A therapeutic nursing process involves an interaction between the nurse and client in which the nurse offers a series of planned, goal-directed activities that are useful to a particular client in relieving discomfort, promoting growth, and satisfying interpersonal relationships.

1. CHARACTERISTICS of therapeutic nursing:
1. Movement from first contact through final outcome:
1. Eight general phases occur in a typical unfolding of a natural process of problem-solving.
2. Stages are not always in the same sequence.
3. Not all stages are present in a relationship.
2. Phases^†
1. Beginning the relationship. Goal: build trust.
2. Formulating and clarifying a problem and concern. Goal: clarify client's statements.
3. Setting a contract or working agreement. Goal: decide on terms of the relationship.
4. Building the relationship. Goal: increase depth of relationship and degree of commitment.
5. Exploring goals and solutions, gathering data, expressing feelings. Goals: (a) maintain and enhance relationship (trust and safety), (b) explore blocks to goal, (c) expand self-awareness, and (d) learn skills necessary to reach goal.
6. Developing action plan. Goals: (a) clarify feelings, (b) focus on and choose between alternative courses of action, and (c) practice new skills.
7. Working through conflicts or disturbing feelings. Goals: (a) channel earlier discussions into specific course of action and, (b) work through unresolved feelings.
8. Ending the relationship. Goals: (a) evaluation of goal attainment; (b) pointing out assets and gains; and (c) leave-taking reactions (repression, regression, anger, withdrawal, acting out).
2. THERAPEUTIC NURSE-CLIENT INTERACTIONS:
1. Plans/goals:
1. Demonstrate unconditional acceptance, interest, concern, and respect.
2. Develop trust—be consistent and congruent.
3. Make frequent contacts with the client.
4. Be honest and direct, authentic and spontaneous.
5. Offer support, security, and empathy, not sympathy.
6. Focus comments on concerns of client (client centered), not self (social responses). Refocus when client changes subject.
7. Encourage expression of feelings; focus on feelings and here-and-now behavior.
8. Give attention to a client who complains.
9. Give information at client's level of understanding, at appropriate time and place.
10. Use open-ended questions; ask how, what, where, who, and when questions; avoid why questions; avoid questions that can be answered by yes or no.
11. Use feedback or reflective listening.
12. Maintain hope, but avoid false reassurances, clichés, and pat responses.
13. Avoid verbalizing value judgments, giving personal opinions, or moralizing.
14. Do not change the subject unless the client is redundant or focusing on physical illness.
15. Point out reality; help the client leave "inner world."
16. Set limits on behavior when client is acting out unacceptable behavior that is self-destructive or harmful to others.
17. Assist clients in arriving at their own decisions by demonstrating problem-solving or involving them in the process.
18. Do not talk if it is not indicated.
19. Approach, sit, or walk with clients who are agitated; stay with the person who is upset, if he or she can tolerate it.
20. Focus on nonverbal communication.
21. Remember the psyche has a soma! Do not neglect appropriate physical symptoms.
2. Examples of therapeutic responses as interventions:
1. Being silent—being able to sit in silence with a person can connote acceptance and acknowledgment that the person has the right to silence. (Dangers: The nurse may wrongly give the client the impression that there is a lack of interest, or the nurse may discourage verbalization if acceptance of this behavior is prolonged; it is not necessarily helpful with acutely psychotic behavior.)
2. Using nonverbal communication—for example, nodding head, moving closer to the client, and leaning forward; use as a way to encourage client to speak.
3. Give encouragement to continue with openended leads—nurse's responses: "Then what?" "Go on," "For instance," "Tell me more," "Talk about that."
4. Accepting, acknowledging—nurse's responses: "I hear your anger," or "I see that you are sitting in the corner."
5. Commenting on nonverbal behavior of client—nurse's responses: "I notice that you are swinging your leg," "I see that you are tapping your foot," or "I notice that you are wetting your lips." Client may respond with, "So what?" If she or he does, the nurse needs to reply why the comment was made—for example, "It is distracting," "I am giving the nonverbal behavior meaning," "Swinging your leg makes it difficult for me to concentrate on what you are saying," or "I think when people tap their feet it means they are impatient. Are you impatient?"
6. Encouraging clients to notice with their senses what is going on—nurse's response: "What did you see (or hear)?" or "What did you notice?"
7. Encouraging recall and description of details of a particular experience—nurse's response: "Give me an example," "Please describe the experience further," "Tell me more," or "What did you say then?"
8. Giving feedback by reflecting, restating, and paraphrasing feelings and content:
• Client: I cried when he didn't come to see me.
• Nurse: You cried. You were expecting him to come and he didn't?
9. Picking up on latent content (what is implied)—nurse's response: "You were disappointed. I think it may have hurt when he didn't come."
10. Focusing, pinpointing, asking "what" questions:
    Client: They didn't come.
    Nurse: Who are "they"?
    Client: [Rambling.]
    Nurse: Tell it to me in a sentence or two. What is your main point? What would you say is your main concern?
11. Clarifying—nurse's response: "What do you mean by 'they'?" "What caused this?" or "I didn't understand. Please say it again."
