Learning Objectives
By the end of this section, you will be able to:
- Describe the significance of self-awareness in nursing practice
- Demonstrate therapeutic communication strategies and techniques when working with clients
- Identify barriers to therapeutic communication
- Discuss the therapeutic relationship and physical, emotional, and social boundaries between nurses and clients
- Explain treatment issues and obstacles in the therapeutic relationship
Therapeutic communication and relationships with clients are at the core of nursing. As nurses greet, involve, and evaluate clients, the manner of interaction is critical. The nurse must use communication techniques to help get the best picture of the client. Therefore, the nurse must know how to communicate effectively. Nurses learn and develop communication skills through every client and colleague interaction, and improving communication is a lifelong pursuit.
Nurses learn to use specific communication techniques and to identify the barriers to communication as they interact and practice with clients. There must be clear communication between nurse and client or there will be a disconnect between the message intent and the message received. If the client perceives the tone of voice of the nurse to be harsh or uncaring, for example, it might present a barrier to establishing trust between the nurse and the client. Active listening is key as a nurse. When the nurse is engaged in the therapeutic process and seeks to capture the meaning, intention, and content of the message, this is called active listening. It requires being an active participant in the communication process. Active listening entails facing the client, maintaining appropriate eye contact, and focusing on the client’s words, nonverbal cues, and body language. The nurse does so without judgment or interrupting for clarification.
Along with effective communication, nurses need to keep appropriate physical, emotional, social, and cultural boundaries to build and maintain a therapeutic and caring relationship. This section focuses on identifying, explaining, and demonstrating communication and therapeutic relationships as the foundation of the nursing process when caring for clients.
Self-Awareness
Nursing for clients who are in psychiatric care requires self-awareness, which entails a nurse being aware of their own behavior, responses, and thoughts during interactions with clients. A nurse with self-awareness will gain understanding of how to develop and improve upon these interactions. The Johari Window is a model of self-awareness (Figure 3.2) developed by American psychologists Joseph Luft and Harry Ingham in 1955. In this model, there are four quadrants: what is known to the person is the y-axis, and what is known to others is the x-axis.
The first quadrant is the arena. This is what is known to self and others. Thoughts are open and provided to others. Both verbal and nonverbal communication are open. The individuals that the person is interacting with are aligned with the person’s thoughts, opinions, and viewpoints.
Second, is the façade area. This area is where the person hides thoughts, feelings, and skills from others. They have capabilities that may be desired, but they choose to keep them to themselves. Those around the person do not know that they are holding anything back.
The blind spot is the next area. This is where others know things about the person, but the person is not aware of these things. Others know these skills, opinions, or viewpoints from prior experience with the person. Others may know the person can handle a situation or problem, based on prior interaction, but the person has no self-awareness of this.
Lastly, there is the unknown area. This area is where neither the person or others know the skills, thoughts, opinions, viewpoints, or feelings a person has. This is when a person does not know they have some idea or feeling and others do not know it either.
As a nurse, it is important to know where to start in communication with clients. It is best to be self-aware to improve and have the best outcome for the client. The nurse should start by sharing who they are, what their goal is for the communication, and encourage the client to do the same. The nurse should limit self-disclosure, which is an interactive communication process wherein one person shares information about themselves in an appropriate context, modeling the behavior for others in the therapeutic relationship. This can be a therapeutic technique, if utilized within professional boundaries. For example, if the client is tearful when talking about their children, the nurse may offer, “I’m a parent, too.” Used in proper context, this comment can show empathy while not elaborating or placing the focus on the nurse.
Link to Learning
This video explains how to use the Johari Window to increase self-awareness and thereby improve communication with clients.
Reflection should accompany and enhance self-awareness. There are many models of self-reflection in the research. One reflective model nurses often use is the Gibbs Reflective Cycle (Figure 3.3) because of its link between introspection and action.
