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CHAPTER II. THE NURSING PROCESS IN PSYCHIATRIC MENTAL HEALTH CARE

LESSON 3: PLANNING AND IMPLEMENTATION OF CARE

INTRODUCTION OF THE LESSON

AND PRESENTATION OF OUTCOMES

Based on the assessment and diagnosis, the nurse sets measurable and achievable
short- and long-range goals for the patient. Assessment data, diagnosis, and goals are written
in the patient’s care plan so that nurses as well as other health professionals caring for the
patient have access to it. Nursing care is implemented according to the care plan, so
continuity of care for the patient during hospitalization and in preparation for discharge needs
to be assured. The care plan is individualized to the client’s mental health problems,
condition, or needs and is developed in collaboration with the client, significant others, and
interdisciplinary team members, if possible. For each diagnosis identified, the most
appropriate interventions, based on current psychiatric/mental health nursing practice and
research, are selected.

This lesson describes the planning and implementation of care in psychiatric mental
health care. Specifically, it explores on the principles, goals, components, phases, and factors
affecting communication and the phases of development of a therapeutic nurse-client
relationship. Moreover, it also includes the discussion of the Mental Health Gap Action
Programme (mhGAP) and the different treatment modalities.

LEARNING OUTCOMES FOR THIS LESSON

At the end of this lesson, you must have:

1. Described the relevance and dynamics of a therapeutic nurse-client

relationship.
2. Identified goals of the nurse-client relationship.
3. Identified and discussed essential conditions for a therapeutic
relationship to occur.
4. Described the phases of relationship development and the tasks
associated with each phase.
5. Identified types of preexisting conditions that influence the outcome of
the communication process.
6. Identified components of nonverbal expression.
7. Described therapeutic and nontherapeutic verbal communication
techniques.
8. Described active listening.
9. Discussed therapeutic feedback.

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LEARNING OUTCOMES FOR THIS LESSON

At the end of this lesson, you must have:

10. Described the differences among social, intimate, and therapeutic

relationships.
11. Described and implement the phases of the nurse–client relationship.
12. Described mhGAP and its integration with psychiatric nursing care.
13. Applied the concepts and principles of mhGAP in the care of psychiatric
patients.
14. Described the different treatment modalities in psychiatric care.
15. Explained the goals of the different treatment modalities in psychiatric
care.
16. Described the role of a nurse in the the different treatment modalities in
psychiatric care.

WARM-UP ACTIVITY. For example, you have arrived for your first day
on the psychiatric unit. You are apprehensive, uncertain what to
expect, and standing in a row just inside the locked doors. You are not
at all sure how to react to your clients and are fearful of what to say
at the first meeting. Suddenly, you hear one of the client shout, “Oh
look, the learners are here. Now we can have some fun!” Another
client replies, “Not me, I just want to be left alone.” A third client says,
“I want to talk to the good-looking one.” When working with a client
with psychiatric problems, some of the symptoms of the disorder,
such as paranoia, low self-esteem, and anxiety, may make trust
difficult to establish. Given the situation, how are you going to
establish rapport with your client?

CENTRAL ACTIVITIES

This part of the lesson includes four learning inputs and activities. You need to
accomplish the activities and submit them in the designated folders of this lesson.

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LEARNING INPUT 1.

Nurse-Client Communication

The nurse-client relationship is the foundation on 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. To
relate therapeutically with a patient, it is necessary for the nurse to understand his or her role
and its relationship to the patient’s illness. The role of the nurse is described as providing the
client with the opportunity to identify and explore problems in relating to others, discover
healthy ways of meeting emotional needs, and experience a satisfying interpersonal
relationship.

The therapeutic interpersonal relationship is the process by which nurses provide care
for clients in need of psychosocial intervention. Therapeutic use of self is the instrument for
delivery of that care. Interpersonal communication techniques (both verbal and nonverbal)
are the “tools” of psychosocial intervention.

Principles, Dynamics and Components of Therapeutic Communication

The ability to establish therapeutic relationships with clients is one of the most
important skills a nurse can develop. Although important in all nursing specialties, the
therapeutic relationship is especially crucial to the success of interventions with clients
requiring psychiatric care because the therapeutic relationship and the communication within
it serve as the underpinning for treatment and success.

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 (Wasajja, 2018). Verbal communication
consists of the words a person uses to speak to one or more listeners. In verbal
communication, content is the literal words that a person speaks. Context is the environment
in which communication occurs and can include time and the physical, social, emotional, and
cultural environments. Context includes the situation or circumstances that clarify the
meaning of the content of the message. Nonverbal communication is the behavior that
accompanies verbal content such as body language, eye contact, facial expression, tone of
voice, speed and hesitations in speech, grunts and groans, and distance from the listeners.
Nonverbal communication can indicate the speaker’s thoughts, feelings, needs, and values
that he or she acts out mostly unconsciously.

Process denotes all nonverbal messages that the speaker uses to give meaning and
context to the message. The process component of communication requires the listeners to
observe the behaviors and sounds that accent the words and to interpret the speaker’s
nonverbal behaviors to assess whether they agree or disagree with the verbal content. A
congruent message is conveyed when content and process agree. For example, a client says,
“I know I haven’t been myself. I need help.” She has a sad facial expression and a genuine and

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sincere voice tone. The process validates the content as being true. But when the content and
process disagree—when what the speaker says and what he or she does do not agree—the
speaker is giving an incongruent message. For example, if the client says, “I’m here to get
help,” but has a rigid posture, clenched fists, and an agitated and frowning facial expression
and snarls the words through clenched teeth, the message is incongruent. The process or
observed behavior invalidates what the speaker says (content).

