3.4.

Building Nurse-Client Relationship

Introduction

The ability to establish therapeutic relationships with clients is one of the most important skills a
nurse can develop. Although important in all nursing specialties, the therapeutic relationship is
especially crucial to the success of interventions with client requiring psychiatric care because
the therapeutic relationship and the communication within it serve as the underpinning for
treatment and success.

Learning Objectives:

At the end of this module, the students will be able to:

 Describe how the nurse uses the necessary components involved in building and
enhancing the nurse-client relationship
 Explain the importance of values, beliefs, and attitudes in the development of the nurse-
client relationship
 Describe the importance of self –awareness and therapeutic use of self in the nuse-client
relationship
 Describe and implement the phases of the nurse-client relationship as outlined by
Hildegard Peplau
Learning Contents

1. THERAPEUTIC RELATIONSHIP

 It focuses on the needs, experiences, feelings and ideas of the client only.
 The nurse and the client agree about the areas to work on and evaluate the outcomes.
 The nurses uses communication skills, personal strengths and understanding of human
behaviour to interact with the client
 The parameters are clear: the focus is the client’s needs, not the nurse’s.
 COMPONENTS OF THERAPEUTIC RELATIONSHIP

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.

TRUST
The nurse-client relationship requires trust. Trust builds when the client is confident in
the nurse and when the nurse’s presence conveys integrity and reliability. It develops when the
client believes that the nurse will be consistent in his or her words and actions and can be relied
on to do what he or she says.

TRUSTING BEHAVIORS

TRUST is built in the nurse-client relationship

when the nurse exhibits the following behaviors:
Friendliness
Caring
Interest
Understanding
Consistency
Treating the client as a human being
Suggesting without telling
Approachability
Listening
Keeping promises
Providing schedules of activities
Honest

The nurse needs to exhibit congruent behaviors to build trust with the client. Congruence
occurs when words and actions match. Trust erodes when a client sees inconsistency between
what the nurse says and does.

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 to 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 behaviour and doing one’s best to make messages clear, simple and
congruent help to facilitate trust between the nurse and client.
 GENUINE INTEREST

A client with mental illness perceives a genuine person showing genuine interest and can
detect when someone is exhibiting dishonest or artificial behaviour such as asking a question and
then not waiting for the answer, talking over him or her, or assuring him or her everything will
be all right. The nurse should be open and honest and display congruent behaviour.
Sometimes, the nurse may choose to disclose to the client a personal experience related to
the client’s current concerns. Doing so helps to develop trust and allows the client to see the
nurse as a real person with perhaps similar problems. This self-disclosure, can enhance openness
and honesty.
 Nevertheless, the nurse must not shift emphasis to his or her own problems rather
than the client’s

EMPATHY

The ability of the nurse to perceive the meanings and feelings of the client and to communicate
that understanding to the client is EMPATHY. It is considered one of the essential skills a nurse
must develop.
Both the client and the nurse give a “gift of self” when empathy occurs – the client by feeling
safe enough to share the feelings and the nurse by listening closely enough to understand.
Empathy has been shown to positively influence client outcomes. Client tend to feel better about
themselves and more understood when the nurse is empathetic. (Welch, 2005)

 The nurse must understand the difference

between empathy and sympathy (feelings
of concern or compassion one shows for
another). By expressing sympathy, the nurse
may project his or her personal concerns
onto the client, thus inhibiting the client’s
expression of feelings. the nurse’s feelings of
sadness or even pity could influence the
relationship and hinder the nurse’s abilities to
focus on the client’s needs. Sympathy often
shifts the emphasis to the nurse’s feelings,
hindering the nurse’s ability to view the
client’s needs objectively.

ACCEPTANCE

The nurse who does not become upset or respond negatively to a client’s outbursts, anger or
acting out conveys acceptance to the client. Avoiding judgments of the person, no matter what
the behaviour, is acceptance.
This does not mean acceptance of inappropriate behaviour but acceptance of the person as
worthy. The nurse must set boundaries for behaviour in the nurse-client relationship. By being
clear and firm without anger and judgment, the nurse allows the client to feel intact while still
conveying that certain behaviour is unacceptable.

Example:

A client puts his arm around the nurse’s waist.

 Appropriate response: “John, do not place your hand on me. We are working POSITIVE
on your relationship with your girlfriend and that does not require you to
REGARD
touch me. Now, let’s continue..”
The nurse who
Inappropriate response: “John, stop that! What’s gotten with you? I am appreciates
the leaving and maybe I’ll return tomorrow.” client as a
unique
worthwhile
human
being can respect
the client regardless of his or her behaviour, background or lifestyle. This unconditional non-
judgmental attitude is known as POSITIVE REGARD and implies respect.
Calling the client by name, spending time with the client and listening and responding
openly, considering client’s ideas and preferences are measures by which the nurse conveys
respect and positive regard to the client.
The nurse relies presence or attending, which is using nonverbal and verbal communication
techniques to make the client aware that he or she is receiving full attention. Nonverbal
techniques that create an atmosphere of presence include leaning toward the client, maintaining
eye contact, being relaxed, having arms resting at the sides, and having an interested but neutral
attitude. Verbal attending means that the nurse avoids communicating value judgments about the
client’s behaviour. The nurse maintains attention on the client and avoids communicating
negative opinions or value judgments about the client’s behaviour.

2. SELF-AWARENESS AND THERAPEUTIC USE OF SELF

SELF-AWARENESS

-The process of developing an understanding of one’s own values, beliefs, thoughts,

feelings, attitudes, motivations, prejudices, strengths, and limitations and how these qualities
affect others.

-Allows the nurse to observe, pay attention to, and understand the subtle responses and
reactions of clients when interacting with them.

