Section Five

Therapeutic Relationships Teaching activities and resources

Also in this section

Outcomes

Purpose

This section supports educators with the knowledge and skills required to incorporate the foundational concept of therapeutic relationships into mental health and addiction entry-level nursing curricula.

Outcomes

At the end of this section, the educator will:

  • At the end of this section, the educator will ensure students achieve the following:
  • Identify the definition, purpose and theories which inform the nurse-client therapeutic relationship.
  • Recognize and understand different phases of the therapeutic and non-therapeutic relationship.
  • Recognize professional boundaries, counter transference, transference, and power dynamics of the nurse-client therapeutic relationship.
  • Understand concepts of therapeutic use of self in providing care (i.e., health promotion, prevention, supportive care).
  • Understand and implement effective therapeutic communication skills (i.e., listening, respect, empathy) in assessment and care planning.
  • Promote cultural competency and safety (i.e., creating inclusive, safe space) in therapeutic relationships.

CASN/CFMHN Competencies

2.8, 3.1, 3.2

Therapeutic Relationships

A “therapeutic relationship” is a relationship that occurs between a client and the nurse that is goal-directed and works towards advancing the best interest and outcomes for the client (RNAO, 2006b). Establishing therapeutic relationships recognizes that effective nursing care is dependent on the nurse coming to know his or her client and engaging in a relationship that supports recovery. Key qualities of a therapeutic relationship include active listening, trust, respect, genuineness, empathy, and responding to client concerns (RNAO, 2006b).

The phases of a therapeutic relationship (Forchuk, 2000) include orientation, working and resolution. Nurses must also be prepared to experience a series of non-therapeutic phases, which include orientation, grappling and struggling and mutual withdrawal. Respecting boundaries that define the limits of the professional role is also important in a therapeutic relationships (RNAO, 2006b). Establishing and maintaining a sense of self-awareness allows a nurse to assess when counter transference and transference—inappropriate meanings and feelings are assigned to the client or vice versa—has taken place, and to assess his or her own ability to address client dynamics (RNAO, 2006b).

Therapeutic relationships are of critical importance to nursing practice and help promote awareness and growth to work through difficulties (RNAO, 2010b). Therapeutic relationships were originally highlighted in psychiatric nursing literature (RNAO, 2010b) before being recognized as fundamental to all nursing (Orlando, 1961; Peplau, 1952; Sundeen, Stuart, Rankin, & Cohen, 1989) and focus on the value associated of developing therapeutic relationships (Brown, 2012).

Establishing therapeutic relationships works in tandem with person-centred-care principles that reflect the belief of getting to know the whole person. Caring for the ‘whole person’ entails coming to know the person with respect to all components—biological, psychological, emotional, physical, personal, social, environmental, and spiritual—and treating the person holistically rather than treating only their illness or disease (Lovering, 2012; Morgan & Yoder, 2012). According to RNAO’s Best Practice Guideline Person- and Family- Centred Care (2015):

“When optimized, health-care partnerships can improve the autonomy of individuals to make decisions related to their health care and can increase their satisfaction with care.” (RNAO, 2015, p. 21).

Recent health-care restructuring resulted in removal of organizational policies and supports that encourage the manifestation of therapeutic relationships (RNAO, 2010b). It is therefore even more important for nursing to place an emphasis on the importance of this best practice in mental health and addiction curricula. The RNAO Nursing Best Practice Guideline Establishing Therapeutic Relationships (2006) developed a Framework for Therapeutic Relationships that organizes learnings around requisite knowledge and capacities for establishing therapeutic relationships, as well as the phases of therapeutic relationships.

For more information about therapeutic practice, see Resources in this section.

Teaching and Learning Activities

The following are teaching and learning activities that can be employed in the classroom to further support nurses in the integration of theory, principles and best practices related to therapeutic relationships.

  • Process recordings (Appendix B, C, and D)
  • Case studies (Section 9.3)
  • Communication labs
  • Simulation (standardized patients; lived client experience/family experience, peer support)
  • Appendix E).Reflective assignments (pre- and post-clinical practice; portfolios; logs; diaries; journals–
  • to death across all health-care settings and situations.interventions. Applicable for mental health promotion of and well-being in clients from birth Group role play: Learning exercise for the application to practice of relational care
  • Clinical supervision/peer supervision
  • Peer learning
  • Handouts (reflective questions)
  • Lived client experience/family experience— Appendix H
  • Arts-based approaches
    • Theatre
    • Photography
  • Narratives/stories

Learner Engagement Questions

The following are thought-provoking and engaging learner questions that can be used to further discussions with nursing students regarding establishing therapeutic relationships. These questions can be used either to stimulate discussion, engage students in critical thinking or be tied to class assignments and/or reflection exercises.