Therapeutic communication is an interpersonal interaction between the nurse and the

client during which the nurse focuses on the client’s specific needs to promote an effective
exchange of information. Skilled use of therapeutic communication techniques helps the
nurse understand and empathize with the client’s experience. All nurses need skills in
therapeutic communication to effectively apply the nursing process and to meet standards of
care for their clients. Therapeutic communication can help nurses accomplish many goals:
1. Establish rapport with the client by being empathetic, genuine, caring, and
unconditionally accepting of the client regardless of his or her behavior or beliefs.
2. Actively listen to the client to identify the issues of concern and to formulate a client-
centered goal for the interaction.
3. Gain an in-depth understanding of the client’s perception of the issue and foster
empathy in the nurse–client relationship.
4. Explore the client’s thoughts and feelings.
5. Facilitate the client’s expression of thoughts and feelings.
6. Guide the client in developing new skills in problem-solving.
7. Promote the client’s evaluation of solutions.

Establishing a therapeutic relationship is one of the most important responsibilities of

the nurse when working with clients. Communication is the means by which a therapeutic
relationship is initiated, maintained, and terminated. To have effective therapeutic
communication, the nurse must also consider privacy and respect of boundaries, use of touch,
and active listening and observation.

Privacy is desirable but not always possible in therapeutic communication. An

interview in a conference room is optimal if the nurse believes this setting is not too isolative
for the interaction. The nurse can also talk with the client at the end of the hall or in a quiet
corner of the day room or lobby, depending on the physical layout of the setting. The nurse
needs to evaluate whether interacting in the client’s room is therapeutic. For example, if the
client has difficulty maintaining boundaries or has been making sexual comments, then the
client’s room is not the best setting. A more formal setting would be desirable. Proxemics is
the study of distance zones between people during communication. People feel more

comfortable with smaller distances when communicating with someone they know rather
than with strangers (McCall, 2017). People generally observe four distance zones:
• Intimate zone (0–18 in between people): this amount of space is comfortable for
parents with young children, people who mutually desire personal contact, or
people whispering. Invasion of this intimate zone by anyone else is threatening
and produces anxiety;

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• personal zone (18–36 in): This distance is comfortable between family and
friends who are talking;
• social zone (4–12 ft): This distance is acceptable for communication in social,
work, and business settings; and
• public zone (12–25 ft): This is an acceptable distance between a speaker and an
audience, small groups, and other informal functions (Hall, 1963).

Both the client and the nurse can feel threatened if one invades the other’s personal
or intimate zone, which can result in tension, irritability, fidgeting, or even flight. When the
nurse must invade the intimate or personal zone, he or she should always ask the client’s
permission. For example, if a nurse performing an assessment in a community setting needs
to take the client’s blood pressure, he or she should say, “Mr. Smith, to take your blood
pressure I will wrap this cuff around your arm and listen with my stethoscope. Is this
acceptable to you?” He or she should ask permission in a yes-or-no format so the client’s
response is clear. This is one of the times when yes-or-no questions are appropriate.

The therapeutic communication interaction is most comfortable when the nurse and
client are 3 to 6 ft apart. If a client invades the nurse’s intimate space (0–18 in), the nurse
should set limits gradually, depending on how often the client has invaded the nurse’s space
and the safety of the situation.

As intimacy increases, the need for distance decreases. Knapp (1980) identified five
types of touch: 1) functional–professional touch is used in examinations or procedures such
as when the nurse touches a client to assess skin turgor or a massage therapist performs a
massage; 2) social–polite touch is used in greeting, such as a handshake and the “air kisses”
some people use to greet acquaintances, or when a gentle hand guides someone in the
correct direction; 3) friendship–warmth touch involves a hug in greeting, an arm thrown
around the shoulder of a good friend, or the backslapping some people use to greet friends
and relatives; 4) love–intimacy touch involves tight hugs and kisses between lovers or close
relative; and 5) sexual–arousal touch is used by lovers.

Touching a client can be comforting and supportive when it is welcome and permitted.
The nurse should observe the client for cues that show whether touch is desired or indicated.
For example, holding the hand of a sobbing mother whose child is ill is appropriate and
therapeutic. If the mother pulls her hand away, however, she signals to the nurse that she
feels uncomfortable being touched. The nurse can also ask the client about touching (e.g.,
“Would it help you to squeeze my hand?”). The nurse must evaluate the use of touch based
on the client’s preferences, history, and needs. The nurse may find touch supportive, but the
client may not. Likewise, a client may use touch too much, and again the nurse must set
appropriate boundaries.

Although touch can be comforting and therapeutic, it is an invasion of intimate and

personal space. Some clients with mental illness have difficulty understanding the concept of
personal boundaries or knowing when touch is or is not appropriate. Clients with a history of
abuse have had others touch them in harmful, hurtful ways, usually without their consent.
They may be hesitant or even unable to tell others when touch is uncomfortable.

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Consequently, most psychiatric inpatient, outpatient, and ambulatory care units have policies
against clients touching one another or staff. Unless they need to get close to a client to
perform some nursing care, staff members should serve as role models and refrain from
invading clients’ personal and intimate space. When a staff member is going to touch a client
while performing nursing care, he or she must verbally prepare the client before starting the
procedure. A client with paranoia may interpret being touched as a threat and may attempt
to protect him or herself by striking the staff person.

To receive the sender’s simultaneous messages, the nurse must use active listening
and active observation. Active listening means refraining from other internal mental activities
and concentrating exclusively on what the client says. Active observation means watching the
speaker’s nonverbal actions as he or she communicates.

Peplau (1952) used observation as the first step in the therapeutic interaction. The
nurse observes the client’s behavior and guides him or her in giving detailed descriptions of
that behavior. The nurse also documents these details. To help the client develop insight into
his or her interpersonal skills, the nurse analyzes the information obtained, determines the
underlying needs that relate to the behavior, and connects pieces of information (makes links
between various sections of the conversation). Active listening and observation help the
nurse recognize the issue that is most important to the client at this time, know what further
questions to ask the client, use additional therapeutic communication techniques to guide
the client to describe his or her perceptions fully, understand the client’s perceptions of the
issue instead of jumping to conclusions, and interpret and respond to the message
objectively.

Nonverbal communication is the behavior a person exhibits while delivering verbal

content. It includes facial expression, eye contact, space, time, boundaries, and body
movements.