 VALUES
- are abstract standards that give a person a sense of right and wrong and establish a code of
conduct for living. Sample values include hard work, honesty, sincerity, cleanliness, and
orderliness.
To gain insight into oneself and personal values, the values clarification process is helpful.
VALUES CLARIFICATION PROCESS STEPS:

1. CHOOSING- when the person considers a range of possibilities

and freely chooses the value that feels right.

2. PRIZING – when the person considers the value, cherishes it, and
publicly attaches it to himself or herself.

3. ACTING- when the person puts the value into action.

EXAMPLE SCENARIO:

A clean and orderly student has been assigned to live with another
student who is messy. At first the orderly student is unsure why
she hesitates to return to the room and feels tense around her
roommate. As she examines the situation, she realizes that they
view the use of personal space differently (CHOOSING). Next she
discussed her conflict and choices with her adviser and friends
(PRIZING). Finally, she decides to negotiate with her roommate for
a compromise (ACTING).

 BELIEFS
- are ideas that one holds to be true.

EXAMPLE:

People who believe in evolution have accepted the evidence that

supports this explanation for the origins of live

 ATTITUDE
- Are general feelings or a frame of reference around which a person organizes
knowledge about the world.

 POSITIVE MENTAL ATTITUDE – occurs when a person chooses to put a

positive spin on an experience, comment, or judgment.
 NEGATIVE MENTAL ATTITUDE- occurs when a person chooses to put a
negative spin on an experience, comment, or judgment.
o A negative attitude also colors how one views the world and other people
 The nurse should re-evaluate and readjust beliefs and attitudes periodically as he or she
gains experience and wisdom. Ongoing self- awareness allows the nurse to accept values,
attitudes, and beliefs of others that may differ from his or her own.
A person who does not assess personal attitudes and beliefs may hold prejudice
(HOSTILE ATTITUDE) toward a group of people because of preconceived ideas or
stereotypical images of that group.

THERAPEUTIC USE OF SELF

By developing self-awareness and beginning to understand his or her attitudes, the

nurse can begin to use aspects of his or her personality, experiences, values, feelings,
intelligence, needs, coping skills, and perceptions to establish relationships with clients. This is
called THERAPEUTIC USE OF SELF.

Nurses use themselves as a therapeutic tool to establish therapeutic relationships with

clients and to help clients GROW, CHANGE AND HEAL.

Nurses must clearly understand themselves to promote their client’s growth and to
avoid limiting clients’ choices to those that nurses value (Peplau, 1952)

JOHARI WINDOW (Luft, 1970)

- One tool that is useful in learning more about oneself.

- It creates a “word portrait” of a person in four areas and indicates how well that person
knows himself or herself and communicates with others.

PATTERNS OF KNOWING (Carper, 1978)

- these patterns provides the nurse with a clear method of observing and understanding every
client interaction.

-understanding where knowledge comes from and how it affects behaviour helps the nurse
become more self-aware.

Client with panic disorder Client's face shows the panic

begins to have an attack. Panic
attack will raise pulse rate

EMPIRICAL PERSONAL
KNOWING KNOWING
(obtained from (obtained
the science of from life
nursing) experience)

Client with panic disorder begins to

ETHICAL AESTHETIC
although the client shows outward
have an attack. Panic attack will
KNOWING KNOWINGsignals now, the nurse has sensed
raise pulse rate (obtained previously
from the client's jumpiness and
(obtained from the art of sutle differences in the client's
the moral nursing)
knowlege of demeanor and behavior
nursing

MUNHALL (1993) added another pattern that she called UNKNOWING: for the nurse to admit
she or he does not know the client or the client’s subjective world opens the way for a truly
authentic encounter.

The nurse in a state of unknowing is open to seeing and hearing the client’s view without
imposing his or her values or viewpoints.

In psychiatric nursing, negative preconceptions on the nurse’s part can adversely effect the
therapeutic relationship; thus, it is especially important for the nurse to work on developing this
openness and acceptance toward the client.

PRECONCEPTIONS – ways one person expects another to behave or speak.

- Roadblocks to the formation of authentic relationship
- Prevents people from getting to know one another.
- Patterns of knowing prevents this
3. GOAL OF THERAPEUTIC RELATIONSHIP

The goals of a therapeutic relationship are directed toward achieving the patient's optimal growth
and include the following dimensions:
 Self-realization, self –acceptance, and an increased genuine self-respect.
 A clear sense of personal identity and an improved level of personal integration.
 An ability to form intimate, interdependent, interpersonal relationships with a
capacity to give and receive love.
 Improved functioning and increased ability to satisfy needs and achieve realistic
personal goals

4. PHASES OF THE NURSE-CLIENT RELATIONSHIP

Peplau’s model (1952) has three phases: ORIENTATION, WORKING, and RESOLUTION OR
TERMINATION. These phases in real life are not clearcut; they overlap and interlock. Her work
provides the nursing profession with a model that can be used to understand and document
progress with interpersonal interactions.

ORIENTATION TERMINATION
WORKING PHASE
PHASE PHASE

ORIENTATION PHASE

 Begins when the nurse and client meet and ends when the client begins to identify
problems to examine.
 The nurse establishes roles, the purpose of meeting, and the parameters of subsequent
meetings.
 Identifies the client’s problems; and clarifies expectations.

 Before meeting the client:

 The nurse reads background materials available on the client, becomes familiar
with any medications the client is taking, gathers necessary paperwork, and
arranges for a quiet, private, and comfortable setting.
 This is the time for self-assessment--the nurse should consider his or her personal
strengths and limitations in working with this client.
  The nurse must examine preconceptions about the client and ensure that he or she
can put them aside and get to know the real person.
 The nurse must come to each client without preconceptions or prejudices.

