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Psychiatric-Mental Health Nursing

6.1 Nurse-Client Relationship

Psychiatric-Mental Health Nursing6.1 Nurse-Client Relationship

Learning Objectives

By the end of this section, you will be able to:

  • Describe the phases of the nurse-client relationship
  • Discuss the importance of building trust and rapport between the nurse and client
  • Describe boundaries and how to maintain a professional nurse-client relationship

Establishment of the therapeutic nurse-client relationship is vital in nursing care. Nurses engage in compassionate, supportive, professional relationships with their clients as part of the “art of nursing” (American Nurses Association, 2021). This is especially true in psychiatric care, where the therapeutic relationship is the foundation of client care and healing (Ross & Goldner, 2009). The nurse-client relationship establishes trust and rapport with a specific purpose; it facilitates therapeutic communication and engages the client in partnership for decision-making regarding their plan of care.

Therapeutic nurse-client relationships vary in depth, length, and focus. Brief therapeutic encounters might last only a few minutes and focus on the client’s immediate needs, current feelings, or behaviors. For example, in the emergency department setting, a nurse may therapeutically communicate with a client in crisis who recently experienced a situational trauma. In inpatient care settings, nurses work with clients in setting short-term goals and outcomes that are documented in the nursing care plan and evaluated regularly. In long-term care settings, such as residential facilities, the therapeutic nurse-client relationship may last several months and include frequent interactions focusing on behavior modification.

Phases of the Nurse-Client Relationship

Hildegard Peplau is considered the mother of psychiatric nursing through her development of the interpersonal relations theory (see 2.2 Interpersonal Theories and Therapies). This theory helps nurses understand the importance of therapeutic communication with their clients. According to the theory, there are four phases of the nurse-client relationship: pre-orientation, orientation, working, and termination (see link 2.2 Interpersonal Theories and Therapies Peplau’s nurse/client relationship phases). This relationship is of a professional nature in which both the client’s and the nurse’s “feelings, emotions, and behaviors are taken into consideration” (Deane & Fain, 2016, p. 38). This theory is beneficial to nursing students as they learn how to communicate effectively with their clients.

Pre-orientation Phase

The pre-orientation phase is when the nurse prepares to meet the client by reviewing their chart, getting reports from another nurse or department, and planning for the initial assessment that will be performed with this client. This is a time when the nurse mentally readies for the interaction that is about to occur.

Orientation Phase

During the brief orientation phase, clients may realize they need assistance as they adjust to their current health status or condition. Simultaneously, nurses introduce themselves and begin to obtain essential information about clients as individuals with unique needs, values, beliefs, and priorities. During this phase, the nurse and the client begin to establish trust and develop a rapport. Nurses must ensure privacy when talking with the client and providing care and should respect the client’s values, beliefs, and personal boundaries.

A common framework used for introductions during the orientation phase of the nurse-client relationship is AIDET, a mnemonic for Acknowledge, Introduce, Duration, Explanation, and Thank You.

  • Acknowledge: Greet the client by their preferred name, verifying their identity per policy. Make eye contact, smile, and acknowledge any family or friends in the room. Ask the client their preferred way of being addressed (for example, “Mr. Doe,” “Jonathon,” or “Johnny”) and their preferred pronouns (e.g., he/him, she/her, or they/them).
  • Introduce: Introduce yourself by name and role. For example, “I’m John Doe, and I am a nursing student working with your nurse to take care of you today.”
  • Duration: Estimate a timeline for how long it will take to complete the task you are doing. For example, “I am here to perform an admission assessment. This should take about 15 minutes.”
  • Explanation: Explain step-by-step what to expect next and answer questions. For example, “I will be putting this blood pressure cuff on your arm and inflating it. It will feel as if it is squeezing your arm for a few moments.”
  • Thank you: At the end of the encounter, thank the client and ask if anything is needed before leaving. In an acute or long-term care setting, ensure the call light is within reach and that the client knows how to use it. If family members are present, thank them for being there to support the client as appropriate. For example, “Thank you for taking time to talk with me today. Is there anything I can get for you before I leave the room? Here is the call light (place within reach). Press the red button if you would like to call the nurse.”

