The Nurse-Client Relationship

• Respect patients’ values, preferences and expressed needs

• Coordinate and integrate care across boundaries of the system

• Provide the information, communication, and education that people need and want

• Guarantee physical comfort, emotional support, and the involvement of family and friends (pp. 52–53)

Creating the Physical Environment: Specific client needs dictate the most appropriate interpersonal setting. When the interview takes place at the client’s bed in a hospital setting, the curtain should be drawn and the nurse can sit at an angle facing the client. One-on-one relationships with psychiatric clients commonly take place in a designated, noiseless room apart from the client’s bedroom. In the client’s home, the nurse is always the client’s guest. A private space in which the nurse and client can talk without being uninterrupted is essential. Each time a nurse is sensitive to the environment in a nurse-client relationship, the nurse models thoughtfulness, respect, and empathy.

Clarifying the Purpose of the Relationship: Clarity of purpose related to identifiable health needs is an essential dimension of the nurse-client relationship (LaSala, 2009). It is difficult to fully participate in any working partnership without understanding its purpose and expectations. Clients need basic information about the purpose and nature of the interview or relationship, including what information is needed and how the information will be used, how the client can participate in the treatment process, and what the client can expect from the encounter. To understand the importance of orientation information, consider the value of having a clear syllabus for your nursing courses.

The length of the relationship dictates the depth of the orientation. An orientation given to a client by a nurse assigned for a shift would be different from that given to a client when the nurse assumes the role of primary care nurse over an extended period. When the relationship is of longer duration, the nurse should discuss the parameters of the relationship (e.g., length of sessions, frequency of meetings, and role expectations of the nurse and client).

Initial meetings should have two outcomes: First, the client should emerge from the encounter with a better idea of the most relevant health issues; second, the client should feel that the nurse is interested in him or her as a person. At the end of the contact, the nurse should thank the client for his or her participation and indicate what will happen next.

Establishing Trust: Carter (2009) defines trust as “a relational process, one that is dynamic and fragile, yet involving the deepest needs and vulnerabilities of individuals” (p. 404). Starting with the first encounter, clients begin to assess the nurse’s trustworthiness. Kindness, competence, and a willingness to become involved are communicated through the nurse’s words, tone of voice, and actions. Does the nurse seem to know what he or she is doing? Is the nurse tactful and respectful of cultural differences? Data regarding the level of the nurse’s interest and knowledge base are factored into the client’s decision to engage actively in a therapeutic relationship. Confidentiality, sensitivity to client needs, and honesty strengthen the relationship.

The level of trust fluctuates with illness, age, and successful and unsuccessful encounters with others (Carter, 2009). Knowledge of the client’s developmental level helps frame therapeutic conversations. For example, you would hold a different conversation with an adolescent client than you would with an elderly client. The acutely ill client will need short contacts that are to the point and related to providing comfort and care. The client’s current health situation is a good starting place for choice of topic.

Trusting the nurse is particularly difficult for the seriously mentally ill, for whom the idea of having a professional person care about them can be incomprehensible. Having this awareness helps the nurse look beyond the bizarre behaviors that these clients present in response to their fears about helping relationships. Many mentally ill clients will respond better to shorter, frequent contacts until trust is established. Schizophrenic clients often enter and leave the space occupied by the nurse, almost circling around a space that is within visual distance of the nurse. With patience and tact, the nurse engages the client slowly with a welcoming look and brief verbal contact. Over time, brief meetings that involve an invitation and a statement as to when the nurse will return help reduce the client’s anxiety, as indicated in the following dialogue.

Identifying Client Needs: Therapeutic relationships should directly revolve around the client’s needs and preferences. Each person’s experience and individualized expression of them will be different. How clients perceive their health status, reasons for seeking treatment at this time, and expectations for health care are critical data, which you can begin to elicit by simply asking the client why he or she is seeking treatment at this time. Using questions that follow a logical sequence and asking only one question at a time help clients feel more comfortable, and is likely to elicit more complete data.

Client and family expectations can facilitate or hinder the treatment process. When health professionals treat elderly, adolescent, or physically handicapped clients as though they are mentally incapacitated in assessment interviews, it devalues them as a person. On the other hand, family members are sometimes reluctant to challenge a client’s perceptions in front of the client and may need a private interview. Nurses need to include both perspectives for accurate assessment.

Similarities and differences between client and family perceptions of illness and treatment are important data. If there is reason to suspect the reliability of the client as a historian, interviewing significant others assumes greater importance. Family/client agreement or disagreement about diagnosis, treatment goals, or ways to provide care are critical data. For example, if a client has one perception about personal self-care abilities and family members have a completely different awareness, these differences can become a nursing concern.