 During the orientation phase

 The nurse begins to build trust with the client. It is the nurse’s responsibility to
establish a therapeutic environment that fosters trust
 The nurse should share appropriate information about himself or herself at this
time, including name, reason for being on the unit.
 The nurse needs to listen closely to the client’s history, perceptions, and
misconceptions. He or she needs to convey empathy and understanding.
At the first meeting, the client may be distrustful if previous relationships
with nurses have been unsatisfactory. The client may use rambling speech,
act out, or exaggerate episodes as ploys to avoid discussing the real
problems. It may take several sessions until the client believes that he or she
can trust the nurse.

 Nurse–Client Contracts
 The nurse once again outline the responsibilities of the nurse and the client.
 Both nurse and client should agree on these responsibilities in an informal or
verbal contract.
 In some instances, a formal or written contract may be appropriate; examples
include if a written contract has been necessary in the past with the client or if the
client “forgets” the agreed-on verbal contract.

The contract should state the following:

 Time, place, and length of sessions

 When sessions will terminate
 Who will be involved in the treatment plan (family members or health team
members)
 Client responsibilities (arrive on time and end on time)
 Nurse’s responsibilities (arrive on time, end on time, maintain
confidentiality at all times, evaluate progress with client, and document
sessions).

 Confidentiality
  Means respecting the client’s right to keep private any information about his or
her mental and physical health and related care.
 It means allowing only those dealing with the client’s care to have access to the
information that the client divulges. Only under precisely defined conditions can
third parties have access to this information.
 The nurse must clearly state information about who will have access to client
assessment data and progress evaluations. He or she should tell the client that
members of the mental health team share appropriate information among
themselves to provide consistent care and that only with the client’s permission
will they include a family member.
 The nurse must be alert if a client asks him or her to keep a secret because this
information may relate to the client’s harming himself or herself or others.
 The nurse must avoid any promises to keep secrets. If the nurse has promised not
to tell before hearing the message, he or she could be jeopardizing the client’s
trust. In most cases, even when the nurse refuses to agree to keep information
secret, the client continues to relate issues anyway.

The following is an example of a good response to a client who is

suicidal but requests secrecy:

Client: “I am going to jump off the 14th floor of my apartment

building tonight, but please don’t tell anyone.”

Nurse: “I cannot keep such a promise, especially if it involves your

safety. I sense you are feeling frightened. The staff and I will help you
stay safe.”

Homicidal Threat (The Tarasoff vs. Regents of the University of California, (1976)

-The nurse requires to notify intended victims and police of such a threat. The nurse must report
the homicidal threat to the nursing supervisor and attending physician so that both the police
and the intended victim can be notified. This is called a duty to warn

 Self-Disclosure

 Means revealing personal information such as biographical information and

personal ideas, thoughts, and feelings about oneself to clients.
 It is believed that some purposeful, well-planned, self-disclosure can improve
rapport between the nurse and the client.
 It may help the client feel more comfortable and more willing to share thoughts
and feelings, or help the client gain insight into his or her situation.
 The nurse must also consider cultural factors. Some clients may deem self-
disclosure inappropriate or too personal, causing the client discomfort.
. Note: Disclosing personal information to a client can be
harmful and inappropriate, so it must be planned and
considered thoughtfully in advance

WORKING PHASE

 Has two subphases:

o During problem identification- the client identifies the issues or concerns

causing problems.
o During exploitation- the nurse guides the client to examine feelings and
responses and to develop better coping skills and a more positive
selfimage; this encourages behavior change and develops independence.

Note: Peplau’s use of the word exploitation had a very

different meaning than current usage, this phase is better
conceptualized as intense exploration and elaboration on
earlier themes that the client discussed.)
 The trust established between nurse and client at this point allows them to examine
the problems and to work on them within the security of the relationship.
 Testing behavior --Sometimes the client will use outrageous stories or acting-out
behaviors to test the nurse. Often when the client becomes uncomfortable because
he or she is getting too close to the truth, he or she will use testing behaviors to
avoid the subject.

o The nurse must remember that it is the client who examines

and explores problem situations and relationships. The
nurse must be nonjudgmental and refrain from giving
advice; the nurse should allow the client to analyze
situations.
o The nurse can guide the client to observe patterns of
behavior and whether or not the expected response occurs.
The nurse can then help the client explore more effective
ways of communicating in the future.

Specific tasks of the working phase:

  Maintaining the relationship
 Gathering more data
 Exploring perceptions of reality
 Developing positive coping mechanisms
 Promoting a positive self-concept
 Encouraging verbalization of feelings
 Facilitating behavior change
 Working through resistance
 Evaluating progress and redefining goals as appropriate
 Providing opportunities for the client to practice new behaviors
 Promoting independence.

o Transference
-when the client unconsciously transfer to the nurse the feelings he or she has for significant
others.

o Countertransference
- when the nurse responds to the client based on personal unconscious needs and conflicts

Again, self-awareness is important so that the nurse can identify when transference and
countertransference might occur. By being aware of such “hot spots,” the nurse has a better
chance of responding appropriately rather than letting old unresolved conflicts interfere with
the relationship.

TERMINATION/RESOLUTION PHASE

 The final stage in the nurse–client relationship.

 It begins when the problems are resolved, and it ends when the relationship is
ended.
 Client especially may feel the termination as an impending loss. Often clients try
to avoid termination by acting angry or as if the problem has not been resolved.
The nurse can acknowledge the client’s angry feelings and assure the client that
this response is normal to ending a relationship.
 If the client tries to reopen and discuss old resolved issues, the nurse must avoid
feeling as if the sessions were unsuccessful; instead, he or she should identify the
client’s stalling maneuvers and refocus the client on newly learned behaviors and
skills to handle the problem.
 Note: It is appropriate to tell the client that the nurse enjoyed the time
spent with the client and will remember him or her, but it is
inappropriate for the nurse to agree to see the client outside the
therapeutic relationship

Avoiding Behaviors that Diminish the Therapeutic Relationship

 Inappropriate boundaries
 Feeling of sympathy and encouraging client dependency
 Nonacceptance and avoidance

5. THERAPEUTIC AND NON THERAPEUTIC COMMUNICATION TECHNIQUE

o Communication
- is the process that people use to exchange information.
- Messages can be verbally through the use of words and nonverbally by behaviors that
accompany the words (DeVito, 2008).
 Verbal communication- consists of the words a person uses to speak to one or more
listeners.
 Nonverbal communication - the behavior that accompanies verbal content such as body
language, eye contact, facial expression, tone of voice, speed and hesitations in speech,
grunts and groans, and distance from the listeners. It can indicate the speaker’s thoughts,
feelings, needs, and values that he or she acts out mostly unconsciously.

