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The nurse-patient relationship is a key aspect of mental health nursing. The Nursing and Midwifery Council (NMC) recognise the importance of the nurse-patient relationship in the NMC Code of Professional Conduct in that registered nurses are responsible for ensuring that they safeguard the interests of the patient and develop and maintain appropriate relationships. (Castleford, 2004 and NMC, 2006)

A critical element of effective health care delivery is competent communication in the form of professional knowledge, attitudes and values which combine to create interpersonal skills set for nurses. (Rungapadiachy, 1999) Communication occurs at both a general level as well as a therapeutic level. At the general level communication can be regarded as a complex process of sending and receiving verbal and non-verbal messages that allows for exchange of information, feelings, needs, and preferences. Therapeutic communication on the other hand is a purposive, patient centred approach in the context of patient care to help patients identify, resolve, or adapt to health problems. (Castleford, 2004 and Rungapadiachy, 1999)

Rungapadiachy, (1999) suggests that therapeutic communication involves skills such as listening, attending, responding, trust, disclosure and feedback. Barriers such as overuse of medical terminology, sympathy rather than empathy, arguing and disapproval should be avoided.

A useful model through which to explore communication in nurse-patient relationships in mental health is that of Peplau's psychodynamic framework wherein nursing is seen as a four-phase, therapeutic and goal directed interpersonal process between nurse and patient. Peplau (1992) argued that people with mental health needs have traditionally followed a biomedical model of care in that they have been managed with psychoactive drugs that address patient symptoms rather than a psychodynamic approach. The psychodynamic focus is on the interpersonal process itself and not the nurse or patient as individuals. This means that a nurse's role is seen as both educative and therapeutic in the movement of patient towards health. Peplau's four phases in the development of the nurse-patient relationship are orientation, identification, exploitation and resolution. (Jones, 1996, Peplau, 1952, and Peplau, 1992)

Naish (1996) argues that effective communication is essential in the delivery of appropriate nursing care but that structural factors such as ward organisation and management style may inhibit responsive care. The clear implication is a need for continuity of care by the same nurse through the phases. The nurse and patient have changing goals and roles as they pass through each phase which is iterative in nature. Peplau (1952) described the phases as overlapping and interlocking as the nurse facilitates the patient's movement towards health. (Castledine, 2004 and Jones, 1998)

The first phase, orientation, occurs when the patient and the nurse meet one another for the first time. An example is that of a thirty year old mother referred by a health visitor to a community psychiatric nurse with extreme post natal depression (PND) who had presented symptoms of puerperal psychosis. After a review of the case notes and all available information, the initial meeting occurred in the patient's home. Expectations of the relationship were clarified in a non-threatening way. The patient considered the initial meeting with the referring health visitor to be hostile and was concerned "about her baby being taken away." Trust was established through attentive listening, empathy and non verbal communication techniques such as touch. The meeting allowed the patient an emotional release and the soft issues surrounding the case were elicited. The patient had recently moved to the area and had not developed a network of friends as a support network. The father worked long hours and was often away on business trips. At the patient recognised that she needed help. Boundaries were negotiated (e.g. time and frequency of meetings, types of services) and roles within the relationship were defined. This reinforced an understanding of the therapeutic nature of the relationship to meet the patient needs.

The second phase is identification, in which the patient and the nurse are interdependent as they identify needs. The patient was encouraged to express needs whilst the nurse offered support to reduce anxiety and tension during a process of eliciting and identifying priority issues. It was essential that the patient identified the nurse as an individual able to provide the help required. Heron's model using two basic categories or styles of "authoritative" (providing information, challenging or suggesting) and "facilitative" (eliciting ideas, and encouraging dialogue to identify own needs was used. (Jones, 1996 and Young, 1998) A range of options including marriage counselling, baby clinics, PND support group and anti-depressant therapy was identified.

The third phase, exploitation, occurred as the patient accepted help and took advantage of the available services on offer. The nurse continued to facilitate the exploration of thoughts and feelings flowing from the therapeutic encounters on a weekly basis.

The final phase, resolution, occurred when the patient accepted new goals and became free from the relationship as her experience of PND integrated with her life experience. As her confidence was built and new support networks through group sessions started emerging, the need for the therapeutic relationship came to an end. The ending of the relationship was based on mutual understanding and a celebration of achievement as the patient achieved independence.


Castledine, G. (2004) "The importance of the nurse-patient relationship" British Journal of Nursing Vol 13 No 4

Jones, A. (1996) "The value of Peplau's theory for mental health nursing" British Journal of Nursing Vol 7 No 5

Naish, J. (1996) "The route to effective nurse-patient communication" Nursing Times Vol 92, No 16

NMC (2006) "Nursing Midwifery Council" Accessed 2 July 2006

Peplau, H. E. (1952) "Interpersonal relations in nursing" Second Edition" Putmans, New York

Peplau, H. E. (1992) "Interpersonal relations: A theoretical framework for application in nursing practice" Nursing Science Quarterly Vol 5, No 1.

Roper, N., Logan, W., and Tierney, A. (1990). "The elements of nursing" Churchill Livingstone, Edinburgh

Rungapadiachy, D. M. (1999). "Interpersonal communication and psychology for health professionals: Theory and practice" Elsevier Health Sciences, Edinburgh

Young, R. (1998) "A comparison of the Peplau interpersonal relations model and the Neuman health care systems model applied to a clinical situation" Douglas College, New Westminster

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