There are six stages of this cycle: the description of the situation, what feelings erupt from the situation, evaluating what is good and not so good about the situation, analyzing the situation to determine what there is to learn from it, concluding what could be done differently, and developing an action plan to improve handling the situation next time. Self-awareness with self-reflection allows for further development of therapeutic communication and it enables the relationship between the nurse and client to remain open to change and become enriched with therapeutic actions.
Therapeutic Communication Strategies and Techniques
Communication is an art and a science. When a nurse supports, draws out information for an assessment, or provokes deeper understanding on what a client is communicating, they are participating in therapeutic communication. Communication between the client and the nurse must be honest, ethical, and legal. The science portion of communication relates to the process of how communication is accomplished. There is a sender and a receiver of the message. There is interpretation of the message also, through coding and encoding (Figure 3.4). The nurse needs to explain to the client that what the client reveals will be kept confidential within the treatment team. Information that relates to the health and safety of the client or others, or if the client is homicidal or suicidal, would be shared with the health-care team for the safety of all concerned. The client is made aware that this information will be confidentially shared with those who care for them.
While information in a medical record is privacy protected, there is legal precedent for releasing the information if it poses a serious threat to persons or the public, or when disclosure to law enforcement is required. See this link to the HIPAA Privacy Rule for further information.
Verbal Communication
There are five basic elements of the communication cycle:
- The sender/source: The sender is the one who transports the message. The sender role and the receiver role interact with one another in two-person communication.
- The message: The message is the intended purpose or content of the communication, what is said, relayed, or delivered.
- The channel or mode of communication: The channel is the manner through which the communication takes place. Is it through visual, auditory, or tactile senses?
- The receiver: The receiver is the one who gathers the message.
- Feedback: The feedback is the actual response to the sender.
Because this is a cycle, the elements follow one another, and the process continues, sometimes fluidly and sometime with gaps.
The closer the relationship or how much the two parties have in common often influences how similar the intent of the sent message is to the received message. Meaning and response will be more closely aligned when parties have more in common.
Nonverbal Communication
Communication that takes place without words is called nonverbal communication. It includes body movements, facial expressions (called affect), and gestures. It also includes nonverbal sounds, such as sighing, laughing, humming, or chuckling. Body movements and facial expressions, such as eye-rolling, grimacing, tapping the foot, crossing the legs and arms, posture, and eye contact or the lack of eye contact, help nurses see the emotion behind the words when communicating with a client. Nurses must be aware that there can be nonverbal messages behind their own body movements and facial expressions.
Sometimes the emotions revealed by nonverbal cues are different than the words that are accompanying them. As a nurse, it is vital to observe and assess the nonverbal signals clients are offering, both during conversations and at times when not verbally communicating with one another. If the client is squirming in their seat while being asked questions about their interaction with a person they are in conflict with, it tells the nurse the client is uncomfortable and to inquire about this feeling. Often, clients are unable to disclose their feelings verbally until the nurse points out the nonverbal signals. This can be an effective way to encourage clients to express themselves verbally, allowing the nonverbal to match the verbal.
Take note of the fact that in American culture, eye contact and head nodding demonstrate acknowledgment and are viewed as positive and agreeable accompaniments to interactions with words. At the same time, however, eye contact that is maintained for too long or in an intense manner can be interpreted as rude or jarring and aggressive. However, in some other cultures, eye contact does not indicate accord or agreement, but may be perceived as disrespectful. Likewise, although nodding in America generally indicates agreement, in some other cultures, it actually can mean “no” or “thank you” instead. Nurses must be aware of the possible meanings and interpretations of common gestures, facial expressions, and body movements across different cultures. The nurse must be mindful that gestures and expressions in one culture may not mean the same thing in another. Therefore, the nurse needs to be culturally sensitive. See Chapter 8 Cultural Considerations for more information on cultural awareness.
Clients are aware of the nurse’s facial expressions, so it is vital that nurses know what they look like when they are speaking (and not speaking) and how to convey concern, caring, and no judgment. If the nurse’s face expresses surprise at a client response, for example, the client may feel like they answered a question incorrectly and may attempt to alter their response to please the nurse or get the “right” answer.