Process

- denotes all nonverbal messages that the speaker uses to give meaning and context to
the message.
 - It requires the listeners to observe the behaviors and sounds that accent the words and
to interpret the speaker’s nonverbal behaviors to assess whether they agree or disagree
with the verbal content.

 Congruent message-conveyed when content and process agree.

For example, a client says, “I know I haven’t been myself. I need help.” She has a sad facial
expression and a genuine and sincere voice tone.
o The process validates the content as being true.
 Incongruent message -when the content and process disagree.

 Nonverbal process represents a more accurate message than does verbal content.

Therapeutic Communication

 An interpersonal interaction between the nurse and client

during which the nurse focuses on the client’s
specific needs to promote an effective exchange of
information.

 All nurses need skills in therapeutic

communication to effectively apply the nursing
process and to meet standards of care for their
clients.

Therapeutic communication can help nurses to accomplish many goals:

 Establish a therapeutic nurse–client relationship.

 Identify the most important client concern at that moment (the client-centered goal).
 Assess the client’s perception of the problem as it unfolds. This includes detailed
actions (behaviors and messages) of the people involved and the client’s thoughts
and feelings about the situation, others, and self.
 Facilitate the client’s expression of emotions.
 Teach the client and family necessary self-care skills.
 Recognize the client’s needs.
 Implement interventions designed to address the client’s needs.
 Guide the client toward identifying a plan of action to a satisfying and socially
acceptable resolution.
Establishing a therapeutic relationship is one of the most important responsibilities of the nurse
when working with clients. Communication is the means by which a therapeutic relationship is
initiated, maintained, and terminated.

To have effective therapeutic communication, the nurse also must consider:

1. Privacy and Respecting Boundaries

Privacy is desirable but not always possible in therapeutic communication. The nurse
needs to evaluate whether interacting in the client’s room is therapeutic.

Proxemics - the study of distance zones between people during communication

Four Distance Zones:

 Intimate zone (0 to 18 inches between people): This amount of space is

comfortable for parents with young children, people who mutually desire
personal contact, or people whispering. Invasion of this intimate zone by
anyone else is threatening and produces anxiety.
 Personal zone (18 to 36 inches): This distance is comfortable between
family and friends who are talking.
 Social zone (4 to 12 feet): This distance is acceptable for communication in
social, work, and business settings.
 Public zone (12 to 25 feet): This is an acceptable distance between a
speaker and an audience, small groups, and other informal functions (Hall,
1963).

People from some cultures (e.g., Hispanic, Mediterranean, East Indian, Asian, and Middle
Eastern) are more comfortable with less than 4 to 12 feet of space between them while talking.
The nurse of European American or African American heritage may feel uncomfortable if clients
from these cultures stand close when talking. Conversely, clients from these backgrounds may
perceive the nurse as remote and indifferent (Andrews & Boyle, 2007).

Both the client and the nurse can feel threatened if one invades the other’s personal or intimate
zone, which can result in tension, irritability, fidgeting, or even flight. When the nurse must
invade the intimate or personal zone, he or she always should ask the client’s permission.

2. Touch
Five Types of Touch (Knapp ,1980):

1. Functional-professional touch- used in examinations or procedures

such as when the nurse touches a client to assess skin turgor or a
masseuse performs a massage.

2. Social-polite touch is used in greeting, such as a handshake and the “air

kisses” some women use to greet acquaintances, or when a gentle hand guides
someone in the correct direction.

3. Friendship-warmth touch- involves a hug in greeting, an arm

thrown around the shoulder of a good friend, or the backslapping some
men use to greet friends and relatives.

4. Love-intimacy touch -involves tight hugs and kisses between lovers or

close relatives. • Sexual-arousal touch is used by lovers.

 The nurse should observe the client for cues that show whether touch is desired or
indicated.
 When a staff member is going to touch a client while performing nursing care, he or she
must verbally prepare the client before starting the procedure. A client with paranoia may
interpret being touched as a threat and may attempt to protect himself or herself by
striking the staff person
3. Active Listening and Observation

Active listening -refraining from other internal

mental activities and concentrating exclusively on
what the client says.

Active observation- watching the speaker’s

nonverbal actions as he or she communicates.
  Peplau (1952) used observation as the first step in the therapeutic interaction.
 The nurse observes the client’s behavior and guides him or her in giving detailed
descriptions of that behavior.
 To help the client develop insight into his or her interpersonal skills, the nurse analyzes
the information obtained, determines the underlying needs that relate to the behavior, and
connects pieces of information (makes links between various sections of the
conversation).
 COMMON PROBLEM: the nurse must be ready with questions the instant the client
has finished speaking. Hence, they are constantly thinking ahead regarding the next
question rather than actively listening to what the client is saying. The result can be that
the nurse does not understand the client’s concerns, and the conversation is vague,
superficial, and frustrating to both participants.
 In therapeutic communication, the nurse must ask specific questions to get the entire
story from the client’s perspective, to clarify assumptions, and to develop empathy with
the client.
 The nurse asks as many questions as needed to gain a clear understanding of the client’s
perceptions of an event or issue.
 Active listening and observation help the nurse to:
o Recognize the issue that is most important to the client at this time.
o Know what further questions to ask the client.
o Use additional therapeutic communication techniques to guide the client to
describe his or her perceptions fully.
o Understand the client’s perceptions of the issue instead of jumping to conclusions.
o Interpret and respond to the message objectively.

