Interpersonal Relationships in Nursing

Introduction

Interpersonal relationships in nursing are the foundation of effective patient care. They involve reciprocal social and emotional interactions between nurses and patients, creating a framework for therapeutic communication and intervention.

What is an Interpersonal Relationship in Nursing?

An interpersonal relationship in nursing refers to a mutually significant experience where both nurse and patient view each other as unique human beings. It’s characterized by:

Professional boundaries
Therapeutic communication
Mutual respect and trust
Goal-oriented interactions
Therapeutic use of self

Remember: T-R-U-S-T

The foundation of any therapeutic nurse-patient relationship

Truthfulness in all interactions
Respect for patient autonomy
Understanding of patient’s needs
Support through the healthcare journey
Therapeautic presence and communication

1. Elements of Nurse-Patient Contract

A nurse-patient contract is a formal or informal agreement between the nurse and patient that outlines expectations, goals, and responsibilities. It forms the basis of the therapeutic relationship and serves as a roadmap for care.

Core Elements of a Nurse-Patient Contract

Goals & Objectives

Clear healthcare outcomes and timeline for achievement

Roles & Responsibilities

Specific duties of both nurse and patient

Mutual Agreement

Consent and understanding from both parties

Time & Duration

Schedule of meetings and expected duration of relationship

Boundaries & Limits

Professional boundaries and ethical guidelines

Evaluation Criteria

Methods to assess progress and outcomes

Types of Nurse-Patient Contracts

Formal Contracts

Written documentation
Signed by both parties
Used in specialized settings (mental health, addiction)
Clearly defined expectations and consequences
May be legally binding

Informal Contracts

Verbal agreements
Implied understanding
Common in general care settings
Flexible and adaptable
Based on therapeutic relationship

Clinical Tip

Always document the key elements of even informal nurse-patient contracts in your nursing notes. This creates accountability and ensures continuity of care when multiple healthcare providers are involved.

The Contract Development Process

Assessment

Identify patient needs, capabilities, and goals through comprehensive assessment

Negotiation

Discuss expectations, boundaries, and responsibilities with the patient

Formulation

Create the contract (verbal or written) with clear, measurable goals

Agreement

Obtain mutual consent on the terms and conditions

Implementation

Put the contract into action with ongoing communication

Evaluation

Regularly assess progress and adjust as needed

Termination or Renewal

Conclude the contract when goals are met or renew if necessary

Remember: C-O-N-T-R-A-C-T

Key elements for successful nurse-patient contracts:

Clear communication of expectations
Objectives that are specific and measurable
Negotiated terms with patient input
Timelines for achievement
Roles and responsibilities defined
Agreement that is mutual
Commitment from both parties
Tracking progress regularly

Common Pitfalls to Avoid

Creating unrealistic or unattainable goals
Imposing goals without patient input
Neglecting cultural or individual differences
Failing to document important elements
Not revisiting or updating the contract as circumstances change

2. Review of Techniques of Interpersonal Relationships (IPR)

Interpersonal relationship techniques are essential tools that nurses use to establish, maintain, and enhance therapeutic communication with patients. These techniques facilitate understanding, trust, and effective care delivery.

Historical Context

The concept of therapeutic interpersonal relationships in nursing was significantly developed by Hildegard Peplau in her 1952 work “Interpersonal Relations in Nursing.” She described nursing as “a significant, therapeutic, interpersonal process.”

Phases of Nurse-Patient Relationship

1

Pre-Orientation Phase

The nurse prepares for the initial patient encounter by:

Reviewing available patient information
Self-reflecting on personal biases or assumptions
Planning for the initial meeting
Considering cultural factors that may influence the relationship

2

Orientation Phase

Initial meeting where the nurse and patient:

Establish identities and roles
Begin building trust
Identify patient problems and needs
Set preliminary goals
Establish the nurse-patient contract

3

Working Phase

The core of the relationship where:

Therapeutic interventions are implemented
Problem-solving occurs
Patient resources are mobilized
Progress toward goals is evaluated
The nurse assumes various roles (resource, counselor, surrogate)

4

Termination Phase

The conclusion of the relationship involving:

Summarizing achievements and progress
Evaluating goal attainment
Planning for continuing care if needed
Managing separation anxiety
Saying goodbye

Core IPR Techniques

1. Listening

The process of consciously receiving another person’s message, listening eagerly, actively, responsively, and seriously.

Example: Maintaining eye contact and nodding while a patient describes their symptoms.

2. Acknowledgement

Recognizing the other person without inserting your own values or judgment.

Example: “I hear what you’re saying about your concerns with this treatment.”

