This document discusses therapeutic communication and the nurse-patient relationship. It begins by defining communication and outlining communication skills. It then discusses the importance of establishing a therapeutic relationship between nurses and patients. Some key points include: The goals of therapeutic communication are to establish a relationship with the patient, identify their main concerns, facilitate expression of emotions, and guide the patient towards resolving issues. Effective communication relies on both verbal and nonverbal skills like active listening. Relationship development occurs in phases from pre-orientation to termination. Building rapport, trust, respect, genuineness and empathy are important characteristics of a positive therapeutic relationship.

1. Unit 5-Therapeutic
communication and interpersonal
relationship
Mr. Vinodkumar Patil

2. Objectives
• General objective
▫ After completion of the unit student is able to
establish effective nurse patient relationship

3. Specific objectives
 Define communication
 Explain communication skills
 Describe the relevance of a therapeutic nurse-client
relationship.
 Discuss the dynamics of a therapeutic nurse-client
relationship.
 Discuss the importance of self-awareness in the
nurse-client relationship.
 Identify goals of the nurse-client relationship.
 Describe the phases of relationship development
and the tasks associated with each phase.

4. Introduction
• Communication refers to
• Communication is very significant in nursing

5. Definitions of Communication
• It is a complex process of sending and receiving
verbal and nonverbal messages and allows for
exchange of information’s, feelings, needs and
preference.
• Communication is the process that people use
to exchange information. Messages are
simultaneously sent and received on two levels:
verbally through the use of words and
nonverbally by behaviors that accompany the
words (Balzer Riley, 2000).

6. Conti…
• Communication is ‘a process by which two or
more people exchange ideas, facts, feelings or
impressions in ways that each gains ‘common
understanding’ of meaning, intent and use of a
message’. – Paul Leagens.
• Webster’s New Collegiate Dictionary defines
“Communication as a process by which information
is exchanged between individuals through a
common system of symbols, signs or behavior. A
person who sends the message is called sender or
encoder and the other who receives the message is
called receiver or decoder.

7. Communication skills or Abilities of
the Nurse
• GENERAL ABILITIES
▫ Ability to read
▫ Ability to express oneself in writing
▫ Ability to speak
▫ Ability to listen and interpret

8. SPECIAL ABILITIES
• Ability to observe and interpret observation
• Ability to guide the nurse-patient interaction in
order to accomplish goals.
• Ability to recognize when to speak and when to
be silent - developing a sense of timing.
• Ability to wait - to proceed at the patient's
pace/speed.
• Ability to evaluate participation of the patient in
the nurse-patient relationship.

9. Communication takes place on two
levels
• Verbal Communication
• Nonverbal Communication
▫ It has been estimated that about 7% of meaning is
transmitted by words
▫ 38% is transmitted by paralinguistic cues such as
voice
▫ And 55% is transmitted by body cues.

10. Types of Nonverbal Behavior
• Vocal cues include all the nonverbal qualities of
speech.
• Action cues are body movements
• Object cues are the speaker's intentional and
non-intentional use of all objects

11. Conti…
• Space
▫ Intimate space: up-to 18 inches
▫ Personal space: 18 inches to 4 feet
▫ Social-consultative space: 9 to 12 feet
▫ Public space: 12 feet and more
• Touch

12. Elements of a professional
communication
• Courtesy
▫ To practice courtesy, the nurse says hello, goodbye
and knock the door before entering, and use self
introduction.
▫ The nurse states her purpose, address people by
name, say please and thank you to team members
are included in it.

13. Conti…
• Use of names
• Privacy and confidentiality
• Trustworthiness
▫ Being trustworthy means helping others without
hesitation when help is needed.
▫ To foster trust, the nurse communicates warmth
and demonstrates consistency, reliability, honesty
and competence.

