Nursing is a noble profession that aims to serve humanity. Generally, nurses face many physical, psychological, emotional and social challenges during their work but out of them, one of the most prevailing and visible challenges is ineffective communication with the patient, their families and other health care professionals. “Communication can be defined as the process of transmitting information and common understanding from one person to another” ( Keyton, 2011). There are two types of communication: i) Therapeutic communication; which is a mutual learning and emotional experience for both nurse and patient ( Stuart, 2009). ii) Non-therapeutic communication; that may demonstrate non-caring attitude along with scaring and giving warnings to the patients ( Demirkiran et al, 2006). In mental health settings, therapeutic communication is a key competency to attain or develop a successful nurseclient relationship in order to identify clients need and mental health issues. In addition, nurses use therapeutic communication skills as an intervention in order to facilitate the clients to set their goals and attain them, so to ultimately achieve emotional well-being. In contrast, absence of therapeutic communication skill by nurses may lead to early termination of therapeutic relationship resulting in unmet goals and ineffective care. If rapport building through effective communication is not achieved, it leads to ignorance and value conflict as well. Individuals may have same or different values that are either inherited or socially developed. Similarly, nurses' values may differ from patients' values in terms of their beliefs, lifestyles, and perceptions. Unresolved clash of values gradually begins to hinder the process of care keeping both nurse and patient unsatisfied. Therefore, therapeutic communication is a mandatory skill that should be learnt by all health care professionals (Collage of nurses of Ontario, 2006).

A 33- year old middle aged female client came to the hospital with a chief complaint of severe depression due to her current stressor like her increased workload which required multitasking that disengaged her from socialization. As she worked in an advertising company, she had enormous work load which she was unable to complete efficiently, leading to work strain. She was diagnosed with Bipolar Affective Disorder (BAD). It was noticed that this client was always found wearing male attire including her haircut (boy cut). To cope with her stress, she adopted smoking and occasionally drinking alcohol. Living in a traditional society like Pakistan, it was astonishing for the nurse to see a female smoking and carrying her-self as a male thus it was difficult to accept her personality. This scenario created a value conflict for the nurse and created a barrier to accept the client and provide due care.

One's attire has a great impact in shaping one's personality and identity as male or female. The way one dresses up depends upon their gender and culture; thus, one's attire plays a significant role in displaying their values ( Froelich et al., 2004 ). In western cultures, male wear jeans and shirts and females wear short-dresses; whereby, in eastern cultures, specifically Pakistan, males prefer pant, shirt or plain shalwar kameez (Pakistani traditional dress for males)and females prefer Pakistani traditional dress that is salwar (a long trousers that covers the lower body from waist till ankle) kameez (a long shirt which covers the upper body till knees) with dupatta ( a long Scarf that women takes on their head and upper body)( Subhani et al., 2011).Due to these stereo typed thoughts about male and female demeanor in Pakistani context, the nurse was not able to accept the client's attire and thus she initiated conversation with a biased thought. Stuart (2009) refers acceptance as a therapeutic phenomenon whereby a nurse acknowledge patients for what they are. However, in this case, during the interaction, the nurse inquired from the client, “Why do you dress like a male?” In response, client didn't tell the reason but simply ignored the question and asked to terminate the interview. This piece of communication clearly depicts a non- therapeutic approach by the nurse towards the client. Firstly, she asked the “why” question that seemed challenging and rude ( Stuart, 2009). Secondly, it appeared that the nurse was interested to know the reason of her unusual attire which was socially unacceptable according to the values of that nurse. This value conflict among nurse and client hindered the therapeutic relationship. There could be many reasons for the client to dress like this. Literature suggests that attire of working women is more controversial than men( Subhani et al, 2011). One reason that can be assumed was the demand of client's profession, as she worked in an advertising company.

Along with her peculiar attire, Author was observed with frequent smoking, in fact a chain smoker. The client's smoking habits became the second value conflict for the nurse. In addition, watching her smoke during the conversation with the nurse was quite displeasing for the nurse. There were two reasons for the nurse's dis likable response. First, her judgmental perspective due to the traditional/parental values, for example in a conventional society like Pakistan, it is taught that a male who smokes is acceptable; whereas, a female who smokes is objectionable. The second reason was the nurse's health belief to prevent from the effects of passive smoking. This health belief created ambivalence for nurse to start the communication. As the client worked in a male dominating profession in Pakistan (Advertisement Company), thus, smoking may not be considered objectionable even for females; rather, it may be a part of their working environment. A woman working in a male dominating organization undergoes challenges in acceptance, credibility and legitimacy ( Subhani et al, 2011 ). Therefore, they might adopt such attire and habits like males to show that they are part of that working environment.

Another non-therapeutic attitude was lack of respect. Bhanji (2013), which defines respect as being esteemed. Respect is a core value of human rights and also part of nursing ethics. Thus, every individual has a right to receive respect. As the nurse was not clear about client's gender identity, this was also depicted in her attitude and, thus, she spontaneously asked a direct question in the beginning of nurse-client relationship i.e.“Why do you dress like a male?” In response, the client terminated her interaction with the nurse when she was asked directly about her gender identity. This approach itself was non- therapeutic. Whereas, in the beginning of rapport building the nurse's communication should start with general questions about client's health before she in-depth explores the client's mental health and underlying causes of a problem. In addition, the nurse should be equipped with her skill of being empathetic and respectful which were necessary to build on client's trust( Lambert, 2011) before she starts an indepth assessment of client's personal matters.