3. Feedback

The process where the receiver relays the effect of the message to the sender, helping to keep communication on course.

Example: “You did that breathing exercise well.”

4. Mutual Congruence

Harmony of verbal and nonverbal messages.

Example: “You say you feel okay, but you’re crying. Let’s talk about what’s going on.”

5. Clarification

The process of checking out or making the intent or hidden meaning of the message clear.

Example: “You said you feel ‘funny.’ Can you describe what ‘funny’ means?”

6. Focusing/Refocusing

Picking up on central topics or cues; concentrating attention on a single point.

Example: “You were telling me how hard it was to talk to your mother.”

7. Validation

The process of verifying the accuracy of the sender’s message.

Example: “Yes, it is confusing with so many people around.”

8. Reflection

Identifying and sending a message back acknowledging the feeling expressed.

Example: “You feel depressed?” or simply repeating “Depressed?”

9. Open-Ended Questions

Asking questions that cannot be answered with ‘yes’ or ‘no’ to broaden conversation.

Example: “How did your weekend pass go?” instead of “Did you have a good time?”

10. Non-Verbal Encouragement

Using body language to show interest, understanding, support, and caring.

Example: Nodding appropriately as someone talks.

11. Restatement

Restating what the patient says; repeating the main idea expressed.

Example: “You said that you hear voices.”

12. Paraphrase

Summarizing or rewording what has been said.

Example: “What I hear you saying is that you can’t live comfortably at home.”

13. Neutral Response

Showing interest and encouragement without saying anything else.

Example: “Yes,” “Uh-hmm.”

14. Incomplete Sentences

Encouraging the patient to continue by leaving a sentence unfinished.

Example: “Then your life is…”

15. Minimum Verbal Activity

Keeping your own verbalization minimum and letting the patient lead the conversation.

Example: “You feel…?”

16. Broad Opening Statements

Opening communication by allowing the patient freedom to talk and focus on themselves.

Example: “How have you been feeling?” “What would you like to talk about today?”

Remember: L-I-S-T-E-N

Essential components of effective IPR techniques:

Look at the patient (maintain appropriate eye contact)
Inquire with open-ended questions
Stay focused on the patient’s concerns
Touch appropriately (when culturally acceptable)
Empathize with their situation
Nod to show understanding and encouragement

Therapeutic Use of Self

Therapeutic use of self refers to the nurse’s conscious use of personality, insights, perceptions, and judgments as part of the therapeutic process. It involves:

Self-awareness of one’s own feelings, biases, and reactions
Intentional use of one’s personality and knowledge to influence patient change
Understanding how one’s behavior affects others
Using personal attributes to establish relationships and interventions
Conscious decision-making about when to share personal information

“When a nurse uses self therapeutically, she consciously makes use of her personality and knowledge to effect a change in the ill person.” – Joyce Travelbee

Barriers to Effective IPR

Blocks to Therapeutic Communication

Giving unwanted advice
Changing the subject inappropriately
False reassurance
Asking “why” questions
Using medical jargon
Being judgmental

Inappropriate self-disclosure
Defensive responses
Lack of cultural sensitivity
Minimizing feelings
Being too busy to listen
Environmental distractions

3. The Johari Window

The Johari Window is a psychological tool developed by Joseph Luft and Harry Ingham in 1955 (the name “Johari” comes from combining their first names). It’s used to enhance self-awareness and improve interpersonal relationships, making it particularly valuable in nursing practice.

Definition and Purpose

The Johari Window is a cognitive psychological model that illustrates the process of human interaction. It’s also known as the disclosure/feedback model of self-awareness. This framework helps nurses:

Develop self-awareness
Understand how they are perceived by others
Improve communication with patients and colleagues
Build more effective therapeutic relationships
Recognize blind spots in their interpersonal interactions

The Four Quadrants of the Johari Window

1. Open Arena (Public Self)

Known to self and others

Information, behaviors, attitudes that are known to you and visible to others.

Example: A nurse who is aware of her strong communication skills, which are also recognized by colleagues and patients.

2. Blind Spot (Blind Area)

Unknown to self but known to others

Aspects of yourself that others can see but you are unaware of.

Example: A nurse who doesn’t realize they appear rushed when talking to patients, though patients perceive this clearly.

3. Hidden Area (Private Self)

Known to self but unknown to others

Information you know about yourself but choose not to reveal to others.

Example: A nurse’s anxiety about handling emergency situations that they conceal from colleagues.

4. Unknown Area

Unknown to self and unknown to others

Information, abilities, or feelings neither you nor others are aware of yet.

Example: A nurse’s untapped leadership potential that emerges only during a crisis situation.