  • How would you know that you have established a therapeutic relationship?
  • Can we have therapeutic relationships with anybody?
  • What do therapeutic boundaries look like in different settings/situations? Which boundaries never change?
  • When is it okay to touch? When is it okay to use humour?
  • How do you terminate the therapeutic relationship? How do you say “Goodbye”?
  • How would you determine if it’s your needs and/or the client’s needs that are being met?
  • How do you address observed boundary violations between other clinicians and clients?
  • How long can you sit without saying anything? Describe the importance of silence.
  • What would it be like to be a patient in this setting?

Evaluation and Self-reflection

The following tools can be used to evaluate students in their understanding and application of therapeutic relationships:

  • Process recordings (Appendix B, C, and D)
  • Assignments, such as analysis of a video to determine understanding of concepts related to therapeutic/non-therapeutic relationships
  • Questions on exams regarding theoretical concepts

SELF-REFLECTION

  • Journaling (Appendix E)
  • Portfolios
  • Pre- and post-clinical placement reflections
  • Process recordings (Peplau, 1952; 1988; 1989) (Appendix B, C, and D)

Resources

WEBSITES

VIDEOS AND FILMS

RNAO RESOURCES

REFERENCE MATERIALS

  • Alex, M. R., Whitty-Rogers, J., & Panagopoulos, W. (2013). The Language of Violence in Mental Health: Shifting the Paradigm to the Language of Peace. Advances in Nursing Science, (3), 229-242.
  • Lasiuk, G., (2015) Mental Status Exam (Chapter 11). In W. M.A.,Psychiatric & mental health nursing for Canadian practice (3rd Canadian ed., pp175-197). Philadelphia, PA: Wolters Kluwer.
  • Bouchard, L., Montreuil, M., & Gros, C.P. (2010). Peer support among inpatients in an adult mental health setting. Issues in Mental Health Nursing, 31(9), 589-598.
  • College of Nursing Standards
  • Eliason, M. J., Dibble, S., DeJoseph, J. (2010). Nursing’s silence on Lesbian, gay, bisexual, and transgender issues: The need for emancipatory efforts. Advances in Nursing Science, 33(3), 206-218.
  • Goldberg, L., Ryan, A., & Sawchyn, J. (2009). Feminist and queer phenomenology: a framework for perinatal nursing practice, research, and education for advancing lesbian health. Health Care For Women International, 30(6), 536-549.
  • Gros, C.P., Jarvis, S., Mulvogue, T., Wright, D., (2012), Les interventions infirmières estimées bénéfiques par les adolescents à risque de suicide Santé mentale au Québec, (37) 2, 193-207
  • Lasiuk, G. (2015). The assessment process. In W. Austin & M. A. Boyd (Eds.), Psychiatric & mental health nursing for Canadian practice (3rd ed., Chapter 10, pp. 148–164). Philadelphia, PA: Wolters Kluwer.
  • McGibbon, E.A. (Ed.). (2012). Oppression: A Social Determinant of Health. Black Point, NS: Fernwood.
  • McGibbon, E.A., & Etowa, J.B. (2009). Anti-Racist Health Care Practice. Toronto, On: Canadian Scholars’ Press.
  • Montreuil, M., Butler, K., Stachura, M., & Gros, C. P. (2015). Exploring helpful nursing care in pediatric mental health settings: The perceptions of children with suicide risk factors and their parents. Issues in Mental Health Nursing, 36(11), 849-859.
  • Orlando, I. (1961). Orlando’s Dynamic Nurse-Patient Relationship: Function, process and principles. New York: Putman.
  • Orlando, I. (1972). The discipline and teaching of nursing process, an evaluation study. New York: Putnam.
  • Peplau, H.E. (1952). Interpersonal Relations in Nursing. New York: G.P. Putnam’s Sons.
  • Wright, D & Gros, C.P. (2010) Let’s Talk About Sex: Promoting Staff Dialogue on a Mental Health Nursing Unit. Journal for Nurses in Staff