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INTRODUCTION
The therapeutic interaction between the nurse and the
patient helps to develop mutual growth of 2 individuals.
The therapeutic nurse patient reaction or interaction is a
mutual learning experience and corrective emotional
experience for the patient. Therapeutic communication in
nursing reinforces the nurse-patient relationship. It makes
the nurse appears more humane to a patient.


DEFINITION
According to R.K. Gupta
Therapeutic communication is a process in which the
nurse consciously influences a client or helps the client to a
better understanding through verbal-non-verbal
communication

According to R.Sreevani
Therapeutic communication is an interpersonal
interaction between the nurse and the patient during which
the nurse focuses on the patient specific needs to promote
an effective exchange of information




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PROCESS OF COMMUNICATION



MESSAGE
SENDER RECEIVER
FEEDBACK

Therapeutic Relationship

A relationship is defined as a state of being related or state
of affinity between two individuals. In a therapeutic
relationship nurse and the patient works together towards
the goal of assisting the patient to regain their inner sources
to meet life challenges and facilitates growth.

Types of Therapeutic Relationship

There are three types of relationship
1. Social Relationship- These relationships are
primarily initiated for the purpose of friendship,
socialization, enjoyment or for accomplishing a task.
2. Initimate Relationship- These relationships are
formed between two individuals who have emotional
Commitment to each other.


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3. Therapeutic Relationship- In therapeutic relationship
the nurse and client work together towards a goal.
The interaction is purposefully established,
maintained, carried out with anticipated outcome.

BOUNDARIES IN NURSE-CLIENT RELATIONSHIP

A boundary indicates a border or limit. It determines the
extent of acceptable limits. Many types of boundaries exist.
Examples include-
1) Material Boundaries- These are physical properties
that can be seen such as fences in the border land.
2) Social Boundaries- These are established within a
culture and define how individuals are expected to
behave in social situations.
3) Person Boundaries- These are boundaries that
individuals define for themselves. These include
physical distance boundaries or just how close
individuals choose to disclose of their most private
and intimate self to others,
4) Professional Boundaries- These boundaries limit and
outline expectations for appropriate professional
relationships with clients. They separate therapeutic


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Behavior from any other behavior that, well intended or not
could lessen the benefit of care to the clients. Concerns
regarding professional boundaries are commonly related to
following issues.
a) Self-disclosure- Self-disclosure should never be used
for the purpose of meeting the nurse needs.
b) Gift-giving-Individuals who are receiving care often,
feel indebted toward health care providers, And,
indeed, gif giving may be a part of therapeutic
process for people who receive care. Accepting
financial gift is never appropriate in a therapeutic
relationship. In all instances the nurse should exercise
professional judgment when deciding whether to
accept a gift from a client.
c) Touch- Touching is required to perform many
therapeutic procedures involved in the physical care of
clients. Caring touch is the touching of client when
there is no physical need. Caring touch often provides
comfort or encouragement and when it is used
appropriately, it can have a therapeutic effect on
client.
d) Friendship or Intimate Association-When a nurse is
acquainted with a client, the relationship must move


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From one of a personal nature to professional. If the nurse
is unable to make separation, he or she should withdraw
from the nurse- client relationship.

BARRIERS TO EFFECTIVE COMMUNICATION
There are certainly many reasons why interpersonal
communication may fail or become ineffective. In many
communication, the message(what is said) may not
received exactly the way the sender intended. It is,
therefore important that the communication seeks feedback
to check that their message is clearly understood.

COMMON BARRIERS TO EFFECTIVE
COMMUNICATION
1. The use of jargon, over-complicated , unfamiliar
technical terms.
2. Emotional barriers or taboos.
3. Lack of attention, interest or distractions or
irrelevance to the receiver.
4. Differences in perception and viewpoint
5. Physical disabilities such as hearing problem or
speech difficulties.
6. Physical barriers to non- verbal communication.


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Not being able to see the non-verbal clues, gestures, posture
and general body language can make communication less
effective.
7. Language differences
8. Expectations and prejudices which may lead to false
assumptions or stereotyping. People often hear what
they expect to hear than what is actually said and
jump to incorrect conclusions.
9. Cultural differences- The norms of social interaction
vary greatly in different cultures, as do the way in
which emotions are expressed.

OTHER INEFFECTIVE BARRIERS AND RESPONSES
1. Defending
2. Requesting an explanation
3. Reflecting
4. Avoiding sensitive topics
5. Incorrect Posture
6. Making false promises
7. Ignoring the patient
8. Being opinionated
9. Showing disproval



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CATEGORISATION OF BARRIERS TO EFFECTIVE
COMMUNICATION
1. Language Barriers- Language and linguistic ability
may act as a barrier to communication. However
even when communication is in the same language,
the terminology used in message may act as a barrier,
if it is not fully understood by the receiver. A
message should not include a lot of technical terms
and jargons, abbreviations
2. Physiological Barriers- Physiological barrier may
result from the receivers physical state for example-
a client with reduced hearing may not grasp to
entirety of a spoken conversation especially if there
is significant background noise.
3. Physical Barriers- An example of barrier to
communication is geographic distance between the
sender and the receiver. Communication is generally
easier over shorter distances as more communication
channels are available and less technology is
required. The advantages and disadvantages of each
communication channel should be understood so that
an appropriate channel can be used to overcome the
physical barriers.


