 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 nurse–client
relationship.
A therapeutic nurse-patient relationship is defined
as “a helping relationship that's based on mutual
trust and respect, the nurturing of faith and hope,
being sensitive to self and others, and assisting
with the gratification of your patient's physical,
emotional, and spiritual needs through your
knowledge and skill”.
 Crucial components involved in establishing
appropriate therapeutic nurse–client
relationships: trust, genuine interest,
acceptance, positive regard, self-awareness,
and therapeutic use of self.
 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. Trust 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.
 Trust is built in the nurse–client relationship
when the nurse exhibits the following
behaviors:
 Caring
 Openness
 Objectivity
 Respect
 Interest
• Understanding
• Consistency
• Treating the client as a human being
• Suggesting without telling
• Approachability
• Listening
• Keeping promises
• Honesty
 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.
 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.
 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
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.
 The nurse who appreciates the client as a unique
worthwhile human being can respect the client
regardless of his or her behavior, background, or
lifestyle. This unconditional nonjudgmental
attitude is known as positive regard and implies
respect.
 It is 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.
It 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.
 The values clarification process has three
steps:
 Choosing
 Prizing
 Acting. Choosing is when the person
considers
 When the person considers the range of
responsibilities and freely chooses the
value that feels right.
 Is when the person considers the value,
cherishes it, and publicly attaches it to
himself or herself.
 Acting is when the person puts the value
into action.
 Beliefs are ideas that one holds to be
true, for example, “All old people are
hard of hearing,”
 Attitudes are general feelings or a frame
of reference around which a person
organizes knowledge about the world.
 Zunaira Aziz
Senior Nursing Instructor
Medicare College of Nursing
 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.
“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”. The four areas
evaluated are as follows:
 Quadrant 1: Open/public self—qualities
one knows about oneself and others also
know.
 Quadrant 2: Blind/unaware, self qualities
known only to others.
 Quadrant 3: Hidden/private, self qualities
known only to oneself.
 Quadrant 4: Unknown, an empty
quadrant to symbolize qualities as yet
undiscovered by oneself or others.
Carper (1978) identified four patterns of
knowing in nursing:
 Empirical knowing (derived from the
science of nursing)
 Personal knowing (derived from life
experiences)
 Ethical knowing (derived from moral
knowledge of nursing)
 Aesthetic knowing (derived from the art
of 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 views without
imposing any of his or her values or
viewpoints.
All relationships may be categorized into
three major types:
 Social
 Intimate
 Therapeutic .
 A social relationship is primarily initiated
for the purpose of friendship,
socialization, companionship, or
accomplishment of a task.
 When a nurse greets a client and chats
about the weather or a sports event or
engages in small talk or socializing, this is
a social interaction.
 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 intimate relationship has no place in
the nurse–client interaction.
 This relationship differs from the social or
intimate relationship in many ways because
it focuses on the needs, experiences,
feelings, and ideas of the client only. The
nurse and client agree about the areas to
work on and evaluate the outcomes.
 The nurse uses communication skills,
personal strengths, and understanding of
human behavior to interact with the client.
In the therapeutic relationship the
parameters are clear: the focus is the
client’s needs, not the nurse’s.
 Teacher
 Advocate
 Parent Surrogate
 Care giver
 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.
 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.
 In the advocate role, the nurse informs
the client and then supports him or her in
whatever decision he or she makes.
 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.
 When a client exhibits child-like behavior
or when a nurse is required to provide
personal care such as feeding or
bathing, the nurse may be tempted to
assume the parental role as evidenced
in choice of words and nonverbal
communication.
 Zunaira Aziz
Senior Nursing Instructor
Medicare College of Nursing
 Peplau’s model (1952) has three phases:
 Orientation
 Working
 Resolution or termination
In real life, these phases are not that clear-
cut; they overlap and interlock.
This begins when the nurse and client meet
and ends when the client begins to identify
problems to examine. During the
orientation phase:
 The nurse establishes roles
 The purpose of meeting
 The parameters of subsequent meetings
 Identifies the client’s problems and
clarifies expectations.
 It is usually divided into two sub phases:
 Problem identification, the client
identifies the issues or concerns causing
problems.
 Exploitation ,the nurse guides the client
to examine feelings and responses and
to develop better coping skills and a
more positive self- image; this
encourages behavior change and
develops independence.
• 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.
 The termination is the final stage in the
nurse–client relationship. It begins when
the problems are resolved, and it ends
when the relationship is ended.
 The nurse has power over the client by
virtue of his or her professional role. That
power can be abused if excessive
familiarity or an intimate relationship
occurs or if confidentiality is breached.
 All staff members, both new and
veteran, are at risk for allowing a
therapeutic relationship to expand into
an inappropriate relationship. Self-
awareness is extremely important
 The nurse must maintain professional
boundaries to ensure the best
therapeutic outcomes. It is the nurse’s
responsibility to define the boundaries of
the relationship clearly in the orientation
phase and to ensure those boundaries
are maintained throughout the
relationship. The nurse must act warmly
and empathetically but must not try to
be friends with the client
 The nurse must not let feelings of
empathy turn into sympathy for the
client.
 Unlike the therapeutic use of empathy,
the nurse who feels sorry for the client
often tries to compensate by trying to
please him or her.
 When the nurse’s behavior is rooted in
sympathy, the client finds it easier to
manipulate the nurse’s feelings. This
discourages the client from exploring his
or her problems, thoughts, and feelings;
discourages client growth; and often
leads to client dependency.
 The nurse–client relationship can be
jeopardized if the nurse finds the client’s
behavior unacceptable or distasteful
and allows those feelings to show by
avoiding the client or making verbal
responses or facial expressions of
annoyance or turning away from the
client.
 The nurse should be aware of the client’s
behavior and background before
beginning the relationship; if the nurse
believes there may be conflict, he or she
must explore this possibility with a
colleague.