Participant Observation: Peplau describes the role of the nurse in all phases of the relationship as being a participant observer. This means that the nurse simultaneously participates in and observes the progress of the relationship from the nurse and the client perspective. When validated with the client, observations about the client’s behavior and words serve as guides for subsequent dialogue and actions in the relationship. According to Peplau, observation includes self-awareness and self-reflection on the part of the nurse. This is as critical to the success of the relationship as is the assessment of the client’s situation (McCarthy and Aquino-Russell, 2009).

By linking the emotional context with the content of the client’s message, the nurse enters into the client’s world and shows a desire to understand the situation from the client’s perspective. Nurses need to be aware of the different physical and nonverbal cues clients give with their verbal messages. Noting facial expressions and nonverbal cues with “You look exhausted” or “You look worried” acknowledges the presence of these factors and normalizes them. Exercise 5-3 is designed to help you to critically observe a person’s nonverbal cues.

Defining the Problem: Nurses act as a sounding board, asking questions about parts of the communication that are not understood and helping clients to describe their problems in concrete terms. The nurse asks for specific details to bring the client’s needs into sharper focus, for example, “Could you describe for me what happened next,” or “Tell me something about your reaction to (your problem),” or “how do you feel about…”? Time should be allowed between questions for the client to respond fully. Commonly, such questions are asked but not enough time is allowed for the client to respond.

Clients usually find it easier to talk about factual data related to a problem rather than to express the feelings associated with the issue. For example, saying “It sounds as if you feel ____________ because of ____________” helps the client to articulate the relationships between situational data and its emotional impact.

Once the nurse and client develop a working definition of the problem, they can begin to brainstorm the best ways to meet treatment goals. The brainstorming process occurs more easily when nurses are relaxed and willing to understand views different from their own. Brainstorming involves generating multiple ideas and suspending judgment until after all possibilities are presented. The next step is to look realistically at ideas that could work given the resources the client has available right now. Resistance can be worked through with empathetic reality testing. Peplau (1997) suggests that a general rule of thumb in working with clients is to “struggle with the problem, not with the patient” (p. 164). The last part of the process relates to determining the kind of help needed and who can best provide it. Assessment of the most appropriate source of help is an important but often overlooked part of the evaluation needed in the orientation phase.

Defining Goals: Unless clients are physically or emotionally unable to participate in their care, they should be treated as active partners in developing personal goals. Goals should have meaning to the client. For example, modifying the exchange lists with a diabetic adolescent’s input so that they include substitutions that follow normal adolescent eating habits can facilitate acceptance of unwelcome dietary restrictions. The nurse conveys confidence in the client’s capacity to solve his or her own problems by expecting the client to provide data, to make constructive suggestions, and develop realistic goals.

Tuning in to Client Response Patterns: The art of nursing requires that nurses recognize differences in client response patterns. Elderly adults may need a slower pace, and people in crisis will need a simple structured level of support. Throughout the working phase, nurses need to be sensitive about whether the client is still responding at a useful level. Looking at difficult problems and developing strategies to resolve those problems is not an easy process, especially when resolution requires significant behavioral changes. If the nurse is perceived as inquisitive rather than facilitative, communication breaks down.

It is the responsibility of the nurse, not the client, to pace interactions in ways that offer support, as well as challenge. Deciding whether to proceed is a clinical judgment that should be based on the client’s response and overall body language. Examples of warning signs that the pace may need adjustment include loss of eye contact, fidgeting, abrupt changes in subject, or asking to be left alone. At the same time, strong emotion should not necessarily be interpreted as reflecting a level of interaction stretching beyond the client’s tolerance. Tears or an emotional outburst may reflect honestly felt emotion. A well-placed comment, such as, “I can see that this is difficult for you,” acknowledges the feeling and may stimulate further discussion.

The working phase may produce uneven results, with two steps forward and one backward, even when the plan is appropriate. Mistakes are to be expected. They should be treated as temporary setbacks and new information requiring a modification in strategy. Developing alternative constructive coping mechanisms is as important to support as the actual plan. Coping with unexpected responses can strengthen the client’s problem-solving abilities by compelling the person to consider alternative options (i.e., a Plan B) when the original plan does not bring about the desired results. Exercise 5-4 examines the role of brainstorming in generating alternative strategies.

As clients use the relationship to support coping with health-related situations, nurses can offer anticipatory guidance and role rehearsal for difficult aspects of this process. Sometimes, simply anticipating the worst-case scenario for a given action allows the client to see that even the worst possibility is manageable.