It is during the orientation phase that nurses begin to understand the client as a person, while also being self-aware enough to recognize how the interaction affects them. Acting professionally, asking questions, listening to the client’s answers, and setting the tone for the rest of the interaction provides a foundation for a strong nurse-client rapport.

Working Phase

Most of the nurse’s time with a client is spent in the working phase. During this phase, nurses use active listening and begin by asking the reason the client is seeking care to determine what is important to them. Nurses use therapeutic communication techniques to facilitate clients’ awareness and encourage them to express their thoughts and feelings. They also use this time to develop goals and an individualized plan of care. Nurses provide reflective and nonjudgmental feedback to clients to help them clarify their thoughts, goals, and coping strategies (Hagerty et al., 2018). If a care plan has already been established on admission, nurses use this time to implement interventions targeted to meet short-term objectives and long-term goals. During the working phase, clients begin to accept nurses as health educators, counselors, and care providers. During this phase, the nurse also acts as a resource person who assists the client in gathering more information about their illness (Deane & Fain, 2016).

Resolution/Termination Phase

The final phase of a nurse-client relationship is the termination phase. This phase typically occurs at the end of a shift or on discharge from care. Success in the working phase means that the client, nurses, and interprofessional health-care team members have met the client’s needs. The nurse should be aware that the client may try to return to the working phase to avoid termination of the relationship. During the termination phase, the nurse can encourage the client to reflect on progress they have made and review post discharge goals. Even student nurses can be involved in discharge teaching as the client prepares to return to their normal routines (Deane & Fain, 2016). The nurse also makes community referrals for follow-up and continuation of support to meet goals. During this phase, the nurse reviews how well the plan of care worked. They can then apply the knowledge gathered to the care provided to future clients.

Building Trust and Rapport

The theory of interpersonal relations is holistic in the way that it uses both verbal and nonverbal communication skills to assist the client in dealing with their illness (Deane & Fain, 2016). The student nurse can learn a lot about communication by using this theory to guide their interactions with their clients. Deane and Fain (2016) suggest that gaining education about the importance of communication will allow nursing students to develop “empathy, active listening, the use of silence and touch, and being there” (p. 37). A nurse develops rapport by offering themselves as a genuine presence, being aware of nonverbal communication, being empathetic, and actively listening. Correct use of these techniques will increase trust and rapport between the student nurse and the client.

Peplau’s theory is based on what happens between two people, focusing on feelings, emotions, and behaviors of both the nurse and the client. Having students practice their communication skills through dialogue with their clients not only increases the nursing students’ self-confidence, but also helps to grow the level of rapport between the student and the client. Deane and Fain (2016) point out that this interaction encourages the student to have conversations with their clients and not simply concentrate on the tasks at hand. After the interaction has taken place, the instructor can then meet with the student to talk about what did and did not work during the interaction, giving feedback and support as needed to guide the student.

Boundaries in the Therapeutic Relationship

The limits people set to define their levels of comfort when interacting with others are called boundaries. Personal boundaries include those in the physical, sexual, intellectual, emotional, and financial areas of people’s lives. Boundaries promote safety in relationships at work, home, and with partners by protecting one’s well-being and limiting the stress response. For example, if an individual comes away from a meeting or conversation with someone feeling depleted, anxious, or tense, they might consider if something in the meeting crossed their boundaries. It is important to maintain professional boundaries, while also building rapport. For example, you might talk about your family in a general way with a client, but you would not provide specific and personal details to them. You may also have to reinforce professional boundaries if a client attempts to contact you via social media or asks you to continue contact after care is completed. A lack of healthy personal boundaries, or situations that consistently penetrate and cross those boundaries, can lead to emotional and physical fatigue (Pattemore, 2021).