In addition, an interesting observation that came across was that the client did not converse in Urdu (national language of Pakistan) and preferred to talk in English. This act from client could be because the client didn't want to disclose her gender identity. As in Urdu language, the expression for female and male differs; whereas, in English language, it remains same. For example, client stated “When I feel stressed, I prefer to go out and do window shopping” so in English if a male or female says this sentence they would use same expression. However, it was nurse's personal interest to explore if there was any gender issue with client. This judgmental thinking was due to the difference in personal values of the nurse that was hindering her to accept this client the way she was.

Another non-therapeutic approach in this case was boundary violation; this occurred when a nurse goes out of the set boundaries and asks personal questions ( Stuart, 2009 ). The nurse in the above case seemed more personally interested to know about the personal/intimate relationships of the client due to the client's difference in dressing. The obsession of the nurse about the client's male attire generated different questions in her mind which she asked later. For instance,

“Is the client married?”

“Will she ever marry? If yes, then to whom, a male or a female?”

“What is the reason for her to look like a male knowing that she is a female?”

Rather than exploring the client's present condition and reason for admission, the nurse was more inclined towards getting details about her personal life. The above scenario represents that the nurse directly asked these questions in the first interaction rather than building rapport at the orientation phase. Thus, the role of the nurse as a communicator was not fulfilled as she was not able to maintain the therapeutic relationship. According to Stuart (2009), role boundary violation is when the nurse fails to fulfill the expected professional roles and responsibilities. This act of the nurse depicted that the nurse has not only violated the client's personal boundary but her own professional boundary as well. The analysis of this scenario clearly depicts that if nurses' have value conflicts with their clients it may reflect in their verbal and non-verbal communication and may end-up into non- therapeutic approaches of communication. As a result it may also negatively impact nurse-client relationship.

Reflecting on the above case study, it is very critical to intervene some of the strategies formed to triumph over this issue. The individual strategies to overcome this issue may include value clarification of nurses through self-awareness before they interact with such clients. According to Stuart (2009), value clarification is a process whereby an individual understands their own and others values. This helps the nurse to reorganize her values in order to harmonize it with the new values formed for self and others.

Value clarification is also vital to demonstrate empathy, build acceptance, create self-awareness and deliver holistic care to the client. “Empathy is the ability to enter into the life of another person, to accurately perceive the person's current feelings and their meanings, and to communicate this understanding to the patient” ( Stuart, 2009 ).Moreover, awareness of self-values helps to understand client's different values and consider him as an unique individual. The other therapeutic communication techniques include, using neutral facial expressions and asking open ended questions such as, “Would you like to tell me about your personality?” In addition, apologizing for the unintentional hurt and then rephrasing it. For instance, in the above case when the client asked to terminate the interview, the nurse should have apologized for asking personal questions. Such questions should be avoided during the orientation phase and if necessary, should be asked in the working phase only when enough rapport has already been developed ( Lambert, 2011).

Clients may reject or manipulate certain interventions (communication patterns) that they find culturally inappropriate. Therefore, choosing right words, proper form of address and considering their point of view should be used to strengthen the trusting relationship ( Froelich et al, 2004 ). Moreover, using non-verbal gestures is salient e.g. maintaining eye contact, sitting with an open stance, avoiding crossing arms and use of therapeutic touch when culturally appropriate. Similarly, to deal client with respect, the nurse should acknowledge client's suffering, be nonjudgmental, be fair and consider that the client can predict others' attitudes towards him (Chiovitti, 2008c ited in Bhanji, 2013).

It is observed that mental health nursing students and novice nurses usually have difficulty in initiating communication with mentally ill clients because of their anxiety and their lack of exposure to interact with psychiatric clients. Therefore, at institutional level, concepts like respect and acceptance should be apart of nursing code of conduct, curriculum, and mental health laws ( Bhanji, 2013&Cutcliffe, 2013).In order to enhance nurses' capacity to deal with such cases Hammer et al (2014) suggested a 'Therapeutic Communication Simulation Model' that is a pedagogy in which students are taught to deal with such clients through role-plays or simulation. Critical self-reflections and engaging learners in legal and ethical debates can be used as a clinical instrument to enhance their self-awareness and value clarification before they interact with such clients in actual hospital settings.

Besides this, national level media could play a significant role in the awareness of such cases in a positive manner for example a girl wearing a male attire and smoking does not indicate that the credibility of that particular person have negative personality. The positive portray through media would also lower the stigmatization of such clients in our society and thus health care professional as well as other members of our society would accept and respect them within their traditional social norms (Bhanji, 2013).

Finally this paper concludes, that it is important for nurses to engage in critical self-reflection, self-awareness, value clarification, and empathetic approaches as a core to clinical practice. This clinical experience has opened up several avenues for learning, particularly not to be judgmental and respect and accept a mentally-ill client with their differences and uniqueness. Being a novice nurses our unawareness of others' world may become a restricting factor for us to initiate therapeutic communication and relationship with our clients. At the end the contribution of client in this scenario is highly acknowledged, which had changed the perspectives of the authors to look into the depth of the issue rather than looking at it in surface only.