14. Conti…
• Autonomity and Responsibility
▫ Autonomity is the ability to be self directed and
independent in gain goals and advocating for
others
• Assertiveness
▫ It comprises respect for others, respect for
yourself, self awareness, and effective, clear, and
consistent communication.
▫ Assertiveness conveys a sense of self assurance
while also communicating respect for the other
person.

15. In last class
• Definition of communication
• Levels of communication
• Abilities of nurse
• Elements of professional communication

16. Types of communication techniques
• Therapeutic communication technique
▫ These are specific responses that encourage the
expression of feelings and ideas and convey the
nurse’s acceptance and respect.
• Non-therapeutic communication
technique
▫ The technique, which hinder or damage
professional relationships are called non-
therapeutic communication techniques.

17. Goals of therapeutic communication
• 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 unfolded
• Facilitate the client’s expression of emotions

18. Conti…
• 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.

19. Principles and Characteristics of
Therapeutic communication
• The patient should be the primary focus of
interaction
• A professional attitude sets the tone of the
therapeutic relationship
• Use self-disclosure cautiously and only when it
has a therapeutic purpose.
• Avoid social relationship with patients
• Maintain patient confidentiality

20. Conti…
• Assess the patient’s intellectual competence to
determine the level of understanding
• Implement interventions from a theoretic base
• Maintain a non-judgmental attitude. Avoid
making judgments about patient’s behavior
• Avoid giving advice
• Guide the patient to reinterpret his or her
experiences rationally.

21. Therapeutic communication
technique
• Interview
▫ face to face interaction
▫ Helps
▫ Interview can be structured or unstructured
• History collection
• Mental status examination
• Health education
• Counseling

22. Conti…
• Active listening
▫ Several nonverbal skills have been identified as
facilitative skills for attentive listening. SOLER.
▫ S – Sit facing the client
▫ O – Observe an open posture
▫ L – Lean toward the client
▫ E – Establish and maintain intermittent eye
contact
▫ R – Relax

23. Therapeutic value
• Listening is an active process of receiving
information.
• Non-verbally communicates to the patient the
nurse’s interest and acceptance.

24. Empathy
• Is the ability to understand and accept another
person’s reality to accurately perceive feelings,
and to communicate this understanding to the
client.
• Definition:
• Ability to enter in to the life of other person, to
accurately perceive his current feelings and their
meanings. It understands the patients’ world
from his internal frame of reference rather than
from the nurses own external frame of reference.

25. Development of Empathy
• Nurse must be receptive to the patients feeling
and perceptions
• Nurse must understand the patients
communication
• Nurse should be able to put herself in the
patient’s place and assume his role and
communicate this understanding to patient
• It’s not desirable to feel the same emotions as
the patient
• Empathy should not be confused with sympathy

26. Conti…
• Several therapeutic communication techniques,
such as reflection, restatement, and clarification,
help the nurse to send empathetic messages to
the client.
• For example, a client says, “I’m so confused! My
son just visited and wants to know where the
safety deposit box key is.”

27. Conti…
• Using reflection, the nurse responds, “You’re
confused because your son asked for the safety
deposit key?”
• The nurse using clarification responds, “Are you
confused about the purpose of your son’s visit?”

28. A nursing study conducted by Mansfield identified specific
verbal and nonverbal behaviors that conveyed high levels
of empathy to patient:
• Having nurse introduce himself/herself to the patient
• Head and body positions turned towards patient and
occasionally leaning forward
• Verbal responses to the patients previous comments,
responses that focus on his strengths and resources
• Consistent eye contact, facial expressions
• Conveying interest, concern, and warmth by the nurse’s
own facial expression
• A tone of voice consistent with facial expressions and
verbal responses
• Mirror imaging of body positions and gestures

29. Techniques Conti…
• Accepting: Conveys an attitude of reception
and regard.
• Example: “Yes.” “I follow what you said.”
Nodding
• Rationale: An accepting response indicates the
nurse has heard and followed the train of
thought.

