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Unit 3 Fostering Communication

c h a p t e r

The NurseClient Relationship

Words to Know
affective touch
intimate space
introductory phase

Learning Objectives
personal space
public space
social space
task-oriented touch
terminating phase
therapeutic verbal
verbal communication
working phase

On completion of this chapter, the reader will

Name four roles that nurses perform in nurseclient relationships.

Describe the current role expectations for clients.
List at least five principles that form the basis of the nurseclient
Identify the three phases of the nurseclient relationship.
Differentiate between social communication and therapeutic verbal
Give five examples of therapeutic and nontherapeutic communication
List at least five factors that affect oral communication.
Describe the four forms of nonverbal communication.
Differentiate task-related touch from affective touch.
List at least five situations in which affective touch may be appropriate.

n intangible factor that helps a client to hold a nurse

in high regard is the relationship that develops between
them. One of the primary keys to establishing and maintaining positive nurseclient relationships is the manner
and style of the nurses communication. This chapter
offers information about techniques for communicating
therapeutically, listening empathetically, sharing information, and providing client education, all of which are
among the most basic processes within the context of
nurseclient relationships.



A relationship (association between two or more people) is established between the nurse and client when
nursing services are provided. Nurses provide services,
or skills, that assist individuals, called clients or patients,
to promote or restore health, cope with disorders that
will not improve, and die with dignity.

The nurseclient relationship requires the nurse to respond to the clients needs. The National Council of State
Boards of Nursing, which develops the national licensing
examination for practical nurses (NCLEX-PN), designates
four categories of client needs as the structure for the test
plan: (1) safe, effective care environment, (2) health promotion and maintenance, (3) psychosocial integrity, and
(4) physiologic integrity. These four categories apply to all
areas of nursing practice regardless of the stage in the
clients life span or the setting for health care delivery. To
meet these client needs, nurses perform four basic roles:
caregiver, educator, collaborator, and delegator.

The Nurse as Caregiver

A caregiver is one who performs health-related activities
that a sick person cannot perform independently. Caregivers provide physical and emotional services to restore
or maintain functional independence. Box 7-1 highlights
the many differences between the services that nurses
provide and those that other caring people provide.


BOX 7-1

UNIT 3 Fostering Communication

Differentiating Caring Acts

From Nursing Acts

Caring Acts

Nursing Acts

Prompted by observing a person in


Prompted by a concern for the wellbeing of everyone

Motivated by sympathy

Motivated by altruism



Goal is to relieve crisis

Goal is to promote self-reliance

Outcomes are short-term

Outcomes are long-term

Assume major responsibility for

resolving the persons problem

Expect mutual cooperation in

resolving health problems



Modeled on a personal moral code

Modeled on a formal code of ethics

Guided by common sense

Legally defined

Accountability based on acting

reasonably prudent

Accountability based on meeting

professional standards

information empowers clients to become involved with

self-help groups or those that offer rehabilitation, financial assistance, or emotional support.

The Nurse as Collaborator

The nurse also acts as a collaborator (one who works
with others to achieve a common goal) (Fig. 7-1). The
most obvious example of collaboration occurs between the
nurse responsible for managing care and those to whom
he or she delegates care. Collaboration also occurs when
the nurse and physician share information and exchange
findings with other health care workers.

Stop, Think, and Respond BOX 7-1

With whom would the nurse collaborate when
caring for an older adult with a fractured hip?

The Nurse as Delegator

Although the traditional nursing role is associated with
physical care, it also involves developing close emotional
relationships. The contemporary caregiving role incorporates an understanding that illness and injury cause feelings of insecurity that may threaten a persons ability to
cope. Nurses use empathy (an intuitive awareness of
what a client is experiencing) to perceive the clients emotional state and need for support. Empathy helps nurses to
become effective in providing for the clients needs while
remaining compassionately detached.