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4. Psychological barrier- The psychological state of the
receiver will influence how the message is received.
Stress management is an important personal skill that
affects our interpersonal relationships. Anger is
another example of a psychological barrier to
communication, people with low self-esteem may be
less assertive and therefore may not feel comfortable
communicating.
5. Systemic Barriers-Systemic barriers to
communication may exist in structures and
organizations where there are inefficient or
inappropriate information system and
communication channels or where there is lack of
understanding of the roles and responsibilities for
communication.
6. Attitudnal Barriers- Attitudnal barriers are behaviors
or perceptions that prevent people from
communicating effectively. Attitudnal barriers to
communication may result from personality
conflicts, poor management, resistance to change or a
lack of motivation. Effective receivers of messages
should attempt to overcome their own attitudinal
barriers to facilitate effective communication.


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ROLE OF NURSE
1. Boundary crossing can threaten the integrity of the
nurse-client relationship. Nurses must gain self-
awareness and insight to be able to recognize when
professional integrity is compromised
2. The nurses should leave the ability to make decisions
about boundaries based on the best interests of the
clients in their care.
3. Conferences with supervisors and group discussions
with staffs are the ways in which the nurse can be
best assisted to overcome the barriers encountered.
4. The nurse should be aware of the patients feelings
and able to deal with them appropriately .The nurse
can assist the patient by open eliciting his thoughts
and feelings about termination.
5. Use of self in a therapeutic relationship in a
therapeutic manner requires that nurse has a great
deal of self- awareness and self-understanding of
overall human condition

THERAPEUTIC USE OF SELF
Travelbee(1971) described the instrument used for
delivering the process of interpersonal nursing as the


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Therapeutic use of self which is defined as the ability to
use ones personality consciously and in full awareness in
an attempt to establish relatedness and to structure nursing
intervention
Therapeutic Attitude
An attitude is a frame of reference around which an
individual organizes knowledge about his or her world
An attitude has also an emotional component. It
can be prejudgment and may be selective and biased.
Values, attitudes and beliefs can influence communication
in many ways.The attitude of therapist has paramount
importance for success of any psychotherapy,
communication. The right attitude of a person will lead to
development of a good rapport with the patient.

ELEMENTS AFFECTING THE THERAPEUTIC
RELATIONSHIP
1. Personal Qualities
2. Facilitative Communication
3. Responsive Dimensions
4. Action Dimensions
5. Therapeutic Impasses
6. Therapeutic Outcome



















PERSONAL
QUALITIES
FACILITATIVE
COMMUNICATION
RESPONSIVE
DIMENSIONS
ACTION
DIMENSION
THERAPEUTIC
IMPASSES
THERAPEUTIC
OUTCOME
1. Self-
Awareness
2. Clarification
of values
3. Role-
Modelling
4. Ethics &
Responsibilty
5. Exploration
of feelings
6. Altruism
1. Genuiness
2. Respect
3. Empathy
4. Concretness
1. Confrontation
2. Immediacy
3. Self-
disclosure
4. Catharis
5. Role-playing
1. Resistance
2. Transference
3. Counter-
Transference
4. Boundary
Violations
1. For Patient
2. For Sociey
3. For Nurses
1. Verbal
Behavior
2. Non- Verbal
Behavior
3. Analysis of
Problem
4. Therapeutic
techniques
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Elements Affecting the nurses ability to be therapeutic

Personal Qualities
1. The therapeutic use of the psychiatric nurse is the
use of oneself. Thus self-analysis is the first building
block in providing quality nursing care.
i) Awareness of one-self- The nurse must be able to
examine personal feelings, actions and reactions.
A good understanding and acceptance of self
allow the nurse to acknowledge a patient;s
difference and uniqueness.
Campbell(1980) has identified a holistic nursing
model of self-awareness that consists of 4
components-
a) The psychological component include knowledge
of emotions, motivations, self-concept and
personality.
b) The physical component is the knowledge of
personal and general physiology as well as body
of sensations, body image and physical potential
c) The environmental component consists of socio-
cultural environment relationship with others and
knowledge of the relationships between human
and nature.



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d) The philosophical component is the sense of life
having meaning. It takes inti account the
responsibility to the world and the ethics of
behavior.
Together these components provide a
model that can be used to promote self-awareness
and .self-growth of nurses and patients for whom
they care.
2) Clarification of values- Answers of ones values helps
the nurse to be honest, to better accept difference in others
and to avoid unethical use of patients to meet personal
needs.
3) Exploration of feelings- The nurse should explore their
feelings, should open up and aware of and in control of
their feelings so that they can be used to help the patients.

5) Serving as a role model- Research has shown the
power of role models in molding socially adaptive,
as well as maldaptive behavior, thus a nurse has an
obligation to model adaptive and growth producing
behavior.
6) Altruism- Altruism is concern for the welfare of
others


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7) Ethics & Responsibility- The code for nurse reflect
common values regarding nurse-patient relationship
and responsibilities and serve as a frame of reference
for all nurses in their judgments about welfare and
social responsibility. Responsible ethical choice
involves accountability, risk, commitment and
justice.