30. Broad Openings
• Allows the client to take the initiative in
introducing the topic; emphasizes the
importance of the client's role in the interaction.
• Example: “Is there something you’d like to talk
about?” “Where would you like to begin?”
• Rationale: Broad openings make explicit that the
client has the lead in the interaction.
• For the client who is hesitant about talking,
broad openings may stimulate him or her to take
the initiative.

31. Encouraging description of
perceptions
• Asking the client to verbalize what is being
perceived; often used with clients experiencing
hallucinations.
• Example: “Tell me when you feel anxious.”
“What is happening?” “What does the voice
seem to be saying?”
• Rationale: To understand the client, the nurse
must see things from his or her perspective.

32. Conti…
• Restating
• Reflecting
• Focusing

33. Exploring
• Delving further into a subject, idea, experience,
or relationship; especially helpful with clients
who tend to remain on a superficial level of
communication.
• Example: “Tell me more about that.” “Would you
describe it more fully?” “What kind of work?”
• Rationale: When clients deal with topics
superficially, exploring can help them examine
the issue more fully.

34. Seeking clarification and validation
• Clarifying the meaning of what has been said
facilitates and increases understanding for both
client and nurse.
• Example: “Tell me whether my understanding of it
agrees with yours.” “Are you using this word to
convey that . . . ?”
• Rationale: For verbal communication to be
meaningful, it is essential that the words being used
have the same meaning for both (all) participants.
• Sometimes words, phrases, or slang terms have
different meanings and can be easily
misunderstood.

35. Presenting reality
• When the client has a misperception of the
environment, the nurse defines reality.
• Example: “I see no one else in the room.” “Your
mother is not here; I am a nurse.”
• Rationale: When it is obvious that the client is
misinterpreting reality, the nurse can indicate what
is real.
• The nurse does this by calmly and quietly expressing
the nurse’s perceptions or the facts not by way of
arguing with the client or belittling his or her
experience

36. Touch
• Many messages, such as affection, emotional
support, encouragement, tenderness, and
personal attention are conveyed through touch.

37. Knapp (1980) identified five types of
touch:
• Functional-professional touch
• Social-polite touch
• Friendship-warmth touch
• Love-intimacy touch
• Sexual-arousal touch

38. Using silence
• Silence allows the client to think and gain
insight.

39. Non-therapeutic communication
techniques
• Asking personal questions
• Giving personal opinions
• Changing the subject
• False reassurance
• Sympathy
• Approval or disapproval
• Passive or aggressive responses
• Arguing
• Rejecting

40. Barriers in effective communication
• Personal barriers
▫ Language
▫ Mental state
▫ Personality complexes
▫ Bias and prejudice
▫ Impatience
▫ Inhibition attitude
▫ Hospitalization
▫ Cultural factors
▫ Age and sex

41. Conti…
• Physical impediments
• Psychological factors
• Mechanical factors
• Educational difference
• Organizational barriers
• Rumours
• Pathological barriers

42. Dynamics of therapeutic nurse patient
relationship
• 1. Therapeutic use of self:
– Is defined as the ability to use one’s personality
consciously and in full awareness in an attempt to
establish relatedness and to structure nursing
interventions.
• 2. Self awareness:
– The process of understanding one’s own beliefs,
thoughts, motivations, biases and limitations and
recognizing how they affect others.

43. 3. Johari window
1. 2
Behaviors, feelings and thoughts known
to the individual and others
Things that other know but the individual
does not know
3 4
Private/hidden self things about self
known only to self.
Unknown self aspects of the self that are
unknown to the individual and to others.

44. Therapeutic Nurse Patient relationship

45. INTRODUCTION
• The nurse-client relationship is the foundation
upon which psychiatric nursing is established.
• It is a relationship in which both participants
must recognize each other as unique and
important human beings.
• It is also a relationship in which mutual
learning occurs.