Defusing Challenging Behaviors: Challenging behaviors can sabotage the therapeutic relationship if they are not addressed early in the relationship process. There is no one way to approach a client, and no single interpersonal strategy that works equally well with every client. Some clients clearly are more emotionally accessible and attractive to work with than others. When a client seems unapproachable or uninterested in human contact, it can be quite disheartening for the nurse. It is not uncommon for the nurse to report the kind of initial contact with a client seen in the following case examples.

Although, from the nurse’s perspective, this client’s behavior may represent a lack of desire for a relationship, in most cases, the rejection is not personal. It can reflect boredom, insecurity, or physical discomfort. Anxiety expressed as anger or unresponsiveness may be the only way a client can control fear in a difficult situation. Rarely does it have much to do with the personal approach used by the nurse unless the nurse is truly insensitive to the client’s feelings or the needs of the situation. In this situation, the nurse might say, “It seems to me that you just want to be alone right now. But I would like to help you, so if you don’t mind, I’ll check back later with you. Would that be OK with you?” Most of the time, clients appreciate the nurse’s willingness to stay involved.

For novice nurses, it is important to recognize that all nurses have experienced some form of client rejection at one time or another. The nurse needs to explore whether the timing was right, whether the client was in pain, and what other circumstances might have contributed to the client’s attitude. Behaviors that initially seem maladaptive may appear quite adaptive when the full circumstances of the client’s situation are understood.

Before confronting a client, the nurse should anticipate possible outcomes. The nurse needs to appreciate the impact of the confrontation on a client’s self-esteem. Calling a client’s attention to a contradiction in behavioral response is usually threatening. Constructive feedback involves drawing the client’s attention to the existence of unacceptable behaviors or contradictory messages whereas respecting the fragility of the therapeutic alliance and the client’s need to protect the integrity of the self-concept. To be effective, constructive confrontations should be attempted only when the following criteria have been met:

Self-disclosure: Self-disclosure by the nurse refers to the intentional revealing of personal experiences or feelings that are similar to or different from those of the client. The purpose of self-disclosure is to deepen trust, to role-model self-disclosure as a beneficial mode of communicating for people who have trouble disclosing information about themselves. Appropriate self-disclosure can facilitate the relationship, providing the client with information that is both immediate and personalized (Deering, 1999).

Quality, not quantity, is a key characteristic of effective sharing in the working phase. Sharing should be solely for the clinical benefit of the client and never to meet the personal agenda of the nurse. Nurses should not share intimate details of their lives with their clients. The nurse, not the client, is responsible for regulating the amount of disclosure needed to facilitate the relationship. If the client asks a nonoffensive, superficial question, the nurse may answer briefly with a minimum of information and return to a client focus. Simple questions such as, “Where did you go to nursing school?” and “Do you have any children?” may represent the client’s effort to establish common ground for conversation (Morse, 1991). Answering the client briefly and returning the focus to the client is appropriate. If the client persists with questions, the nurse may need to redirect the client by saying, “I’d like to spend this time talking about you,” or simply indicate that personal questions are not relevant to understanding the client’s health care needs.

Deering (1999) suggests the following guidelines for keeping self-disclosure at a therapeutic level: (a) use self-disclosure to help clients open up to you, not to meet your own needs; (b) keep your disclosure brief; and (c) don’t imply that your experience is exactly the same as the client’s. Exercise 5-5 provides an opportunity to explore self-disclosure in the nurse-client relationship.

Gift Giving: Clients sometimes wish to give nurses gifts at the end of a constructive relationship because they value the care nurses have given to them. Gift giving is a delicate matter that does not lend itself to absolute dictums, but instead invites reflection and professional judgment. Nurses should consider: What meaning does the gift have for the relationship, and in what ways might accepting it change the dynamics of the therapeutic alliance? Would giving or receiving a gift present issues for other clients or their families?

There is no one answer about whether gifts should or should not be exchanged. In fact, if the nurse handled every situation in the same fashion, the nurse would be denying the uniqueness of each nurse-client relationship. Each relationship has its own character and its own strengths and limitations, so what might be appropriate in one situation would be totally inappropriate in another. Token gifts such as chocolates or flowers may be acceptable. In general, nurses should not accept money or gifts of significant material value. Should this become an issue, you might suggest making the gift to the health care agency or a charity. It is always appropriate to simply thank the client for their generosity and thoughtfulness (Lambert, 2009). Exercise 5-6 is designed to help you think about the implications of gift giving in the nurse-client relationship.