Before the nurse performs the role of delegator (one who

assigns a task to someone), he or she must know what
tasks are legal and appropriate for particular health care
workers to perform. It is potentially litigious to delegate a
task to someone who does not have the knowledge or

The Nurse as Educator

Being an educator (one who provides information) is a
necessity in todays complex health care arena. Nurses
provide health teaching pertinent to each clients needs
and knowledge base (see Chap. 8). Some examples include explanations about diagnostic test procedures, selfadministration of medications, techniques for managing
wound care, and restorative exercises like those performed after a mastectomy.
When it comes to treatment decisions, the nurse avoids
giving advice, reserving the right of each person to make
his or her own choices on matters affecting health and
illness care. The nurse shares information on potential
alternatives, promotes the clients freedom to choose, and
supports the clients ultimate decision.
Nursing is considered a practice without walls because it extends beyond the original treatment facility.
Consequently nurses are resources for information about
health services available in the community. This type of






assistive personnel




FIGURE 7.1 Collaboration may involve many members of the health

care team.


expertise to perform it correctly. Once a task is assigned,

it is still the delegators responsibility to check that the
task has been completed and determine the resulting outcome. For example, if a nurse asks a nursing assistant to
change a clients position, the nurse verifies that the assistant complied with the nurses request and obtains additional pertinent information such as the condition of the
clients skin. If the delegated task is not performed or is
performed incorrectly, the nurse is accountable for the
inadequate care.

Stop, Think, and Respond BOX 7-2

Before delegating the task of taking a clients vital
signs (temperature, pulse, respiratory rate, and blood
pressure) to a student nurse, how might the nurse
determine if the task is appropriate for the student,
and if appropriate, that it has been performed?



Responsibilities Within the

NurseClient Relationship

Possess current knowledge.
Be aware of unique age-related differences.
Perform technical skills safely.
Be committed to client care.
Be available and courteous.
Facilitate participation of client and family in decisions.
Remain objective.
Advocate on the clients behalf.
Provide explanations in easily understood language.
Promote clients independence.
Identify current problem.
Describe desired outcomes.
Answer questions honestly.
Provide accurate historical and subjective data.
Participate to the fullest extent possible.
Be open and flexible to alternatives.
Comply with the plan for care.
Keep appointments for follow-up care.

The nurseclient relationship also can be called a therapeutic relationship because the desired outcome of the
association is almost always moving toward restored
health. A therapeutic relationship differs from a social
relationship. A therapeutic relationship is client-centered
with a focus on goal achievement. It is also time-limited:
the relationship ends when goals are achieved.
The relationship between nurses and clients has
changed. In the past, the role of a sick person was passive;
this allowed others to make decisions and submit to treatments without question or protest. Nurses now encourage
and expect people for whom they care to become actively
involved, to communicate, to question, to assist in planning their care, and to retain as much independence as
possible (Box 7-2).

Underlying Principles
A therapeutic nurseclient relationship is more likely to
develop when the nurse

Treats each client as a unique person

Respects the clients feelings
Strives to promote the clients physical, emotional,
social, and spiritual well-being

Encourages the client to participate in problem

solving and decision making

Accepts that a client has the potential for growth

and change

Communicates using terms and language the client


BOX 7-2

The NurseClient Relationship

Uses the nursing process to individualize the clients


Incorporates people to whom the client turns for

support, such as family and friends, when providing care
Implements health care techniques that are compatible with the clients value system and cultural

Phases of the NurseClient Relationship

Nurseclient relationships are ordinarily brief. They
begin when people seek services that will maintain or
restore health, or prevent disease. They end when clients
can achieve their health-related goals independently.
This type of relationship generally is described as having
three phases: introductory, working, and terminating.

Introductory Phase
The relationship between client and nurse begins with
the introductory phase (period of getting acquainted).
Each person usually brings preconceived ideas about the
other to the initial interaction. These assumptions eventually are confirmed or dismissed.
The client initiates the relationship by identifying one
or more health problems for which he or she is seeking
help. It is important for the nurse to demonstrate courtesy,
active listening, empathy, competency, and appropriate
communication skills to ensure that the relationship
begins positively.


UNIT 3 Fostering Communication

Working Phase
The working phase (period during which tasks are performed) involves mutually planning the clients care and
enacting the plan. Both nurse and client participate. Each
shares in performing those tasks that lead to the desired
outcomes identified by the client. During the working
phase, the nurse tries not to retard the clients independence: doing too much is as harmful as doing too little.