Facial expression. Facial movements connect with words to illustrate meaning; this
connection demonstrates the speaker’s internal dialogue. Facial expressions can be
categorized into expressive, impassive, and confusing: a) an expressive face portrays the
person’s moment-by-moment thoughts, feelings, and needs. These expressions may be
evident even when the person does not want to reveal his or her emotions; b) an impassive
face is frozen into an emotionless deadpan expression similar to a mask; and c) a confusing
facial expression is one that is the opposite of what the person wants to convey. A person
who is verbally expressing sad or angry feelings while smiling is exhibiting a confusing facial
expression.

Body language. Body language (e.g., gestures, postures, movements, and body
positions) is a non- verbal form of communication. Closed body positions, such as crossed
legs or arms folded across the chest, indicate that the interaction might threaten the listener
who is defensive or not accepting. A better, more accepting body position is to sit facing the
client with both feet on the floor, knees parallel, hands at the side of the body, and legs
uncrossed or crossed only at the ankle. This open posture demonstrates unconditional
positive regard, trust, care, and acceptance. The nurse indicates interest in and acceptance of

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the client by facing and slightly leaning toward him or her while maintaining nonthreatening
eye contact.

Vocal cues. Vocal cues are nonverbal sound signals transmitted along with the
content: voice volume, tone, pitch, intensity, emphasis, speed, and pauses augment the
sender’s message. Volume, the loudness of the voice, can indicate anger, fear, happiness, or
deafness. Tone can indicate whether someone is relaxed, agitated, or bored. Pitch varies from
shrill and high to low and threatening. Intensity is the power, severity, and strength behind
the words, indicating the importance of the message. Emphasis refers to accents on words or
phrases that highlight the subject or give insight into the topic. Speed is the number of words
spoken per minute. Pauses also contribute to the message, often adding emphasis or feeling.

Eye contact. The eyes have been called the mirror of the soul because they often
reflect our emotions. Messages that the eyes give include humor, interest, puzzlement,
hatred, happiness, sadness, horror, warning, and pleading. Eye contact, looking into the other
person’s eyes during communication, is used to assess the other person and the environment
and to indicate whose turn it is to speak; it increases during listening but decreases while
speaking (Wasajja, 2018). Although maintaining good eye contact is usually desirable, it is
important that the nurse doesn’t “stare” at the client.

Silence. Silence or long pauses in communication may indicate many different things.
The client may be depressed and struggling to find the energy to talk. Sometimes, pauses
indicate the client is thoughtfully considering the question before responding. At times, the
client may seem to be “lost in his or her own thoughts” and not paying attention to the nurse.
It is important to allow the client sufficient time to respond, even if it seems like a long time.
It may confuse the client if the nurse “jumps in” with another question or tries to restate the
question differently.

Factors Affecting Communication

There are many reasons why interpersonal communications may fail. In many
communications, the message (what is said) may not be received exactly the way the sender
intended. It is, therefore, important that the communicator seeks feedback to check that their
message is clearly understood. Environment, physical limitations and kinesics all contribute
to the way people communicate. These are some of the barriers to communication and these
may occur at any stage in the communication process. Barriers may lead to your message
becoming distorted and you therefore risk wasting both time and/or money by causing
confusion and misunderstanding. Effective communication involves overcoming these
barriers and conveying a clear and concise message.

Environment. People usually communicate most effectively in a comfortable

environment, temperature extremes, excessive noise, and a poorly ventilated environment
can all interfere with a client’s communication. Lack of privacy about matters consider by the
client as private A client who is worried about the ability of his wife to care for him after
discharge from hospital may not wish to discuss this concern with a nurse within hearing of
other clients in the room.

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Kinesics. A person’s body position will communicate messages in several ways. For
example, when a nurse stands over and peers down at a seated patient, it may demonstrate
the desire of the nurse to maintain some distance physically or appear to have a position of
authority. This quite rightly may be perceived by the patient as indicating that the nurse is not
really concerned and does not care to listen. Slumping body posture may indicate disinterest
or boredom. Folded arms may indicate a resistance to hearing a message. To demonstrate a
willingness to communicate effectively with your patients, you need to communicate at eye
level with the other person, lean slightly forward, and maintain an open body posture.

Physical limitations. Communication barriers are experienced by people who have

disabilities that affect hearing, speaking, reading, writing, and or understanding, and who use
different ways to communicate than people who do not have these disabilities.

Mental illnesses can result in memory loss, for instance, in dementia patients. This
condition can cause permanent damage to communication abilities and require
comprehensive approaches and therapies for treatment. According to studies, mental health
issues such as depression and anxiety may lead to speech deficits such as long pauses during
a conversation. People who are depressed tend to be interrupted a lot because of this. It can
further influence their social skills and dysphasia (swallowing pattern).

Bipolar patients, on the other hand, may remain active and social. However, they can
occasionally characterize erratic behavior and communication difficulties. Mental illnesses
can affect both children and adults. In children, selective mutism is among the prevalent
mental health conditions that require early addressing. Mental illness affects how you talk
and what you say.

Types of Communication

The nurse can use many therapeutic communication techniques to interact with
clients. The choice of technique depends on the intent of the interaction and the client’s
ability to communicate verbally. Overall, the nurse selects techniques that facilitate the
interaction and enhance communication between client and nurse. Table 1 lists these
techniques and gives examples.

