Which of the following best describes the nurse-client relationship?

Orientation:

In the beginning of the therapeutic relationship, the nurse and client are strangers to each other, yet each individual has preconceptions of what to expect – based on previous relationships, experiences, attitudes and beliefs
The parameters of the relationship are established (e.g., place of meeting, length, frequency, role or service offered, confidentiality, duration of relationship)
The client and nurse begin to learn to trust and know each other as partners in the relationship
Trust, respect, honesty and effective communication are key principles in establishing a relationship

Working Phase:

The working or middle phase of the relationship is where nursing interventions frequently take place
Problems and issues are identified and plans to address these are put into action. Positive changes may alternate with resistance and/or lack of change
It is important for the nurse to validate thoughts, feelings and behaviours
The nurse assists the client to explore thoughts (e.g. views of self, others, environment, and problem solving), feelings (e.g. grief, anger, mistrust, sadness), and behaviours (e.g. promiscuity, aggression, withdrawal, hyperactivity)
The content to be explored is chosen by the client although the nurse facilitates the process
The nurse continues his/her assessment throughout all phases of the relationship
New problems and needs may emerge as the nurse-client relationship develops and as earlier identified issues are addressed
The nurse advocates for the client to ensure that the client’s perspectives and priorities are reflected in the plan of care

Resolution Phase:

The resolution or ending phase is the final stage of the nurse-client relationship
After the client’s problems or issues are addressed, the relationship needs to be completed before it can be terminated
The ending of the nurse-client relationship is based on mutual understanding and a celebration of goals that have been met
Both the nurse and the client experience growth
Termination may be met with ambivalence
The nurse and the client must recognize that loss may accompany the ending of a relationship
Both should share feelings related to the ending of the therapeutic relationship
Validating plans for the future may be a useful strategy
Increased autonomy of both the client and the nurse is observed in this phase

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Summary of papers and quality ratings.

Author, year	Design	Sample and setting	N	Nature of intervention	Primary outcome	Summary of findings	Effect size (Cohen's D)*	EPHPP quality rating⁎⁎
Berry et al., 2012	Pre-post intervention, no control group	Adult low secure psychiatric inpatient unit, NHS, UK. Nursing staff employed at least three months, 10 h contact with patients per week, including day shifts.	25 baseline (60% mental health nurses); 13 with both intervention and follow up measures	Three hour workshop by clinical psychologist, eliciting psychological factors to understand patients.	WAI-short form Staff report	No significant change in WAI. Rated as helpful, relevant by attendees. Low take-up (42% of baseline).	0.28 (not in favour of intervention)	A Selection 2B Design 2C Confounders 3D Blinding 3E Data 1F Withdrawal 3 GLOBAL Weak
Berry et al., 2016	Single-blind cluster RCT. Intervention plus TAU versus TAU alone	Adult psychiatric rehabilitation units, UK NHS and private. Nursing staff on units, at least three months experience, including day shifts.	85 baseline (42% mental health nurses), 74 at follow up.	24 1 h sessions per unit over six months. Facilitated by clinical psychologist. Formulation-based with written report and care planning.	WAI- short form (staff and patient report), completed in relation to key worker	Intention to treat analysis controlling for clustering. T-tests showed no significant difference for staff or patient reported outcomes. 87% completed follow up.	0.45 staff (not in favour of intervention) 0.92 patient	A Selection 2B Design 1C Confounders 1D Blinding 2E Data 1F Withdrawal 2 GLOBAL Strong
Byrne and Deane, 2011	Pre and post, no control group	Adult community services for severe mental illness, Australia. Workers (including nurses), at least 12 month experience, therapeutic relationship at least 12 months.	46 clinicians (‘mostly nurses’)	Three day workshop on medication alliance training, clinician attitudes addressed. Six and 12- month follow up.	WAI- short form, clinician rated only.	72% remained until completion. Significant change in WAI between baseline and six mth.	0.53	A Selection 2B Design 2C Confounders 3D Blinding 3E Data 1F Withdrawal 2 GLOBAL Weak
Carpenter et al., 2007	Quasi-experimental design. Results compared between training cohort and cohort from another setting, also pre-post course evaluation.	Staff training context with follow up of outcomes with patients in community, mostly with psychotic disorders, NHS, UK.	36 trainees (60% nursing)	Training in psycho-social interventions	Non-validated measure of relationships between service user and trainee, service-user rated.	No significant differences between time 1 and 2 (6 months). Some differences between those in training cohort and those not.	Insufficient data to report.	A Selection 2B Design 2C Confounders 3D Blinding 3E Data 3F Withdrawal 3 GLOBAL Weak
Kellett et al., 2019	Two nested studies: pre-post one group design with three sites (1) and case series (2)	Secondary Care Community Mental Health NHS-based services (UK)	58 staff-patient dyads in study 1, five dyads in case series (study 2). Hard to engage clients not receiving individual therapy.	Cognitive analytic consultancy delivered by accredited practitioners to staff-patient dyads. Five sessions (typically lasting 1 h)	Working alliance inventory: staff and patient long form in study 1 (NB only one site used this with n = 12) and short form (Staff and patient versions) in study 2.	No significant difference in study 1. Client-rated WAI improved significantly between intervention and follow-up (large effects size). No significant difference for staff- rated.	Study 1client = 0.22 and staff = 0.23Study 2(case series) client = 1.11 staff = 0.29	A Selection 2B Design 2C Confounders 3D Blinding 3E Data 1F Withdrawal 3 GLOBAL Weak
Molin et al., 2018	Pre-post visual display of findings, no control group.	Three adult psychiatric clinics in three hospitals in Sweden.	50 staff members across three ‘systems’. 70% nurses in training or registered nurses.	‘Time together’ intervention, focusing on protected time for shared activities between staff and patients.	Caring professional scale completed by patients	No reported effects on quality of interactions. Statistics not reported.	Insufficient data to report.	A Selection 2B Design 2C Confounders 3D Blinding 3E Data 1F Withdrawal 3 GLOBAL Weak
Moreno-Poyato et al., 2018	Participatory action research. Quasi-experimental pre-post design.	Adult acute psychiatric hospital, Barcelona, two sites	26 nurses, four dropped out Permanent staff, at least 21 h per week.	Ten months. Individual interactions, reflective groups, scientific texts.	WAI-short form, clinician-rated	Significant difference between groups post-intervention Wilcoxon signed rank	1.14	A Selection 2B Design 2C Confounders 1D Blinding 3E Data 1F Withdrawal 2 GLOBAL Moderate
Stringer et al., 2015	Comparative multiple case study design	Adult borderline personality disorder services, community. Netherlands. Caseloads of nurses approached in random order.	Ten nurses for experimental condition and five from the control condition.	Collaborative care programme versus care as usual. Allocated by patient, not nurse.	STAR- scale to assess therapeutic relationships	No significant effect of intervention.	0.13 at time 2 (nine months)	A Selection 3B Design 2C Confounders 3D Blinding 3E Data 1F Withdrawal 3 GLOBAL Weak

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