46. Definition of relationship
• It is defined as a state of being related or state
affinity between two individuals. Example-
friendship and colleagues
• TYPES OF RELATIONSHIP
– SOCIAL RELATIONSHIP
– INTIMATE RELATIONSHIP
– THERAPEUTIC RELATIONSHIP

47. SOCIAL RELATIONSHIP
• It is most common type of relationship between
two individuals in every day life.
• Individuals are equally involved in this relationship
and meet their needs through relationship
• There is no predetermined goal or focus in
relationship.
• Continuation of the relationship is not determined
at the onset
• It may last for months or years.
• Ex: friends, work colleagues and neighbors.

48. INTIMATE RELATIONSHIP
• It is the relationship between two individuals
committed to one another, caring for and
respecting each other.
• The intimate relationship forms the basis for
marriage and other partner type relationship

49. THERAPEUTIC RELATIONSHIP
• Definition therapeutic relationship:
–it is a relationship where the nurse and
client work together towards the goal
of assisting the client to regain the
inner resources to meet life challenges
and facilitate growth.

50. Conti…
• It is the professional relationship
• The client and nurse work together
• It is goal oriented, interaction is purposefully
established

51. GOALS OF THE THERAPEUTIC NURSE
CLIENT RELATIONSHIP
• The nurse helps the client to cope with the present
problems
• The nurse helps the client to understand his
problem
• The nurse helps the client to find out a new
alternative for his or her problem
• The nurse helps the client to communicate.
• The nurse helps the client to socialize
• The nurse helps the client to find a meaning in his
illness

52. Characteristics
• Rapport
• Trust
• Respect
• Genuineness
• Empathy

53. Rapport
• Rapport implies special feelings on the part of
both the client and the nurse based on
acceptance, warmth, friendliness, common
interest, a sense of trust and non judgmental
attitude.

54. Trust
• To trust another, one must feel confidence in
that person’s presence, reliability, integrity,
veracity and sincere desire to provide
assistance when requested.
• Trustworthiness is demonstrated through
nursing interventions that convey a sense of
warmth and caring to the client.

55. Respect
• To show respect is to believe in the dignity and
worth of an individual regardless of his or her
unacceptable behavior.
– Calling the client by name ( and title, if the client
prefers)
– Spending time with the client
– Allowing for sufficient time to answer the client’s
questions and concern.

56. Genuineness
• The concept of genuineness refers to the
nurse’s ability to be open, honest, and “real”
in interactions with the client.

57. Empathy
• Empathy is the ability to see beyond outward
behavior and to understand the situation from
client’s point of view.
• With empathy, while understanding the
client’s thoughts and feelings, the nurse is
able to maintain sufficient objectivity to allow
the client to achieve problem resolution with
minimal assistance

58. PHASES OF NURSE CLIENT
RELATIONSHIP
1. Pre-orientation phase
2. Orientation phase
3. Working phase
4. Termination phase

59. PRE-INTERACTION PHASE
• Definition:
– This is a phase in which a nurse goes through
before the actual interaction with the client.
– This phase begins when the nurse is assigned a
client to develop therapeutic relationship with
him, till she goes to him for interaction.

60. Reaction of the nurse in pre-
interaction phase
• The nurse feels and thinks about the client
before interaction according to her
knowledge, fears and mis-concepts
• Express feelings of inadequacy and fear of
hurting or exploiting the client
• Fear of psychiatric clients related to the
stereotyped psychiatric clients abusive and
violent behaviour

61. Conti…
• Nurse tries to collect information from secondary
sources
• The nurse plans how she is going to interact with
the clients.
• The nurse may express anxiety regarding the client
related to whether my client talks to me? He may
not like me or not accept me?
• The nurse should also explore feelings of inferiority,
insecurity, approval seeking behavior etc.

62. TASKS
• Explores own feelings, fantasies and fears
• Analyze own professional strengths and
limitations
• Gather data about client wherever possible
• Plan for first meeting with client .
• Set the objectives for interaction phase
• Takes help of the clinical supervisor or co-
worker to overcome fears.