Table 1. Therapeutic Communication Techniques

Therapeutic Examples Rationale

Communication
Technique
Accepting— indicating “Yes.” An accepting response indicates
reception “I follow what the nurse has heard and followed
you said.” the train of thought. It does not
Nodding indicate agreement but is
nonjudgmental. Facial
expression, tone of voice, and so

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forth also must convey

acceptance or the words lose
their meaning.
Broad openings— “Is there Broad openings make it explicit
allowing the client to take something that the client has the lead in
the initiative in you’d like the interaction. For the client
introducing the topic to talk who is hesitant about talking,
about?” broad openings may stimulate
“Where would him or her to take the
you like to initiative.
begin?”
Consensual “Tell me For verbal communication to be
validation— whether my meaningful, it is essential
searching for understanding that the words being used have
mutual of it agrees the same meaning for both
understanding, for with yours.” or all participants. Sometimes,
accord in the “Are you using words, phrases, or slang
meaning of the this word to terms have different meanings
words convey to different people and can
that…?” be easily misunderstood.
Encouraging “Was it Comparing ideas, experiences,
comparison— something or relationships brings out
asking that like…?” many recurring themes. The
similarities and “Have you had client benefits from making
differences be similar these comparisons because he
noted experiences?” or she might recall past
coping strategies that were
effective or remember that he
or she has survived a similar
situation.
Encouraging “Tell me when To understand the client, the
description of you feel nurse must see things from his
perceptions— anxious.” or her perspective. Encouraging
asking the client to “What is the client to fully describe
verbalize what he happening?” ideas may relieve the tension
or she perceives “What does the the client is feeling, and he or
voice seem to she might be less likely to take
be saying?” action on ideas that are
harmful or frightening.
Encouraging “What are your The nurse asks the client to
expression— feelings in consider people and events in
asking the client to regard to…?” light of his or her own values.
appraise the “Does this Doing so encourages the
quality of his or contribute to client to make his or her own
her experiences your appraisal rather than to accept
distress?” the opinion of others.

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Exploring—delving “Tell me more When clients deal with topics

further into a about that.” superficially, exploring can
subject or an idea “Would you help them examine the issue
describe it more fully. Any problem or
more fully?” concern can be better
“What kind of understood if explored in depth.
work?” If the client expresses an
unwillingness to explore a
subject, however, the nurse
must respect his or her wishes.
Focusing— “This point The nurse encourages the client
concentrating on a seems worth to concentrate his or her
single point looking at energies on a single point, which
more closely.” may prevent a multitude
“Of all the of factors or problems from
concerns overwhelming the client. It is
you’ve also a useful technique when a
mentioned, client jumps from one topic
which is most to another.
troublesome?”
Formulating a plan “What could It may be helpful for the client
of action—asking you do to let to plan in advance what he or
the client to your anger out she might do in future similar
consider kinds of harmlessly?” situations. Making definite
behavior likely to “Next time this plans increases the likelihood
be appropriate in comes up, that the client will cope more
future situations what might effectively in a similar situation.
you do to
handle it?”
General leads— “Go on.” General leads indicate that the
giving “And then?” nurse is listening and following
encouragement to “Tell me about what the client is saying without
continue it.” taking away the initiative for the
interaction. They also encourage
the client to continue if he or
she is hesitant or uncomfortable
about the topic.
Giving information “My name is Informing the client of facts
—making …” increases his or her knowledge
available the facts “Visiting hours about a topic or lets the client
that the client are …” know what to expect. The
needs “My purpose in nurse is functioning as a
being here resource person. Giving
is …” information also builds trust with
the client.

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Giving recognition “Good morning, Greeting the client by name,

—acknowledging, Mr. S …” indicating awareness of change,
indicating “You’ve or noting efforts the client has
awareness finished your made all show that the nurse
list of things recognizes the client as a
to do.” person, as an individual. Such
“I notice that recognition does not carry the
you’ve notion of value, that is, of
combed your being “good” or “bad.”
hair.”
Making “Are you Sometimes clients cannot
observations— uncomfortable verbalize or make themselves
verbalizing what when…?” understood. Or the client may
the nurse perceives “I notice that not be ready to talk.
you’re biting
your lip.”
Offering self— “I’ll sit with you The nurse can offer his or her
making oneself awhile.” presence, interest, and desire to
available “I’ll stay here understand. It is important that
with you.” this offer is unconditional;
“I’m interested that is, the client does not have
in what you to respond verbally to get
think.” the nurse’s attention.
Placing event in “What seemed Putting events in proper
time or sequence to lead up sequence helps both the nurse
—clarifying the to…?” and the client to see them in
relationship of “Was this before perspective. The client may gain
events in time or after…?” insight into cause-and-effect
“When did this behavior and consequences or
happen?” the client may be able to see
that perhaps some things are
not related. The nurse may gain
information about recurrent
patterns or themes in the
client’s behavior or
relationships.
Presenting reality— “I see no one When it is obvious that the
offering for else in the client is misinterpreting reality,
consideration that room.” the nurse can indicate what is
which is real “That sound was real. The nurse does this by
a car calmly and quietly expressing his
backfiring.” or her perceptions or the
“Your mother is facts, not by way of arguing with
not here; I am the client or belittling his
a nurse.” or her experience. The intent is
to indicate an alternative

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line of thought for the client to

consider, not to “convince”
the client that he or she is wrong.
Reflecting— Client: “Do you Reflection encourages the client
directing client think I should to recognize and accept his or
actions, thoughts, tell the her own feelings. The nurse
and feelings back doctor…?” indicates that the client’s
to client Nurse: “Do you point of view has value and that
think you the client has the right to
should?” have opinions, make decisions,
Client: “My and think independently.
brother
spends all my
money and
then has nerve
to ask for
more.”
Nurse: “This
causes you to
feel angry?”
Client: “I can’t
sleep. I stay awake all
night.”
Restating— Nurse: “You The nurse repeats what the
repeating the main have client has said in approximately
idea expressed difficulty or nearly the same words the
sleeping.” client has used. This
Client: “I’m restatement lets the client know
really mad, that he or she communicated
I’m really the idea
upset.” effectively. This encourages the
Nurse: “You’re client to continue. Or if the
really mad client has been misunderstood,
and upset.” he or she can clarify his or
her thoughts.
Seeking “I’m not sure The nurse should seek
information— that I follow.” clarification throughout
seeking to make “Have I heard interactions with clients. Doing
clear that which is you so can help the nurse to avoid
not meaningful or correctly?” making assumptions that
that which is understanding has occurred
vague when it has not. It helps the
client articulate thoughts,
feelings, and ideas more clearly.
Silence—absence of Nurse says Silence often encourages the
verbal nothing but client to verbalize, provided that

