Chapter 5

Relationship Development and

Therapeutic Communication

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 Introduction
 The nurse–patient relationship is the
foundation on which psychiatric nursing is
established.
 The therapeutic interpersonal relationship is
the process by which nurses provide care for
patients in need of psychosocial intervention.

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 Introduction (continued)
 Therapeutic use of self is the instrument
for delivery of care to patients in need of
psychosocial intervention.
 Interpersonal communication techniques are
the “tools” of psychosocial intervention.

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 The Therapeutic Nurse–Patient
Relationship
 Therapeutic nurse–patient relationships can
occur only when each views the other as a
unique human being. When this occurs, both
participants have needs met by the
relationship.
 Therapeutic relationships are goal-oriented
and directed at learning and growth
promotion.

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 The Therapeutic Nurse–Patient
Relationship (continued_1)
 Goals are often achieved through use of the
problem-solving model.
• Identify the patient’s problem.
• Promote discussion of desired changes.
• Discuss aspects that cannot realistically be
changed and ways to cope with them more
adaptively.
• Discuss alternative strategies for creating
changes that the patient desires to make.

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 The Therapeutic Nurse–Patient
Relationship (continued_2)
 Goals and the problem-solving model
• Weigh benefits and consequences of each
alternative.
• Help patient select an alternative.
• Encourage patient to implement the change.
• Provide positive feedback for patient’s attempts
to create change.
• Help patient evaluate outcomes of the change
and make modifications as required.

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 Clicker Question 1

1. Which is the primary nursing goal when

establishing a therapeutic relationship with
a patient?
A. To promote patient growth
B. To develop the nurse’s personal identity
C. To establish a purposeful social interaction
D. To develop communication skills

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 Clicker Question Answer 1

Correct Answer: A

The goal of a therapeutic nursing interaction is

to promote patient insight and behavioral
change directed toward patient growth.

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 Therapeutic Use of Self
 Ability to use one’s personality consciously
and in full awareness in an attempt to
establish relatedness and to structure
nursing interventions
 Nurses must possess self-awareness, self-
understanding, and a philosophical belief
about life, death, and the overall human
condition.

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 Conditions Essential to Development of a
Therapeutic Relationship
 Rapport
 Trust
 Respect
 Genuineness
 Empathy

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 Therapeutic Nurse–Patient Relationship

Preinteraction phase
 Obtain information about the patient from
chart, significant others, or other health
team members.
 Examine one’s own feelings, fears, and
anxieties about working with a particular
patient.

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 Therapeutic Nurse–Patient Relationship
(continued_1)
Orientation (introductory) phase
 Create an environment for trust and rapport.
 Establish contract for intervention.
 Gather assessment data.
 Identify patient’s strengths and limitations.

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 Therapeutic Nurse–Patient Relationship
(continued_2)
Orientation phase (continued)
 Formulate nursing diagnoses.
 Set mutually agreeable goals.
 Develop a realistic plan of action.
 Explore feelings of both patient and nurse.

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 Therapeutic Nurse–Patient Relationship
(continued_3)
Working phase
 Maintain trust and rapport.
 Promote patient’s insight and perception of
reality.
 Use problem-solving model to work toward
achievement of established goals.
 Overcome resistance behaviors.
 Continuously evaluate progress toward
goal attainment.
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 Therapeutic Nurse–Patient Relationship
(continued_4)
Working phase (continued)
 Transference: Occurs when the patient
unconsciously displaces (or “transfers”) to
the nurse feelings formed toward a person
from the past
 Countertransference: Refers to the nurse’s
behavioral and emotional response to the
patient

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 Therapeutic Nurse–Patient Relationship
(continued_5)
Termination phase
 Therapeutic conclusion of relationship
occurs when
• Progress has been made toward attainment of
the goals.
• A plan of action for more adaptive coping with
future stressful situations has been established.
• Feelings about termination of the relationship
are recognized and explored.

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 Clicker Question 2
2. A patient threatens to kill himself, his wife, and
their children if the wife follows through with
divorce proceedings. During the pre-interaction
phase of the nurse–patient relationship, which
interaction should the nurse employ?
A. Acknowledging the patient's actions and encouraging
alternative behaviors
B. Establishing rapport and developing treatment goals
C. Providing community resources on aggression
management
D. Exploring personal thoughts and feelings that may
adversely impact the provision of care
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 Clicker Question Answer 2

Correct Answer: D

In the pre-interaction phase, the nurse must

clarify personal attitudes, values, and beliefs to
become aware of how these might affect the
nurse’s ability to care for various patients. This
occurs before the nurse meets the patient.

