The Effectiveness of Therapeutic Communication Techniques in Building Nurse–Patient Relationships in Mental Health Settings

Introduction

Therapeutic communication is widely regarded as the foundational skill through which psychiatric and mental health nurses establish trust, gather clinically meaningful information, and support patients toward recovery, yet the degree to which specific therapeutic communication techniques translate into measurably stronger nurse–patient relationships remains inconsistently documented across mental health care settings (Kornhaber et al., 2021). Contemporary mental health nursing practice emphasizes person-centered engagement, active listening, empathy, and the deliberate therapeutic use of self, but frontline nurses frequently report that high patient acuity, understaffing, and institutional time pressures constrain their ability to apply these techniques consistently, raising questions about whether therapeutic communication training reliably produces the relational outcomes it is designed to achieve (Molin et al., 2020). This chapter introduces the background, problem, purpose, and design of a study examining the effectiveness of therapeutic communication techniques in building nurse–patient relationships within mental health settings, situating the inquiry within existing nursing theory and identifying the gap in empirical evidence that the proposed study is intended to address.

Background Of The Study

The nurse–patient relationship has long been considered the central therapeutic vehicle in psychiatric nursing, an idea traced most directly to Hildegard Peplau’s interpersonal relations theory, which conceptualizes nursing as an interpersonal process unfolding through orientation, working, and termination phases, during which the nurse deliberately uses communication to help the patient reframe distress and build coping capacity (Peplau, 1997/2021 reprint). Building on this foundation, subsequent nursing scholarship has identified a set of discrete therapeutic communication techniques, including active listening, reflection, open-ended questioning, silence, clarification, and summarizing, that are taught in psychiatric nursing curricula as the practical mechanisms through which the interpersonal relationship is enacted (Videbeck, 2020).

Empirical interest in therapeutic communication has grown alongside broader recognition that the therapeutic alliance, a construct originating in psychotherapy research but increasingly applied to nursing, is itself a significant predictor of patient engagement, treatment adherence, and clinical outcomes in mental health care (Priebe & McCabe, 2022). Several qualitative studies have found that psychiatric inpatients consistently identify feeling listened to, understood, and treated with genuine warmth as central to their perception of a helpful nurse, while nurses themselves report that empathy and non-judgmental presence are core to what they consider therapeutic engagement (McAndrew et al., 2021; O’Brien et al., 2020). However, a parallel body of research has documented persistent gaps between the communication techniques nurses are trained to use and those they actually enact in day-to-day inpatient practice, with task-focused, custodial communication patterns frequently observed even in units with strong institutional commitment to therapeutic models of care (Molin et al., 2020; Sharac et al., 2021).

A further body of literature has begun to examine whether specific, discrete therapeutic communication techniques, rather than a generalized therapeutic orientation, can be shown to produce measurable improvements in relational and clinical outcomes. Structured communication skills training programs for mental health nurses have demonstrated improvements in self-reported empathy and communication confidence, though evidence regarding whether such training reliably improves patient-rated relationship quality or clinical outcomes remains mixed and methodologically limited, often relying on small samples, single-site designs, or self-report measures susceptible to social desirability bias (Chan et al., 2022; Hagerty & Patusky, 2020). This inconsistency in the empirical record, set against the strong theoretical and professional consensus regarding the centrality of therapeutic communication, constitutes the central gap motivating the present study.

Statement Of The Problem

Mental health nurses are professionally and educationally expected to apply therapeutic communication techniques as the primary means of building a working nurse–patient relationship, yet there remains insufficient empirical clarity regarding which specific techniques most strongly predict patient-perceived relationship quality, and whether nurses’ self-assessed use of these techniques aligns with patients’ actual experience of being understood and supported (Kornhaber et al., 2021; McAndrew et al., 2021). Existing research has tended to examine therapeutic communication either as a broad, undifferentiated construct or through isolated case studies, leaving unresolved the question of which discrete techniques, such as active listening, reflection, or the therapeutic use of silence, carry the greatest weight in shaping the strength of the relationship as perceived by patients themselves (Molin et al., 2020; Sharac et al., 2021).

This gap is problematic because mental health care organizations continue to invest substantial resources in communication skills training premised on the assumption that such training improves relational and clinical outcomes, yet without clearer empirical evidence distinguishing more effective from less effective techniques, and without evidence on how nurse-reported and patient-reported perceptions of the relationship align or diverge, these investments risk being poorly targeted (Chan et al., 2022; Hagerty & Patusky, 2020). Absent stronger empirical clarity, mental health nursing practice, education, and policy continue to rely substantially on theoretical assumption and professional tradition rather than on robust, patient-centered evidence regarding what specifically builds a therapeutic nurse–patient relationship in practice (Priebe & McCabe, 2022).

