NURSE -

PATIENT
INTERACTION
(NPI)
B Y : D A R LY N I . A M P L A Y O
 • The nurse-client relationship is the foundation on which
psychiatric nursing is established.
• It is a relationship in which both participants must recognize
each other as unique and important human beings.
• It is also a relationship in which mutual learning occurs.
NURSE-CLIENT Peplau (1991) states:

RELATIONSHIP – Shall a nurse do things for a patient or can participant

relationships be emphasized so that a nurse comes to
do things with a patient as her share of an agenda of
work to be accomplished in reaching a goal—health. It is
likely that the nursing process is educative and
therapeutic when nurse and patient can come to know
and to respect each other, as persons who are alike, and
yet, different, as persons who share in the solution of
problems.
I.TRUST
• Trust builds when the client is
confident in the nurse and the nurse’s
presence conveys integrity and COMPONENTS
reliability.
• . The nurse needs to exhibit congruent
OF A
behaviors to build trust with the client THERAPEUTIC
• When working with a client with
psychiatric problems, some of the
RELATIONSHIP
symptoms of the disorder, such as
paranoia, low self-esteem, and anxiety,
may make trust difficult to establish
II. Genuine Interest

When the nurse is comfortable with himself or

herself, aware of his or her strengths and
limitations, and clearly focused, the client will
perceive a genuine person showing genuine interest
• III. EMPATHY
• Empathy is the ability of the nurse to perceive the meanings and feelings of the
client and to communicate that understanding to the client. It is considered one
of the essential skills a nurse must develop.
• Both the client and the nurse give a “gift of self” when empathy occurs—the
client by feeling safe enough to share feelings, and the nurse by listening closely
enough to understand. Empathy has been shown to positively influence client
outcomes. Clients tend to feel better about themselves and more understood
when the nurse is empathetic (Reynolds & Scott, 1999; Kunyk & Olson, 2001).
IV. ACCEPTANCE

The nurse who does not become

upset or respond negatively to a
client’s outbursts, anger, or acting out
conveys acceptance to the client.

Avoiding judgments of the person, no

matter what the behavior, is
acceptance.
V. POSITIVE REGARD The nurse who appreciates the
client as a unique, worthwhile
human being can respect the client
regardless of his or her behavior,
background, or lifestyle.
VI. SELF-AWARENESS AND THERAPEUTIC USE OF SELF

Self-awareness is the process of developing an understanding of

one’s own values, beliefs, thoughts, feelings, attitudes, motivations,
prejudices, strengths, and limitations and how these qualities affect
others
THERAPEUTIC USE OF SELF
By developing self-awareness and beginning to understand his or her attitudes, the nurse
can begin to use aspects of his or her personality, experiences, values, feelings,
intelligence, needs, coping skills, and perceptions to establish relationships with clients.

Nurses use themselves as a therapeutic tool to establish the therapeutic relationship

with clients and to help clients grow, change, and heal.

Peplau (1952), who described this therapeutic use of self in the nurse–client relationship,
believed that nurses must clearly understand themselves to promote their clients’
growth and to avoid limiting clients’ choices to those that nurses value
Social Relationship

• A social relationship is primarily initiated for the

purpose of friendship, socialization, companionship, or
accomplishment of a task.
• This is acceptable in nursing, but for the nurse–client
relationship to accomplish the goals that have been
decided on, social interaction must be limited.