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communication, continues to it is interested and expectant.

which provides maintain eye Silence gives the client time to
time for the client contact and organize thoughts, direct the
to put thoughts or conveys topic of interaction, or focus
feelings into interest. on issues that are most
words, to regain important. Much nonverbal
composure, or to behavior takes place during
continue talking silence, and the nurse needs to
be aware of the client and his or
her own nonverbal behavior.
Suggesting “Perhaps you The nurse seeks to offer a
collaboration— and I can relationship in which the client
offering to share, discuss and can identify problems in living
to strive, and to discover the with others, grow emotionally,
work with the triggers for and improve the ability to form
client for his or her your anxiety.” satisfactory relationships.
benefit “Let’s go to The nurse offers to do things
your room, with, rather than for, the
and I’ll help client.
you find what
you’re
looking for.”
Summarizing— “Have I got this straight?” Summarization seeks to bring
organizing and summing “You’ve said that….” out the important points of the
up that which has gone “During the past hour, discussion and seeks to increase
before you and I have the awareness and
discussed….” understanding of both
participants. It omits the
irrelevant and organizes the
pertinent aspects of the
interaction. It allows both client
and nurse to depart with the
same ideas and provides a sense
of closure at the completion of
each discussion.
Translating into Client: “I’m Often what the client says, when
feelings—seeking dead.” taken literally, seems
to verbalize Nurse: “Are you meaningless or far removed
client’s feelings suggesting from reality. To understand,
that he or she that you feel the nurse must concentrate on
expresses only lifeless?” what the client might be
indirectly Client: “I’m feeling to express him or herself
way out in the this way.
ocean.”
Nurse: “You
seem to feel

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lonely or
deserted.”
Verbalizing the Client: “I can’t Putting into words what the
implied—voicing talk to you or client has implied or said
what the client has anyone. It’s a indirectly tends to make the
hinted at or waste of discussion less obscure. The
suggested time.” nurse should be as direct as
Nurse: “Do you possible without being
feel that no unfeelingly blunt or obtuse. The
one client may have difficulty
understands?” communicating directly. The
nurse should take care to
express only what is fairly
obvious; otherwise, the nurse
may be jumping to conclusions
or interpreting the client’s
communication.
Voicing doubt— “Isn’t that Another means of responding to
expressing unusual?” distortions of reality is to
uncertainty about “Really?” express doubt. Such expression
the reality of the “That’s hard to permits the client to
client’s believe.” become aware that others do
perceptions not necessarily perceive events
in the same way or draw the
same conclusions. This does
not mean the client will alter his
or her point of view, but at
least the nurse will encourage
the client to reconsider or
reevaluate what has happened.
The nurse neither agreed nor
disagreed; however, he or she
has not let the misperceptions
and distortions pass without
comment.

On the other hand, there are several approaches are considered to be barriers to open
communication between the nurse and client. Hays and Larson (1963) identified a number of
these techniques, which are presented in Table 2. Nurses should recognize and eliminate the
use of these patterns in their relationships with clients. Avoiding these communication
barriers maximizes the effectiveness of communication and enhances the nurse–client
relationship.

Table 2. Non-therapeutic Communication Techniques

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Non- therapeutic Examples Rationale

Communication
Technique
Advising—telling the “I think you Giving advice implies that only
client what to do should …” the nurse knows what is best for
“Why don’t you the client.
…”
Agreeing—indicating “That’s right.” Approval indicates the client is
accord with the client “I agree.” “right” rather than “wrong.”
This gives the client the
impression that he or she is
“right” because of agreement
with the nurse. Opinions and
conclusions should be
exclusively the client’s. When
the nurse agrees with the client,
there is no opportunity for the
client to change his or her mind
without being “wrong.”
Belittling feelings Client: “I have When the nurse tries to equate
expressed— nothing to live the intense and
misjudging the degree for … I wish I overwhelming feelings the
of the client’s discomfort was dead.” client has expressed to
Nurse: “everybody” or to the nurse’s
“Everybody own feelings, the nurse
gets down in implies that the discomfort is
the dumps,” or temporary, mild, self-limiting,
“I’ve felt that way myself.” or not that important. The client
is focused on his or her own
worries and feelings; hearing
the problems or feelings of
others is not helpful.
Challenging— “But how can you Often, the nurse believes that if
demanding proof from be president of he or she can challenge
the client the United the client to prove unrealistic
States?” ideas, the client will realize
“If you’re dead, there is no “proof” and then will
why is your recognize reality. Actually,
heart beating?” challenging causes the client to
defend the delusions or
misperceptions more strongly
than before.
Defending—attempting “This hospital has Defending what the client has
to protect someone or a fine reputation.” criticized implies that he or she
something from “I’m sure your has no right to express
verbal attack doctor has your impressions, opinions, or

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best interests in feelings. Telling the client that

mind.” his or her criticism is
unjust or unfounded does not
change the client’s
feelings but only serves to block
further communication.
Disagreeing—opposing “That’s wrong.” Disagreeing implies the client is
the client’s ideas “I definitely “wrong.” Consequently,
disagree with the client feels defensive about
…” his or her point of view
“I don’t believe or ideas.
that.”
Disapproving— “That’s bad.” Disapproval implies that the
denouncing the “I’d rather you nurse has the right to pass
client’s behavior or wouldn’t …” judgment on the client’s
ideas thoughts or actions. It further
implies that the client is
expected to please the nurse.
Giving approval— “That’s good.” Saying what the client thinks or
sanctioning the “I’m glad that …” feels is “good” implies that the
client’s behavior or opposite is “bad.” Approval,
ideas then, tends to limit the client’s
freedom to think, speak, or act
in a certain way. This can lead to
the client’s acting in a particular
way just to please the nurse.
Giving literal Client: “They’re Often, the client is at a loss to
responses— looking in my describe his or her feelings, so
responding to a head with a such comments are the best he
figurative comment as television or she can do. Usually, it is
though it were a camera.” helpful for the nurse to focus on
statement of fact Nurse: “Try not the client’s feelings in response
to watch to such statements.
television” or
“What
channel?”
Indicating the “What makes you The nurse can ask, “What
existence of an say that?” happened?” or “What events
external source— “What made you led you to draw such a
attributing the source do that?” conclusion?” However, to
of thoughts, feelings, “Who told you question, “What made you
and behaviors to that you were a think that?” implies that the
others or to outside prophet?” client was made or compelled to
influences think in a certain way.
Usually, the nurse does not
intend to suggest that the