THERAPEUTIC COMMUNICATION TECHNIQUES

 Techniques the nurse can use when interacting with clients.

 Choice of techniques: depends on the intent of the interaction and
the client’s ability to communicate verbally.
 The nurse should select techniques that facilitate the interaction
and enhance communication between client and nurse.

THERAPEUTIC COMMUNICATION TECHNIQUES

Therapeutic Examples Rationale

Communication
Techniques
Accepting—indicating “Yes.” An accepting response indicates the
reception
Broad openings—allowing
the client to take the
initiative in introducing the
topic
Consensual validation—
searching for mutual
understanding, for accord in
the meaning of the words
Encouraging comparison
—asking that similarities
and differences be noted
Encouraging description
of perceptions—asking the
client to verbalize what he
or she perceives
Encouraging expression—
asking the client to appraise
the quality of his or her
experiences
Exploring—delving further
“I follow what nurse has heard and followed the
you said.” train of thought. It does not indicate
Nodding agreement but is non-judgmental.
Facial expression, tone of voice, and
so forth also must convey
acceptance or the words lose their
meaning.
Is there Broad openings make explicit that
something you’d the client has the lead in the
like to talk interaction.
about?” For the client who is hesitant about
“Where would talking, broad openings may
you like to stimulate him or her to take the
begin?” initiative
“Tell me whether For verbal communication to be
my meaningful, it is essential that the
understanding of words being used have the same
it agrees with meaning for both (all) participants.
yours.” Sometimes, words, phrases, or slang
“Are you using terms have different meanings and
this word to can be easily misunderstood.
convey that…?”
“Was it Comparing ideas, experiences, or
something relationships brings out many
like…?” recurring themes. The client benefits
“Have you had from making these comparisons
similar because he or she might recall past
experiences?” coping strategies that were effective
or remember that he or she has
survived a similar situation.
“Tell me when To understand the client, the nurse
you feel must see things from his or her
anxious.” “What perspective. Encouraging the client
is happening?” to describe ideas fully may relieve
“What does the the tension the client is feeling, and
voice seem to be he or she might be less likely to take
saying?” action on ideas that are harmful or
frightening.
“What are your The nurse asks the client to consider
feelings in regard people and events in light of his or
to…?” “Does this her own values. Doing so
contribute to encourages the client to make his or
your distress?” her own appraisal rather than to
accept the opinion of others.
“Tell me more When clients deal with topics
into a subject or an idea
Focusing—concentrating
on a single point
Formulating a plan of
action—asking the client to
consider kinds of behavior
likely to be appropriate in
future situations
General leads—giving
encouragement to continue
Giving information—
making available the facts
that the client needs
Giving recognition—
acknowledging, indicating
awareness
about that.” superficially, exploring can help
“Would you them examine the issue more fully.
describe it more Any problem or concern can be
fully?” better understood if explored in
“What kind of depth. If the client expresses an
work?” unwillingness to explore a subject,
however, the nurse must respect his
or her wishes.
“This point The nurse encourages the client to
seems worth concentrate his or her energies on a
looking at more single point, which may prevent a
closely.” multitude of factors or problems
“Of all the from overwhelming the client. It is
concerns you’ve also a useful technique when a client
mentioned, jumps from one topic to another.
which is most
troublesome?”
“What could you It may be helpful for the client to
do to let your plan in advance what he or she
anger out might do in future similar situations.
harmlessly?” Making definite plans increases the
“Next time this likelihood that the client will cope
comes up, what more effectively in a similar
might you do to situation.
handle it?”
“Go on.” General leads indicate that the nurse
“And then?” is listening and following what the
“Tell me about client is saying without taking away
it.” the initiative for the interaction.
They also encourage the client to
continue if he or she is hesitant or
uncomfortable about the topic.
“My name is….” Informing the client of facts
“Visiting hours increases his or her knowledge about
are….” a topic or lets the client know what
“My purpose in to expect. The nurse is functioning
being here is….” as a resource person. Giving
information also builds trust with the
client.
“Good morning, Greeting the client by name,
Mr. S.….” indicating awareness of change, or
“You’ve finished noting efforts the client has made all
your list of things show that the nurse recognizes the
to do.” client as a person, as an individual.
 “I notice that Such recognition does not carry the
you’ve combed notion of value, that is, of being
your hair.” “good” or “bad.”

Making observations— “You appear Sometimes clients cannot verbalize

verbalizing what the nurse tense.” or make themselves understood. Or
perceives “Are you the client may not be ready to talk.
uncomfortable
when…?”
“I notice that
you’re biting
your lip.”
Offering self—making “I’ll sit with you The nurse can offer his or her
oneself available awhile.” presence, interest, and desire to
“I’ll stay here understand. It is important that this
with you.” offer is unconditional; that is, the
“I’m interested in client does not have to respond
what you think.” verbally to get the nurse’s attention.

Placing event in time or “What seemed to Putting events in proper sequence

sequence—clarifying the lead up to…?” helps both the nurse and the client to
relationship of events in “Was this before see them in perspective. The client
time or after…?” may gain insight into cause-and-
“When did this effect behavior and consequences, or
happen?” the client may be able to see that
perhaps some things are not related.
The nurse may gain information
about recurrent patterns or themes in
the client’s behavior or
relationships.

Presenting reality— “I see no one else When it is obvious that the client is
offering for consideration in the room.” misinterpreting reality, the nurse can
that which is real “That sound was indicate what is real. The nurse does
a car backfiring.” this by calmly and quietly
“Your mother is expressing his or her perceptions or
not here; I am a the facts, not by way of arguing with
nurse.” the client or belittling his or her
experience. The intent is to indicate
an alternative line of thought for the
client to consider, not to “convince”
the client that he or she is wrong.

