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BRIDGES & BARRIERS IN

THE THERAPEUTIC
RELATIONSHIP

Dr. Muhammad Arsyad Subu

 Learning Outcomes
 Identify concepts of nurse – client therapeutic relationships: respect, caring, empowerment,
trust, empathy, mutuality, and confidentiality.
 Describe nursing actions designed to promote therapeutic relationships: trust, empowerment,
empathy, mutuality and confidentiality
 Describe barriers to the development of therapeutic relationships: anxiety, stereotyping, and
lack of personal space, culture and gender differences
 Identify nursing actions that can be used in therapeutic relationships to reduce anxiety and
respect personal space and confidentiality.
 Discuss barriers and bridges of effective therapeutic communication.
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 1. NURSE – CLIENT
THEAPEUTIC RELATIONSHIP
 How Does Nurse's Interaction
and Communication Affect
Client?
 INTRODUCTION
 Nurse’s interaction/relationship and communication skills influence
client outcomes such as:
1. satisfaction with care

2. level of anxiety

3. adherence to treatment (adherence versus compliance with

treatment).

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 BRIDGES & BARRIERS IN
THERAPEUTIC RELATIONSHIP
 To establish a therapeutic relationship, the nurse must:
• Understand & apply concepts of respect, caring,
empowerment, trust, empathy, mutuality, and veracity;
which are bridges to therapeutic relationship
• Appreciate barriers such as anxiety, stereotyping, violations
of personal space or violations of confidentiality

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 BRIDGES & BARRIERS IN
THERAPEUTIC RELATIONSHIP

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 BRIDGES & BARRIERS TO
RELATIONSHIP
 Bridges – Respect:
• Convey genuine respect for client’s values & opinions

• Asking client how he/she would prefer to be addressed

and always addressing him as such.
• Avoid addressing someone as “baba, mama, habibi,
“mom, hold your baby” or “how are we feeling
today?”

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 BRIDGES & BARRIERS TO
RELATIONSHIP
 Barrier - Lack of Respect (disrespectful):
• In study (William & Irurita, 2004) , clients felt devalued when
they felt that staff were avoiding talking with them or were
unfriendly
• Lack of respect among health care team has been cited as cause
of adverse client outcomes.

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 BRIDGES TO RELATIONSHIP
 Bridges – Caring:
• Caring is an intentional human action
• One person (nurse) offers caring to another (client) through therapeutic
relationship
• In professional nursing, the focus of a caring relationship is placed on
meeting the client’s needs
• Clients can focus on accomplishing the goals of health care instead of
worrying about whether caring is forthcoming.
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 BRIDGES TO RELATIONSHIP

 Bridges – Caring:
• The nurse in a caring relationship gives of herself/himself to a client

through compassion, concern, and interest

• Caring has a positive influence on client health status and healing, as well,

on providing the nurse with job satisfaction

• As a caring nurse, you will involve clients in their struggle for health &

well being rather than simply doing for your clients.

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BRIDGES & BARRIERS TO
RELATIONSHIP
 Barrier - Lack of caring:
• When there is lack of caring, a nurse is apathetic, trying to
meet her own needs rather than the client’s needs
• Nurse rushed to meet multiple demands & forgetting to
focus on client, is showing lack of caring.

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 BRIDGES & BARRIERS TO
RELATIONSHIP
 Bridges – Empowerment:
 Empowerment encourages clients to assume responsibility for their own health; in
contrast to paternalistic approach, “I know what is best for you or I can do it
better”
 Through therapeutic communication, we provide information, tools, & resources to
help our clients reach their health goals
 The more involved a client is in his care, the better the health outcome; also
empowered clients feel valued, adopt successful coping methods, and think
positively.
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 BRIDGES & BARRIERS TO
RELATIONSHIP
 Bridges – Empowerment:
• Empowerment addressed in
Orem’s self-care theory.

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 BRIDGES & BARRIERS TO
RELATIONSHIP
 Barrier – Empowerment:
• Study has shown that lack of information about giving care, managing
medicines, or recognizing approaching crises were major barriers to
empowering family members to care for sick relatives
• Failure to:

allow client to assume personal responsibility; or

provide client with appropriate resources and support weakens client

empowerment.
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 BRIDGES TO
RELATIONSHIP
 Bridges – Trust:
 Establishing trust is foundation in all relationships which enables nurse to make
accurate assessment of client needs
 In nurse-client relationship, developing sense of feeling safe is key
 In a trusting relationship, client feels comfortable to reveal his needs to the nurse,
and nurse is perceived as dependable
 In nurse-client relationship, maintaining an open exchange of information
contributes to trust.

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 BRIDGES TO
RELATIONSHIP TRUST
Techniques That Promote Trust
 Convey respect
 Consider client’s uniqueness
 Show warmth and caring
 Use client’s proper name
 Use active listening
 Give sufficient time to answer questions
 Maintain confidentiality
 Show congruence between verbal & nonverbal behaviors
 Use warm, friendly voice
 Use appropriate eye contact
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 BRIDGES TO
RELATIONSHIP TRUST
Techniques That Promote Trust (cont.)

 Smile
 Be flexible
 Provide for allowed preferences
 Be honest and open
 Give complete information
 Provide consistency
 Plan schedules
 Follow through on commitments
 Set limits
 Use attending posture; arms, legs, & body relaxed; leaning slightly forward.