Intimate Relationship TYPES OF

• A healthy intimate relationship involves two people RELATIONSHIPS
who are emotionally committed to each other. Both
parties are concerned about having their individual
needs met and helping each other to meet needs as
well.
• The relationship may include sexual or emotional
intimacy as well as sharing of mutual goals.
• The intimate relationship has no place in the nurse–
client interaction.
• Therapeutic Relationship
– The therapeutic relationship differs from the social or intimate
relationship in many ways because it focuses on the needs, experiences,
feelings, and ideas of the client only.
PHASES OF THERAPEUTIC
RELATIONSHIP

• Peplau studied and wrote about the

interpersonal processes and the
phases of the nurse–client relationship
for 35 years
 involves preparation for
THE PREINTERACTION the first encounter with
PHASE the client. Tasks include
the following:

■ Obtaining available information about the client from his or her chart,
significant others, or other health-team members. From this information,
the initial assessment is begun. This initial information may also allow the
nurse to become aware of personal responses to knowledge about the
client.
■ Examining one’s feelings, fears, and anxieties about working with a
particular client. For example, the nurse may have been reared in an
alcoholic family and have ambivalent feelings about caring for a client who
is alcohol dependent. All individuals bring attitudes and feelings from prior
experiences to the clinical setting. The nurse needs to be aware of how
these preconceptions may affect his or her ability to care for individual
clients.
 begins when the nurse During the The nurse
and client meet and should share
ends when the client orientation appropriate
The begins to identify
problems to examine.
phase, the information
nurse about himself
orientation During the orientation or herself at
phase, the nurse begins to
phase
this time: name,
establishes roles, the
purpose of meeting, and build trust reason for
the parameters of with the being on the
subsequent meetings; unit, and level
identifies the client’s client. of schooling
problems; and clarifies
expectations

needs to overcome nervousness

and convey feelings of warmth,
The nurse needs to listen expertise, and understanding. If
closely to the client’s history, the relationship gets off to a
perceptions, and positive start, it is more likely to
succeed and to meet established
misconceptions. goals (Forchuk et al., 2000).
NURSE-CLIENT CONTRACTS
• Both nurse and client should agree on these responsibilities in an informal
or verbal contract.
• In some instances, a formal or written contract may be appropriate;
examples include if a written contract has been necessary in the past with
the client or if the client “forgets” the agreed-on verbal contract.
• The contract should state:
• Time, place, and length of sessions
• When sessions will terminate
• Who will be involved in the treatment plan (family members,
health team members)
• Client responsibilities (arrive on time, end on time)
• Nurse’s responsibilities (arrive on time, end on tie, maintain
confidentiality at all times, evaluate progress with client, document
sessions)
CONFIDENTIALITY

Confidentiality means allowing

only those dealing with the
means respecting the client’s right client’s care to have access to the
Ideally the people close to the
to keep private any information information that the client
client and responsible for his or
about his or her mental and divulges. Only under precisely
her care are involved.
physical health and related care. defined conditions can third
parties have access to this
information
THE WORKING PHASE
• The working phase of the nurse–client
relationship is usually divided into two
subphases.
– During problem identification, the client
identifies the issues or concerns causing
problems.
– During exploitation, the nurse guides the
client to examine feelings and responses and to
develop better coping skills and a more positive
self-image; this encourages behavior change and
develops independence.
Transference:

• As the nurse and client work

together, it is common for the client
unconsciously to transfer to the
nurse feelings he or she has for
significant others.

Countertransference

• A similar process can occur when the

nurse responds to the client based on
personal unconscious needs and
conflicts.
• The specific tasks of the working phase include the following:
– Maintaining the relationship
– Gathering more data
– Exploring perceptions of reality
– Developing positive coping mechanisms
– Promoting a positive self-concept
– Encouraging verbalization of feelings
– Facilitating behavior change
– Evaluating progress and redefining goals as appropriate
– Providing opportunities for the client to practice new
behaviors
– Promoting independence
resolution phase, is the final stage in the
nurse–client relationship.

It begins when the problems are resolved,

and it ends when the relationship is ended. TERMINATION

Both nurse and client usually have feelings

about ending the relationship; the client
especially may feel the termination as an
impending loss.
 TEACHER CAREGIVER
ROLES OF A
NURSE IN A
THERAPEUTIC
RELATIONSHIP ADVOCATE
PARENT
SURROGATE
 The process that people use to
exchange information. Messages are
simultaneously sent and received on
COMMUNICATION two levels: verbally through the use
of words and nonverbally by
behaviors that accompany the
words (Balzer Riley, 2000).
Consists of the words a person uses to
speak to one or more listeners.

