Practice Recommendations

The nurse must acquire the necessary knowledge to participate effectively in therapeutic relationships.

Reflective Practice and Self Awareness

Establishment of a therapeutic relationship requires reflective practice. This concept includes the required capacities of: self-awareness, self-knowledge, empathy, awareness of ethics, boundaries and limits of the professional role.

The Process of Developing a Therapeutic Relationship

The nurse needs to understand the process of a therapeutic relationship and be able to recognize the current phase of his/her relationship with the client.

1. Background knowledge.

This is knowledge the nurse brings with him/her before meeting the client. This includes
education, the readings he/she has engaged in, and one’s life experiences.

2. Knowledge of interpersonal, caring and development theory.

This includes knowledge of theories, which provide an understanding of the development of the sense of self (who we are), and how that self influences our way of being in the world with others. There are different theoretical approaches such as:

Interpersonal (Orlando, 1961; Peplau, 1952)
Object relation theory (Lego, 1980; Winnicott, 1965)
Developmental (Erickson, 1963; Freud, 1912; Stern, 1985)
Gender/developmental (Gilligan, 1987; Miller, 1985; Stiver, 1985)
Caring Theories (Benner, 1989; Leininger, 1988; Watson, 1999; Watson, 2005)

3. Knowledge of diversity influences and determinants.

Knowledge about the relationship of social justice to social, cultural and racial diversity is essential. The nurse needs to be aware of the effects of “differences” and how these influence
the therapeutic relationship.

4. Knowledge of person.

This knowledge refers to the particular narrative of the client which includes:

Understanding of the client’s particular world;
Identifying and confirming what is meaningful and concerning to that client; and
Hearing the client’s life history.
Awareness of ways and patterns of knowing: empirical (evidence based), personal, ethical, aesthetic and political.

5. Knowledge of health/illness.

The nurse requires specific knowledge of the client’s presenting issue so that he/she can engage effectively in a therapeutic relationship. For example, if a young man presented with a diagnosis of schizophrenia, the nurse would need to know about:

Explanatory models including multi-determinants of health/illness which would be biological, psychological and/or socio-contextual;
Symptoms;
Standard interventions and issues of rehabilitation;
Pharmacology-in order to administer, monitor, and instruct; and
Knowledge of best practices.

6. Knowledge of the broad influences on health care and health care policy.

The nurse needs to have knowledge of the forces that may influence the context of the client’s care:

Social and political forces;
The client’s expectations of the health care system;
How the health care professional functions; and
Changes in the health care system such as accessibility, resources, etc.

7. Knowledge of systems.

The nurse needs knowledge of the system and how it operates so that he/she can provide instrumental assistance to the client. Through the therapeutic relationship, the nurse can help the client navigate the system and obtain access to services.

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1. Self-awareness. The ability to reflect on one’s subjective thoughts, feelings and actions.

Thus, the nurse may realize she is conveying an attitude that could impede the therapeutic process and tries to counteract any potential negative effects on the client.

2. Self-knowledge.

The nurse appreciate the unique perspective of the client, is able to avoid burdening the client with his/her issues, and can prevent superimposing his/her own beliefs and preferred solutions upon the client.

3. Empathy.

Empathy involves the nurse being able to attend to the subjective experience of the client and validate that his/her understanding is an accurate reflection of the client’s experience.

4. Awareness of boundaries and limits of the professional role.

Boundaries define the limits of the professional role. A nurse is obligated to place the client’s needs before his/her own needs.

Indications that boundaries may have been crossed include:

Having special clients
Spending extra time with clients
Keeping secrets with clients
Doing activities with clients that you do not share with colleagues.

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Orientation:

The parameters of the relationship are established (e.g., place of meeting, length, frequency, role or service offered, confidentiality, duration of relationship).
Trust, respect, honesty and effective communication are key principles in establishing a relationship.
The expectations the nurse and the client have of each other and of their relationship are discussed and clarified (Peplau, 1952).
The nurse gathers information and ensures that priority issues are appropriately addressed.
Consistency and listening are considered by clients to be critical at the beginning of the relationship (Forchuk et al., 1998abcd; Sundeen et al., 1989).
The nurse assists in promoting client comfort that may include reducing anxiety or tension.

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 (Sundeen et al., 1989).
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 (Parse, 1981; Peplau, 1989) 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 (Hall, 1993; Hall, 1997).
Termination may be met with ambivalence.
Both should share feelings related to the ending of the therapeutic relationship.
Validating plans for the future may be a useful strategy (Hall, 1997; Sundeen et al., 1989).
Increased autonomy of both the client and the nurse is observed in this phase (Sundeen et al., 1989).

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