Thoughts on the Therapeutic Relationship

I believe that one of the core elements of effective nursing practice in any setting is the interpersonal relationship the nurse forms with a person responding to a change in health status. 

The goal of nursing intervention is to benefit the client by meeting needs.  When the nurse-client relationship is beneficial, the client need can be met more effectively.  The client can be an individual with a health need (patient), the friend or family member(s) of the patient, or a broader population (community, class, group of patients, etc.)

The term “therapeutic” is synonymous with “beneficial.”  The nurse-client relationship is a “therapeutic relationship” when the nurse uses interpersonal skill and expertise to help the client.

The skill and expertise that the nurse uses to create a therapeutic relationship are called therapeutic communication techniques. 

The concept of communication includes a two-way process involving the sending and receiving of messages.  Therapeutic communication techniques include saying the right things (sending) as well as listening effectively (receiving).  Additionally, the nurse must recognize that the majority of communication is unspoken (nonverbal and paraverbal).

Therapeutic communication skill includes awareness of the unspoken communication that the nurse both sends and receives throughout the relationship, and awareness of personal effectiveness, personal challenges, and a desire to improve based on this self-awareness.

Skill at using unspoken elements of communication is essential when the nurse cares for a client who is unable to communicate verbally.

The concept of relationship means that the communication occurs over time.  This may be time-limited to one conversation or even one interaction, but there is still a time element.  Each message builds upon previously sent and received messages, strengthening the trust and confidence the client feels about the nurse and the care being delivered. 

There are substantial differences between a therapeutic relationship and a social relationship.  In the following chart I use the word client to describe the person in need of nursing intervention in response to a change in health status.  However, the “client” could also be a family member, a group, or a community.

Therapeutic Relationship	Social Relationship
Primary focus is on the client.  The goal or purpose of the relationship is to benefit the client.	Mutual focus.
Client and nurse perceive the nurse as helper and the client as in need of help.	Friends give and receive help and perceive each other in both roles.
More defined limits of time, space, place, and type of relationship.  The nurse has the responsibility to establish and maintain these limits.	Fewer limits on the relationship.  Limits are set mutually.
The nurse must maintain a balance between intimacy and detachment.  Intimacy means forming a close relationship with the client.  Detachment means not becoming friends with the client and not taking client behavior personally.  Simply stated, the nurse must be friendly with, but not be a friend with the client.	Detachment skills are not crucial to communication in a social relationship.
The nurse has professional responsibility to communicate therapeutically. Two keys to this: 1.  Nurse should get social needs met outside the therapeutic relationship. 2.  Nurse must increase self-awareness through self-assessment to improve therapeutic communication skill.	Friends may communicate therapeutically, but may not consider this a responsibility.
The nurse is professionally bound to honor confidentiality.	Confidentiality is important but not an obligation.

I'd be interested in hearing comments from my nurse friends.  What do you think about the concept of the therapeutic relationship?  Do you see yourself using relationship and communication skills in your practice?