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The Therapeutic Relationship

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Sylvia Student

on 27 October 2013

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Transcript of The Therapeutic Relationship

The Therapeutic Relationship
Application of the Standards
Maintaining a Quality Practice Setting
What is a nurse-client relationship made up of?
Standard Statements
Indicators:
Formal introduction of himself/herself to the client eg. Your name, role in the client’s care and the period of being involved in the client’s care

Making sure the client is well informed that the information disclosed by them will be known within the health care team

Being aware of the client’s non-verbal and verbal gestures or communication styles

Communication style can be modified to best suit client’s needs

Considering client’s opinions, values, needs and ethno-cultural beliefs and possibly integrate these into the care plan with the client’s help

Involving the family or significant others into the client’s care by listening to their concerns and acting on those concerns when appropriate

Refrain from self-disclosure as much as possible

Continuous discussion of the plans for meeting the client’s care needs after termination of nurse-patient relationship


3. Maintaining Boundaries
Indicators:

Assist client to be aware when their requests are beyond the limit of therapeutic relationship

The nurse must always be self-aware not to interfere with client’s personal relationships

Refraining from disclosing personal information to the client unless it meets a specific therapeutic need of the client

Constantly clarifying his/her role in the nurse-client therapeutic relationship

Avoids financial involvement especially if unrelated to the client’s provision of care

Recognising the client’s cultural beliefs/values in the context of maintaining boundaries including giving of gifts and self-disclosure

Discussing with colleagues and/or manager any situation or behaviour that may cross boundaries of therapeutic
relationship


4. Protecting the Client from Abuse
Indicators:

When appropriate, intercede and report incidents of non-verbal and verbal behaviours that exhibit disrespect to the client

Intercede and report behaviour that is perceived as threats by the client and/or threatening or intended by the nurse to inflict physical harm

Not being involved in a friendship, romantic, sexual or any other personal relationship with the client while therapeutic relationship still exists or even with a former client as well

Not engaging in any activity that would lead to monetary, material or personal gain for the nurse


1. Therapeutic Communication
2. Client-Centered Care
Indicators:

Involvement of the client in their care through recognizing the client’s goals, wishes and preferences and making them the basis of the care plan

Communicating with the client to ensure understanding of nurse’s, client’s and family’s role in achieving goals identified in the care plan

Being aware of the client’s limitations, abilities and needs in regards to their health condition to assist in offering appropriate nursing care and services

Demonstrating respect and being sensible for the client’s preferences considering the client’s individual values and religious and/or cultural beliefs

Commitment of being available for the client within the duration of the nurse-patient relationship

Professional Intimacy
Refers to physical, psychological and emotional care

Physical care can include showering, body contact or touch due to procedure required

Professional intimate care enhances quality of care, whilst still maintaining therapeutic boundaries
Empathy
Understanding the clients situation with professional emotions

Listening without being judgemental

Establishes a sense of connection

Empathy brings about equality
Power
Nurses have a great influence and authority on the client's health

Nurses are to educate the client and their families so they can all make decisions as a team

Nurse-client relationships is based on the equality of power

Taking advantage of or having an imbalance of this power is reflected as abuse
Trust
One of the most important elements of a nurse-client relationship

Clients are vulnerable and require assistance

Once trust is lost, it is very hard to gain back

Without trust, clients may not disclose any relevant or required medical information
Respect
Address the clients how they want to be called

Respect the clients privacy, dignity, culture and beliefs

Never make assumptions or discriminate

Every client is equal regardless of their socio-economic status
Daisy, Joanarose, Kerry, Manisha & Sylvia
Advantages
Recommendations in Establishing Therapeutic Relationship
Acquire the necessary knowledge

Require reflective practice

Learn, understand and recognise the process of the relationship

Provide opportunities to effectively develop the relationship

Workload is maintained at certain levels to support the nurse's well-being

Highly visible nursing leadership

Resources must be available
References
C. Forchuk, K. Carmichael, G. Gole,Nancy J. Mary-Lou, P. Patterson, K. Ray, T. Robinson & S. Sogbein 2006, “Establishing Therapeutic Relationships”, published in “RNAO Nursing Best Practice Guidelines Program”, viewed 1st October 2013, <http://rnao.ca/bpg/guidelines/establishing-therapeutic-relationships>