Nonverbal information from a client can often provide a more accurate assessment of the client’s feelings than the verbal information. A client may say they are not in pain or are not sad, but then wince when the nurse reaches to assess the area or have a flat affect conveying sadness. The reason this information is often more accurate is there is less conscious control over nonverbal actions. If the verbal and nonverbal cues do not match, the nurse must be aware of this and note it as part of the assessment.
Cultural Context
Trust and Health Communication
As a nurse, it is important to be culturally sensitive with each client. There are certain cultural groups that, because of historical events or cultural mores, do not trust health providers and information; trust is built over time with health-care providers and nurses. When communicating with members of cultures that lack trust in the health-care system, it is important to ask the client if and how they prefer to be touched and to explain the unknown as much as possible. Nurses should convey respect and understanding, should ask for clarification, and should restate what the client is saying to ensure that the nurse is understanding correctly.
Along with this lack of trust, according to Maercker et al. (2019), certain groups also hold a strong belief in fatalism, that life events are determined by forces outside one’s control. As nurses engage with people with fatalistic beliefs, it is important to acknowledge and discuss some of these beliefs with them before offering assistance. Understanding this can help the nurse communicate better with the client. Overall, clients want to be well and want to know they are on the road to wellness. With some information and sensitivity, nurses can help clients from all cultures by empowering them with the tools to feel more in control of their health and to care for themselves.
Barriers to Therapeutic Communication
Nurses should be mindful of barriers to therapeutic communication so they can overcome the obstacles to communicate with clients effectively. Several common barriers to optimal therapeutic communication that nurses should avoid include challenging, probing, changing the subject, becoming defensive, providing false reassurances, disagreeing, judging, rejecting, and minimizing importance to the client. Here are some other barriers the nurse should consider.
Inattentive Listening
Clients notice when a nurse is not tuned into the communication. If the nurse breaks eye contact, appears to be daydreaming, fidgets, talks over the client, or asks a new question without waiting for an answer to the last one, the nurse is not being attentive. Other obvious inattentive behaviors include tapping the foot or pen on the table, looking at a watch or clock frequently in the interaction, or gazing at the computer or out the window while the client speaks. Nurses should make a concerted effort not only to be attentive, but also to communicate attentiveness. Utilizing similar or the same words a client says verbally communicates active listening. A nonverbal cue like nodding can go a long way toward making it clear that the nurse is listening.
Nurses may record data during interaction with clients, and this should be done with consideration of the client’s perception. A brief request or explanation can contribute to the therapeutic quality of the interaction, such as, “I will make a few notes while we talk,” or “I will be entering some information into the computer.”
Using Medical Terminology
When a nurse uses medical terminology without defining or explaining it clearly, it may create a barrier to communication with the client. Medical jargon can confuse a client, cause anxiety for them, and create a power differential between the nurse and client. The client may ultimately feel less informed because they do not understand the words the nurse is using and do not feel comfortable revealing their lack of understanding. At the same time, it is important that the nurse not talk down to the client; understanding and meeting the client where they are in terms of ability to understand information related to their health is a skill nurses should develop.
Asking Personal Questions Unrelated to the Visit
Asking inappropriate questions for the sake of interest is invasive. If the client chooses to communicate personal information, they will, but the nurse should not inquire about it. Examples of inappropriate questions would be those that address political party affiliation or views on reproductive issues, or questions that challenge the client’s coping, such as “Why do you always show up here when you are in trouble?” or “Don’t you think it is time for you to stay on your medications?”
Assessment questions should not include presumptions such as, “Since you refuse to answer the question about sex, are you gay?” These types of questions are inappropriate, judgmental, and cruel. Another is “I see you sitting close to that other male who visits you, daily. That is not your spouse. Is he your other spouse?” Again, this is intrusive. The nurse can ask the question as, “How are you related to the male visitor who comes daily?” The client can then answer as they want.