Five major types of boundaries include (Pattemore, 2021):

  • Physical: Physical boundaries refer to one’s personal space, privacy, and body. For example, some people are comfortable with public displays of affection (hugs, kisses, and hand-holding), while others prefer not to be touched in public.
  • Sexual: Sexual boundaries refer to one’s comfort level with intimacy and attention of a sexual nature. This can include sexual comments and touch, not just sexual acts.
  • Intellectual: Intellectual boundaries refer to one’s thoughts and beliefs. When someone dismisses another person’s ideas and opinions, they are crossing intellectual boundaries.
  • Emotional: Emotional boundaries refer to a person’s feelings. For example, an individual might not feel comfortable sharing feelings with another person and may prefer to share information gradually over time.
  • Financial: Financial boundaries refer to how one earns money as well as how one prefers to spend or save money.

When caring for clients with mental health disorders, it is common to notice problems with setting appropriate boundaries. For example, a client experiencing bipolar disorder may exhibit a lack of financial and sexual boundaries. When they are experiencing a manic episode, they may spend thousands of dollars on a credit card over a weekend or have sexual relations with someone they just met. Another example of boundary issues is an individual with a depressive disorder who is treated poorly by their partner but does not leave or assert boundaries because they don’t feel that they deserve to be treated any better.

Nurses must establish professional boundaries with all clients while also maintaining a respectful and caring relationship. Due to their professional role, nurses have authority and access to sensitive information that can make clients feel vulnerable. A Nurses Guide to Professional Boundaries by the National Council of State Boards of Nursing (NCSBN, 2018) states that it is the nurse’s responsibility to use clinical judgment to determine and maintain professional boundaries. Nurses should limit self-disclosure of personal information and avoid situations where they have a personal or business relationship with a client. The difference between a caring nurse-client relationship and an overinvolved relationship can be difficult to discern, especially in small communities or in community health nursing where roles may overlap. In these circumstances, it is important for the nurse to openly acknowledge their dual relationship and recognize when they are performing in a professional capacity. Signs of inappropriate boundaries within the nurse-client relationship include the following (National Council of State Boards of Nursing, 2018):

  • self-disclosing intimate or personal issues with a client
  • engaging in behaviors that could be interpreted as flirting
  • keeping secrets with a client
  • believing the nurse is the only one who truly understands or can help the client
  • spending more time than is necessary with a particular client
  • speaking poorly about colleagues or the employment setting with the client and/or their family
  • showing favoritism to a particular client
  • meeting a client in settings outside of work
  • contacting or permitting contact by a client and/or their family members using social media

Several concepts related to therapeutic boundaries of which a nursing student should be aware include transference and countertransference. Transference is when the client reacts emotionally toward the nurse when triggered by memories of a past relationship. This could happen, for example, if the nurse resembles someone from the client’s life or if the nurse provides support that the client wishes they were receiving from their significant other and this support makes the client feel extra close to the nurse.

Countertransference occurs when the nurse has these types of triggers toward the client. For example, if the client reminds the nurse of a previous client who was angry and threatening, those feelings might influence the nurse’s attitude toward the current client. It is important for health-care professionals to regularly perform self-reflection exercises to monitor and adjust their reactions to their clients (Prasko et al., 2022). Establishing professional boundaries with clients diagnosed with mental health disorders is essential due to the vulnerability of the client population, as well as the behavioral manifestations of some disorders. For safety purposes, nurses and nursing students should keep their last name, home address, personal telephone number, and social media handles private.

Real RN Stories

Nurse: Lenore, MSN, RN-BC
Years in Practice: 19
Clinical Setting: Community mental health center
Geographic Location: New Hampshire

In my years as a psychiatric nurse, I have always been cautious about nurse-client boundaries. In fact, I teach my nursing students the importance of maintaining strict boundaries. Our nursing role is meant to have the client’s best interests as the focus of our interactions with them. We cannot muddy the waters by accepting their friend request on Facebook or building a relationship with them after our nursing role is over. Even if we build a strong rapport with a long-term client, it is better to terminate the entire relationship once the nursing relationship has reached the termination phase.


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