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Decy Alavata

on 20 September 2013

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Transcript of Therapeutic


Knowledge requisites
of Therapeutic Relationship

By: Lalaine Arevalo
Components and Obstacles
Therapeutic Relationship
By: Nuch Junrueang
Therapeutic & Non-Therapeutic
Communication Techniques
By: Abbygail Amis
By: Suyeon An
Communication Techniques


By: Yichu Ma
Working Phase

Client: I can't believe the terrible job I did on that project.

Clinician: You seem too feel a deep sense of shame about your project.

Client: Yes, I do feel ashamed. I just always screw things up.

Clinician: You're sounding really frustrated with yourself.

Get Well soon my dear patient!
Thank you for listening!
Therapeutic Relationship
Presented by:

Decy Alavata
Abbygail Amis
Suyeon An
Lalain Arevalo
Nuch Junrueang
Yichu Ma
We are now ready to answer you questions.......
If you have ;)
By: Decy Alavata
in Therapeutic Relationship

• Frequently thinking of the client away from work.
• Seeking social contact or seeking free time with
the client.
• Sharing personal information to the client.
• Feeling a sense of longing related to the client.
• Using the client to meet personal needs for
status, social support or financial gain.
• Making special exceptions for the client
because s/he is appealing, impressive or well

Warning Signals of
Nurse’s Behaviours
College of Registered Nurses of British Columbia 2006
Crossing Boundaries
Behaviors that violate the professional
standard of the nurse-client relationship.

Giving & Receiving
Monetary or Personal
Hugging or Touching
Atkins, K., Britton, B. & de Lacey, S. 2011, Ethics and law for Australian nurses, Cambridge
University Press, Port Melbourne, Victoria.

College of Registered Nurses of British Columbia 2006, Nurse-client relationship, CRNBC,
viewed 10 September 2013, <http://www.crnbc.ca/Standards/Lists/Standard

Jane, S. P. 2009, Patient and Person: interpersonal skill in nursing, 4 thed, Elsevier, NSW, Australia.

Bunkers & Schmidt S., 2012, ‘Theory Development in Nursing’, Nursing Science Quarterly, vol. 25, No. 4, pp 300, viewed 14 September 2013

Cioffi J , 2012, ‘Being inclusive of diversity in nursing care: A discussion paper’, The Australian Journal of Nursing Practice, Vol.

Panns W., Sermeus W., Nieweg R. MB., Krijnen W. P. & Schans C. P. V, 2012, ‘Do knowledge, knowledge sources are reasoning skills affect the accuracy of nursing diagnoses? A randomised study’, BMC Nursing, vol. 11, No. 11, pp. 1-12, viewed 14 September 2013, http://www.biomedcentral.com/content/pdf/1472-6955-11-11.pdf

Lake Sumter State College (LSSC), n.d., ‘Techniques of Therapeutic Communication’ Date Accessed: 16th September 2013

Stainton, K., Hughson, J., Funnell, R.., Koutoukidis, G., Lawrence, K., 2011, Tabbner’s Nursing Care, Date Accessed: 16th of September, 2013 <http://books.google.com.au/books?id=kKSFGMI5hAcC&pg=PT2263&lpg=PT2263&dq=false+reassurance+nursing&source=bl&ots=9dy1UnCy2I&sig=jQd9Qf4a_4STWpE0JfuN6bFw-3M&hl=en&sa=X&ei=dJw1Uoa7PKWCiQem-YD4Dg&ved=0CDMQ6AEwAA#v=onepage&q=false%20reassurance%20nursing&f=false>

Stein-Parbury, 2009, Patient and Person: Interpersonal skills in Nursing (4th ed), Elsevier, Australia, pp. 4-6; 83-84; 109-115;
155-158; 174-181.

Atkins, K., Britton, B. & De Lacey, S. 2011, Ethics and Law for Australian Nurses, Cambridge University Press, New York.
Ramjan, L.M. 2004, 'Nurses and the ‘therapeutic relationship’: caring for adolescents with
anorexia nervosa', Journals of Advanced Nursing, vol. 45, no. 5, pp. 495-503.
Stein-Parbury, J. 2013, 'Communication', in J. Crisp, C. Taylor, C. Douglas & G. Rebeiro (eds), Potter & Perry's Fundamentals of Nursing, 4th edn, Elsevier, Australia, pp. 198-216.

College of Registered Nurses of British Columbia 2006

Nurses may accept a token gift on behalf of others who provided care.
A gift may be a part of a
therapeutic plan for the client
Gifts from client may be accepted
through charitable oraganizations.
Textbook knowledge
Experiences through the nurses’ lives
Experiences from similar patients

Background Knowledge

The development of the sense of human.