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source is external, but that is

often what the client
thinks.
Interpreting—asking to “What you really The client’s thoughts and
make conscious that mean is …” feelings are his or her own, not
which is unconscious; “Unconsciously to be interpreted by the nurse
telling the client the you’re saying for hidden meaning.
meaning of his or her …” Only the client can identify or
experience confirm the presence of
feelings.
Introducing an Client: “I’d like The nurse takes the initiative for
unrelated topic to die.” the interaction away
Nurse: “Did you last from the client. This usually
evening?” happens because the nurse
is uncomfortable, doesn’t know
how to respond, or has
a topic he or she would rather
discuss.
Making stereotyped “It’s for your own Social conversation contains
comments—offering good.” many clichés and much
meaningless clichés or “Keep your chin meaningless chit-chat. Such
trite comments up.” comments are of no value
“Just have a in the nurse–client relationship.
positive Any automatic responses lack
attitude and the nurse’s consideration or
you’ll be better thoughtfulness.
in no time.”
Probing—persistent “Now tell me Probing tends to make the client
questioning of the about this feel used or invaded. Clients
client problem. You have the right not to talk about
know I have to issues or concerns if they
find out.” choose. Pushing and probing by
“Tell me your the nurse will not encourage the
psychiatric client to talk.
history.”
Reassuring—indicating “I wouldn’t worry Attempts to dispel the client’s
there is no reason for about that.” anxiety by implying that
anxiety or other “Everything will there is not sufficient reason for
feelings of discomfort be alright.” concern completely devalue the
“You’re coming client’s feelings. Vague
along just reassurances without
fine.” accompanying facts are
meaningless to the client.
Rejecting—refusing to “Let’s not discuss When the nurse rejects any
consider or showing …” topic, he or she closes it off
contempt for the “I don’t want to

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client’s ideas or hear about …” from exploration. In turn, the

behaviors client may feel personally
rejected along with his or her
ideas.
Requesting an “Why do you There is a difference between
explanation—asking think that?” asking the client to describe
the client to provide “Why do you feel what is occurring or has taken
reasons for thoughts, that way?” place and asking him or her to
feelings, behaviors, explain why. Usually, a “why”
and events question is intimidating. In
addition, the client is unlikely to
know “why” and may become
defensive trying to explain him
or herself.
Testing—appraising the “Do you know These types of questions force
client’s degree of what kind of the client to try to recognize his
insight hospital this or her problems. The client’s
is?” acknowledgment that he or she
“Do you still have doesn’t know these things may
the idea meet the nurse’s needs but is
that…?” not helpful for the client.
Using denial—refusing Client: “I’m The nurse denies the client’s
to admit that a nothing.” feelings or the seriousness
problem exists Nurse: “Of of the situation by dismissing his
course you’re course or her comments without
you’re attempting to discover the
something— feelings or meaning behind
everybody’s them.
something.”
Client: “I’m
dead.”
Nurse: “Don’t be
silly.”

Challenges in Communication
Providing appropriate communication with the patients is one of the necessary tools for
nurses in psychiatry wards, which is useful in management of the patients with psychiatric
disorders.(9). Some important reasons for inappropriate relationship between the nurse and
patient can be lack of necessary skills to communicate with patients because of insufficient
training.

In a certain studies on the factors of effective communication of the nurses with the
hospitalized psychiatric patients, it was demonstrated that the ability to understand the
patient; empathize with him/her; appropriately communicate with him/her has a deep effect

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on the bilateral relationship of nurses and patients in emergency psychiatry wards (Shattell
M.M., 2006).

Many factors have been reported as influencing effective communication in

healthcare. These include individual abilities and characteristics, team behaviors and systemic
factors and the lack of organizational support of a culture safety. In addition, it has been
suggested that improving communication requires a detailed understanding of the setting
and context in which patient care is delivered and a commitment on behalf of a healthcare
organization to a culture of safety and quality improvement, such as supporting team-based
delivery of care. Sustainable improvements towards effective communication in healthcare
settings involve synchronizing efforts across the three levels that is, the individual, the team
and the organization.
In addition, certain obstacles occur in the nurse-patient relationship that affects the
nature of the communication. These obstacles are due to the patient's disorder or lack of
knowledge, and the nurse's own inability to be effective because of inexperience, or personal
problems for the relationship to grow in a healthy manner. Nurses entering psychiatric-
mental health settings bring with them values, beliefs and perspectives that influence their
interactions with patients. At the same time, these patients usually have intense emotions
and complex behaviors, their care can pose unique challenges for nurses to control their own
emotional reactions and check their social biases.

Attitudes and behaviors that may block effective interaction with patients
experiencing mental health problems include judgmental attitudes, excessive probing, and
lack of self-awareness. Nurses need to approach each patient with unbiased perspectives, and
during discussions, nurses need to make sure to remain focused on essential problems and
avoid explorations unrelated to the issue or challenge of concern. Additionally, nurses must
be able to monitor and contain their own responses when patients discuss frightening
incidents or relate tragedies that generate feelings of hopelessness, despair, anxiety, disgust,
fear, anger, or distress.