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 Boundaries in the Nurse–Patient
Relationship
Types of boundaries
 Material
 Social
 Personal
 Professional: limit and outline expectations
for appropriate professional relationships
with patients.

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 Boundaries in the Nurse–Patient
Relationship (continued_1)
 Professional
boundary concerns
commonly include
issues such as
• Self-disclosure
• Gift-giving
• Touch
• Friendship or
romantic association

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 Boundaries in the Nurse–Patient
Relationship (continued_2)
 Warning signs that indicate that professional
boundaries of the nurse–patient relationship
may be in jeopardy
• Favoring one patient’s care over another’s
• Keeping secrets with a patient
• Changing dress style when working with a
particular patient

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 Boundaries in the Nurse–Patient
Relationship (continued_3)
 Warning signs (continued)
• Swapping patient assignments to care for a
particular patient
• Giving special attention or treatment to one
patient over others
• Spending free time with a patient
• Frequently thinking about the patient when away

from work

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 Boundaries in the Nurse–Patient
Relationship (continued_4)
 Warning signs (continued)
• Sharing personal information or work concerns
with the patient
• Receiving of gifts or continued contact and
communication with the patient after discharge

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 Interpersonal Communication
 Interpersonal communication is a
transaction between the sender and the
receiver. Both persons participate
simultaneously.
 In the transactional model, both participants
perceive each other, listen to each other, and
simultaneously engage in the process of
creating meaning in a relationship.

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 The Impact of Preexisting Conditions
 Values, attitudes, and beliefs
• Learned ways of thinking
 Culture and religion
• Cultural mores, norms, ideas, and customs
provide the basis for our way of thinking

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 The Impact of Preexisting Conditions
(continued_1)
 Social status
• High-status persons often convey their high-
power position with gestures of hands on hips,
power dressing, greater height, and more
distance when communicating with individuals
considered to be of lower social status.
 Gender
• Masculine and feminine gestures influence
messages conveyed in communication with
others.

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 The Impact of Preexisting Conditions
(continued_2)
 Age or developmental level
• Example: The influence of developmental level
on communication is especially evident during
adolescence, with words such as dude, cool,
awesome, and others.

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 The Impact of Preexisting Conditions
(continued_3)
 The environment in which the transaction
takes place
• Territoriality, density, and distance are aspects of
environment that communicate messages.
‒ Territoriality: The innate tendency to own space
‒ Density: The number of people within a given
environmental space
‒ Distance: The means by which various cultures use
space to communicate

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 The Impact of Preexisting Conditions
(continued_4)
 There are four kinds of distance in
interpersonal interactions.
• Intimate distance: The closest distance that
individuals allow between themselves and others
• Personal distance: The distance for interactions
that are personal in nature
• Social distance: The distance for conversation
with strangers or acquaintances
• Public distance: The distance for speaking in
public or yelling to someone some distance away

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 Clicker Question 3

3. The unit manager needs to meet with a

patient who is exhibiting escalating hostility.
Which would be the most appropriate
location for the nurse to meet with this
patient?
A. The patient’s room with the door shut
B. A quiet corner of the day room
C. The nurse’s station
D. The unit’s treatment room
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 Clicker Question Answer 3

Correct Answer: B

A quiet corner of the day room provides for

some privacy in a neutral space while not
limiting access to help if safety issues arise.

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 Nonverbal Communication
 Components of nonverbal
communication
 Physical appearance and
dress
 Body movement and posture
 Touch
 Facial expressions
 Eye behavior
 Vocal cues or paralanguage
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 Therapeutic Communication Techniques
 Using silence: Allows patient to take control
of the discussion, if he or she so desires
 Accepting: Conveys positive regard
 Giving recognition: Acknowledging,
indicating awareness
 Offering self: Making oneself available
 Giving broad openings: Allows patient to
select the topic

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 Therapeutic Communication Techniques
(continued_1)
 Offering general leads: Encourages patient
to continue
 Placing the event in time or sequence:
Clarifies the relationship of events in time
 Making observations: Verbalizing what is
observed or perceived
 Encouraging description of perceptions:
Asking patient to verbalize what is being
perceived

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 Therapeutic Communication Techniques
(continued_2)
 Encouraging comparison: Asking patient to
compare similarities and differences in ideas,
experiences, or interpersonal relationships
 Restating: Lets patient know whether an
expressed statement has been understood
 Reflecting: Directs questions or feelings back
to patient so that they may be recognized
and accepted

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 Therapeutic Communication Techniques
(continued_3)
 Focusing: Taking notice of a single idea or
even a single word
 Exploring: Delving further into a subject,
idea, experience, or relationship
 Seeking clarification and validation: Striving
to explain what is vague and searching for
mutual understanding
 Presenting reality: Clarifying misconceptions
that the patient may be expressing

