The nurse–client relationship is an interaction between a nurse and "client" (patient) aimed at enhancing the well-being of the client, who may be an individual, a family, a group, or a community.
Peplau Peplau's theory is of high relevance to the nurse-client relationship, with one of its major aspects being that both the nurse and the client become more knowledgeable and mature over the course of their relationship. Hildegard Peplau believed that the relationship depended on the interaction of the thoughts, feelings, and actions of each person and that the patient will experience better health when all their specific needs are fully considered in the relationship.Peplau, Hildegard E. Interpersonal Relations in Nursing. New York: G.P. Putnam's Sons, 1952. Interpersonal Theory in Nursing Practice: Selected Works of Hildegard E. Peplau. New York: Springer Publishing Company, 1989. The nurse-patient relationship enables nurses to spend more time, to connect, to interact with their patients as well as to understand their patient's needs. It assists nurses to establish a unique perspective regarding the meaning of the patient's illness, beliefs, and preferences of patients/families. Thus, the patients/families feel that they are being cared for and they feel more motivated to open up to the nurses as well as working together to achieve better outcomes/satisfaction.Duffy, J. R. (2005). Implementing the Quality‐Caring model in acute care. Journal of Nursing Administration, 35(1), 4-6.
Elements
The nurse-client relationship is composed of several elements.
Boundaries
Boundaries are an integral part of the nurse-client relationship. They represent invisible structures imposed by legal, ethical, and professional standards of nursing that respect the rights of nurses and clients.Arnold, E., & Underman-Boggs, K. (2011). Interpersonal Relationships: Professional Communication Skills for Nurses (sixth edition). St.Louis, Missouri: Elsevier Saunders These boundaries ensure that the focus of the relationship remains on the client's needs, not only by word but also by law. The College of Nurses of Ontario (CNO) Standards identifies that it is the nurse's responsibility to establish the boundaries and limits of the relationship between the nurse and client.Therapeutic Nurse-Client Relationship, Revised 2006. (1 March 1999). 1 June 2009, Retrieved from http://www.cno.org/Global/docs/prac/41033_Therapeutic.pdf The boundaries have a specific purpose and health goal, and the relationship terminates when identified goal is met.
Any action or behaviour in a nurse-client relationship that personally benefits the nurse at the expense of the client is a boundary violation. Some examples of boundary violations are engaging in a romantic or sexual relationship with a current client, extensive non-beneficial disclosure to the client and receiving a gift of money from the client. Abuse and neglect are extreme examples. They involve the betrayal of respect and trust within the relationship. This includes withholding communication from a client because it is considered to be an example of neglect.College of Registered Nurses of Nova Scotia. (2012) Professional boundaries and the nurse-client relationship: keeping it safe and therapeutic: guidelines for registered nurses. Retrieved from http://www.crnns.ca/documents/ProfessionalBoundaries2012.pdfIt
It is the nurse's job to be aware of signs that professional boundaries may be crossed or have been crossed. Warning signs of boundary crossing that may lead to boundary violations include frequently thinking of a client in a personal way, keeping secrets with a specific client, favouring one client's care at the expense of another's and telling a client personal things about yourself in order to make an impression. Anything that could comprise the client's well-being if the relationship with a registered nurse is continued or discontinued can be considered a warning sign. Boundary violations are never acceptable and it is the nurse's job to handle any situation with any regards to it professionally and therapeutically regardless of who initiated it.
Confidentiality
This makes the relationship safe and establishes trust. The patient should feel comfortable disclosing personal information and asking questions.Erickson, M., & Blazer-Riley, J. (2012). The Client-Nurse Relationship: A Helping Relationship. In Communications in Nursing (Seventh ed., pp. 16-31). St.Louis, Missouri: Elsevier Mosby. The nurse is to share information only with professional staff that needs to know and obtain the client's written permission to share information with others outside the treatment team.Wiesman, Shirley A. "A Development of Trust in the Nurse–Client Relationship." Diss. UW-Eau Claire, 1992.
Therapeutic nurse behaviours
Nurses are expected to always act in the best interests of the patient to maintain a relationship that is strictly with all intent to only benefit the client. The nurse must ensure that their client's needs are met while being professional. Extensive research and clinical observation has shown that the body, mind and emotions are in unity. Therefore, in order to help another person, one must consider all these aspects; this means not neglecting the person and strictly just treating the illness. Caring for patients is beyond the treatment of disease and disability.Brown, E. L. (1961). Newer dimensions of patient care, Part 1: The use of the physical and social environment of the general hospital for therapeutic purposes. New York. Russell Sage Foundation.