Reflecting—directing client Client: “Do you Reflection encourages the client to

actions, thoughts, and think I should tell recognize and accept his or her own
feelings back to client
Restating—repeating the
main idea expressed
Seeking information—
seeking to make clear that
which is not meaningful or
that which is vague
Silence—absence of verbal
communication, which
provides time for the client
to put thoughts or feelings
into words, to regain
composure, or to continue
talking
the doctor…?” feelings. The nurse indicates that the
Nurse: “Do you client’s point of view has value and
think you that the client has the right to have
should?” Client: opinions, make decisions, and think
“My brother independently.
spends all my
money and then
has nerve to ask
for more.”
Nurse: “This
causes you to feel
angry?”
Client: “I can’t The nurse repeats what the client has
sleep. I stay said in approximately or nearly the
awake all night.” same words the client has used. This
Nurse: “You restatement lets the client know that
have difficulty he or she communicated the idea
sleeping.” effectively. This encourages the
Client: “I’m client to continue. Or if the client
really mad, I’m has been misunderstood, he or she
really upset.” can clarify his or her thoughts.
Nurse: “You’re
really mad and
upset.”
“I’m not sure that The nurse should seek clarification
I follow.” throughout interactions with clients.
“Have I heard Doing so can help the nurse to avoid
you correctly?” making assumptions that
understanding has occurred when it
has not. It helps the client to
articulate thoughts, feelings, and
ideas more clearly.
Nurse says Silence often encourages the client
nothing but to verbalize, provided that it is
continues to interested and expectant. Silence
maintain eye gives the client time to organize
contact and thoughts, direct the topic of
conveys interest. interaction, or focus on issues that
are most important. Much nonverbal
behavior takes place during silence,
and the nurse needs to be aware of
the client and his or her own
nonverbal behavior.
Suggesting collaboration
— offering to share, to
strive, and to work with the
client for his or her benefit
Summarizing—organizing
and summing up that which
has gone before
Translating into feelings
— seeking to verbalize
client’s feelings that he or
she expresses only
indirectly
Verbalizing the implied—
voicing what the client has
hinted at or suggested
“Perhaps you and The nurse seeks to offer a
I can discuss and relationship in which the client can
discover the identify problems in living with
triggers for your others, grow emotionally, and
anxiety.” improve the ability to form
“Let’s go to your satisfactory relationships. The nurse
room, and I’ll offers to do things with, rather than
help you find for, the client.
what you’re
looking for.”
“Have I got this Summarization seeks to bring out
straight?” the important points of the
“You’ve said discussion and to increase the
that….” “During awareness and understanding of both
the past hour, participants. It omits the irrelevant
you and I have and organizes the pertinent aspects
discussed….” of the interaction. It allows both
client and nurse to depart with the
same ideas and provides a sense of
closure at the completion of each
discussion.
Client: “I’m Often what the client says, when
dead.” Nurse: taken literally, seems meaningless or
“Are you far removed from reality. To
suggesting that understand, the nurse must
you feel concentrate on what the client might
lifeless?” Client: be feeling to express himself or
“I’m way out in herself this way.
the ocean.”
Nurse: “You
seem to feel
lonely or
deserted.”
Client: “I can’t Putting into words what the client
talk to you or has implied or said indirectly tends
anyone. It’s a to make the discussion less obscure.
waste of time.” The nurse should be as direct as
Nurse: “Do you possible without being unfeelingly
feel that no one blunt or obtuse. The client may have
understands?” difficulty communicating directly.
The nurse should take care to
express only what is fairly obvious;
otherwise, the nurse may be jumping
to conclusions or interpreting the
 client’s communication.
Voicing doubt—expressing “Isn’t that Another means of responding to
uncertainty about the reality unusual?” distortions of reality is to express
of the client’s perceptions “Really?” doubt. Such expression permits the
“That’s hard to client to become aware that others
believe.” do not necessarily perceive events in
the same way or draw the same
conclusions. This does not mean the
client will alter his or her point of
view, but at least the nurse will
encourage the client to reconsider or
reevaluate what has happened. The
nurse neither agreed nor disagreed;
however, he or she has not let the
misperceptions and distortions pass
without comment.

NONTHERAPEUTIC COMMUNICATION TECHNIQUES

 Techniques that nurses SHOULD AVOID!

 These responses cut off communication and make it more
difficult for the interaction to continue.