Terminating Phase
The nurseclient relationship is self-limiting. The terminating phase (period when the relationship comes to an
end) occurs when nurse and client mutually agree that
the clients immediate health problems have improved.
The nurse uses a caring attitude and compassion in facilitating the clients transition of care to other health care
services or independent living.

Barriers to a Therapeutic Relationship

It is impossible for a nurse to develop a positive relationship with every client. Box 7-3 lists examples of behaviors
that are likely to interfere. The best approach is to treat
clients in the manner one would like to be treated.


Communication (exchange of information) involves

both sending and receiving messages between two or more
people followed by feedback indicating that the information was understood or requires further clarification

BOX 7-3

Barriers to a NurseClient Relationship

Appearing unkempt: long hair that dangles on or over the client during
care, offensive body or breath odor, wrinkled or soiled uniform, dirty shoes
Failing to identify oneself verbally and with a name tag
Mispronouncing or avoiding the clients name
Using the clients first name without permission
Showing disinterest in the clients personal history and life experiences
Sharing personal or work-related problems with the client or with staff in
the clients presence
Using crude or distasteful language
Revealing confidential information or gossip about other clients, staff, or
people commonly known
Focusing on nursing tasks rather than the clients responses
Being inattentive to the clients requests (e.g., food, pain relief, assistance
with toileting, bathing)
Abandoning the client at stressful or emotional times
Failing to keep promises such as consulting with the physician about a
current need or request
Going on a break or to lunch without keeping the client informed and
identifying who has been delegated for the clients care during the
temporary absence

(Fig. 7-2). Communication takes place simultaneously

on a verbal and nonverbal level. Because no relationship
can exist without verbal and nonverbal communication,
nurses develop skills that enhance their therapeutic interactions with clients.

Verbal Communication
Verbal communication (communication that uses
words) includes speaking, reading, and writing. Both
nurse and client use verbal communication to gather facts.
They also use it to instruct, clarify, and exchange ideas.
The following factors affect ability to communicate
orally or in writing:

Attention and concentration

Language compatibility
Verbal skills
Hearing and visual acuity
Motor functions involving the throat, tongue, and
Sensory distractions
Interpersonal attitudes
Cultural similarities

The nurse promotes the factors that enhance the

communication of verbal content and controls or eliminates those that interfere with the accurate perception
of expressed ideas.

Therapeutic Verbal Communication

Communication can take place on a social or therapeutic level. Social communication is superficial; it includes
common courtesies and exchanges about general topics.
Therapeutic verbal communication (using words and
gestures to accomplish a particular objective) is extremely
important especially when the nurse is exploring problems with the client or encouraging expression of feelings. Techniques that the nurse may find helpful are
described in Table 7-1.
The nurse must never assume that a quiet, uncommunicative client has no problems or understands everything. It is never appropriate to probe and pry; rather, it
may be advantageous to wait and be patient. It is not
unusual for reticent clients to share their feelings and
concerns after they conclude that the nurse is sincere
and trustworthy.
Nurses must approach vocal, emotional clients delicately. For instance, when clients are angry or crying, the
best nursing response is to allow them to express their
emotions. Allowing clients to display their feelings without fear of retaliation or censure contributes to a therapeutic relationship.
Although nurses often have the best intentions of interacting therapeutically with clients, some fall into traps


The NurseClient Relationship


FIGURE 7.2 Communication is a twoway process between a sender and a







Broad opening

Relieves tension before getting to the real

purpose of the interaction
Provides facts
Acquires specific information
Encourages the client to elaborate

Wonderful weather were having.

Confirms that the nurse is following the

Restates what the client has said to demonstrate

Client: I havent been sleeping well.

Nurse: You havent been sleeping well.
Client: After every meal, I feel like I will throw up.
Nurse: Eating makes you nauseous, but you dont
actually vomit.
Client: All the nurses are so busy.
Nurse: Youre feeling that you shouldnt ask for help.
I have 15 minutes. If your pain is relieved, we
could discuss how your test will be done.
Uh, huh, or Go on.
You seem depressed.
I dont quite understand what youre asking.
Youre concerned about your weight loss, but you
didnt eat any breakfast.
Youve asked me to check on increasing your pain
medication and getting your diet changed.

