. Know and maximize personal assets and minimize
limitation.
3. Gather information about pt.
4. Plan first interaction.
5. Review of general goals of therapeutic relationship.
6. Obtain information about the client from chart, significant
others or other health learn members.
7. Examine ones own feelings. Fears and anxieties about
working with a particular client.

22. B –Initiating phase:
Focus on:
-Data gathering activities.
-The development of a trusting relationship.
-The phase is a long one depending on how trusting & how
ready the pt is for the help.
Characteristic Behavior of the phase:
1 -Orientation
2 -Contract
3 -Mutual expectation
4 -Testing behavior
5 -Determine

23. C –Working phase:
It is the second step of a therapeutic relationship
process when the PT is able to focus on the unpleasant and
often painful aspects of his life.
The therapeutic tasks:to be accomplished by the nurse in
the working phase:
1 –Increase the individual’s awareness and perception of the
reality.
2 –Assist him in developing a realistic self concept.
3 –Promote self-confidence.
4 –Assist him in recognized areas of discomfort and distress.
5 –Increase his ability to verbally describe his feelings.

24. 6 –Assist him in drawing conclusions.
7 –Encourage him to evaluate the results of his behavior.
8 –Provide him with opportunity for independent
functioning.
9 –Maintain trust and rapport.
10 –Promote client's insight and perception of reality.
11 –Use problem-solving model to work toward
achievement of established goals.
12-Continuously evaluate progress toward goal
attainment.

25. Problem of this phase:
1 –Resistance: pt attempt to remain unaware in his
problem.
2-Behavior transference.
Tasks of this phase:
1 –Establish the reality of separation.
2 –Review the progress of therapy and attainment of
goals.
3 –Explore feelings of sadness, rejection and anger.
4 –Problem in this phase to be able to help the pt
through out this phase.

26. D –Termination phase :
The pt should have been prepared for final stage during the
beginning of relationship:
a. Progress has been made toward attainment of the goals.
b. A plan of action for more adaptive coping with future stressful
situations has been established.
c. Feelings about termination of the relationship are recognized and
explored .
Problems of this stage are:
1-If the nurse tries to keep the pt helpless and dependent up on her.
2-The nurse who tends to push the pt toward dismissal.
3-Some regression of pt behavior will be observed.
4-The pt own feeling & problems in leaving the nurse and the
hospital.
5-Feeling of separation, depression, fear of immobility to produce in
normal life again or adjust to occupation.

27. The main principles in creating
therapeutic relationship:
To follow the principles of psychiatric nursing.
To understand the pt & his needs & way of
expressing it.
To benefit from her previous experience of pt.
To prevent the nurse–pt relax from reacting an
untherapeutic level.

28. Therapeutic manners
These are techniques suggested
to help the nurse in the
management of the pt during
phases.
1 -Offering support.
2 -Setting limits.
3 -Expressing feelings.

29. ROLES OF THE NURSE IN A
THERAPEUTIC RELATIONSHIP
As when working with clients in any other nursing setting,
the psychiatric nurse uses various roles to provide needed
care to the client. The nurse understands the importance
of assuming the appropriate role for the work that he or
she is doing with the client.
Teacher
The teacher role is inherent in most aspects of client care.
During the working phase of the nurse–client relationship,
the nurse may teach the client new methods of coping and
solving problems. He or she may instruct about the
medication regimen and available community resources.
To be a good teacher,

30. Caregiver
The primary caregiving role in mental health settings is
the implementation of the therapeutic relationship to
build trust, explore feelings, assist the client in problem
solving, and help the client meet psychosocial needs. If the
client also requires physical nursing care, the nurse may
need to explain to the client the need for touch while
performing physical care. Some clients may confuse physical
care with intimacy and sexual interest, which can erode
the therapeutic relationship. The nurse must consider the
relationship boundaries and parameters that have been
established and must repeat the goals that were established
together at the beginning of the relationship.

31. Advocate
In the advocate role, the nurse informs the client and then
supports him or her in whatever decision he or she makes
(Edd, Fox, & Burns, 2005). In psychiatric–mental health
nursing, advocacy is a bit different from medical-surgical settings
because of the nature of the client’s illness. For example, the
nurse cannot support a client’s decision to hurt himself or herself
or another person. Advocacy is the process of acting on the
client’s behalf when he or she cannot do so. This includes
ensuring privacy and dignity, promoting informed consent,
preventing unnecessary examinations and procedures, accessing
needed services and benefits, and ensuring

32. Complete the following:
a.Definitionofthetermcommunicationis:
………………………………………
a.Verbalcommunicationinclude:
b.………………………………………………………
c.Nonverbal communication include:
………………………………………………………………
Phasesofnursepatientrelationship:
1.…………………………………………
2.…………………………………………
3.…………………………………………
4.…………………………………………