12. Focusing on reality by expressing doubt on "unreal" perceptions:
    Client: Run! There are giant ants flying around after us.
    Nurse: That is unusual. I don't see giant ants flying.
13. Focusing on feelings, encouraging client to be aware of and describe personal feelings:
    Client: Worms are in my head.
    Nurse: That must be a frightening feeling. What did you feel at that time? Tell me about that feeling.
14. Helping client to sort and classify impressions, make speculations, abstract and generalize by making connections, seeing common elements and similarities, making comparisons, and placing events in logical sequence—nurse's responses:

"What are the common elements in what you just told me?" "How is this similar to . . .?" "What happened just before?" or "What is the connection between this and . . .?"

15. Pointing out discrepancies between thoughts, feelings, and actions—nurse's response: "You say you were feeling sad when she yelled at you, yet you laughed. Your feelings and actions do not seem to fit together."
16. Checking perceptions and seeking agreement on how the issue is seen, checking with the client to see if the message sent is the same one that was received—nurse's response: "Let me restate what I heard you say," "Are you saying that . . .?" "Did I hear you correctly?" "Is this what you mean?" or "It seems that you were saying . . ."
17. Encouraging client to consider alternatives—nurse's response: "What else could you say?" or "Instead of hitting him, what else might you do?"
18. Planning a course of action—nurse's response: "Now that we have talked about your on-thejob activities and you have thought of several choices, which are you going to try out?" or "What would you do next time?"
19. Imparting information—give additional data as new input to help client (e.g., state facts and reality-based data that client may lack).
20. Summing up—nurse's response: "Today we have talked about your feelings toward your boss, how you express your anger, and about your fear of being rejected by your family."
21. Encouraging client to appraise and evaluate the experience or outcome—nurse's response: "How did it turn out?" "What was it like?" "What was your part in it?" "What difference did it make?" or "How will this help you later"?
3. Examples of nontherapeutic responses:
1. Changing the subject, tangential response, moving away from problem or focusing on incidental, superficial content:
   Client: I hate you.
   Nurse: Would you like to take your shower now?
   Suggested responses: use reflection: "You hate me; tell me about this," or "You hate me; what does hate mean to you?"
   Client: I want to kill myself today.
   Nurse: Isn't today the day your mother is supposed to come?
   Suggested responses: (a) give open-ended lead, (b) give feedback: "I hear you saying today that you want to kill yourself," or (c) clarifying: "Tell me more about this feeling of wanting to kill yourself."
2. Moralizing: saying with approval or disapproval that the person's behavior is good or bad, right or wrong; arguing with stated belief of person; directly opposing the person:
   Nurse: That's good. It's wrong to shoot yourself.
   Client: I have nothing to live for.
   Nurse: You certainly do have a lot!
   Suggested responses: similar to those in C. 1. previous.
3. Agreeing with client's autistic inventions:
   Client: The eggs are flying saucers.
   Nurse: Yes, I see. Go on.
   Suggested response: use clarifying response first: "I don't understand," and then, depending on client's response, use either accepting and acknowledging, focusing on reality, or focusing on feelings.
4. Agreeing with client's negative view of self: Client: I have made a mess of my life.
   Nurse: Yes, you have.
   Suggested response: use clarifying response about "mess of my life"—"Give me an example of one time where you feel you messed up in your life."
5. Complimenting, flattering:
   Client: I have made a mess of my life.
   Nurse: How could you? You are such an attractive, intelligent, generous person.
   Suggested response: same as in C. 4.
6. Giving opinions and advice concerning client's life situation—examples of poor responses include: "In my opinion . . ." "I think you should . . ." or "Why not?"
   Suggested responses: (a) encourage the client to consider alternatives ("What else do you think you could try?"); (b) encourage the client to appraise and evaluate for himself or herself ("What is it like for you?").
7. Seeking agreement from client with nurse's personal opinion—examples of poor responses include: "I think . . . don't you?" and "Isn't that right?"
   Suggested responses: (a) it is best to keep personal opinion to oneself and only give information that would aid the client's orientation to reality; (b) if you give an opinion as a model of orienting to reality, ask client to state his or her opinion ("My opinion is . . . what is your opinion?").
8. Probing or offering premature solutions and interpretations; jumping to conclusions:
   Client: I can't find a job.
   Nurse: You could go to an employment agency.
   Client: I'd rather not talk about it.
   Nurse: What are you unconsciously doing when you say that? What you really mean is . . .
   Client: I don't want to live alone.
   Nurse: Are you afraid of starting to drink again?
   Suggested responses: use responses that seek clarification and elicit more data.
9. Changing client's words without prior validation:
   Client: I am not feeling well today.
   Nurse: What makes you feel so depressed?
   Suggested response: "In what way are you not feeling well?" Use the same language as the client.
10. Following vague content as if understood or using vague global pronouns, adverbs, and adjectives:
    Client: People are so unfair.
    Nurse: I know what you mean.
    Suggested response: clarify vague referents such as "people" and "unfair."
    Client: I feel sad.
    Nurse: Everyone feels that way at one time or another.
    Suggested response: "What are you sad about?"
11. Questioning on different topics without waiting for a reply:
    Client: [Remains silent.]