Purpose Of The Study

The purpose of this quantitative, correlational study is to examine the relationship between mental health nurses’ use of specific therapeutic communication techniques and the strength of the nurse–patient relationship as perceived by both nurses and patients within inpatient and community mental health settings. The study will use validated self-report instruments completed by nurse–patient dyads to assess the frequency of specific therapeutic communication techniques used, alongside standardized measures of therapeutic relationship quality, in order to identify which techniques most strongly predict relationship strength and whether nurse and patient perceptions of relationship quality are significantly associated.

Research Questions And Hypotheses

RQ1. To what extent does mental health nurses’ self-reported use of therapeutic communication techniques predict patient-rated nurse–patient relationship quality?

H1. Nurses’ self-reported frequency of therapeutic communication technique use will significantly and positively predict patient-rated nurse–patient relationship quality.

RQ2. Which specific therapeutic communication techniques (active listening, empathic reflection, open-ended questioning, therapeutic silence, and clarification/summarizing) are most strongly associated with patient-rated relationship quality?

H2. Active listening and empathic reflection will demonstrate significantly stronger associations with patient-rated relationship quality than open-ended questioning, therapeutic silence, or clarification/summarizing.

RQ3. Is there a significant association between nurses’ self-perceived relationship quality and patients’ perceived relationship quality within the same dyad?

H3. Nurse-rated and patient-rated relationship quality within the same dyad will show a statistically significant, but only moderate, positive correlation, indicating meaningful divergence between nurse and patient perception.

Significance Of The Study

This study carries significance for nursing theory, clinical practice, and mental health workforce education. Theoretically, the study extends Peplau’s interpersonal relations theory and contemporary therapeutic alliance research by empirically disaggregating therapeutic communication into discrete, measurable techniques and testing their relative predictive strength, contributing needed specificity to a body of theory that has historically treated therapeutic communication as a unified construct (Peplau, 1997/2021 reprint; Priebe & McCabe, 2022).

Practically, findings may directly inform psychiatric nursing curricula and continuing education programs by clarifying which specific communication techniques merit the greatest instructional emphasis, potentially allowing training resources to be allocated more efficiently toward the techniques most strongly associated with patient-perceived relationship quality (Chan et al., 2022). Additionally, by directly comparing nurse and patient perceptions of relationship quality within the same dyads, the study offers evidence relevant to ongoing efforts to incorporate patient-reported experience measures into mental health care quality assessment, a priority increasingly emphasized by health system accreditation bodies (Sharac et al., 2021). More broadly, given persistent workforce pressures in mental health nursing, evidence clarifying which communication practices most efficiently build therapeutic relationships carries practical relevance for units seeking to preserve relational quality of care under significant staffing and time constraints (Molin et al., 2020).

Theoretical Framework

This study is grounded primarily in Hildegard Peplau’s interpersonal relations theory, which frames the nurse–patient relationship as a purposeful, developmental interpersonal process moving through orientation, identification, exploitation, and resolution phases, within which the nurse’s deliberate communicative behavior functions as the principal therapeutic instrument (Peplau, 1997/2021 reprint). Peplau’s framework provides the theoretical basis for treating specific communication techniques not merely as generic interpersonal skills but as clinically purposeful interventions whose effective use is expected to directly shape the depth and trajectory of the therapeutic relationship.

This substantive nursing framework is paired with the broader therapeutic alliance construct originating in psychotherapy research, which conceptualizes the strength of the helping relationship along dimensions of affective bond, agreement on treatment goals, and agreement on tasks, and which has been increasingly adapted to describe the nurse–patient relationship in mental health nursing contexts (Priebe & McCabe, 2022). Integrating these two frameworks allows the study to examine not only whether therapeutic communication techniques predict relationship quality in the aggregate, consistent with Peplau’s theory, but also whether the more granular, multidimensional structure of therapeutic alliance theory helps explain why nurse-rated and patient-rated perceptions of the same relationship may diverge (Hagerty & Patusky, 2020).