The nurse may have to gather personal information for therapeutic purposes, but should do it in a nonthreatening way. There are assessment data that will lead a nurse to ask personal questions to collect further information about the client or their situation. An example is if the client presents with signs and symptoms of physical abuse. Inquiring about how a bruise, abrasion, or laceration was acquired may lead the nurse to dig deeper with questioning. That client may show signs of apprehension and shifting eye contact if these questions require the client to admit abuse. This can be a very sensitive issue for the client. The nurse should be cognizant of this. The nurse must remain calm and professional. The nurse could say to the client, “I’m concerned about your safety. I can understand if this conversation is uncomfortable for you. I am here to help you and keep you safe.” A caring approach can help reassure the client that the nurse is seeking to gain a better understanding and thus advocate for the client.
Expressing Approval or Disapproval
Nurses should not agree or disagree with clients’ values and beliefs. It is the nurse’s responsibility to respect clients who carry different types of beliefs, whether they are in accord with the nurse’s or are diametrically opposed. If nurses use words, such as should, ought, good, bad, right, or wrong, these terms can send the message that the nurse is judging the client or their decision. The nurse may agree with the client’s decision process or the actual decision, just not the value of the decision. A therapeutic response may be, “It sounds like you have given this some thought,” or “I can see you have made a decision, tell me how you came to this outcome.”
Changing the Subject
When a client is disclosing something that is painful or personal, the nurse needs to use therapeutic techniques to show the client that the information is important and offer care and empathy while this disclosure is happening. Often, nurses who are uncomfortable with the client’s information will dismiss the message by changing the topic of discussion. Instead of changing the subject, nurses in this situation should use active listening and ask clarifying questions to keep the message flowing. Clients could view changing the subject as insensitive and uncaring.
Making Remarks That Are Minimizing
Saying something like, “At least you are not here for treatment for terminal cancer; it could be worse” conveys a lack of concern. These types of remarks, though they may be intended to offer a broader perspective, belittle a client’s message and feelings. They imply that the nurse is not taking the client’s questions or condition seriously. Any statement that begins with “at least” communicates one should be grateful for what is not happening. It implies that the problem the client is experiencing could be worse and to consider themselves fortunate. This is not an empathic response and works against the nurse’s objectives because the goal is to have the client open up and share more about their feelings and situation.
Providing False Reassurance
Similarly, when nurses offer trite responses to a client who is seriously distraught, it can come across as not genuine. It may be the intention of the nurse to offer hope or assurance when saying to a grieving parent, for instance, “In a few years, this will look totally different to you.” But the client may actually feel discounted and as if their feeling is not valid now, in the moment. The nurse can explore open-ended questions to encourage the client to discover their voice related to the issue. A better alternative statement of assurance may be, “I am sorry for your loss, grief is hard work and takes time.” Another alternative to speaking or replying to the client is to actively listen to the client’s thoughts and feelings. This allows the client to feel heard and validated.
Expecting Justifications
Asking “why” can imply an accusation or judgment and often results in defensiveness. For example, suppose a nurse asks a client, “Why did you take all the pills in the bottle, and then call 911?” In response, a client may feel challenged to defend their actions rather than dig deeper to the underlying emotions behind the actions. Instead, the nurse can ask, “Help me understand the desire to hurt yourself” or “Tell me your feelings at this time of self-harm.” These questions show concern and caring for the client and allow the client to explore the reason for their actions without feeling judged or defensive.
Disagreeing with the Client
Challenging the client’s perception of a situation can also create a barrier to therapeutic communication. It implies that they are lying, misinformed, or uneducated. For example, a nurse says to a client who has anorexia, “Your weight is exactly the same as last week, so you haven’t stayed on your nutritional plan in spite of you telling me you are hungry at lunchtime.” This statement accuses the client of noncompliance and lying, which can only serve to make the client feel attacked, guilty, and defensive, and that they have “failed” their plan of care. A better response is: “The numbers on the scale are the same as last week. Can you give me your food list for last week’s meals?” This helps the client explore with the nurse the reasons for the lack of weight change and is not challenging the client’s statement that they were hungry at lunchtime.
Knowing what not to do is part of learning how to care for clients. Self-awareness and knowledge of these communication barriers can help nurses enhance their therapeutic communication techniques and form positive and productive nurse-client relationships.
