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Chapter 2 Therapeutic Communication and the Nurse-Client Relationship
2.1. INTRODUCTION
Learning Objectives
Review basic concepts of client-centered communication
Outline effective therapeutic communication techniques
Describe barriers to effective therapeutic communication
Explore guidelines for effective communication during teletherapy
Nurses engage in compassionate, supportive, professional relationships with their clients as part of the “art of nursing.” [1] This chapter will review the nurse-client relationship, therapeutic communication, and motivational interviewing. It will also introduce teletherapy and telehealth.

References
1.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
2.2. BASIC CONCEPTS OF COMMUNICATION
Communication Standard of Professional Performance
The Standard of Professional Performance for Communication established by the American Nurses Association (ANA) is defined as, “The registered nurse communicates effectively in all areas of professional practice.” [1] See the following box for the competencies associated with the Communication standard.

ANA’s Communication Competencies
The registered nurse:

Assesses one’s own communication skills and effectiveness.
Demonstrates cultural humility, professionalism, and respect when communicating.
Assesses communication ability, health literacy, resources, and preferences of health care consumers to inform the interprofessional team and others.
Uses language translation resources to ensure effective communication.
Incorporates appropriate alternative strategies to communicate effectively with health care consumers who have visual, speech, language, or communication difficulties.
Uses communication styles and methods that demonstrate caring, respect, active listening, authenticity, and trust.
Conveys accurate information to health care consumers, families, community stakeholders, and members of the interprofessional team.
Advocates for the health care consumer and their preferences and choices when care processes and decisions do not appear to be in the best interest of the health care consumer.
Maintains communication with interprofessional team members and others to facilitate safe transitions and continuity in care delivery.
Confirms with the recipient if the communication was heard and if the recipient understands the message.
Contributes the nursing perspective in interactions and discussions with the interprofessional team and other stakeholders.
Promotes safety in the care or practice environment by disclosing and reporting concerns related to potential or actual hazards or deviations from the standard of care.
Demonstrates continuous improvement of communication skills.
Review basic communication concepts for nurses in the “Communication” chapter in Open RN Nursing Fundamentals.
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.” [2] This is especially true in psychiatric care, where the therapeutic relationship is considered to be the foundation of client care and healing. [3] The nurse-client relationship establishes trust and rapport with a specific purpose; it facilitates therapeutic communication and engages the client in 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. During longer periods of time, such as inpatient care, 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.

Read more about crisis and crisis intervention in the “Stress, Coping, and Crisis Intervention” chapter.
Phases of Development of a Therapeutic Relationship
The nurse-client relationship goes through three phases. A well-known nurse theorist named Hildegard Peplau described these three phases as orientation, working, and termination. [4]

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

A common framework used for introductions during patient care is AIDET, a mnemonic for Acknowledge, Introduce, Duration, Explanation, and Thank You.

Acknowledge: Greet the patient by the name documented in their medical record. Make eye contact, smile, and acknowledge any family or friends in the room. Ask the patient 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 your 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 patient and ask if anything is needed before you leave. In an acute or long-term care setting, ensure the call light is within reach and the patient knows how to use it. If family members are present, thank them for being there to support the patient 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.”
Working Phase
The majority of a nurse’s time with a client is 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. They use assessment findings to develop a nursing plan of care and plan patient education. If a care plan has already been established on admission, nurses use this time to implement interventions targeted to meet short-term outcomes and long-term goals. During the working phase, clients begin to accept nurses as health educators, counselors, and care providers. Nurses use therapeutic communication techniques to facilitate clients’ awareness of their thoughts and feelings and mutually 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. [5] Therapeutic communication techniques used during this phase, including motivational interviewing, are discussed later in this chapter.

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. If the previous working phase has been successful, the client’s needs have been successfully met by collaboration among the client, nurses, and interprofessional health care team members. The nurse should be aware 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. The nurse also makes community referrals for follow-up and continuation of support in meeting goals.