Content is verbal communication, the VERBAL

literal words that a person speaks.
COMMUNICATION

Context is the environment in which

communication occurs and can include the
time and the physical, social, emotional, and
cultural environment (Weaver, 1996).
• behavior that accompanies verbal content such as body language, eye
contact, facial expression, tone of voice, speed and hesitations in speech,
grunts and groans, and distance from the listener.

NONVERBAL COMMUNICATION
PROCESS

Incongruent message
denotes all nonverbal is when the content and
A congruent message
messages that the speaker process disagree—when
is when content and
uses to give meaning and what the speaker says and
process agree
context to the message what he or she does do
not agree
ADAPTIVE: Solves the problem that is causing the
anxiety, so the anxiety is decreased. The patient is
objective, rational, and productive

PALLIATIVE: termporarily decreases the anxiety but

does not solve the problem, so the anxiety eventually

TYPES OF
returns. Temporarily relief allows the patient to
return to problem solving

MALADAPTIVE: Unsuccessful attempts to decrease

the anxiety without attempting to solve the problem.
COPING
The anxiety remains.

DYSFUNCTIONAL: Is not successful in reducing

anxiety or solving the problem. Even minimal
functioning becomes difficult, and new problems
begin to develop
THERAPEUTIC COMMUNICATION

an interpersonal interaction between the nurse and client during which the
nurse focuses on the client’s specific needs to promote an effective exchange of
information.

Skilled use of therapeutic communication techniques helps the nurse understand

and empathize with the client’s experience.
GOALS

Identify the most important

Establish a therapeutic nurse– client concern at that
client relationship. • moment (the client-centered
goal)

• Assess the client’s perception of the

problem as it unfolded. This includes
detailed actions (behaviors and • Facilitate the client’s
messages) of the people involved and
the client’s thoughts and feelings
expression of emotions.
about the situation, others, and self.
 • RECOGNIZE • GUIDE THE
• TEACH THE • IMPLEMENT CLIENT TOWARD
CLIENT AND THE CLIENT’S INTERVENTIONS IDENTIFYING A
FAMILY NECESSARY DESIGNED TO
SELFCARE SKILLS. NEEDS. ADDRESS THE
PLAN OF ACTION
CLIENT’S NEEDS.
TO A SATISFYING
AND SOCIALLY
ACCEPTABLE
RESOLUTION.
PRIVACY AND RESPECTING
BOUNDARIES

Distance
Zone
Proxemics is the study of Intimate zone (0 to 18 inches
Privacy is desirable but not between people)
always possible in distance zones between
therapeutic communication people during Personal zone (18 to 36 inches)
communication. People feel Social zone (4 to 12 feet)
more comfortable with Public zone (12 to 25 feet)
smaller distances when
communicating with
someone they know rather
than with strangers
(Northouse & Northouse,
1998).
 The therapeutic communication
Both the client and the nurse can feel threatened if one
interaction is most comfortable when the
invades the other’s personal or intimate zone, which nurse and client are 3 to 6 feet apart.
can result in tension, irritability, fidgeting, or even flight.
When the nurse must invade the intimate or personal
zone, he or she always should ask the client’s
permission.
• As intimacy increases, the need for distance decreases.
TOUCH
Knapp (1980) five types of touch:
• Functional-professional touch is used in examinations
or procedures such as when the nurse touches a client to
assess skin turgor or a masseuse performs a massage.
• Social-polite touch is used in greeting, such as a
handshake and the “air kisses” some women use to greet
acquaintances, or when a gentle hand guides someone in the
correct direction.
• Friendship-warmth touch involves a hug in greeting, an
arm thrown around the shoulder of a good friend, or the
back slapping some men use to greet friends and relatives.
• Love-intimacy touch involves tight hugs and kisses
between lovers or close relatives.
• Sexual-arousal touch is used by lovers.
ACTIVE LISTENING AND
OBSERVATION
• Active listening means refraining from other internal mental activities and
concentrating exclusively on what the client says
• Active observation means watching the speaker’s nonverbal actions as he or
she communicates.
• Peplau (1952) used observation as the first step in the therapeutic interaction.
The nurse observes the client’s behavior and guides him or her in giving
detailed descriptions of that behavior. The nurse also documents these details.
To help the client develop insight into his or her interpersonal skills, the nurse
analyzes the information obtained, determines the underlying needs that relate
to the behavior, and connects pieces of information (makes links between
various sections of the conversation).
I. USING CONCRETE MESSAGES