Nature Of The Study

This study will employ a quantitative, correlational, dyadic survey design, in which matched nurse–patient pairs within inpatient psychiatric units and community mental health centers independently complete validated self-report instruments assessing communication technique use and relationship quality, allowing within-dyad comparison of nurse and patient perceptions (Creswell & Creswell, 2023). Nurses will complete a modified version of an established therapeutic communication technique inventory reporting their frequency of use of active listening, empathic reflection, open-ended questioning, therapeutic silence, and clarification/summarizing with each participating patient, while patients will independently complete a standardized measure of perceived nurse–patient relationship quality regarding the same nurse.

Participants will be recruited from multiple inpatient psychiatric units and community mental health centers using purposive sampling to ensure adequate representation of both acute inpatient and outpatient/community treatment contexts. Data will be analyzed using multiple regression to test the predictive relationship between specific communication techniques and patient-rated relationship quality, and Pearson correlation to examine the association between nurse-rated and patient-rated relationship quality within matched dyads. Relative importance analysis will be used to determine which individual techniques contribute the greatest unique variance to patient-rated relationship quality.

Definitions Of Key Terms

Therapeutic communicationA set of purposeful, patient-centered verbal and non-verbal communication techniques used by nurses to build trust, understanding, and rapport with patients in support of therapeutic goals (Videbeck, 2020).

Nurse–patient relationshipThe interpersonal, developmental process through which a nurse and patient collaboratively work toward the patient’s health goals, characterized by trust, mutual respect, and purposeful engagement (Peplau, 1997/2021 reprint).

Therapeutic allianceThe quality of the collaborative bond between a care provider and patient, typically conceptualized as comprising affective bond, agreement on goals, and agreement on tasks (Priebe & McCabe, 2022).

Active listeningA therapeutic communication technique involving full attentiveness to a patient’s verbal and non-verbal communication, characterized by attentive body language, minimal interruption, and reflective responding (McAndrew et al., 2021).

Therapeutic use of selfThe deliberate, conscious use of one’s own personality, insight, and communication skills as a therapeutic instrument within the nurse–patient relationship (Hagerty & Patusky, 2020).

Patient-reported experience measureA standardized instrument through which patients report their subjective experience of care, including perceived relationship quality with care providers (Sharac et al., 2021).

Assumptions

This study operates under several assumptions. It is assumed that nurse participants will respond to the therapeutic communication technique inventory honestly rather than in a manner reflecting social desirability bias, despite the professionally valorized status of these techniques within mental health nursing culture (Chan et al., 2022). It is assumed that patient participants possess sufficient insight and clinical stability at the time of survey administration to meaningfully reflect on and report the quality of their relationship with their assigned nurse, and that acute symptomatology will not substantially distort these self-reports. It is further assumed that the validated instruments selected for measuring communication technique use and relationship quality possess adequate reliability and construct validity within both inpatient and community mental health populations, and that matched nurse–patient dyads accurately correspond to a shared, identifiable therapeutic relationship rather than a series of brief, interchangeable clinical contacts.

Scope And Delimitations

The scope of this study is delimited to registered nurses and patients within adult inpatient psychiatric units and community mental health centers, and does not examine pediatric or geriatric-specific mental health nursing contexts, nor does it examine communication between patients and non-nursing mental health professionals such as psychiatrists, psychologists, or social workers. The study is further delimited to five specific therapeutic communication techniques, active listening, empathic reflection, open-ended questioning, therapeutic silence, and clarification/summarizing, selected on the basis of their prominence within psychiatric nursing curricula, and does not attempt to capture the full range of communication behaviors that may occur in practice. The study is delimited to a single, cross-sectional measurement of relationship quality following an established care relationship, and does not examine the developmental trajectory of the nurse–patient relationship over time nor the effect of communication technique use during the earliest, initial encounters between nurse and patient.

Limitations

Several limitations should be acknowledged. The reliance on self-report instruments for both communication technique use and relationship quality introduces the possibility of common method bias and social desirability bias, particularly among nurse participants reporting on techniques they have been professionally trained to value. The cross-sectional design precludes causal inference regarding the direction of the relationship between communication technique use and relationship quality, as it remains possible that nurses who already perceive a stronger relationship with a given patient report more frequent use of therapeutic techniques with that patient, rather than technique use driving relationship quality. The use of purposive sampling across a limited number of inpatient and community sites may not fully capture the diversity of mental health nursing contexts, patient populations, or organizational cultures present across the broader mental health care system, potentially limiting generalizability of findings. Finally, patients experiencing acute symptom exacerbation at the time of data collection may have limited capacity to reliably reflect on relationship quality, and the study’s reliance on patients well enough to complete a survey instrument may systematically exclude the most acutely unwell patients, who may also be those for whom therapeutic communication is most clinically consequential (Molin et al., 2020).