References
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association.
Ross C. A., Goldner E. M. Stigma, negative attitudes and discrimination towards mental illness within the nursing profession: A review of the literature. Journal of Psychiatric and Mental Health Nursing. 2009;16(6):558–567. [PubMed] [CrossRef]
Hagerty T. A., Samuels W., Norcini-Pala A., Gigliotti E. Peplau’s Theory of Interpersonal Relations: An alternate factor structure for patient experience data? Nursing Science Quarterly. 2018;30(2):160–167. [PMC free article] [PubMed] [CrossRef]
Hagerty T. A., Samuels W., Norcini-Pala A., Gigliotti E. Peplau’s Theory of Interpersonal Relations: An alternate factor structure for patient experience data? Nursing Science Quarterly. 2018;30(2):160–167. [PMC free article] [PubMed] [CrossRef]
2.3. THERAPEUTIC COMMUNICATION
Therapeutic communication has roots going back to Florence Nightingale, who insisted on the importance of building trusting relationships with patients. She taught that therapeutic healing resulted from nurses’ presence with patients. [1] Since then, several professional nursing associations have highlighted therapeutic communication as one of the most vital elements in nursing. Therapeutic communication is a type of professional communication defined as the purposeful, interpersonal, information-transmitting process that leads to client understanding and participation. [2] Read an example of a nursing student using therapeutic communication in the following box.

Example of Nurse Using Therapeutic Listening
Ms. Z. is a nursing student (as simulated in Figure 2.1) [3] who enjoys interacting with patients. When she goes to patients’ rooms, she greets them and introduces herself and her role in a calm tone. She kindly asks patients about their problems and notices their reactions. She provides information and answers their questions. Patients perceive that she wants to help them. She treats patients professionally by respecting boundaries and listening to them in a nonjudgmental manner. She addresses communication barriers and respects patients’ cultural beliefs. She notices patients’ health literacy and ensures they understand her messages and patient education. As a result, patients trust her and feel as if she cares about them, so they feel comfortable sharing their health care needs with her. [4]

Figure 2.1
Figure 2.1
Nursing Student Using Therapeutic Communication

Therapeutic communication is different from social interaction. Social interaction does not have a goal or purpose and includes casual sharing of information, whereas therapeutic communication has a goal or purpose for the conversation. An example of a nursing goal before using therapeutic communication is, “The client will share feelings or concerns about their treatment plan by the end of the conversation.”

Therapeutic communication includes active listening, professional touch, and a variety of therapeutic communication techniques.

Active Listening
Listening is an important part of communication. There are three main types of listening, including competitive, passive, and active listening. Competitive listening occurs when we are mostly focused on sharing our own point of view instead of listening to someone else. Passive listening occurs when we are not interested in listening to the other person, and we assume we understand what the person is communicating correctly without verifying their message. During active listening, we communicate both verbally and nonverbally that we are interested in what the other person is saying while also actively verifying our understanding with them. For example, an active listening technique is to restate what the person said and then verify our understanding is correct. This feedback process is the major difference between passive listening and active listening. [5]

Nonverbal communication is an important component of active listening. SOLER is a mnemonic for establishing good nonverbal communication with clients. SOLER stands for the following [6]:

S: Sitting and squarely facing the client
O: Using open posture (i.e., avoid crossing arms)
L: Leaning towards the client to indicate interest in listening
E: Maintaining good eye contact
R: Maintaining a relaxed posture
Touch
Professional touch is a powerful way to communicate caring and empathy if done respectfully while also being aware of the client’s preferences, cultural beliefs, and personal boundaries. Nurses use professional touch when assessing, expressing concern, or comforting patients. For example, simply holding a patient’s hand during a painful procedure can effectively provide comfort.

For individuals with a history of trauma, touch can be negatively perceived, so it is important to ask permission before touching. Inform the person before engaging in medical procedures requiring touch such as, “I need to hold down your arm so I can draw blood.”

Nurses should avoid using touch with individuals who are becoming agitated or experiencing a manic or psychotic episode because it can cause escalation. It is also helpful to maintain a larger interpersonal distance when interacting with an individual who is experiencing paranoia or psychosis.

Therapeutic Communication Techniques
There are a variety of therapeutic techniques that nurses use to engage clients in verbalizing emotions, establishing goals, and discussing coping strategies. See Table 2.3a for definitions of various therapeutic communication techniques discussed in the American Nurse, the official journal of the American Nurses Association.

Table 2.3a
Table 2.3a
Therapeutic Communication Techniques [7]

Nontherapeutic Responses
Nurses must be aware of potential barriers to communication and avoid nontherapeutic responses. Nonverbal communication such as looking at one’s watch, crossing arms across one’s chest, or not actively listening may be perceived as barriers to communication. Nontherapeutic verbal responses often block the client’s communication of feelings or ideas. See Table 2.3b for a description of nontherapeutic responses to avoid.