the words are explicit and need no

interpretation; the speaker uses nouns instead VERBAL
of pronouns COMMUNICATION
SKILLS
Abstract messages,in contrast, are unclear
patterns of words that often contain figures of
speech that are difficult to interpret. They
require the listener to interpret what the
speaker is asking.
 Concrete (clear): “John
The following are
Abstract (unclear): “Get will be home today at 5
examples of concrete and
the stuff from him.” pm, and you can pick up
abstract messages:
your clothes at that time.”

Concrete (clear): “To

administer medications
Abstract (unclear): “Your
tomorrow, you’ll have to
clinical performance has
be able to calculate
to improve.”
dosages correctly by the
end of today’s class.”
• II. USING THERAPEUTIC COMMUNICATION TECHNIQUES
– the nurse selects techniques that will facilitate the interaction and
enhance communication between client and nurse
– Techniques such as exploring, focusing, restating, and reflecting
encourage the client to discuss his or her feelings or concerns in more
depth
NON-THERAPEUTIC COMMUNICATION TECHNIQUES

In contrast, there are many nontherapeutic techniques that nurses should

avoid

These responses cut off communication and make it more difficult for
the interaction to continue. Many of these responses are common in
social interaction such as advising, agreeing, or reassuring. Therefore it
takes practice for the nurse to avoid making these typical comments.
 Often cue words
introduced by the client
can help the nurse to If a client has difficulty
know what to ask next or attending to a conversation
how to respond to the and drifts into a rambling
III. Cues are verbal Finding cues is a client. The nurse builds his discussion or a flight of ideas,
or her responses on these
INTERPRETIN or nonverbal function of active cue words or concepts. the nurse listens carefully for a
G SIGNALS OR messages that listening. Understanding this can theme, a topic around which
relieve pressure on the client composes his or her
CUES signal key words words. Using the theme, the
students who are worried
or issues for the and anxious about what nurse can assess the nonverbal
client. question to ask next behaviors that accompany the
client’s words and build
responses based on these cues
Overt cues are clear statements of intent such
as, “I want to die.” The message is clear that the
client is thinking of suicide or self-harm.

Covert cues are vague or hidden messages that

need interpretation and exploration—for
example, if a client says, “Nothing can help me.”
The nurse is unsure, but it sounds as if the client
might be saying he feels so hopeless and helpless
that he plans to commit suicide. The nurse can
explore this covert cue to clarify the client’s
intent and to protect the client.
Other word patterns that need further clarification for meaning include
metaphors, proverbs, and clichés. When a client uses these figures of speech, the
nurse must follow up with questions to clarify what the client is trying to say

A metaphor is a phrase that describes an object or situation by comparing it to

something else familiar.

Proverbs are old, accepted sayings with generally accepted meanings.

A cliché is an expression that has become trite and generally conveys a stereotype.
Nonverbal communication is behavior that a person exhibits while
delivering verbal content.

It includes facial expression, eye contact, space, time, boundaries, and

body movements. Nonverbal communication is as important, if not
more so, than verbal communication.

