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Course: Mental Health Nursing

Topic: Therapeutic Nurse-Client Relationship - Part II

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COPYRIGHT

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Module Goals

Learners will be able to:

Discuss the essential communication techniques used in the nurse-client therapeutic relationship when caring for a client with a mental health condition.
Identify the nursing factors that foster a therapeutic nurse-client relationship when caring for a client with a mental health condition.

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Essential Communication Techniques

Ernstmeyer & Christman, 2021

Therapeutic communication
Therapeutic touch

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Therapeutic Communication Techniques

Ernstmeyer & Christman, 2021

Active Listening
Using Silence
Accepting
Giving Broad Openings/Open-Ended Questions
Giving Recognition
Offering Self
Seeking Clarification
Validation

Placing the Event in Time or Sequence
Making Observations
Encourage Descriptions of Perception
Encouraging Comparisons
Offering Hope and Humor

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Active Listening: Nodding, saying, “I see/what happened next/then/that is so interesting.”
Using Silence: Sometimes, it is better not to speak at all; it may give clients time and space.
Accepting: Acknowledging clients’ messages and affirming that they’ve been heard. e.g. make eye contact and say, “Yes, I understand what you are trying to say”
Giving Broad Openings/Open-Ended Questions: E.g., How are you feeling this morning? What makes you feel so worried?
Giving Recognition: Praising the positive aspect e.g., I see you are being able to get out of bed without any support.
Offering Self: Give some time to the client, stay with them and listen. OR simply saying where they can find you.
Seeking Clarification: Clarify confusion or ambiguity. E.g., You mentioned…… can you explain that to me?
Validation: Acknowledgment of the client’s feelings and thoughts.
Placing the Event in Time or Sequence: Asking questions about when certain events occurred in relation to other events can help clients (and nurses).
Making Observations: Careful observation of their comforts, discomforts, worries, fear.
Encouraging Descriptions of Perception: Encourage them to verbalize their perception: E.g., for auditory or visual hallucination, ask, “what do you hear? what does it look like?”
Encouraging Comparisons: Drawing upon previous experiences to deal with current problems. Encourage them to make comparisons to situations they have coped with before.
Offering Hope and Humor: Sharing hope that they can persevere through their current situation and lightening the mood with humor can help nurses establish rapport quickly.

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Communicating with the Client with

Mental Health Condition

DO’s

Focus on the person as an individual
Focus on strengths and abilities
Ensure you understand them correctly
Ensure they understand you correctly
Ask, never assume
Support the person
Determine the support they want and need, and ask before helping

New South Wales Government, 2020

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Communicating With the Client with

Mental Health Condition

DON’T

Pretend to know how someone else feels.
Use terms that show pity.
Use words that are stigmatising.
Blame the person for their condition or circumstances.
Use jargon.
Be judgemental or argumentative, show any form of anger or hostility.
Be sarcastic or make jokes about their condition.
Treat them as inferior.

New South Wales Government, 2020

Image by: Max pixel

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Therapeutic Touch

Ernstmeyer & Christman, 2021

A powerful way to professionally communicate caring and empathy.
Done respectfully while being aware of the client’s cultural beliefs.
Nurses commonly use professional touch when assessing, expressing concern, or comforting clients.

For example, simply holding a client’s hand during a painful procedure can be very effective in providing comfort.

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Critical Thinking Question

A 21 year old female is being admitted to an inpatient psychiatric hospital for increased suicidal ideation. Although she was diagnosed with depression 3 years ago, this is her first psychiatric hospitalization. She is tearful and makes minimal eye contact with the nurse as she walks on to the unit.

What can the nurse do to promote a therapeutic relationship?

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Client-Centered Care

Ensures that all professional behaviors and actions meet the therapeutic needs of the client

Role of the nurse

Actively involve the client in the plan of care.
Accept the client's values, individuality, culture, and belief systems.
Use SWOT (Strengths, Weakness, Opportunities, Threat) analysis to meet the goals of care.
Respect the client’s choice and remains open for constructive ideas.

College of Nurses of Ontario, 2006

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While providing Client-centered care, a nurse:

Actively include the client as a partner in care and help identify the goals, wishes, and preferences.
Understand the client’s abilities, weaknesses, limitations and relate the health condition of the client for the planned care.
Discusses the expectations with the client and sets realistic goals to meet those expectations with the resources available.
SWOT: Identifies the strengths, weaknesses, opportunities, and threats in the care and involves the family or closed ones in the plan of care.
Acknowledges the clients feeling and addresses them in a prompt and a culturally effective manner
Accepts the client’s personality, choices, values, belief system, culture or religious beliefs.
Acknowledges the difficulty establishing a therapeutic relationship with a client (if any) and requesting a therapeutic transfer of care when the relationship is not evolving therapeutically (for example, when a nurse is unable to establish a trusting relationship with a client, they may consult with the manager to request that another nurse provide care);
Committed to being available to the client for the duration of care within the employment boundaries and role context
Engage the client in evaluating the nursing care and services the client is receiving.

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Maintaining Therapeutic Boundaries

College of Nurses of Ontario, 2006

Set clear boundaries.
Develop a care plan and aim to achieve the goals.
Practice vigilance to assure treatment plan.
Respect the client's privacy and confidentiality.
Continually clarify the roles in the relationship.
Never engage in financial transactions.
Review organizational policy on the giving and receiving of gifts to and from clients.
Consider the cultural values to maintain boundaries, self disclosure.