The necessary knowledge aspects that are needed to maintain a therapeutic nurse-client relationship are: background knowledge, knowledge of interpersonal and development theory, knowledge of diversity influences and determinants, knowledge of person, knowledge of health/illness, knowledge of the broad influences on health care and health care policy, and knowledge of systems.
Background knowledge is the nurse's education, and her life experience. Knowledge of interpersonal and development theory is the knowledge of theories of the sense of self and self influence on others. The specific theories are: The Interpersonal Theory, Object relation theory, Developmental theory, and Gender/developmental theory. Knowledge of person explains that nurses must take the time to understand the client, and their world; what is meaningful to them, and their history. Knowledge of Health and Illness is the knowledge that the nurse must attain about their client's health issue. Knowledge of the broad influences on health care and health care policy explains that nurses need to be aware of the influences of the client's care; social/political forces, expectations of health-care system, and changes in accessibility, and resources. Knowledge of Systems explains that the nurse needs to know about the health-care system so they can help their clients access services.RNAO. Virani, T., & Tait, A., & McConnell, H., & Scott, C., & Gergolas, E. (2002). Establishing Therapeutic Relationships. Toronto, ON. Effective communication in nursing entails being empathic, non-judgmental, understanding, approachable, sympathetic, caring, and having safe and ethical qualities.Burnard, P., & Gill, P. 2008/> Burnard, P., & Gill, P. (2008). Culture, Communication, and Nursing. Harlow, Essex: Pearson Education Limited. The first statement of the CNO Standard is Therapeutic Communication, which explains that a nurse should apply communication and interpersonal skills to create, maintain, and terminate a nurse-client relationship.
All of the aspects to a therapeutic relationship are interrelated. You cannot efficiently use one aspect without the other; they are all connected and work together to create a successful relationship. Nurses assist clients to achieve their health related goals including improving their relationship with others. "The help that nurses offer to their clients is much more than technical expertise. The relationship between nurse and client is a powerful healing force by itself.L. Williams, C. (2008). Using the Self to Promote Health. In Therapeutic Interaction in Nursing (2nd ed., pp. 18-19). Sudbury, Massachusetts: Jones and Bartlett
Therapeutic nurse-patient communication is a key aspect of the performance of the nurse's role. Therapeutic communication benefits not only the patient but the nurse as well. Nurses report higher job satisfaction connected with positive communication with patients. Improved communication with patients increases the nurses ability to do their job effectively, which in turn increases job satisfaction. Reports of increased job satisfaction reduces the reported instance of compassion fatigue. Increased compassion fatigue reduce the nurse's ability to communicate effectively and compassionately with the patient, impairing therapeutic behaviours and communication, and decreasing the effectiveness of the nurse-patient relationship, and safe care.Fakhr-Movahedi, A., Rahnavard, Z., Salsali, M., & Negarandeh, R. (2016). Exploring nurse's communicative role in nurse-patient relationships: A qualitative study. Journal of Caring Sciences 5(4), 267-276. https://doi.org/ 10.15171/jcs.2016.028 It is a cycle where therapeutic communication leads to a positive relationship that increases both patient and nurse satisfaction that improves the nurses ability to continue therapeutic behaviours.
Of course, other factors are involved in the nurse's ability to engage in therapeutic behaviours. As mentioned, compassion fatigue hinders the nurses ability to form a therapeutic relationship with the patient. Many factors contribute to compassion fatigue, short-staffing and increased responsibilities are highest on the list. These factors also contribute to the patient's perception of a positive nurse-patient relationship. Patient responses indicate that timeliness, attentiveness, and time spent in communication improved the patient's perception of a positive nurse-patient relationship. A therapeutic nurse-patient relationship increases the patient's trust in the nurse. Additionally, the patient is more willing to provide information to the nurse that may be pertinent to the safe care and medical needs of the patient. A therapeutic relationship can help patients cope better and lead to calmness at a time that the patient may be struggling with difficult situations.
Self-awareness
Self-awareness is an internal evaluation of one self and of one's reactions to emotionally charged situations, people and places. It offers an opportunity to recognise how our attitudes, perceptions, past and present experiences, and relationships frame or distort interactions with others. An example of self-awareness would be acknowledging that showing anger is not a sign of weakness, because there were emotions outside of your control.Antai-Otong, D. (2007). Perspectives and Principles of Therapeutic Communication. In Nurse-Client Communication (1st ed., pp. 16-17). Sudbury, Massachusetts: Jones and Bartlett. Self-awareness allows you to fully engage with a client and presence; being with the client in the moment, allows the nurse to know when to provide help and when to stand back. Until individuals can fully understand themselves they cannot understand others. Nurses need self-awareness in this relationship to be able to relate to the patient's experiences to develop empathy.
Genuine, warm and respectful