Developmental theories by Freud &
Erikson; Interpersonal Theory
by Orlando

Knowledge of interpersonal & development theory

Different working environment
Different living styles
Different education
Knowledge of diversity influences and determines

Narrative of the patient
- life experiences

Issues of biological and psychological

Knowledge of person / knowledge of health and illness



Roles of the Nurse



Parent or Surrogate

Components of
Therapeutic Relationship
The formation of trust is essential for the relationship to progress beyond a superficial level. Trust enables patient to place confidence in the nurse. Clients expect the nurse to have the knowledge and skills to provide safe and competent care (Atkins et al. 2011).

Atkins et al. (2011) defined confidentiality as the management of the patient information that patient confides in the nurse. The information cannot be shared to the other people without the permission of the client, except in extreme situations where:

The information may be harmful to the client or to others.
The client threatens self- harm.
The client does not intend to follow through with the treatment plan.

Genuine interest
The ability to communicate when appropriate is a key ingredient in building trust. Essentially, genuineness is the ability to meet person to person in a therapeutic relationship.

Therapeutic use of self
The nurse uses aspects of his or her personality, experience, values, feelings, intelligence, needs, coping skills.

Nurses use themselves as a therapeutic tool to establish therapeutic relationships with clients and to help clients grow, change and heal.

Nurse’s personal actions arise from conscious and unconscious responses that are
formed by life experiences and educational, spiritual and cultural values.


The nurse comes to know and understand the patient experience. This adsorption of the patient’s reality is one way that empathy is realised in nursing. It is important that nurses are able to express empathic understanding because the nursing practice involves the ability to perceive the feeling of the other and the self (Jane 2009).

I see you are sad. How can I help you?
I feel so sorry for you.


The nurse who does not become upset or respond negatively to a client’s outbursts, anger, or acting out conveys acceptances to the client. Avoiding judgment of the person, no matter what the behavior, is acceptance. It does not mean, acceptance of the inappropriate behaviour but acceptance of the person as worthy. The nurse must set the boundaries for behavior the nurse – client relationship (Jane 2009).

Crossing Boundaries
An action or behaviour that deviates from an established professional boundary in the nurse- client relationship; even where the action or behaviour appears appropriate, it is not acceptable when it benefits the nurse’s personal needs rather than the needs of the client.

Encouraging dependence
inhibits autonomy.

makes the patient anxious
and uncomfortable due to the
nurse’s dismissive behaviour.
Jane 2009)

Obstacles to
Therapeutic Relationship

Non acceptance/Avoidance
The act of keeping away from.

The misuse of power or a betrayal of trust, respect or intimacy between the RN and the client. The RN may know the cause, or could be reasonably expected to cause, physical, emotional or spiritual harm to a client (Atkins et al. 2011).

This includes all types of abuse by RNs for example:

(Jane 2009)
(Paans et al. 2012)
(Bunkers & Schmidt 2013).
(Cioffi 2012)
If there is a patient in the hospital who has different background, what kind of knowledge of the nurse has to be used?

(a) background knowledge
(b) knowledge of diversity influences and determines
(c) knowledge of person / knowledge of health and illness
(d) all of above

Second stage of the therapeutic relationship.
Strangers to each other.
Preconceptions: previous relationships, experiences, attitudes & beliefs. (Peplau, 1952).
Consistency and listening are considered by clients to be critical at the beginning of the relationship (Forchuk et al., 1998; Sundeen et al., 1989).
Key principles: Trust, respect, honesty and effective communication.

Orientation Phase

Third stage of therapeutic relationship.
Nursing interventions take place.
Identify problems and address these into action.
The nurse to validate thoughts, feelings and behaviours (Orlando, 1961)

Working Phase
Final stage of therapeutic relationship.
Based on mutual understanding and a celebration of goals that have been met (Hall, 1993; Hall, 1997).
Validating plans for the future.
Increased autonomy of both nurses and patients.

Resolution phase
The continuum of professional behaviour recognizes therapeutic relationship as a zone of helpfulness (Nursing & Midwifery Board of Australia 2010).
Acquiring the necessary knowledge requisites will guide the nurse on how to make decisions and individualised patient care.
Application of the components of good therapeutic relationship assist in the smooth delivery of care and avoid barriers.
Put into practice good therapeutic communication techniques. The quality of a therapeutic relationship depends on the ability of the healthcare provider to communicate effectively.
Be organize. The phases of therapeutic relationship outlines the nursing activities to provide a systematic and effective management of patient care.
Therapeutic relationship is a professional relationship. Therefore, nurses must follow the principles outlined in the professional code of conduct.