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 Therapeutic Communication Techniques
(continued_4)
 Voicing doubt: Expressing uncertainty as to
the reality of patient’s perception
 Verbalizing the implied: Putting into words
what patient has only implied
 Attempting to translate words into feelings:
Putting into words the feelings the patient
has expressed only indirectly
 Formulating plan of action: Striving to
prevent anger or anxiety escalating to
unmanageable level when stressor recurs
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 Clicker Question 4

4. As the move-out date to leave the shelter gets closer,

a battered wife states, “I'm afraid to leave here. I'm
afraid for my safety and the safety of my children.”
Which nursing statement is most supportive?
A. “This is a difficult transition. Let's formulate a plan to
keep you all safe in the community.”
B. “It’s the policy that patients can only live here for 30
days. Maybe we can ask for more time.”
C. “You've had a month to come up with a plan for keeping
you and your family safe.”
D. “Hopefully, your husband has been in counseling. I’m
sure this will work out fine.”
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 Clicker Question Answer 4

Correct Answer: A

The nurse is using the therapeutic techniques

of “reflection” and “formulating a plan of
action.” The use of these communication
facilitators indicates that the nurse is
supportive of the patient’s feelings and
appreciates the need for a safety plan.

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 Nontherapeutic Communication
Techniques
 Giving reassurance: May discourage the
patient from a further expression of feelings if
the patient believes the feelings will only be
downplayed or ridiculed
 Rejecting: Refusing to consider the patient’s
ideas or behavior
 Approving or disapproving: Implies that the
nurse has the right to pass judgment on the
“goodness” or “badness” of the patient’s
behavior
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 Nontherapeutic Communication
Techniques (continued_1)
 Agreeing or disagreeing: Implies that the
nurse has the right to pass judgment on
whether the patient’s ideas or opinions are
“right” or “wrong”
 Giving advice: Implies that the nurse knows
what is best for the patient and that the
patient is incapable of any self-direction

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 Nontherapeutic Communication
Techniques (continued_2)
 Probing: Pushing for answers to issues that
the patient does not wish to discuss causes
the patient to feel used and valued only for
what is shared with the nurse
 Defending: To defend what the patient has
criticized implies that the patient has no right
to express ideas, opinions, or feelings
 Requesting an explanation: Asking “why”
implies that the patient must defend his or
her behavior or feelings
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 Nontherapeutic Communication
Techniques (continued_3)
 Indicating the existence of an external
source of power: Encourages the patient to
project blame for his or her thoughts or
behaviors on others
 Belittling feelings expressed: Causes patient
to feel insignificant or unimportant
 Making stereotyped comments, clichés, and
trite expressions: These are meaningless in a
nurse–patient relationship

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 Nontherapeutic Communication
Techniques (continued_4)
 Using denial: Blocks discussion with the
patient and avoids helping the patient
identify and explore areas of difficulty
 Interpreting: Results in the therapist telling
the patient the meaning of his or her
experience
 Introducing an unrelated topic: Causes the
nurse to take over the direction of the
discussion

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 Clicker Question 5

5. The nurse is performing an initial assessment

on a newly admitted patient who is oriented
times four. Which of the following
communication techniques would best facilitate
obtaining accurate and complete patient data?

A. Closed-ended questions
B. Requesting an explanation
C. Open-ended questions
D. Interpreting
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 Clicker Question Answer 5

Correct Answer: C

Open-ended questions are phrased in a way

that gathers as much information as possible.
By the use of phrases such as “Tell me about…”
or “Describe to me…” a varied and rich body of
information can be assessed.

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 Active Listening
 To listen actively is to
be attentive to what
patient is saying, both
verbally and
nonverbally.
 Several nonverbal
behaviors have been
designed to facilitate
attentive listening.

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 Active Listening (continued)
 S: Sit squarely facing the patient
 O: Observe an open posture
 L: Lean forward toward the patient
 E: Establish eye contact
 R: Relax

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 Motivational Interviewing
 Evidence-based, patient-centered style of
communication that promotes behavior
change by guiding patients to explore their
own motivation for change and the
advantages and disadvantages of their
decisions
 Incorporates active listening and therapeutic
communication techniques but focuses on
what the patient wants to do

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 Process Recordings
 Process recordings are written reports of
verbal interactions with patients.
 They are written by the nurse or student as a
tool for improving communication
techniques.

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 Feedback
 Feedback is useful when it:
• Is descriptive rather than evaluative
• Is specific rather than general
• Is directed toward behavior that the patient has
the capacity to modify
• Imparts information rather than offers advice
• Is well-timed

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