01.01 Phases of Nurse-Client Relationship

Okay guys, before we get into specific disease processes in mental health, it’s really important that we talk about the nurse-client relationship. Sometimes it’s hard for nurses to grasp the world of mental health because mental health seems intangible or more difficult because you can’t see or feel it. It’s not like there’s a physical wound you can see or lab values to interpret. It takes a whole different set of communication and assessment skills.

The truth is that many clients who suffer from mental health disorders may feel alone, they may struggle to maintain healthy relationships, they may have a fragmented or shallow support system. So, as nurses, we have a very powerful place and role here to be their rock, to support them, and to BE their support system. Clients need to know that they can trust us to approach them with honesty, empathy, and respect in every interaction. These things should come through in all of our communication with them. And, as with any other client we need to consider any cultural, religious, or spiritual beliefs that impact their care. Especially with mental health, we see religious or spiritual beliefs impacting beliefs about their own health or care.

So when you’re going to start a nurse-client relationship, the goal is to establish trust and rapport as quickly as possible. This will look a little different with every client, but it’s a priority every time. We also want to identify any support system, if they have one, and make sure they’re involved. Do they need education? Do they need resources? Show them how they can be involved in the care of their loved one. We also always consider the boundaries that will need to be established. Again, some clients who suffer from mental health disorders may struggle with maintaining boundaries or healthy relationships, so we can help with that. And we also need to consider our language. Notice I’m not saying “the mental health patient”. We want to make it very clear that their disorder is not their identity. It’s not “the schizophrenic client”, it’s “the client with schizophrenia”. It’s not “the bipolar patient”, it’s “the patient with bipolar disorder”. In that way and many other ways, our language can be VERY powerful to make or break this nurse-client relationship.

A well-constructed nurse-client relationship proceeds through four phases: pre-interaction, introduction, working, and termination. Each one serves a very important purpose and none of them should be skipped. First is pre-interaction. This is where you are preparing yourself professionally for the interaction. You will need to look over the clients chart, try to understand and get your mind around what the client is dealing with. What resources or education might they need, what kind of therapeutic interventions would be best, what do you think will be involved in their plan of care? And during this process, it is SO important that you check your own biases. You may have some preconceived notions about the specific disorder, or maybe you had a client in the past that you had a bad experience with. Make sure that you are not prejudging this client based on those internal biases.

The next phase is introduction - seems simple enough. But actually - your first interaction with the client is going to set the tone for the entire nurse-client relationship. You want to establish rapport, communicate boundaries in a clear, matter-of-fact, non-judgmental way. In fact, if you don’t establish boundaries right away, it may mean the client can push some of those boundaries before you’ve even had a chance to set them! Also, you’ll explain your role and your purpose and basically how the relationship is going to go. Only then can you begin to discuss goals of care and agree on those goals. That might sound something like this “Hi Joe, my name is Nichole, I’m going to be your nurse from 7am to 7pm today. I’ll be doing two assessments during that shift, asking you questions about how you’re feeling and what you’re thinking. I’ll give you any medications prescribed by your provider at the time they’re scheduled. We can talk about anything you like, just know my goal is to help you stay safe and help you move closer to your goals before I leave today at 7pm. Do you have any concerns right now?” Notice I was very clear on my specific role - the nurse, two assessments to do, and giving medications, and with a goal to keep the client safe and help him towards his goals. You’ll also notice I mentioned TWICE that I was leaving at 7pm. It’s important that we begin talking about termination during this phase. Now, this example I gave is for a single shift. But, if you’ll be working with a particular client more long-term, you still want to let them know to expect that the relationship will end at some point.

The working phase is exactly what it sounds like - you are actively working on the goals that you agreed upon in the previous phase. There’s a lot of therapeutic communication involved and this is usually where the therapeutic interventions are occuring.

Then, finally, there’s the termination phase. This is SO important to the long-term success for any client. We want to evaluate their progress toward their goals and give them genuine praise for goals the were able to achieve. We want to make sure they have the resources they need and know what to do if symptoms return. We made sure to prepare the client for termination during the introduction phase, but it’s still important to allow them to discuss their feelings about the relationship ending. Let them know that it’s okay to be upset, but to be encouraged that termination means they’ve met their goals and that it’s a good thing. And then, finally, express gratitude. Thank them for sticking to boundaries, express how grateful you are that they participated in their care.

Remember that people will forget what you said and forget what you did, but they’ll never forget how you made them feel.

So make sure you establish trust and a rapport, communicate your role and goals for care clearly, and establish and maintain boundaries - do not compromise. And remember to complete all phases of the nurse-client relationship because a healthy termination is essential to long-term success for the client.

So, those are the basics of the nurse-client relationship. Now, go out and be your best self today. And, as always, happy nursing!