NONTHERAPEUTIC COMMUNICATION TECHNIQUES

Techniques Examples Rationale

Advising—telling the client
what to do
Agreeing—indicating
accord with the client
Belittling feelings
“I think you Giving advice implies that only the
should….” nurse knows what is best for the
“Why don’t client.
you….”
“That’s right.” Approval indicates the client is
“I agree.” “right” rather than “wrong.” This
gives the client the impression that
he or she is “right” because of
agreement with the nurse. Opinions
and conclusions should be
exclusively the client’s. When the
nurse agrees with the client, there is
no opportunity for the client to
change his or her mind without
being “wrong.”
Client: “I have When the nurse tries to equate the
expressed—misjudging the nothing to live intense and overwhelming feelings
degree of the client’s for… I wish I the client has expressed to
discomfort was dead.” “everybody” or to the nurse’s own
Nurse: feelings, the nurse implies that the
“Everybody gets discomfort is temporary, mild, self-
down in the limiting, or not very important. The
dumps,” or “I’ve client is focused on his or her own
felt that way worries and feelings; hearing the
myself.” problems or feelings of others is not
helpful.
Challenging—demanding “But how can Often the nurse believes that if he or
proof from the client you be president she can challenge the client to prove
of the United unrealistic ideas, the client will
States?” realize there is no “proof” and then
“If you’re dead, will recognize reality. Actually,
why is your heart challenging causes the client to
beating?” defend the delusions or
misperceptions more strongly than
before.
Defending—attempting to “This hospital Defending what the client has
protect someone or has a fine criticized implies that he or she has
something from verbal reputation.” “I’m no right to express impressions,
attack? sure your doctor opinions, or feelings. Telling the
has your best client that his or her criticism is
interests in unjust or unfounded does not change
mind.” the client’s feelings but only serves
to block further communication.
Disagreeing—opposing the “That’s wrong.” Disagreeing implies the client is
client’s ideas “I definitely “wrong.” Consequently, the client
disagree with….” feels defensive about his or her point
“I don’t believe of view or ideas.
that.”
Disapproving— “That’s bad.” Disapproval implies that the nurse
denouncing the client’s “I’d rather you has the right to pass judgment on the
behavior or ideas wouldn’t….” client’s thoughts or actions. It
further implies that the client is
expected to please the nurse.
Giving approval— “That’s good.” Saying what the client thinks or feels
sanctioning the client’s “I’m glad is “good” implies that the opposite is
behavior or ideas that….” “bad.” Approval, then, tends to limit
the client’s freedom to think, speak,
or act in a certain way. This can lead
to the client’s acting in a particular
way just to please the nurse.
Giving literal responses— Client: “They’re Often the client is at a loss to
responding to a figurative looking in my describe his or her feelings, so such
comment as though it were head with a comments are the best he or she can
a statement of fact television do. Usually, it is helpful for the
camera.” nurse to focus on the client’s
Nurse: “Try not feelings in response to such
to watch statements.
television” or
“What channel?”
Indicating the existence of “What makes The nurse can ask, “What
an external source— you say that?” happened?” or “What events led you
attributing the source of “What made you to draw such a conclusion?” But to
thoughts, feelings, and do that?” question, “What made you think
behavior to others or to “Who told you that?” implies that the client was
outside influences that you were a made or compelled to think in a
prophet?” certain way. Usually, the nurse does
not intend to suggest that the source
is external, but that is often what the
client thinks.
Interpreting—asking to “What you really The client’s thoughts and feelings
make conscious that which mean is….” are his or her own, not to be
is unconscious; telling the “Unconsciously interpreted by the nurse for hidden
client the meaning of his or you’re meaning. Only the client can
her experience saying….” identify or confirm the presence of
feelings.
Introducing an unrelated Client: “I’d like The nurse takes the initiative for the
topic—changing the subject to die.” interaction away from the client.
Nurse: “Did you This usually happens because the
have visitors last nurse is uncomfortable, doesn’t
evening?” know how to respond, or has a topic
he or she would rather discuss.
Making stereotyped “It’s for your Social conversation contains many
comments—offering own good.” clichés and much meaningless
meaningless clichés or trite “Keep your chin chitchat. Such comments are of no
comments up.” value in the nurse–client
“Just have a relationship. Any automatic
positive attitude responses lack the nurse’s
and you’ll be consideration or thoughtfulness.
better in no
time.”
Probing—persistent “Now tell me Probing tends to make the client feel
questioning of the client about this used or invaded. Clients have the
problem. You right not to talk about issues or
know I have to concerns if they choose. Pushing and
find out.” probing by the nurse will not
“Tell me your encourage the client to talk.
psychiatric
history.”
 Reassuring—indicating “I wouldn’t Attempts to dispel the client’s
there is no reason for worry about anxiety by implying that there is not
anxiety or other feelings of that.” sufficient reason for concern
discomfort “Everything willcompletely devalue the client’s
be all right.” feelings. Vague reassurances
“You’re coming without accompanying facts are
along just fine.”
meaningless to the client.
Rejecting—refusing to “Let’s not When the nurse rejects any topic, he
consider or showing discuss….” or she closes it off from exploration.
contempt for the client’s “I don’t want toIn turn, the client may feel
ideas or behaviors hear about….” personally rejected along with his or
her ideas.
Requesting an explanation “Why do you There is a difference between asking
—asking the client to think that?” the client to describe what is
provide reasons for “Why do you feel occurring or has taken place and
thoughts, feelings, that way?” asking him to explain why. Usually,
behaviors, events a “why” question is intimidating. In
addition, the client is unlikely to
know “why” and may become
defensive trying to explain himself
or herself.
Testing—appraising the “Do you know These types of questions force the
client’s degree of insight what kind of client to try to recognize his or her
hospital this is?” problems. The client’s
“Do you still acknowledgment that he or she
have the idea doesn’t know these things may meet
that…?” the nurse’s needs but is not helpful
for the client.
Using denial—refusing to Client: “I’m The nurse denies the client’s
admit that a problem exists nothing.” feelings or the seriousness of the
Nurse: “Of situation by dismissing his or her
course you’re comments without attempting to
something— discover the feelings or meaning
everybody’s behind them.
something.”
Client: “I’m
dead.” Nurse:
“Don’t be silly.”

Interpreting Signals or Cues

 Cues (overt and covert) are verbal or nonverbal messages that signal key words or
issues for the client.
o Overt cues- clear, direct statements of intent, such as “I want to die.” The
message is clear that the client is thinking of suicide or self-harm.
 o Covert cues- vague or indirect messages that need interpretation and
exploration

 Finding cues is a function of active listening.

 Cues can be buried in what a client says or can be acted out in the process of
communication.
 Often, cue words introduced by the client can help the nurse to know what to ask
next or how to respond to the client.