“I've learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”
Maya Angelou
Therapeutic communication is the process during face-to-face interaction in which the nurse uses their verbal and non-verbal skills in order to help a patient effectively.
Effective therapeutic communication techniques involve active listening, exploration, and reflection. With effective communication, the nurse is able respond to the patient’s needs therefore reducing their distress and suffering (Stein-Parbury, 2009).

Active listening is a communication technique which requires the listener’s focus and energy as this will enhance the listener’s ability to understand the information.
Active listening enhances the nurse’s ability to establish a connection with the patient at a deeper level. This shows interest in the patient’s lives and also the nurse’s respect and acceptance of patients. This benefits nurses as the patient will feel that they are worth the nurse’s time and energy. Also, the nurse will be able collect information regarding patients and individualised nursing interventions based on the patient’s needs (Stein-Parbury, 2009).

Active Listening

Exploration is the process of delving into a particular idea or experience. It aims at discovering the full thoughts, experiences and feelings that patient’s experience.
Spontaneous exploration promotes the deepening of the nurse-patient relationship and shows the nurse’s concern for the well-being of the patient. Effective exploration can be achieved through prompting skills.


(Stein-Parbury, 2009)

Encouragement during conversation can indicate to the
patient that the nurse supports their verbalisation, which encourages the patient to speak in further detail.
For example, saying ‘uh huh’ shows the nurse’s interest in the patient.

Involves sharing own experiences, feelings and thoughts to the patient.
This demonstrates that the nurse is open which encourages the patient to open up with their own experiences

A nurse may use this technique to request further information about specific topics. This allows a patient to elaborate on their experiences. For example, “Can you describe this experience in detail?” This has to be done in a gentle rather than demanding way.


Gentle Commands


Minimal encouragement

Reflecting feelings involves mirroring
the feelings of the patient. This technique
is useful for recognising the patient’s
emotions while also confirming the existence
of emotions (Stein-Parbury, 2009).


For example,
I have a feeling that everyone here doesn’t like me.
Doesn’t like you? How so?

In this scenario, the nurse verbalises what the patient has expressed.
Reflecting encourages the patient to elaborate (LSCC, n.d.).

There are barriers to effective therapeutic communication. These include passive listening, reluctance to paraphrase, being defensive and false reassurance.

Non-Therapeutic Communication

Passive Listening occurs when:
A nurse hears but doesn’t fully concentrate on what’s being said.
This prevents effective listening to be achieved, as information is not being fully absorbed.
Undivided attention is not present therefore information that is heard can’t be processed (Stein-Parbury, 2009).

Passive Listening

Nurses fail to appreciate the value of paraphrasing, therefore their reluctance of its use.
Nurses also use this technique to avoid reinforcing the patient’s negative state out of fear.
This leads to failure to understand as the nurse fails to build meaning of the patient’s experience.
This gives an impression that nurses have a lack of interest and denying the patient’s emotions (Stein-Parbury, 2009).

Reluctance to paraphrase

Nurses try to relieve emotional discomfort of the
client by providing false reassurance. These responses make patients feel that their worries are being avoided and have
no significance to the nurse. Reassurance should be
truth-focused and ensure the patient’s emotions
are addressed (Stainton et al, 2011).

False reassurance

When faced with an aggressive client, nurses react through defensive responses.
Defensive responses can include responses that involve retaliation. This focuses on the nurse’s feelings rather than the client.

Defensive responses imply that patients can’t express their feelings or give an opinion. Instead, nurses must learn to understand and explore the causes of the patient’s complaints to maintain a therapeutic relationship (Stainton et al, 2011).

Being Defensive

Name the type of non-therapeutic communication technique is present in the following scenario:

No one is listening to me! I’ve told the other nurses that I’ve had this pain for so long.
I’m having the worst stay. You’re a useless nurse!
Just to let you know, the service here is at a good standard. You’re just a whiny patient!


A. Passive Listening
B. Reluctance to Paraphrase
C. False reassurance
D. Being defensive

Is the following scenario experiencing either….

D. Being defensive

The correct answer is….

Beginning of the therapeutic relationship.
Develop self-awareness.
Prepare for the first interaction.
Review patient’s history, diagnosis, review nursing theory.


Professional Relationship between the nurse and the client. It
exists to have a healing or beneficial effect on the clients
(Atkins et al 2011).

It is time bounded, goal directed approach with a high
expectation of confidentiality (Stein-Parbury 2013).

It is a natural progression of 4 directed phases that begins
before the nurse meets the patient until the relationship ends
(Stein-Parbury 2013 ).

Enables the nurses to obtain more accurate information
from the patient that will be useful for the planning of treatment and care. Establishment of a therapeutic
relationship is important because this leads to better client outcomes. It empowers client that results to adherence.
Aids in the quick recovery of the client. (Ramjan 2004)

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