63. PROBLEMS ENCOUNTERED
• Difficulty in self analysis and self acceptance
• Anxiety
• Nurse may also experience boredom, anger,
indifference and depression

64. WAYS TO OVERCOME
• The nurse needs help from her supervisor and
peers in self analysis and feeling reality in
order to help clients to do likewise.
• This provides opportunity to explore feelings
and fears and develops useful insight into
one’s professional role

65. INTRODUCTORY / ORIENTATION
PHASE
• Definition:
– This is a phase which begins when the nurse goes
to the client, introduces self and gets introduction
about him.
– The nurse and client who are strangers meet for
the first time and become acquaintances.
– This ends when the client and nurse accept each
other as a unique human being.

66. TASKS
• Establishment of contact, rapport, trust and
acceptance
• Establish communication, assist in the verbal
expression of thoughts and feelings
• Gather data, including the client’s feelings,
strengths and weaknesses
• Define client’s problems, set priorities for
nursing intervention
• Mutually set goals

67. WORKING PHASE
• During this phase the nurse and client actively
work on meeting the goals which they had
established during the orientation phase.
• The characteristic features of this phase are
that the nurse is able to overcome anxiety and
the client’s fear of unknown is also decreased.

68. TASKS
• The nurse collects the data in detail from primary
and secondary sources and identifies the needs of
the client
• The nurse assists the client to identify his or her
problems
• Help the client to communicate
• Encourages the client to socialize
• The nurse helps the client to find an alternative
solution to his or her problem or development of
insight and use of constructive coping mechanism

69. Conti…
• Encourages the client to use new patterns of
behavior
• The nurse helps the client to understand that he has
a significant role in his treatment
• She prepares the client for termination of
relationship by reminding him during the interviews
• Provide him with opportunities for independent
functioning
• Evaluate problems and goals, refine as necessary

70. Working phases helps the nurse to
• Develop knowledge and skills in psychiatric
nursing
• Identifies his/her strengths and weaknesses as a
nurse while interacting with the client
• She/he learns to take guidance from experts and
the supervisor during difficulty
• Group discussion about the client helps her to
share her knowledge with other team members.

71. BARRIERS
• Testing of nurses
• Progress of the client
• Difficulty in collecting and interpreting the
data
• Fear of closeness
• Life stresses of the nurse
• Resistance behaviour
• Transference
• Counter transference

72. TERMINATION PHASE
• It is also called as resolution phase or end
phase.
• Goal:
– To bring a therapeutic end to the relationship.

73. CRITERIA FOR DETERMINING CLIENT’S
READINESS FOR TERMINATION
• Client experiences relief from presenting
problems
• Client social function has improved and
isolation has decreased
• Clients ego functions are strengthened and he
has attained a sense of identity
• Client employs more effective and productive
defense mechanisms
• Client has achieved planned treatment goals

74. CAUSES OF TERMINATION
• The client may be discharged
• The client may go on parole and does not come
back to the hospital
• The nurse may terminate relationship due to
various reasons i.e., the student nurse completes
her psychiatric posting or experience or client has
improved and no longer needs to have one to one
relationship
• When the client is in hospital and the nurse
terminates relationship

75. TASKS OF TERMINATION PHASE
• Establish reality of separation
• Mutually, explore feelings of rejection, loss,
sadness, anger and related behaviour
• Review progress of therapy and attainment of
goals
• Formulate plans for meetings future therapy
needs.

76. Dynamics of therapeutic Nurse-Patient
Relationship
1. Therapeutic use of self
2. Gaining self-awareness
3. The Johari window

77. Therapeutic use of self
• The ability to use one’s personality consciously
and in full awareness in an attempt to
establishing relatedness and to structure
nursing interventions.

78. Gaining self-awareness
• Self awareness is the process of understanding
one’s own beliefs, thoughts, motivations,
biases and limitations and recognising how
they affect others.

79. The Johari window
• One tool that is useful in learning more about
oneself is the Johari window
• which 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:

80. Conti…
• 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

81. Therapeutic impasses