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Nurses are responsible for effectively establishing and maintaining the limits or boundaries in the therapeutic nurse-client relationship. To meet the standards, a nurse should:

Set the appropriate boundaries (e.g., making clients clear when their requests are beyond the limits of the therapeutic relationship)
Develop a thorough care plan and stick to it to provide care so that it helps to achieve the client's needs
Ensure that any approach or activity that could be perceived as a boundary-crossing is included in the care plan (for example, a health care team in a mental health setting may determine that having coffee with a particular client is an appropriate strategy that all nurses will consistently use when counseling the client)
Recognize the need for vigilance to maintain professionalism and boundaries in certain settings (e.g., While providing care at home, a nurse can get involved in the family's private life). Therefore a nurse has to identify what kind of behavior is crossing the boundaries of the nurse-client relationship.
Put the client's privacy and confidentiality on the priority list. (e.g., disclosing client mental health status to the relatives of friends of the client may make the client feel inferior, neglected, or humiliated)
Constantly clarify the roles and relationships in the nurse-client relationship.
Should not engage in any financial transactions
Consult with colleagues or managers to clear the provision of giving or accepting gifts to an from the clients
Document all the specific information where necessary
Consider the client's cultural values in the context of maintaining boundaries, including situations that involve self-disclosure and gift-giving.

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Signs of Crossing Therapeutic Boundaries

College of Nurses of Ontario, 2006

Spending extra time with one client.
Changing client assignments to give care to one client .
Feeling other members of the team do not understand a specific client as well as you do.
Disclosing personal information to a specific client.
Dressing differently when seeing a specific client.
Frequently thinking about a client when away from work.

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Signs of Crossing Therapeutic Boundaries (continued):

Feeling guarded or defensive when someone questions your interactions with a client.
Spending off-duty time with a client.
Ignoring agency policies when working with a client.
Keeping secrets with the client and apart from the health care team.
Giving a client personal contact information.
The client wants to speak only with one particular nurse and refuses to speak with other nurses or care workers.

College of Nurses of Ontario, 2006

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Giving and Accepting Gifts

College of Nurses of Ontario, 2006

Refrain from accepting gifts from clients and/or their families.
Give client(s) a gift only within your organization’s policy.

Note: Every organizational policies in giving and taking gifts might differ. Therefore a nurse should check the policy.

To know general provision of giving and taking gifts please click here.

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Protecting the Client from Abuse

College of Nurses of Ontario, 2006

Nurses must protect the client from harm by ensuring that abuse is prevented, stopped and/or reported.

Actions:

Promptly report any disrespect or threats of harm to clients.
Intervene or seek help in situations of client abuse.
Never neglect a client irrespective of their behavior.

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A nurse’s responsibility is to protect the client from any acute or potential abuse. To do so, a nurse should:

Intervene and report any form of abuse disrespect (verbal or non-verbal) that shows any disrespect for the client
Report any violence, threatening, intended physical harm to the client by the self or others have to intervene or reported
Intervene and report a health care provider’s inappropriate behaviors or remarks toward a client. ( E.g., a relationship that the nurse or others may perceive to be romantic, sexually suggestive, exploitive, or sexually abusive.)
Not engage in any physical, sexual, or romantic relationship with the client even when a therapeutic relationship is terminated.
Not engage in behaviors toward a client that may be perceived by the client or others to be violent, threatening, or intending to inflict physical harm.
Not exhibit physical, verbal, and non-verbal behaviors toward a client that demonstrate disrespect for the client or are perceived as abusive by the client or others.
Not neglect a client by failing to meet or withholding their basic assessed needs.
Not engaging in activities that could result in monetary, personal, or other material benefits, gain or profit for the nurse (other than the appropriate remuneration for nursing care or services), the

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Decision Tree

College of Nurses of Ontario, 2006

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Critical Thinking Question

You hear a rumor that one of your colleagues is having a private relationship with a client.

One day you are assigned to this client and the client shows you a monetary card that he is intending to give to your colleague.

How would you handle this situation?

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Cultural Considerations

Cultural considerations may impact the appropriateness of personal space when providing client care.

In Asian culture,

It is considered impolite to talk disagree or say “No”.
May not talk openly about their problems as they assume their problem are easily understood by the health professionals.

Queensland Health, n.d

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Cultural Considerations

In Philippines

Doctors and nurses are generally highly respected for their knowledge, education and expertise and few Filipinos will question them.

In Indian culture

Indian clients may say “yes” in order to please the health professional, even if they disagree with the treatment.
They often expect that the physician, not the nurse, will gather a complete history and perform a thorough examination.

Queensland Health, n.d

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References:

College of Nurses of Ontario. (2006). Standard of Care: Therapeutic Nurse-Client Relationship. https://www.cno.org/globalassets/docs/prac/41033_therapeutic.pdf

Ernstmeyer, K., & Christman, E. (Eds.). (2021). Open RN Nursing Fundamentals by Chippewa Valley Technical College is licensed under CC BY 4.0.

New South Wales Government. (2020). Mental Health: What is appropriate language when speaking with someone living with a mental health condition? https://www.health.nsw.gov.au/mentalhealth/psychosocial/strategies/Pages/communicating-language.aspx

Queensland Health (n.d). Multicultural Clinical Support Resource: Cultural Dimension of Pregnancy, Birth and postnatal care. https://www.health.qld.gov.au/__data/assets/pdf_file/0035/158669/14mcsr-pregnancy.pdf

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