Giving information
Direct questioning

Verbalizing what has

been implied

Shares how the nurse has interpreted a

Defines a purpose and sets limits

Giving general leads

Sharing perceptions

Encourages the client to continue

Shows empathy for the clients feelings
Avoids misinterpretation
Calls attention to manipulation, inconsistencies,
or lack of responsibility
Reviews information that has been discussed


Allows time for considering how to proceed or

arouses the clients anxiety to the point that it
stimulates more verbalization

Your surgery is scheduled at noon.

Do you have any allergies?
How are you feeling?


UNIT 3 Fostering Communication

that block or hinder verbal communication. Table 7-2 lists

common examples of nontherapeutic communication.

Listening is as important during communication as speaking. Giving attention to what clients say provides a stim-


ulus for meaningful interaction. It is important to avoid

giving signals that indicate boredom, impatience, or the
pretense of listening. For example, looking out a window
or interrupting is a sign of disinterest. When communicating with most people in the United States, it is best to
position oneself at the persons level and make frequent
eye contact (Fig. 7-3). Refer to Chapter 6 for cultural





Giving False Reassurance

Trivializes the clients unique feelings
and discourages further discussion

Youve got nothing to worry about.

Everything will work out just fine.

Tell me your specific concerns.

Keep a stiff upper lip.

It must be difficult for you right now.

Giving Approval or Disapproval

Holds the client to a rigid standard;
implies that future deviation may lead
to subsequent rejection or disfavor

Im glad youre exercising so regularly.

You should be testing your blood
glucose each morning.

Are you having any difficulty fitting regular

exercise into your schedule?
Lets explore some ways that will help you
remember to test your blood glucose each

Does not allow the client flexibility to
change his or her mind

Youre right about needing surgery


Having surgery immediately is one possibility.

What others have you considered?

Intimidates the client; makes him or her
feel foolish or inadequate

Thats not true! Where did you get

that idea?

Maybe I can help clarify that for you.

Demanding an Explanation
Puts the client on the defensive; he or
she may be tempted to make up an
excuse rather than risk disapproval
for an honest answer

Why didnt you keep your

appointment last week?

I see you couldnt keep your appointment

last week.

Giving Advice
Discourages independent problem
solving and decision making; provides
a biased view that may prejudice the
clients choice

If I were you, Id try drug therapy

before having surgery.

Share with me the advantages and

disadvantages of your options as you see

Ms. Johnson is my best nursing

assistant. She wouldnt have let your
light go unanswered that long.

Im sorry you had to wait so long.

Lots of people learn to give

themselves insulin.

Youre finding it especially difficult to stick

yourself with a needle.

Are we ready for our bath yet?

Would you like your bath now or should

I check with you later?

Client: Im so scared that a mammogram will show I have cancer.

Nurse: Tell me more about your family.

Client: Im so scared that a mammogram will

show I have cancer.
Nurse: It is a serious disease. What concerns
you the most?

Using Clichs
Provides worthless advice and curtails
exploring alternatives

Indicates such a strong allegiance that
any disagreement is unacceptable
Disregards how the client is responding
as an individual
Treats the client condescendingly
(less than capable of making an
independent decision)
Changing the Subject
Alters the direction of the discussion to
a safer or more comfortable topic


The NurseClient Relationship


People communicate nonverbally through the techniques described next: kinesics, paralanguage, proxemics,
and touch.

Kinesics (body language) includes nonverbal techniques
such as facial expressions, posture, gestures, and body
movements. Some add that clothing style and accessories
such as jewelry also affect the context of communication.


FIGURE 7.3 Appropriate positioning, space, eye contact, and attention

promote therapeutic communication. (Copyright B. Proud.)

exceptions. Nodding and making comments such as,

Yes, I see, encourages clients to continue and shows
full involvement in what is being said.