How the Johari Window Works in Practice

In its original form, the Johari Window assessment involves a list of 56 adjectives. The subject chooses 5-6 words that best describe themselves, while peers/colleagues also select 5-6 words that describe the subject. The results are then mapped into the four quadrants to create a visual representation of self-awareness and interpersonal perception.

The Goals of Using the Johari Window in Nursing

The ideal goal is to expand the Open Arena by:

Self-Disclosure

Moving information from the Hidden Area to the Open Arena by selectively sharing relevant personal information with others.

Process: Sharing appropriate feelings, thoughts, and experiences with patients or colleagues

Feedback

Moving information from the Blind Spot to the Open Arena by being receptive to others’ perceptions and observations.

Process: Actively seeking and remaining open to constructive feedback from patients, peers, and supervisors

Self-Discovery and Shared Discovery

Moving information from the Unknown Area into other quadrants through personal growth, education, and new experiences.

Process: Continuous learning, reflection, challenging situations, and interpersonal exploration

Applications in Nursing Practice

Self-Awareness Development

Nurses use the Johari Window to identify their strengths, weaknesses, and blind spots, improving their therapeutic effectiveness.

Team Building

Healthcare teams use this model to improve collaboration, communication, and understanding among members.

Patient Education

Nurses apply this concept to help patients understand their health conditions and behaviors that may be in their blind spots.

Therapeutic Communication

Understanding the window helps nurses communicate more effectively by being aware of disclosure and feedback dynamics.

Nursing Education

Used in teaching to help nursing students develop self-awareness and interpersonal skills.

Mental Health Nursing

Particularly valuable in psychiatric settings to develop therapeutic relationships and help patients increase self-awareness.

Remember: W-I-N-D-O-W

Key principles for applying the Johari Window in nursing:

Willingness to receive feedback
Insight development through reflection
Nurturing an open communication environment
Disclosure that is appropriate and purposeful
Openness to personal and professional growth
Willingness to explore unknown potentials

Clinical Application Tip

When applying the Johari Window concept in clinical practice, start by expanding your own Open Arena through seeking regular feedback from patients and colleagues. Set aside time for reflection after difficult interactions to identify potential blind spots in your communication approach.

Summary: Putting It All Together

Key Takeaways

Nurse-Patient Contract

Forms the foundation of the therapeutic relationship
Establishes mutual goals and expectations
Includes formal and informal agreements
Requires clear communication and negotiation
Evolves through the relationship phases

IPR Techniques

Include 16+ practical communication strategies
Facilitate therapeutic dialogue
Build trust and understanding
Support all phases of the nurse-patient relationship
Require practice for mastery

Johari Window

Enhances self-awareness and interpersonal understanding
Features four quadrants representing different aspects of self
Expands the Open Arena through feedback and disclosure
Improves therapeutic effectiveness
Applies to both individual and team development

Integration in Practice

The Cyclical Nature of Effective Nurse-Patient Relationships

Self-Awareness (Johari Window)

Establishing the Nurse-Patient Contract

Applying IPR Techniques

Evaluation & Feedback

Final Thoughts

Mastering interpersonal relationships in nursing is an ongoing process that requires continuous self-reflection, practice, and refinement. The nurse-patient relationship is at the heart of effective care delivery, and the tools and techniques covered in this guide provide a foundation for building therapeutic connections with patients.

Remember that each patient interaction offers an opportunity to expand your Open Arena, refine your contract-building skills, and apply therapeutic communication techniques. Through this continuous process, you will not only enhance patient outcomes but also experience greater professional fulfillment.

References and Further Reading

Luft, J., & Ingham, H. (1955). The Johari window, a graphic model of interpersonal awareness. Proceedings of the western training laboratory in group development. UCLA, Los Angeles.
Peplau, H. E. (1952). Interpersonal relations in nursing: A conceptual frame of reference for psychodynamic nursing. New York: G. P. Putnam’s Sons.
Travelbee, J. (1971). Interpersonal aspects of nursing (2nd ed.). Philadelphia: F.A. Davis Company.
Arnold, E., & Boggs, K. U. (2019). Interpersonal relationships: Professional communication skills for nurses (8th ed.). Elsevier.
Stuart, G. W. (2022). Principles and practice of psychiatric nursing (11th ed.). Elsevier.
Eckroth-Bucher, M. (2010). Self-awareness: A review and analysis of a basic nursing concept. Advances in Nursing Science, 33(4), 297-309.
Dossey, B. M., & Keegan, L. (2016). Holistic nursing: A handbook for practice (7th ed.). Jones & Bartlett Learning.
McEwen, M., & Wills, E. M. (2021). Theoretical basis for nursing (5th ed.). Wolters Kluwer.