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 BRIDGES TO RELATIONSHIP

 Barrier: Mistrust
 Mistrust has an impact not only on communication but on healing process outcomes

 Examples that lead to mistrust:

 A nurse who labels a client as “noncompliant” because he fails to follow treatment regimen
 Pediatric nurse who tells child that an injection will not hurt
 Nurse telling client that she will be back to change soaked bed sheets & never does
 Client who provides false misleading information.

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 BRIDGES TO RELATIONSHIP

 Bridges – Empathy:
 Ability to be sensitive to and communicate understanding of client’s
feelings
 It is ability of nurse to put herself into the client’s position, however,
holding on to her objectivity and maintaining separate identity from
client
 Empathy is associated with improved client satisfaction & adherence to
treatments.
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 BRIDGES TO RELATIONSHIP

 Bridges – Empathy (cont.):

• Communicate empathy by using verbal & nonverbal
communication behaviors: maintain direct eye contact, use
attending open body language, and keep calm tone of voice.
• Acknowledge client's message about his feelings by restating
what you understand him to be conveying, and have him
validate that this is accurate.

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 BRIDGES TO RELATIONSHIP
 Barrier: Lack of Empathy:
• Failure to understand needs of clients may lead nurse to fail to provide essential
client education or needed emotional support
• Major barriers to empathy exist in the clinical environment, such as: lack of
privacy, lack of time, lack of support, lack of trust.
• It results in less favorable health outcomes and lower client satisfaction.

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 BRIDGES TO
RELATIONSHIP
 Bridges – Mutuality:
• Means that nurse and client agree on:
• client’s health problems
• means for resolving them, and
• are committed to enhancing client’s well-being.

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 BRIDGES TO
RELATIONSHIP
 Bridges – Mutuality:
• A nurse respects client autonomy and value system
• In developing mutuality, you maximize your client’s involvement
in all phases of nursing process
• Evidence of mutuality is seen in development of individualized
client goals and nursing actions that meet a client’s unique needs
• Upon termination of mutual relationship, both parties experience a
sense of accomplishment & satisfaction.

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 BRIDGES TO RELATIONSHIP
 Evaluating mutuality with the client:
 After terminating with a client, answer the following questions:

1. Was I satisfied with the relationship?

2. Did the client express satisfaction with the relationship?

3. Did the client share feelings with me?

4. Did I make decisions for the client?

5. Did the client feel allowed to make his own decisions?

6. Did the client accomplish his goals?

7. Did I accomplish my goals?

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 BRIDGES TO RELATIONSHIP
 Bridges – Veracity (truthfulness):
 Veracity (truthfulness) contributes to the establishment of a
therapeutic relationship with clients
 When client knows he can expect truth from nurse, trust is
promoted between nurse - client and helps build the
relationship.

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 BARRIERS TO THE
RELATIONSHIP
 Other barriers in nurse-client relationship:
1. Anxiety

2. Stereotyping

3. Over involvement

4. Violation of personal space

5. Culture

6. Gender differences.

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 OTHER BARRIERS IN NURSE-CLIENT
RELATIONSHIP

 Anxiety:
 It is a vague, persistent feeling of impending‫حدوث‬LL‫وشيك لا‬
danger
 Universal feeling, impact on self is always uncomfortable
 Occurs when a threat (real or imagined) to one’s self-
concept is perceived
 Lower satisfaction with communication leads to client’s
increased anxiety.
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 OTHER BARRIERS IN NURSE-CLIENT RELATIONSHIP

 Anxiety:
1. A mild anxiety heightens one’s awareness of surrounding
environment & promotes learning & decision making;
desirable when health teaching is given.
2. Moderate to severe anxiety on part of nurse or client hinders
development of therapeutic relationship; thus, to accomplish
goals, greater levels of anxiety must be reduced
3. Severe anxiety requires medical and psychiatric intervention.

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 OTHER BARRIERS IN NURSE-
CLIENT RELATIONSHIP
 Stereotyping:
 It is attributing characteristics to a group of people as though all persons in
identified group possessed them
 It can be on basis of: ethnic origin, culture, religion, social class, occupation,
age, health issues (mental illness), etc. (men have less feelings than women)
 Stereotypes are learned during childhood and reinforced by life experiences.

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 OTHER BARRIERS IN NURSE-CLIENT
RELATIONSHIP

 Stereotyping (cont.):
• Stereotypes go against empathy and destroy nurse-client relationship
• We, as nurses, must be aware of our stereotypes about people (such as study
done in 2008 that revealed nurses’ distrust in fathers’ competence to provide
care for ill children).

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 OTHER BARRIERS IN NURSE-CLIENT
RELATIONSHIP

 Stereotyping (cont.):
 Stereotypes based on strong emotions are called prejudices‫عصب‬
LLL‫ ت‬, less open to
change; in the extreme, these prejudices can lead to discrimination ‫مييز‬
LLL‫ ت‬in
which a person is denied legitimate opportunity offered to others
 Acceptance of the other person, needs to be total: unconditional acceptance;
acceptance occurs without judgment.

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 THANKS
SEE YOU IN MEETING 2