Silence (intentionally withholding verbal commentary)
plays an important role in communication. It may seem
contradictory to include silence as a form of verbal communication. Nevertheless, one of its uses is to encourage
the client to participate in verbal discussions. Other therapeutic uses for silence include relieving a clients anxiety just by providing a personal presence and offering a
brief period during which clients can process information
or respond to questions.
Clients may use silence to camouflage fears or to
express contentment. They also use silence for introspection when they need to explore feelings or pray. Interrupting someone deep in concentration disturbs his or her
thought process. A common obstacle to effective communication is ignoring the importance of silence and talking

Paralanguage (vocal sounds that are not actually words)

also communicates a message. Some examples include
drawing in a deep breath to indicate surprise, clucking the
tongue to indicate disappointment, and whistling to get
someones attention. Vocal inflections, volume, pitch, and
rate of speech add another dimension to communication.
Crying, laughing, and moaning are additional forms of

Proxemics (use and relationship of space to communication) varies among people from different cultural backgrounds. Generally four zones are observed in interactions
between Americans (Hall, 1959, 1963, 1966): intimate
space (within 6 inches), personal space (6 inches to
4 feet), social space (4 to 12 feet), and public space
(more than 12 feet; Table 7-3).
Most people in the United States comfortably tolerate
strangers in a 2- to 3-foot area. Venturing closer may cause






Intimate space

Within 6 inches

Personal space

6 inches to
4 feet

Social space

4 to 12 feet

Public space

12 or more feet

Nonverbal Communication
Nonverbal communication (exchange of information
without using words) involves what is not said. The
manner in which a person conveys verbal information
affects its meaning. A person has less control over nonverbal than verbal communication. Words can be chosen
with care, but a facial expression is harder to control. As
a result, people often communicate messages more accurately through nonverbal communication.

Confiding secrets
Sharing confidential
Physical assessment
involving touch
Private conversations
Teaching one-on-one
Group interactions
Conversations that
are not intended to
be private
Giving speeches
Gatherings of


UNIT 3 Fostering Communication

some to feel anxious. Understanding the clients comfort

zone helps the nurse to know how spatial relations affect
nonverbal communication.
Closeness is common in nursing because of the many
times nurses and clients are in direct physical contact.
Therefore, some clients can misinterpret physical nearness and touching within intimate and personal spaces as
having sexual connotations. Approaches that may prevent
such misunderstanding include explaining beforehand
how a nursing procedure will be performed, ensuring that
a client is properly draped or covered, and asking that
another staff person of the clients gender be present during an examination or procedure.

Touch (tactile stimulus produced by making personal contact with another person or object) occurs frequently in
nurseclient relationships. While caring for clients, touch
can be task-oriented, affective, or both. Task-oriented
touch involves the personal contact required when performing nursing procedures (Fig. 7-4). Affective touch
is used to demonstrate concern or affection (Fig. 7-5).
Affective touch has different meanings to different
people depending on their upbringing and cultural background. Because nursing care involves a high degree of
touching, the nurse is sensitive as to how clients may perceive it. Most people respond positively to touch, but there
are variations among individuals. Therefore, nurses use
affective touching cautiously even though its intention is
to communicate caring and support. In general, affective
touch is therapeutic when a client is

FIGURE 7.4 Examining a client involves task-oriented touch. (Copyright B. Proud.)

FIGURE 7.5 This nurse uses affective touch as she talks with her client.
(Copyright B. Proud.)

Near death
Anxious, insecure, or frightened
Semiconscious or comatose
Visually impaired
Sensory deprived

Begin an initial contact with an exchange of names and a handshake if
appropriate. Before calling a person by his or her first name, obtain
permission or wait to be invited to use a more familiar form of address,
which some cultures reserve for family and close friends.
Never treat older adults as if they are children; avoid using any terms that
are demeaning or connote childlike or infantile behavior or actions
(e.g., remarks such as He acts just like a baby and references to
incontinence products as diapers).
Use touch purposefully as a primary method of nonverbal communication
and to reinforce verbal messages; recognize that touch as a form of
communication is usually more important to older adults than to
younger adults.
Sit in a face-to-face position, provide good lighting while avoiding background glare, and eliminate as much background noise as possible.
Promote as much control over decisions and choices as possible. Dependence is often difficult to accept; independence maintains self-esteem
and dignity.
Allow older adults to pace their own care and maintain as much independence as possible even when this requires more time.
Encourage reminiscing. Ask about past events and relationships associated with positive experiences and feelings. Giving older adults an
opportunity to talk about earlier times in their lives reinforces their
value and unique identity.