Evaluation: Objective evaluation of clinical outcomes achieved in the nurse-client relationship should focus on the following:

Orientation Phase: The therapeutic alliance begins with the same type of introduction and description of purpose identified for long-term relationships, with a focus on the nurse and client working as partners to develop a shared understanding of the client’s health problems. Establishing a working alliance where time is an issue requires a “here and now” focus on problem identification and an emphasis on quickly understanding the context in which it arose.

Begin your client assessment by asking the client the reason for seeking care. Eliciting the client’s concerns and allowing the client to tell his or her story conveys respect and interest. Listen for what is left out and pay attention to what the client’s story elicits in you. Support and empathy help build trust quickly. Dealing with the client’s feelings with a statement such as “Tell me more about…” (with a theme picked up from the client’s choice of words, hesitancy, or nonverbal cues) keeps the conversation flowing.

As the nurse interacts with the client, there are opportunities to observe client strengths and to comment on them. Every client has healthy aspects of his or her personality, and personal strengths that can be drawn on to facilitate individual coping responses. Exercise 5-7 provides an opportunity to explore the value of acknowledging personal strengths.

An important component of brief therapeutic relationships is the rapid development of a central focus, which is developed during an initial client evaluation. Cappabianca, Julliard, Raso and Ruggiero (2009) suggest that a simple statement posed at the beginning of each shift, such as, “What is your most important need today?” or “What is the most important thing I can do for you today?” helps focus the relationship. This type of question demonstrates intent to understand and meet each client’s unique needs in a shortened time frame. It helps client and nurse develop a shared understanding of what is uniquely important to the client in the present moment.

Because the time frame for a therapeutic relationship may be a few hours or days, nurses need to focus on what is absolutely essential, rather than what would be nice to know. Finding out how much the client already knows can save a lot of time. Developed from this discussion are treatment goals that can be realistically achieved, and are consistent with client goals, beliefs, and preferences.

Planning will be smoother if the nurse and client choose problems that are of interest to the client and that offer the best return on investment. Included in the planning should be the risks and cost/benefits for each targeted clinical outcome given the shortened time frame. Looking at the client’s needs from a broader contextual perspective, one that takes into consideration which problems, if treated, would also help correct other health problems, has a double benefit in terms of client success and satisfaction. Engaging the client’s family early in the treatment process is helpful.

As nurses increasingly move from a bedside role into a managerial coordination role, they become increasingly responsible for clarifying, integrating, and coordinating different aspects of the client’s care, as part of an interdisciplinary team. An important component of this responsibility is ensuring that the client/family understands and is able to negotiate treatment initiatives with health care team providers.

Working Phase: Brief relationships need to be solution-focused right from the beginning. Giving clients your undivided attention and using concise active listening responses is absolutely essential to being able to frame issues in a solution focused way. A central focus, agreed on by nurse and client, allows for the small behavioral changes and related coping skills needed to meet client goals in short-term relationships. Finding ways to collaborate makes the most effective use of time, and confrontation should be avoided. Longer term issues are not examined in depth and support beyond what is needed to stabilize the client. Clients respond best to nurses who appear confident and empathetic. An excellent way of helping clients discover the solutions that fit them best is by engaging the client in determining and implementing activities to meet therapeutic goals at every realistic opportunity. Conveying a realistically hopeful attitude that the goals developed with the client are likely to be achieved is important. Action plans should be as simple and specific as possible. Changes in the client’s condition or other circumstances may require treatment modifications that should be expected in short term relationships. Keeping clients and families informed and working with them on alternative solutions is essential to maintaining trust in short term relationships.

Termination Phase: The termination phase in short-term relationships can include discharge planning, agency referrals, and arranging for follow-up appointments in the community for the client and family. Anticipatory guidance in the form of simple instructions or review of important skills also may be appropriate, depending on the circumstances. Interpersonal relationships with other health care disciplines, families, and communities to support positive client health changes should be the norm, not the exception with short-term therapeutic relationships.

The importance of the relationship, no matter how brief, should not be underestimated. Although the client may be one of several persons the nurse has taken care of during that shift, the relationship may represent the only interpersonal or professional contact available to a lonely and frightened person. Even if contact has been minimal, the nurse should endeavor to stop by the client’s room to say good-bye. The dialogue in such cases can be simple and short: “Mr. Jones, I will be going off duty in a few minutes. I enjoyed working with you. Miss Smith will be taking care of you this evening.” If you will not be returning at a later date, this information should be shared with the client.