Therapeutic Nurse-Client Relationships
A therapeutic relationship is a healthy relationship that develops over time, and is based on mutual trust and respect. In the relationship, there is a nurturing of health, hope, wellness, empathy, and therapeutic interventions to help the client through their current encounter. It evolves through therapeutic communication and by understanding the phases of the nurse-client healing relationship. Here are the four phases of the therapeutic relationship as outlined by Peplau (1952):
- Pre-orientation phase: During this phase, the nurse self-reflects on their feelings, fears, and thoughts on the client and the client’s situation. The nurse analyzes their own personal and professional strengths and weaknesses in the context of the client. They collect information about the client and prepare a plan of care. This phase can be done after bedside report or grand rounds on the clients. This can often be collaborative with the nurse giving the report, discussing the best interventions or asking questions about what insightful thoughts, fears, or feelings the nurse has on the client and the circumstances they are currently in.
- Orientation phase: This phase is marked by establishing rapport with the client, gaining trust, and creating an environment where the client feels safe and accepted. The nurse gently starts the communication and collects data about the client’s feelings and reason for seeking assistance. The nurse also identifies problem areas and plans interventions. The nurse then establishes, with the client’s collaboration, mutual goals to help solve the problem(s). The nurse also explains the plan of care to the client. This includes when and how long the nurse will spend with the client and when expected discharge or termination of the relationship may occur.
- Working phase: This is the phase where most of the therapeutic interventions occur. The nurse and client work as a team to identify stressors, promote insight into the client’s problems, and find solutions and ways to implement them. During this phase, the nurse collects more data on the client, promotes healthy coping mechanisms, and helps the client understand their own behavioral changes by encouraging self-evaluation. The nurse is consistently encouraging the client to function independently and redefine the problem as needed.
- Termination phase: This is a critical phase in the nurse-client relationship, and, as mentioned above, is set at the Orientation phase. The main point in the plan of care is to have the client resolve their issues with independence and confidence. This is the phase that brings the relationship to an end. The nurse explains the reality of the separation and evaluates the effectiveness of therapy and the progress toward goals. The nurse and client mutually explore the feelings and behavior related to termination.
Nurses should be aware of these phases and assess progress toward the mission of each one, but should also know that the phases do not necessarily work chronologically. They are more fluid in nature, changing as the nurse and client work together and develop a relationship tailored to the client’s needs. These phases apply to relationships that have a short or longer time frame and in situations that are emergent or long-term. The therapeutic relationship requires having respect for each other. Respect within the relationship means honoring each other’s boundaries within the relationship.
Physical Boundaries
Relationships are characterized by different types of boundaries. It is important to establish and respect physical boundaries in any human interaction. It is particularly critical when developing a therapeutic nurse-client relationship where breach of physical boundaries may be part of the caregiving process. Physical boundaries include what people perceive to be their intimate, personal space, social, and public spaces. These boundaries also include who is allowed to be in these spaces and the degree to which (and by whom) they agree to be touched. According to Van Edwards (2021), proxemic is how much physical distance individuals like to have between them when conversing with other people. The anthropologist Edward Hall created the word in the early 1960s. He organized the boundaries as four zones: the intimate space, personal space, social space, and public space (Table 3.1).
| Zone | Distance | What It Means |
|---|---|---|
| Intimate Space | Physical contact to eighteen inches | It shows close partners, lovers, spouses, and closest of friends. |
| Personal Space | One to four feet in distance to the other person | It shows relationship status. The closer the parties, the relationship is closer in status, length of knowing, and agreement. |
| Social Space | Four to twelve feet in distance to the other person | Most strangers start at this distance; as the relationship develops, the distance will close, to no closer than four feet. |
| Public Space | Greater than twelve feet | Stranger, not known by each other in a public place, both parties are not in any need for contact. |
When interviewing a new client, it is important that the client feels physically safe to express themselves without feeling threatened or defensive. Nurses should carefully assess each client’s individual physical boundaries. Because caregiving may naturally intrude on the client’s physical space, it is paramount for the nurse to express understanding of a client’s boundaries, explain the need to cross them, ask for permission, and not be any more intrusive than a situation requires. Physical boundaries can be specific to a person’s culture. Therefore, nonverbal communication, such as body language, is important to assess when thinking about physical boundaries.