NON-VERBAL
It is estimated that one-third of meaning is transmitted by words and
two-thirds is communicated nonverbally. COMMUNICATION
SKILLS
The speaker may verbalize what he or she thinks the listener wants
to hear, while nonverbal communication conveys the speaker’s actual
meaning.

Nonverbal communication involves the unconscious mind acting out

emotions related to the verbal content, the situation, the
environment, and the relationship between the speaker and the
listener.
Knapp and Hall (2002) list the ways in which nonverbal messages accompany verbal messages:

Accent: using flashing eyes or hand movements

Complement: giving quizzical looks, nodding

Contradict: rolling eyes to demonstrate that the meaning is the opposite of what one is saying

Regulate: taking a deep breath to demonstrate readiness to speak, using “and uh” to signal the wish to continue speaking

Repeat: using nonverbal behaviors to augment the verbal message such as shrugging after saying, “Who knows?”

Substitute: using culturally determined body movements that stand in for words such as pumping the arm up and down
with a closed fist to indicate success
I. FACIAL
EXPRESSIONS
• The human face produces the
most visible, complex, and
sometimes confusing nonverbal
messages (Weaver, 1996).
• Facial movements connect with
words to illustrate meaning; this
connection demonstrates the
speaker’s internal dialogue (Arnold
& Boggs, 1999; Schrank, 1998).
• Facial expressions can be categorized into expressive, impassive, and confusing:
• An expressive face portrays the person’s moment-by-moment
thoughts, feelings, and needs. These expressions may be evident even
when the person does not want to reveal his or her emotions.
• An impassive face is frozen into an emotionless, deadpan expression
similar to a mask.
• A confusing facial expression is one that is the opposite of what the
person wants to convey. A person who is verbally expressing sad or
angry feelings while smiling is an example of a confusing facial
expression. (Cormier et al., 1997; Northouse & Northouse, 1998).
II. BODY LANGUAGE Body language(gestures, Closed body positions, such as Hand gestures add meaning to The positioning of the nurse
postures, movements, and crossed legs or arms folded the content. and client in relation to each
body positions) is a nonverbal across the chest, indicate that other is also important. Sitting
form of communication. the interaction might threaten beside or across from the
the listener, who is defensive client can put the client at
or not accepting ease, while sitting behind a
desk (creating a physical
barrier) can increase the
formality of the setting and
may decrease the client’s
willingness to open up and
communicate freely.
 Vocal cues are The voice volume,
nonverbal sound tone, pitch, intensity,
III.VOCAL CUES signals transmitted emphasis, speed, and
along with the pauses augment the
content. sender’s message.

Volume, the loudness

Tone can indicate if
of the voice, can
someone is relaxed,
indicate anger, fear,
agitated, or bored.
happiness, or deafness.
Pitch varies from shrill and high to low and
threatening.

Intensity is the power, severity, and strength behind

the words, indicating the importance of the message.

Emphasis refers to accents on words or phrases that

highlight the subject or give insight on the topic.
Speed is number of words spoken per minute.

Pauses also contribute to the message, often adding

emphasis or feeling.
IV. EYE CONTACT The eyes have been called the mirror of the soul Eye contact, looking into the other person’s eyes
because they often reflect our emotions. during communication, is used to assess the other
Messages that the eyes give include humor, person and the environment and to indicate
interest, puzzlement, hatred, happiness, sadness, whose turn it is to speak; it increases during
horror, warning, and pleading. listening but decreases while speaking (Northouse
& Northouse, 1998). While maintaining good eye
contact is usually desirable, it is important that the
nurse doesn’t “stare” at the client.
• V. SILENCE
• It is important to allow the client sufficient time to
respond, even if it seems like a long time.
• It may confuse the client if the nurse “jumps in” with
another question or tries to restate the question
differently.
• Also, in some cultures, verbal communication is slow with
many pauses, and the client may believe the nurse is
impatient or disrespectful if he or she does not wait for
the client’s response.