Nurses must also understand the role that culture plays "in professional
communication, experienced nurses are aware that trans-cultural differences may create
barriers to verbal and nonverbal communication that in turn, can negatively affect patient
outcomes by recognizing that these barriers may exist and continually striving for cultural
competence, nurses can increase the likelihood of effective communication with individuals
who identify with another culture or ethnic group. An important reason of inappropriate nurse-
patient communication is the insufficient skill of the nurse in providing the relationship, because
of the inadequate education.

Overall, therapeutic communication is the primary vehicle that nurses use to apply the
nursing process in mental health settings. The nurse’s skill in therapeutic communication
influences the effectiveness of many interventions. Therefore, the nurse must evaluate and
improve his or her communication skills on an ongoing basis. When the nurse examines his
or her personal beliefs, attitudes, and values as they relate to communication, he or she is
gaining awareness of the factors influencing communication. Gaining awareness of how one
communicates is the first step toward improving communication.

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When working with clients from different cultural or ethnic backgrounds, the nurse
needs to know or find out what communication styles are comfortable for the client in terms
of eye contact, touch, proximity, and so forth. The nurse can then adapt his or her
communication style in ways that are beneficial to the nurse–client relationship.

ACTIVITY 1: Based on what you have learned so far, briefly explain the
importance of therapeutic communication in dealing with psychiatric
patients.

Submit your output for this activity in the submission folder 1 of this lesson.

LEARNING INPUT 2.

Nurse-Client Relationship

Principles and Goals of the Therapeutic Nurse-Client Relationship

Travelbee (1971), who expanded on Peplau’s theory of interpersonal relations in

nursing, has stated that it is only when each individual in the interaction perceives the other
as a human being that a relationship is possible. It does not refer to a nurse-client relationship,
but rather to a human-to-human relationship, which she describes as a “mutually significant
experience.” That is, both the nurse and the recipient of care have needs met when each
views the other as a unique human being, not as “an illness,” as “a room number,” or as “all
nurses” in general.

Therapeutic relationships are goal oriented. Ideally, the nurse and client decide
together what the goal of the relationship will be. Most often the goal is directed at learning
and growth promotion in an effort to bring about some type of change in the client’s life. In
general, the goal of a therapeutic relationship may be based on a problem-solving model.

Travelbee (1971) described the instrument for delivery of the process of interpersonal
nursing as the therapeutic use of self, which she 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.” Use of the self in a therapeutic manner requires that the nurse have
a great deal of self-awareness and self-understanding, having arrived at a philosophical belief
about life, death, and the overall human condition. The nurse must understand that the ability
and extent to which one can effectively help others in time of need is strongly influenced by
this internal value system—a combination of intellect and emotions.

Many factors can enhance the nurse–client relationship, and it is the nurse’s
responsibility to develop them. These factors promote communication and enhance

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relationships in all aspects of the nurse’s life. These include trust, genuine interest, empathy,
acceptance, positive regard, and self-awareness and therapeutic use of self.

Trust. 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. Some behaviors the nurse can exhibit
to help build the client’s trust include caring, interest, understanding, consistency, honesty,
keeping promises, and listening to the client. A caring therapeutic nurse– client relationship
enables trust to develop, so the client can accept the assistance being offered. Trust erodes
when a client sees inconsistency between what the nurse says and does. Inconsistent or
incongruent behaviors include making verbal commitments and not following through on
them.

Genuine Interest. When the nurse is comfortable with him or herself, aware of his or
her strengths and limitations, and clearly focused, the client perceives a genuine person
showing genuine interest. A client with mental illness can detect when someone is exhibiting
dishonest or artificial behavior, such as asking a question and then not waiting for the answer,
talking over him or her, or assuring him or her everything will be alright. The nurse should be
open and honest and display congruent behavior.

Empathy. 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 to provide high-quality, compassionate care. Being able
to put him or herself in the client’s shoes does not mean that the nurse has had the exact
experiences as that of the client. Nevertheless, by listening and sensing the importance of the
situation to the client, the nurse can imagine the client’s feelings about the experience.

Acceptance. The nurse who does not become upset or responds 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. By being clear and firm without
anger or judgment, the nurse allows the client to feel intact while still conveying that certain
behavior is unacceptable.

Positive regard. 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. Calling
the client by name, spending time with the client, and listening and responding openly are
measures by which the nurse conveys respect and positive regard to the client. The nurse also
conveys positive regard by considering the client’s ideas and preferences when planning care.
Doing so shows that the nurse believes the client has the ability to make positive and
meaningful contributions to his or her own plan of care.

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Self-awareness and therapeutic use of self. Before he or she can begin to understand
clients, the nurse must first know him or herself. Self-awareness 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. 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 help clients grow, change, and heal.
Peplau (1952), who described this therapeutic use of self in the nurse–client relationship,
believed that nurses must clearly understand themselves to promote their clients’ growth and
to avoid limiting clients’ choices to those that nurses value.

Types of Relationship

Each relationship is unique because of the various combinations of traits and

characteristics of and circumstances related to the people involved. Although every
relationship is different, all relationships may be categorized into three major types: social,
intimate, and therapeutic.

A social relationship is primarily initiated for the purpose of friendship, socialization,

companionship, or accomplishment of a task. Communication, which may be superficial,
usually focuses on sharing ideas, feelings, and experiences and meets the basic need for
people to interact. Advice is often given. Roles may shift during social interactions. Outcomes
of this kind of relationship are rarely assessed. 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.
This is acceptable in nursing, but for the nurse–client relationship to accomplish the goals that
have been decided on, social interaction must be limited. If the relationship becomes more
social than therapeutic, serious work that moves the client forward will not be done.

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 meet the needs as well. The relationship may include sexual or emotional intimacy
as well as sharing of mutual goals. Evaluation of the interaction may be ongoing or not. The
intimate relationship has no place in the nurse–client interaction.

The therapeutic 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. The nurse should not be concerned about whether or not the
client likes him or her or is grateful. Such concern is a signal that the nurse is focusing on a
personal need to be liked or needed. The nurse must guard against allowing the therapeutic

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relationship to slip into a more social relationship and must constantly focus on the client’s
needs, not his or her own.