Emotional Boundaries
The nurse needs to assess the client’s emotional state and evaluate what is best for that client in terms of emotional limits. Once noted, the nurse must be self-aware to separate their own feelings from the client’s feelings. The nurse can have compassion and empathy for the client’s condition without passing judgment and becoming overly involved in placating the client, maintaining respect for the client’s emotional state. Respect toward the client and their reason for seeking assistance should be part of the nurse’s reflection during the communication. If the client is depressed, for instance, they may not be able to answer all the questions in one sitting. This client may need blocks of time to discuss the elements of the admission assessment. The client who is crying or despondent may need to reach an emotionally neutral status with the help of the nurse and then the assessment can move forward.
Social Boundaries
Social boundaries represent another important consideration when developing a therapeutic relationship with a client. The nurse should avoid socializing with clients except when making small talk to open a conversation or start an interview. Opening with a bit of socializing often places the client in a relaxed state. After that, however, a nurse should not share intimate details about their life, should not ask invasive and treatment-irrelevant questions about the client’s life, and should not take lunch or work breaks with clients. Maintaining professional boundaries takes self-reflection when a nurse finds themself reaching to create a friendship with a client.
When nurses share their own feelings about their lives or situations, it often crosses a line and creates a nontherapeutic relationship with the client. This burdens the client with the nurse’s feelings and problems. The nurse-client relationship should be a professional one, characterized by compassion, not a social one. Table 3.2 lists the differences between therapeutic and social relationships.
| Therapeutic Relationship | Social Relationship |
|---|---|
| Directed toward a client’s needs per nursing assessment; a nurse must not cross boundaries and share their personal story (if clients ask personal questions, answer briefly then return to the client’s experience. (“Yes, I have two children. Tell me about your kids.” “No, I have never had surgery. What’s this experience like for you?”) | Two-way: meets needs on both sides; each shares feelings and experiences with the other; may keep secrets, exchange phone numbers, loan/borrow money |
| Follows steps of the nursing process | Does not involve planning or evaluation |
| Involves empathy (acknowledging, respecting the other’s feelings and point of view, having compassion, being available for problem-solving) | Involves sympathy (sharing the person’s feelings, may feel pity, may view the other’s situation from own perspective, could involve judgment) |
| Planned termination with expectations set at the beginning: “I’ll be here until 3:00” | No particular time frame |
| Involves specific phases: pre-oreintation, working, and termination | Does not involve any formal stages |
| Never sexual, no expectation for client to meet the needs of the nurse, who must keep an emotional distance | May be sexual or codependent |
Treatment Issues and Obstacles
The focus should always be on the client, not on the nurse. If, because of crossed boundaries, the relationship starts to become nontherapeutic, nurses should first seek self-awareness about the situation, then ask for and accept feedback from peers and mentors about what path to take forward.
Other obstacles to creating therapeutic relationships when treating clients with psychiatric illnesses are side effects of medications, symptoms of the illnesses, and chronicity of the client’s diagnosis. Many clients enter psychiatric treatment during a crisis of their illness. This can limit the development of the nurse-client relationship until the crisis has subsided, medications reach a therapeutic level, and the environment is such that the client can communicate well. Hallucinations and delusions as symptoms, until treated successfully, can inhibit a developing nurse-client relationship. Sensory deficits can also encumber therapeutic relationships as can the chronic nature of psychiatric illnesses, which can cause hopelessness in clients and nurses alike. The nurse may need to confront and address their own conflicted feelings about clients’ ongoing interventions with their own working peers and supervisor. The nurse’s conscious and unconscious behaviors and attitude affect the therapeutic relationship with the client. If the therapeutic relationship becomes untherapeutic, this can have negative consequences for the client’s improvement and well-being.