Be aware of subtle verbal messages that convey bias or inequality; for example, calling white men Mister but men of color by their first names.
Avoid addressing older adults in familiar terms such as Dear, Grandma,
or Pop, unless the older adult suggests it.

Critical Thinking Exercises

1. What specific services might a person expect within a nurse
client relationship that differ from those within a physician
client relationship?
2. Studies have shown that older adults are not touched with the
same frequency as clients in other age groups. Discuss reasons
for this.


1. A discouraged client says, Im sure this surgery wont

help any more than the others. The best initial nursing
response is
1. Youre saying that you doubt you will improve.
2. Do you want to talk to the surgeon again?
3. Id recommend a more positive attitude.
4. Of course it will; youll be up and around in no
2. When a terminally ill client does not respond to medical
treatment, which nursing action is most helpful in assisting the client to deal with his impending death?
1. Provide literature on death and dying.
2. Allow him privacy to think by himself.
3. Listen to him talk about how he is feeling.
4. Encourage him to get a second opinion.
3. An alarm caused by a loose cardiac monitor lead startles
a client with chest pain. The best nursing intervention is to
1. Identify the clients current heart rhythm.
2. Explain the reason the alarm sounded.
3. Give the client a prescribed tranquilizer.
4. Provide the client with a magazine to read.
4. A 2 year old is admitted to the emergency department
with a high fever of unknown origin. Which of following
is the nurse correct to delegate to a nursing assistant?
1. Administer an aspirin suppository to reduce the
childs fever.
2. Give the toddler a Popsicle or other fluid every
30 minutes.
3. Call the laboratory for the results of diagnostic tests.
4. Listen to the childs lungs for sounds of congestion.

References and Selected Readings

Armstrong, L. & Wright, A. (2002). Communication in day care:
Talking without words. Journal of Dementia Care, 10(5), 189.

The NurseClient Relationship


Caris-Verhallen, W. M. C., deGruijter, I. M., Kerkstra, A., et al.

(1999). Factors related to nurse communication with
elderly people. Journal of Advanced Nursing, 30(5),
Chant, S., Jenkinson, R., Randle, J., et al. (2002). Communication skills training in healthcare: A review of the literature.
Nurse Education Today, 22(3), 189202.
Crowe, M. (2000). The nurse-patient relationship: A consideration of its discursive context. Journal of Advanced Nursing,
31(4), 962967.
Dreger, V. (2001). Communication: An important assessment
and teaching tool. Insight: The Journal of the American Society
of Ophthalmic Registered Nurses, 26(2), 5762.
Gibson, M. V. (2002). Reawakening the language of the body.
Journal of Dementia Care, 10(5), 2022.
Hall, E. T. (1959). The silent language. New York: Fawcett.
Hall, E. T. (1963). A system for the notation of proxemic
behavior. American Anthropologist, 65(3), 10031026.
Hall, E. T. (1966). The hidden dimension. New York: Doubleday.
Heineken, J. (1998). Patient silence is not necessarily client satisfaction: Communication problems in home care nursing.
Home Healthcare Nurse, 16(2), 115121.
Hugg, A. (2002). Universal language. NurseWeek California,
15(2), 2326.
Improving the communication process to improve care. (2002).
Disease Management Digest, 6(5), 67, 1011.
Lawson, M. T. (2002). Nurse practitioner and physician communication styles. Applied Nursing Research, 15(2), 6066.
Lego, S. (1999). The one-to-one nurse-patient relationship. Perspectives in Psychiatric Care, 35(4), 423.
Lotzkar, M., & Bottorff, J. L. (2001). An observational study of
the development of a nurse-patient relationship. Clinical
Nursing Research, 10(3), 275294.
Skott, C. (2001). Caring narratives and the strategy of presence:
Narrative communication in nursing practice and research.
Nursing Science Quarterly, 14(3), 249254.
Southerland, K. (2001). Speak carefully. Journal of Christian
Nursing, 18(3), 36.
Williams, A. (2001). A study of practicing nurses perceptions and experiences of intimacy within the nursepatient relationship. Journal of Advanced Nursing, 35(2),
Wolf, Z. R., Colagan, M., Costello, A., et al. (1998). Research
utilization. Relationship between nurse caring and patient
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