The following example illustrates questions the nurse might ask when responding to a client’s
cue:
Client: “I had a boyfriend when I was younger.”
Nurse: “You had a boyfriend?” (reflecting)
“Tell me about you and your boyfriend.” (encouraging description)
“How old were you when you had this boyfriend?” (placing events in time or sequence)

 If a client has difficulty attending to a conversation and drifts into a rambling discussion
or a flight of ideas, the nurse listens carefully for a theme or a topic around which the
client composes his or her words. Using the theme, the nurse can assess the nonverbal
behaviors that accompany the client’s words and build responses based on these cues.
 Clients may use many word patterns to cue the listener to their intent.
 Other word patterns that need further clarification for meaning include:
o Metaphors - a phrase that describes an object or a situation by comparing it to
something else familiar.
Client: “My son’s bedroom looks like a bomb went off.”
Nurse: “You’re saying your son is not very neat” (verbalizing the implied).
Client: “My mind is like mashed potatoes.”
Nurse: “I sense you find it difficult to put thoughts together” (translating into feelings).

o Proverbs- old accepted sayings with generally accepted meanings.

Client: “People who live in glass houses shouldn’t throw stones.”

Nurse: “Who do you believe is criticizing you but actually has similar problems?” (encouraging
description of perception)

o Cliché - an expression that has become trite and generally conveys a stereotype.
Client: “she has more guts than brains,” the implication is that the speaker believes the woman
to whom he or she refers is not smart, acts before thinking, or has no common sense.
The nurse can clarify what the client means by saying, “Give me one example of how you see
Mary as having more guts than brains” (focusing).
NONVERBAL COMMUNICATION SKILLS

Nonverbal Communication is the behavior a person exhibits

while delivering verbal content.
It includes facial expression, eye contact, space, time,
boundaries, and body movements.
Nonverbal communication is as important as, if not more so
than, verbal communication. It is estimated that one third of
meaning is transmitted by words and two thirds is
communicated nonverbally.
It involves the unconscious mind acting out emotions related to the verbal content, the
situation, the environment, and the relationship between the speaker and the listener.
Ways in which nonverbal messages accompany verbal messages (Knapp and Hall ,2009):

• Accent: using flashing eyes or hand movements

• Complement: giving quizzical looks, nodding

• Contradict: rolling eyes to demonstrate that the meaning is the opposite of what one is saying

• Regulate: taking a deep breath to demonstrate readiness to speak, using “and uh” to signal the
wish to continue speaking

• Repeat: using nonverbal behaviors to augment the verbal message, such as shrugging after
saying “Who knows?”

• Substitute: using culturally determined body movements that stand in for words, such as
pumping the arm up and down with a closed fist to indicate success

1. Facial Expression

The human face produces the most

visible, complex, and sometimes
confusing nonverbal messages.
Facial movements connect with
words to illustrate meaning; this
connection demonstrates the
speaker’s internal dialogue.

Categories of facial expressions:

 o Expressive face- these expressions may be evident even when the person
does not want to reveal his or her emotions.
o Impassive face- frozen into an emotionless deadpan expression similar to a
mask.
o Confusing facial expression -one that is the opposite of what the person
wants to convey.
o
Facial expressions often can affect the listener’s response.
o Strong and emotional facial expressions can persuade the listener to believe the
message.
o Looking away, not meeting the speaker’s eyes, and yawning indicate that the
listener is disinterested, lying, or bored.

Frowns, smiles, puzzlement, relief, fear, surprise, and anger are common facial
communication signals.

To ensure the accuracy of information, the nurse identifies the nonverbal

communication and checks its congruency with the content (Sheldon, 2008).

2. Body Language

Body language (gestures, postures, movements, and

body positions) is a nonverbal form of
communication.
Closed body positions (crossed legs or arms folded
across the chest)-indicate that the interaction might
threaten the listener who is defensive or not accepting.
A better and more accepting body position:

Open posture

 To sit facing the client with both feet on the floor,

knees parallel, hands at the side of the body, and
legs uncrossed or crossed only at the ankle.
 This demonstrates unconditional positive regard,
trust, care, and acceptance.
  The nurse indicates interest in and acceptance of the client by facing and slightly
leaning toward him or her while maintaining nonthreatening eye contact.
 Hand gestures add meaning to the content strengthen the meaning of words.
 The positioning of the nurse and client in relation to each other is also important.
Sitting beside or across from the client can put the client at ease, whereas sitting
behind a desk (creating a physical barrier) can increase the formality of the
setting and may decrease the client’s willingness to open up and communicate
freely.

3. Vocal Cues

Vocal cues are nonverbal sound signals transmitted

along with the content:

o Volume- the loudness of the voice, can

indicate anger, fear, happiness, or deafness.
o Tone -can indicate whether someone is
relaxed, agitated, or bored.
o Pitch -varies from shrill and high to low
and threatening.
o Intensity- the power, severity, and strength
behind the words, indicating the importance of the message.
o Emphasis- accents on words or phrases that highlight the subject or give insight
into the topic.
o Speed- the number of words spoken per minute.
o Pauses also contribute to the message, often adding emphasis or feeling.

Circumstantiality-The use of extraneous words with long, tedious descriptions. It can indicate
the client is confused about what is important or is a poor historian.

4. Eye Contact

Eye contact, looking into the other person’s

eyes during communication, is used to assess
the other person and the environment and to
indicate whose turn it is to speak; it increases
during listening but decreases while speaking
(DeVito, 2008).
 Messages that the eyes give include humor, interest, puzzlement, hatred, happiness,
sadness, horror, warning, and pleading.

Although maintaining good eye contact is

usually desirable, it is important that the
nurse doesn’t “stare” at the client.

5. Silence

Silence or long pauses in communication may indicate

many different things:
o The client may be depressed and struggling to
find the energy to talk.
o Sometimes pauses indicate the client is
thoughtfully considering the question before
responding.
o The client may seem to be “lost in his or her
own thoughts” and not paying attention to the
nurse.

It is important to allow the client sufficient time to respond, even if it seems like a long
time. It may confuse the client if the nurse “jumps in” with another question or tries to
restate the question differently.
Also, in some cultures, verbal communication is slow with many pauses, and the client
may believe the nurse is impatient or disrespectful if he or she does not wait for the
client’s response.