it careful thought. For example, when working with
a client whose parents are getting a divorce, the
nurse says, “My parents got a divorce when I was 12
and it was a horrible time for me.” The nurse has
shifted the focus away from the client and has given
the client the idea that this experience will be horri-
ble for the client. While the nurse may have meant to
communicate empathy, the result can be quite the
opposite. If the client does not seem ready to deal
with the issue, or the conversation is purely social, it
is not a good time to disclose information about one-
self (Hancock, 1998).
WORKING
The working phaseof the nurse–client relation-
ship is usually divided into two subphases. During
problem identification,the client identifies the
issues or concerns causing problems. During ex-
ploitation,the nurse guides the client to examine
feelings and responses and to develop better coping
skills and a more positive self-image; this encour-
ages behavior change and develops independence.
(Note that Peplau’s use of the word exploitation had
a very different meaning than current usage, which
involves unfairly using or taking advantage of a per-
son or situation. For that reason, this phase is better
conceptualized as intense exploration and elabora-
tion on earlier themes that the client discussed.) The
trust established between nurse and client at this
point allows them to examine the problems and to
work on them within the security of the relationship.
The client must believe that the nurse will not turn
away or be upset when the client reveals experiences,
issues, behaviors, and problems. Sometimes the client
will use outrageous stories or acting-out behaviors to
test the nurse. Testing behavior challenges the nurse
to stay focused and not to react or be distracted.
Often when the client becomes uncomfortable because
they are getting too close to the truth, he or she will
use testing behaviors to avoid the subject. The nurse
may respond by saying, “It seems as if we have hit an
uncomfortable spot for you. Would you like to let it go
for now?” This statement focuses on the issue at hand
and diverts attention from the testing behavior.
The nurse must remember that it is the client
who examines and explores problem situations and re-
lationships. The nurse must be nonjudgmental and re-
frain from giving advice; the nurse should allow the
client to analyze situations. The nurse can guide the
client to observe patterns of behavior and whether or
not the expected response occurs. For example, Mrs.
O’Shea suffers from depression. She continues to
complain to the nurse about the lack of concern her
children show her. With Nurse Jones’ assistance, Mrs.
O’Shea explores how she communicates with her chil-
dren and discovers that her approach is usually highly
critical and needy. Mrs. O’Shea begins to realize that
her behavior contributes to driving her children away.
With Nurse Jones, she begins to explore how she
might change her methods of communication.
The specific tasks of the working phase include
the following:- Maintaining the relationship
- Gathering more data
- Exploring perceptions of reality
- Developing positive coping mechanisms
- Promoting a positive self-concept
- Encouraging verbalization of feelings
- Facilitating behavior change
- Working through resistance
- Evaluating progress and redefining goals as
appropriate - Providing opportunities for the client to prac-
tice new behaviors - Promoting independence
As the nurse and client work together, it is com-
mon for the client unconsciously to transfer to the
nurse feelings he or she has for significantothers.
This is called transference.For example, if the client
has had negative experiences with authority figures,
such as a parent or teachers or principals, he or she
may display similar reactions of negativity and resis-
tance to the nurse, who also is viewed as an authority.
A similar process can occur when the nurse responds
to the client based on personal unconscious needs
and conflicts; this is called countertransference.
For example, if the nurse is the youngest in her fam-
ily and often felt as if no one listened to her when she
was a child, she may respond with anger to a client
who does not listen or resists her help. Again, self-
awareness is important so that the nurse can identify
when transference and countertransference might
occur. By being aware of such “hot spots,” the nurse
has a better chance of responding appropriately rather
than letting old unresolved conflicts interfere with the
relationship.
TERMINATION
The termination phase,also known as the resolu-
tion phase,is the final stage in the nurse–client re-
lationship. It begins when the problems are resolved,
and it ends when the relationship is ended. Both nurse
and client usually have feelings about ending the
relationship; the client especially may feel the ter-
mination as an impending loss. Often clients try to
avoid termination by acting angry or as if the prob-
lem has not been resolved. The nurse can acknowl-
edge the client’s angry feelings and assure the client
that this response is normal to ending a relationship.
If the client tries to reopen and discuss old resolved5 THERAPEUTICRELATIONSHIPS 101