College of Nurses of Ontario, "Therapeutic Nurse-Client Relationship", Revised 2006, Toronto, viewed 1st October 2013, <http://www.cno.org/Global/docs/prac/41033_Therapeutic.pdf>

Faculty of Nursing University of Toronto 2004, "Fact Sheet: Quality Practice Settings", published in Nursing Effectiveness, Utilization and Outcomes Research Unit,McMaster University, Toronto.

Rowe, R. and Calnan, M. 2006, ‘Trust relations in health care-the new agenda’, European Journal of Public Health, vol. 16, no. 1, pp. 4-6.
This is a relationship between a healthcare professional and a client
How to Apply this Standard
1. Decision tree

2. Warning signs of crossing a boundary

3. When a colleague's behaviour crosses a boundary
Composed of four statements with indicators that would guide the nurse towards their roles and accountabilities in the nurse-client relationship

Decision Tree
Use this tool to work through a personal situation to determine whether a particular activity or behaviour is appropriate within the context of the nurse-client relationship

The tool may also be useful for self-reflection and peer input as part of the self-assessment process and for guiding client care discussions in your practice

Warning Signs of Crossing a Boundary

Nurses need to reflect on the situation and seek assistance when one or more of the following warning signs are present:

Spending extra time with one client beyond their therapeutic needs

Changing client assignments to give care to one client beyond the purpose of the primary nursing care delivery model

Disclosing personal information to a specific client

Feeling guarded or defensive when someone questions the interactions with a client

Spending off-duty time with a client

Keeping secrets with the client from the health care team (for example, not documenting relevant discussions with the client)

When a Colleague's Behaviour Crosses Boundaries
If a nurse believes that a colleague is crossing a therapeutic boundary, the nurse needs to carefully assess the situation. Address with the colleague:

What was observed

How that behaviour is perceived

The impact on the consumer

The practice standards

Organisational Supports
These are the norms, beliefs and policies of the organisation about client care service

It recognises whether the setting is at increased risk for potential boundary violations and have policies in place on issues, such as accepting gifts from clients, to guide and support nurses in meeting standards

It has a zero tolerance of abuse

By role modeling and promoting an organisational culture of respect, it facilitates delivery of client care/service


Leadership
Includes all levels within an organisation

This is the process of working together and supporting each other to continually improve client care service by promoting professional practice to achieve mutual goals

Ensure that proactive visible leadership and clinical supervision is available to support nurses in developing therapeutic relationships and maintaining boundaries

Care Delivery Processes
Communication Systems
Including planning and providing clinical care and services.

In conjunction with other health professionals, qualitative processes will promote reflective practices and support client-centered care to meet client needs


The internal and external exchange of information and decisions about client care/services

A qualitative communication system will provide abundant resources to support the provision of culturally sensitive care and establish effective therapeutic relationships

Facilities and Equipment
The physical environment, supplies & equipment and support services are accessible on a 24-hour basis to increase client care, efficiency and effectiveness

Response Systems
These provide organisations with the means for a timely response to legislative and other requirements (client demands and changing health care trends) affecting the delivery of care/services

Have a known procedure for reporting abuse of clients and/or staff members

Ensure reports of abuse are investigated and addressed

Debrief after critical incidents to provide support to staff and determine the cause, a possible solution and how to prevent a recurrence
Thank you
Non-Verbal Techniques (active listening)
Body language, positioning and posture

Gestures

Facial expressions and eye contact
Verbal Techniques
Informing

Open-ended questions

Paraphrasing

Clarifying

Silence

Summarising
How to Establish and Maintain Boundaries
Understand the limits and responsibilities of your role

Identify limits that allow a safe connection

Know where you end and the client begins

Be friendly, not friends
http://www.cno.org/Global/docs/prac/41033_Therapeutic.pdf
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