Summary

This chapter introduced the background, problem, purpose, and theoretical grounding of a proposed quantitative study examining the relationship between mental health nurses’ use of specific therapeutic communication techniques and the strength of the nurse–patient relationship as perceived by both nurses and patients. While strong theoretical and professional consensus supports the centrality of therapeutic communication to psychiatric nursing practice, empirical evidence distinguishing the relative effectiveness of specific communication techniques, and clarifying the degree of alignment between nurse and patient perceptions of relationship quality, remains limited. Grounded in Peplau’s interpersonal relations theory and therapeutic alliance research, this quantitative, dyadic correlational study aims to clarify which specific therapeutic communication techniques most strongly predict patient-perceived relationship quality, with implications for psychiatric nursing education, clinical practice, and patient-centered mental health care quality measurement. Chapter Two will present a comprehensive review of the existing literature on therapeutic communication, the nurse–patient relationship, and therapeutic alliance in mental health nursing, further situating this study within its scholarly context.

References

Chan, E. A., Tsang, P. L., Ching, S. S. Y., Wong, F. K. Y., & Lai, T. K. H. (2022). Nurses’ perceptions of and barriers to therapeutic communication in mental health nursing: A qualitative study. Journal of Psychiatric and Mental Health Nursing, 29(4), 612–621.

Creswell, J. W., & Creswell, J. D. (2023). Research design: Qualitative, quantitative, and mixed methods approaches (6th ed.). SAGE Publications.

Hagerty, T. A., & Patusky, K. L. (2020). Reconceptualizing the nurse–patient relationship in psychiatric nursing: Toward a model of therapeutic use of self. Archives of Psychiatric Nursing, 34(2), 65–72.

Kornhaber, R., Walsh, K., Duff, J., & Walker, K. (2021). Enhancing therapeutic communication in nursing practice: A systematic review. Journal of Multidisciplinary Healthcare, 14, 519–531.

McAndrew, S., Chambers, M., Nolan, F., Thomas, B., & Watts, P. (2021). Measuring the evidence: Reviewing the literature of the measurement of therapeutic engagement in acute mental health inpatient settings. International Journal of Mental Health Nursing, 30(1), 40–52.

Molin, J., Graneheim, U. H., & Lindgren, B.-M. (2020). Quality of interactions influences everything: A qualitative study of patients’ experiences of interpersonal interactions in psychiatric inpatient care. International Journal of Qualitative Studies on Health and Well-being, 15(1), 1–9.

O’Brien, L., Anand, M., Brady, P., & Gillies, D. (2020). What matters most: The perspectives of mental health inpatients on nurse–patient relationships. International Journal of Mental Health Nursing, 29(3), 447–457.

Peplau, H. E. (2021). Interpersonal relations in nursing: A conceptual frame of reference for psychodynamic nursing (Reprint edition). Springer Publishing Company. (Original work published 1997)

Priebe, S., & McCabe, R. (2022). The therapeutic relationship in mental health nursing: Conceptual and empirical developments. Epidemiology and Psychiatric Sciences, 31, e15.

Sharac, J., McCrone, P., Clement, S., & Thornicroft, G. (2021). The economic and clinical impact of patient-reported experience measures in mental health services: A review. The Journal of Mental Health Policy and Economics, 24(2), 63–72.

Videbeck, S. L. (2020). Psychiatric-mental health nursing (8th ed.). Wolters Kluwer.

Wei, H., Sewell, K. A., Woody, G., & Rose, M. A. (2021). The state of the science of nurse work environments in the United States: A systematic review. International Journal of Nursing Sciences, 8(3), 258–276.

Wonghongkul, T., Panpakdee, O., Malathum, P., & Sirapo-ngam, Y. (2021). Nurse–patient communication and quality of care in psychiatric settings: An integrative review. Pacific Rim International Journal of Nursing Research, 25(3), 402–417.

Yalden, J., & McCormack, B. (2021). Constructions of dignity: A pluralistic approach to understanding therapeutic relationships in mental health nursing. International Practice Development Journal, 11(1), 1–13.

Zugai, J. S., Stein-Parbury, J., & Roche, M. (2021). Therapeutic alliance, engagement, and outcomes in inpatient mental health care: A concept analysis. Archives of Psychiatric Nursing, 35(4), 349–357.

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