Phases of the Nurse-Client Relationship

The therapeutic interpersonal relationship is the means by which the nursing process
is implemented. Through the relationship, problems are identified and resolution is sought.
Tasks of the relationship have been categorized into four phases: the pre-interaction phase,
the orientation (introductory) phase, the working phase, and the termination phase. Although
each phase is presented as specific and distinct from the others, there may be some
overlapping of tasks, particularly when the interaction is limited. The major nursing goals
during each phase of the nurse–client relationship are listed in Table 3.

Table 3. Phases of Relationship Development and Major Nursing Goals

Phase Goals
Orientation (introductory) Explore self-perceptions
Establish trust
Formulate contract for intervention
Working Promote client change
Termination Evaluate goal attainment
Ensure therapeutic closure

The orientation phase 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, and the parameters of subsequent meetings; identifies the
client’s problems; and clarifies expectations. Before meeting the client, the nurse has
important work to do. The nurse reads background materials available on the client, becomes
familiar with any medications the client is taking, gathers necessary paperwork, and arranges
for a quiet, private, and comfortable setting. This is the time for self-assessment. The nurse
should consider his or her personal strengths and limitations in working with this client. The
nurse must examine preconceptions about the client and ensure that he or she can put them
aside and get to know the person. The nurse must come to each client without
preconceptions or prejudices.

During the orientation phase, the nurse begins to build trust with the client. It is the
nurse’s responsibility to establish a therapeutic environment that fosters trust and
understanding. The nurse should share appropriate information about him.

The working phase of the nurse–client relationship is usually divided into two
subphases. During problem identification, the client identifies the issues or concerns causing
problems. During exploitation, the nurse guides the client to examine feelings and responses
and develop better coping skills and a more positive self-image; this encourages behavior
change and develops independence. The trust established between the nurse and the client
at this point allows them to examine the problems and to work on them within the security
of the relationship.
As the nurse and client work together, it is common for the client to unconsciously
transfer to the nurse feelings he or she has for significant others. This is called transference.

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For example, if the client has had negative experiences with authority figures, such as a
parent, teachers, or principals, he or she may display similar reactions of negativity and
resistance to the nurse, who is also viewed as an authority. A similar process can occur when
the nurse responds to the client based on personal unconscious needs and conflicts; this is
called countertransference. For example, if the nurse is the youngest in her family and often
felt as if no one listened to her when she was a child, she may respond with anger to a client
who does not listen or resists her help.

The termination or resolution phase is the final stage in the nurse–client relationship.
It begins when the problems are resolved and ends when the relationship is ended.
The specific roles and responsibilities of the nurse and client in therapeutic
relationships are seen in the Table 4.

Table 4. Phases of the Nurse–Client Relationship

Working
Orientation Termination
Identification Exploitation
Client • Participates in • Makes full use of services • Abandons old needs
• Seeks identifying problems • Identifies new goals • Aspires to new goals
assistance • Begins to be aware of • Attempts to attain new • Becomes independent of
• Conveys needs time goals helping person
• Asks questions • Responds to help • Rapid shifts in behavior: • Applies new problem-
• Shares • Identifies with nurse dependent and solving skills
preconceptions • Recognizes nurse as a independent • Maintains changes in
and person • Exploitative behavior style of communication
expectations of • Explores feelings • Self-directing and interaction
nurse based on • Fluctuates dependence, • Develops skill in • Shows positive changes
past independence, and interpersonal in view of self
experience interdependence in relationships and • Integrates illness
relationship with nurse problem-solving • Exhibits ability to stand
• Increases focal attention • Displays changes in alone
• Changes appearance (for manner of
better or worse) communication (more
• Understands continuity open, flexible)
between sessions
(process and content)
• Testing maneuvers
decrease
Nurse • Participates in identifying • Continues assessment • Sustains relationship as
• Responds to problems • Meets needs as they long as client feels
client • Begins to be aware of emerge necessary
• Gives time • Understands reason for • Promotes family
parameters of • Responds to help shifts in behavior interaction to assist with
meetings • Identifies with nurse • Initiates rehabilitative goal planning
• Explains roles • Recognizes nurse as a plans • Teaches preventive
• Gathers data person • Reduces anxiety measures
• Helps client • Explores feelings • Identifies positive • Uses community agencies
identify • Fluctuates dependence, factors • Teaches self-care
problem independence, and • Helps plan for total • Terminates nurse–client
• Helps client interdependence in needs relationship
plan use of relationship with nurse

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community • Increases focal attention • Facilitates forward

resources and • Changes appearance (for movement of
services better or worse) personality
• Reduces • Understands continuity • Deals with therapeutic
anxiety and between sessions impasse
tension (process and content)
• Practices active • Testing maneuvers
listening decrease
• Focuses
client’s
energies
• Clarifies
preconceptions
and
expectations of
nurse

ACTIVITY 2. Considering your learning at this point, describe the

different phases of nurse-client relationship as to the responsibilities
of nurses.

Submit your output for this activity in the submission folder 2 of this lesson.

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This ends our discussion in lesson __. Check your understanding

of the topics by answering the 30-item short quiz in the learning
management system (LMS) of this course. Feedback will be
given after the examination is closed.
Good luck!
References:

Townsend, M.C. (2011) Essentials of Psychiatric Mental Health Nursing: Concept of care in
evidence-based practice, 5th edition. Philadelphia PA: F.A. Davis Company.

Videbeck, S.L. (2020). Psychiatric-Mental Health Nursing, 8th edition. Philadelphia PA: Wolters
Kluwer.
Shattell M.M., McAllister S., Hogan B & Thomas S.P. (2006): “She Took The Time to Make Sure
She Understood”: Mental Health Patients Experiences of Being Understood. Journal
of Psychiatry Nurses ,;20(5):234–41.
Elaziz, W.S.( n.d.). Communication problems facing nursing staff during their interaction with
hospitalized mentally ill patients. Tanta Scientific Nursing Journal Vol. 9. Pg. 90-120.

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