Table 2.3b
Table 2.3b
Nontherapeutic Responses [8],[9]

See the following box for a summary of tips for using therapeutic communication and avoiding common barriers to therapeutic communication.

Tips for Effective Therapeutic Communication
Establish a goal for the conversation.
Be self-aware of one’s nonverbal messages.
Observe the client’s nonverbal behaviors and actions as ‘cues’ for assessments and planning interventions.
Avoid self-disclosure of personal information and use professional boundaries. (Review boundary setting in the “Boundaries” section of Chapter 1.)
Be patient-centered and actively listen to what the client is expressing (e.g., provide empathy, not sympathy; show respect; gain the client’s trust; and accept the person as who they are as an individual).
Be sensitive to the values, cultural beliefs, attitudes, practices, and problem-solving strategies of the client.
Effectively use therapeutic communication techniques.
Recognize themes in a conversation (e.g., Is there a theme emerging of poor self-esteem, guilt, shame, loneliness, helplessness, hopelessness, or suicidal thoughts?).
Common Barriers to Therapeutic Communication
Using a tone of voice that is distant, condescending, or disapproving.
Using medical jargon or too many technical terms.
Asking yes/no questions instead of open-ended questions.
Continually asking “why,” causing the client to become defensive or feel challenged by your questions.
Using too many probing questions, causing the client to feel you are interrogating them, resulting in defensiveness or refusal to talk with the nurse.
Lacking awareness of one’s biases, fears, feelings, or insecurities.
Causing sensory overload in the client with a high emotional level of the content.
Giving advice.
Blurring the nurse-client relationship boundaries (e.g., assuming control of the conversation, disclosing personal information, practicing outside one’s scope of practice).
Recognizing and Addressing Escalation
When communicating therapeutically with a client, it is important to recognize if the client is escalating with increased agitation and becoming a danger to themselves, staff, or other patients. When escalation occurs, providing safety becomes the nurse’s top priority, and the focus is no longer on therapeutic communication. Read more information in the “Crisis and Crisis Intervention” section of the “Stress, Coping, and Crisis Intervention” chapter.

Cultural Considerations
Recall the discussion from Chapter 1 on how cultural values and beliefs can impact a client’s mental health in many ways. Every culture has a different perspective on mental health. For many cultures, there is stigma surrounding mental health. Mental health challenges may be considered a weakness and something to hide, which can make it harder for those struggling to talk openly and ask for help. Culture can also influence how people describe and feel about their symptoms. It can affect whether someone chooses to recognize and talk openly about physical symptoms, emotional symptoms, or both. Cultural factors can determine how much support someone gets from their family and community when it comes to mental health. [10]

Nurses can help clients understand the role culture plays in their mental health by encouraging therapeutic communication about their symptoms and treatment. For example, a nurse should ask, “What do you think is wrong? How would you treat your symptoms?”

Read more about providing culturally responsive care in the “Diverse Clients” chapter of Open RN Nursing Fundamentals.
References
1.
Karimi H., Masoudi Alavi N. Florence Nightingale: The mother of nursing. Nursing and Midwifery Studies. 2015;4(2):e29475. [PMC free article] [PubMed] [CrossRef]
2.
Abdolrahimi M., Ghiyasvandian S., Zakerimoghadam M., Ebadi A. Therapeutic communication in nursing students: A Walker & Avant concept analysis. Electronic Physician. 2017;9(8):4968–4977. [PMC free article] [PubMed] [CrossRef]
3.
“beautiful african nurse taking care of senior patient in wheelchair” by agilemktg1 is in the Public Domain.
4.
Abdolrahimi M., Ghiyasvandian S., Zakerimoghadam M., Ebadi A. Therapeutic communication in nursing students: A Walker & Avant concept analysis. Electronic Physician. 2017;9(8):4968–4977. [PMC free article] [PubMed] [CrossRef]
5.
This work is a derivative of Human Relations by LibreTexts and is licensed under CC BY-NC-SA 4.0.
6.
Stickley T. From SOLER to SURETY for effective non-verbal communication. Nurse Education in Practice. 2011;11(6):395–398. [PubMed] [CrossRef]
7.
American Nurse. (n.d.). Therapeutic communication techniques. https://www.myamericannurse.com/therapeutic-communication-techniques/
8.
Abdolrahimi M., Ghiyasvandian S., Zakerimoghadam M., Ebadi A. Therapeutic communication in nursing students: A Walker & Avant concept analysis. Ele