6 THERAPEUTICCOMMUNICATION 113
if interacting in the client’s room is therapeutic. For
example, if the client has difficulty maintaining bound-
aries or has been making sexual comments, then the
client’s room is not the best setting. A more formal set-
ting would be desirable.
Proxemicsis the study of distance zones between
people during communication. People feel more com-
fortable with smaller distances when communicating
with someone they know rather than with strangers
(Northouse & Northouse, 1998). People from the Uni-
ted States, Canada, and many Eastern European
nations generally observe four distance zones:
- Intimate zone(0 to 18 inches between
people): This amount of space is comfortable
for parents with young children, people who
mutually desire personal contact, or people
whispering. Invasion of this intimate zone
by anyone else is threatening and produces
anxiety. - Personal zone(18 to 36 inches): This dis-
tance is comfortable between family and
friends who are talking. - Social zone(4 to 12 feet): This distance is
acceptable for communication in social, work,
and business settings. - Public zone(12 to 25 feet): This is an
acceptable distance between a speaker and
an audience, small groups, and other
informal functions (Hall, 1963).
People from some cultures (e.g., Hispanic,
Mediterranean, East Indian, Asian, Middle Eastern)
are more comfortable with less than 4 to 12 feet of
space between them while talking. The nurse of
European-American or African-American heritage
may feel uncomfortable if clients from these cultures
stand close when talking. Conversely, clients from
these backgrounds may perceive the nurse as remote
and indifferent (Andrews & Boyle, 2003).
Both the client and the nurse can feel threatened
if one invades the other’s personal or intimate zone,
which can result in tension, irritability, fidgeting, or
even flight. When the nurse must invade the inti-
mate or personal zone, he or she always should ask
the client’s permission. For example, if a nurse per-
forming an assessment in a community setting needs
to take the client’s blood pressure, he or she should
say, “Mr. Smith, to take your blood pressure I will
wrap this cuff around your arm and listen with my
stethoscope. Is this acceptable to you?” He or she
should ask permission in a yes/no format so the client’s
response is clear. This is one of the times when yes/
no questions are appropriate.
The therapeutic communication interaction is
most comfortable when the nurse and client are 3 to
6 feet apart. If a client invades the nurse’s intimate
space (0 to 18 inches), the nurse should set limits grad-
ually, depending on how often the client has invaded
the nurse’s space and the safety of the situation.Touch
As intimacy increases, the need for distance decreases.
Knapp (1980) identified five types of touch:- Functional-professionaltouch is used in
examinations or procedures such as when
the nurse touches a client to assess skin
turgor or a masseuse performs a massage. - Social-politetouch is used in greeting, such
as a handshake and the “air kisses” some
women use to greet acquaintances, or when
a gentle hand guides someone in the correct
direction. - Friendship-warmthtouch involves a hug in
greeting, an arm thrown around the shoulder
of a good friend, or the back slapping some
men use to greet friends and relatives. - Love-intimacytouch involves tight hugs and
kisses between lovers or close relatives. - Sexual-arousaltouch is used by lovers.
Touching a client can be comforting and sup-
portive when it is welcome and permitted. The nurse
should observe the client for cues that show if touch is
desired or indicated. For example, holding the hand
of a sobbing mother whose child is ill is appropriate
and therapeutic. If the mother pulls her hand away,
however, she signals to the nurse that she feels un-
comfortable being touched. The nurse also can ask
the client about touching (e.g., “Would it help you to
squeeze my hand?”).
Although touch can be comforting and therapeu-
tic, it is an invasion of intimate and personal space.
Some clients with mental illness have difficulty under-
standing the concept of personal boundaries or know-
ing when touch is or is not appropriate. Consequently
most psychiatric inpatient, outpatient, and ambula-
tory care units have policies against clients touching
one another or staff. Unless they need to get close to a
client to perform some nursing care, staff members
should serve as role models and refrain from invading
clients’ personal and intimate space. When a staff
member is going to touch a client while performing
nursing care, he or she must verbally prepare the
client before starting the procedure. A client with
paranoia may interpret being touched as a threat and
may attempt to protect himself or herself by striking
the staff person.
Active Listening and Observation
To receive the sender’s simultaneous messages, the
nurse must use active listening and active observa-
tion. Active listeningmeans refraining from other