    Nurse: What makes you so silent? Are you angry? Would you like to be alone?
    Suggested response: choose one of the above and wait for a response before asking the next question.
12. Ignoring client's questions or comments:
    Client: Am I crazy, nurse?
    Nurse: [Walking away as if he or she did not hear the client.]
    Suggested responses: "I can't understand what makes you bring this up at this time," or "Tell me what makes you bring this up at this time." Ignoring questions or comments usually implies that the nurse is feeling uncomfortable. It is important not to "run away" from the client.
13. Closing off exploration with questions that can be answered by yes or no:
    Client: I'll never get better.
    Nurse: Is something making you feel that way? Suggested response: "What makes you feel that way?" Use open-ended questions that start with what, who, when, where, etc.
14. Using clichés or stereotyped expressions:
    Client: The doctor took away my weekend pass.
    Nurse: The doctor is only doing what's best for you. Doctor knows best. [Comment: also an example of moralizing.]
    Suggested response: "Tell me what happened when the doctor took away your weekend pass."
15. Overloading: giving too much information at one time:
    Nurse: Hello, I'm Mr. Brown. I'm a nurse here.
    I'll be here today, but I'm off tomorrow. Ms. Anderson will assign you another nurse tomorrow. This unit has five RNs, three LVNs, and students from three nursing schools who will all be taking care of you at some time.
    Suggested response: "Hello, I'm Mr. Brown, your nurse today." Keep your initial orienting information simple and brief.
16. Underloading: not giving enough information, so that meaning is not clear; withholding information:
    Client: What are visiting hours like here?
    Nurse: They are flexible and liberal.
    Suggested response: "They are flexible and liberal, from 10 a.m. to 12 noon and from 6 to 8 p.m." Use specific terms and give specific information.
17. Saying no without saying no:
    Client: Can we go for a walk soon?
    Nurse: We'll see. Perhaps. Maybe. Later.
    Suggested response: "I will check the schedule in the nursing office and let you know within an hour." Vague, ambiguous responses can be seen as "putting the client off." It is best to be clear, specific, and direct.
18. Using double-bind communication: sending conflicting messages that do not have "mutual fit," or are incongruent:
    Nurse: [Continuing to stay and talk with the client.] It's time for you to rest.
    Suggested response: "It's time for you to rest and for me to leave [proceeding to leave]."
19. Protecting: defending someone else while talking with client; implying client has no right to personal opinions and feelings:
    Client: This hospital is no good. No one cares here.
    Nurse: This is an excellent hospital. All the staff were chosen for their warmth and concern for people.
    Suggested response: focus on feeling tone or on clarifying information.
20. Asking "why" questions implies that the person has immediate conscious awareness of the reasons for his or her feelings and behaviors. Examples of this include: "Why don't you?" "Why did you do that?" or "Why do you feel this way?"
    Suggested response: ask clarifying questions using how, what, etc.
21. Coercion: using the interaction between people to force someone to do your will, with the implication that if he or she does not "do it for your sake," you will not love or stay with him or her:
    Client: I refuse to talk with him.
    Nurse: Do it for my sake, before it's too late.
    Suggested response: "Something keeps you from wanting to talk with him?"
22. Focusing on negative feelings, thoughts, actions: Client: I can't sleep; I can't eat; I can't think; I can't do anything.
    Nurse: How long have you not been sleeping, eating, or thinking well?
    Suggested response: "What do you do?"
23. Rejecting client's behavior or ideas:
    Client: Let's talk about incest.
    Nurse: Incest is a bad thing to talk about; I don't want to.
    Suggested response: "What do you want to say about incest?"
24. Accusing, belittling:
    Client: I've had to wait five minutes for you to change my dressing.
    Nurse: Don't be so demanding. Don't you see that I have several people who need me?
    Suggested response: "It must have been hard to wait for me to come when you wanted it to be right away."
25. Evading a response by asking a question in return:
    Client: I want to know your opinion, nurse.
    Am I crazy?
    Nurse: Do you think you are crazy?
    Suggested response: "I don't know. What do you mean by 'crazy'?"
26. Circumstantiality: communicating in such a way that the main point is reached only after many side comments, details, and additions:
    Client: Will you go out on a date with me?
    Nurse: I work every evening. On my day off I usually go out of town. I have a steady boyfriend. Besides that, I am a nurse and you are a client. Thank you for asking me, but no, I will not date you.
    Suggested response: abbreviate your response to: "Thank you for asking me, but no, I will not date you."
27. Making assumptions without checking them: Client: [Standing in the kitchen by the sink, peeling onions, with tears in the eyes.]
    Nurse: What's making you so sad?
    Client: I'm not sad. Peeling onions always makes my eyes water.
    Suggested response: use simple acknowledgment and acceptance initially, such as "I notice you have tears in your eyes."
28. Giving false, premature reassurance: Client: I'm scared.
    Nurse: Don't worry; everything will be all right. There's nothing to be afraid of.
    Suggested response: "I'd like to hear about what you're afraid of, so that together we can see what could be done to help you." Open the way for clarification and exploration, and offer yourself as a helping person—not someone with magic answers.